The United States needs more family physicians, and even though that message is not new, there is a newfound sense of urgency. Based on current projections, the country will be short some 52,000 primary care physicians by 2025.
And just like that, this big problem that's been lurking in the background for years is here and is bound to get worse. New research published in the the March issue of Family Medicine sifts through a decade of statistics in search of solutions to this growing crisis.
In an article(journals.stfm.org) titled "Trends in U.S. Medical School Contributions to the Family Physician Workforce: 2018 Update from the American Academy of Family Physicians," researchers examine the output of U.S. medical schools -- both allopathic and osteopathic -- when it comes to producing family physicians.
For this report, researchers collated AAFP residency census data for U.S. allopathic schools from 2005 to 2017 and for osteopathic schools from 2009 to 2017 to examine trends over time. The authors also examined data from the U.S. Liaison Committee on Medical Education Annual Medical School Questionnaire, Part II, and the American Association of Colleges of Osteopathic Medicine Fast Facts About Osteopathic Medical Education.
- Researchers examined longitudinal medical school census data to calculate allopathic and osteopathic institutions' output of family physicians over time.
- Authors collected data for 179 schools and compared programs' institutional characteristics, such as school size, years in operation and public versus private ownership.
- In allopathic medical schools, the most consistent predictor for students choosing family medicine was the presence of a department of family medicine.
In all, the researchers collected data for 179 allopathic and osteopathic medical schools and analyzed the proportion of students matriculating to family medicine programs accredited by the Accreditation Council for Graduate Medicate Education (ACGME). To break down the relative contributions of different types of medical schools, they compared programs' institutional characteristics, defined as
- percentage of graduates entering family medicine residencies,
- public versus private ownership,
- allopathic versus osteopathic accreditation,
- institution size,
- years in operation and
- whether or not schools had departments of family medicine.
Research co-author Julie Phillips, M.D., M.P.H., of Williamston, Mich., is an associate professor of family medicine at Michigan State University (MSU) College of Human Medicine in East Lansing and a faculty member and director of research for the Sparrow-MSU Family Medicine Residency Program there.
In an interview with AAFP News, Phillips said the presence of a department of family medicine in allopathic schools was an extremely strong predictor of students choosing family medicine.
"It was striking the degree of influence that made, and it was equally surprising that in the osteopathic schools, this particular factor wasn't predictive at all," said Phillips.
The authors noted that the presence of a department could be a proxy for other variables, such as a family medicine clerkship, the presence of family medicine leaders or contact with family medicine faculty.
Regardless, the presence of a family medicine department "appears to be a marker for meaningful institutional power and influence," said the authors. "Newly established allopathic medical schools should be attentive to this relationship and consider establishing FM (family medicine) departments" to promote student choice of the specialty.
The authors further remarked that perhaps osteopathic institutions were not affected by this particular variable because they generally have strong family medicine orientations compared to allopathic schools, where family medicine may viewed as "one of many competing interests."
Co-author Ashley Bentley, M.B.A., C.A.E., the student interest strategist in the AAFP Medical Education division, pointed out that a notable change in this year's research article -- the 37th in this series -- was the rank ordering of both U.S. allopathic and osteopathic schools by family medicine production on the same list.
"We also created lists that look not only at the percentage of graduates who enter family medicine residencies by each medical school, but also the number of graduates who enter family medicine," said Bentley.
That's an important distinction.
"Some schools have small classes but graduate a large proportion into family medicine, and others graduate a smaller proportion of a large class size and so may be an even larger contributor to the overall workforce.
"We've never reported the data in this way before," said Bentley.
Interestingly, "these lists run opposite to the highly touted traditional 'top medical school' lists published by major media outlets" that likely are less informed about the primary care workforce shortage, she said.
"We think that looking at graduation rates into family medicine is vitally important because it is a more accurate predictor of primary care production than what schools typically report when they include in their production numbers all family medicine, internal medicine, pediatrics and sometimes even OB/Gyn graduates."
In fact, evidence shows fewer than half of all pediatric residency graduates and as few as 10 percent of all internal medicine residency graduates actually practice primary care, said Bentley.
"Family medicine makes up the largest proportion of the physician workforce in primary care and has the highest rate -- some 90 percent -- of residency graduates who actually practice primary care," she said.
The researchers found that since 2009, the overall percentage of U.S. medical school seniors choosing ACGME-accredited family medicine residency programs increased from 9 percent to 12.6 percent.
In particular, the authors noted "a relatively substantial increase" in the overall percentage between 2016 and 2017 -- from 10.6 percent to 12.6 percent -- but said it merely reflected an increase in osteopathic graduates entering the ACGME match. The five-year shift to a single accreditation system will be complete in 2020.
Among other findings, the study authors reported that
- from 2009 to 2017, the absolute number of U.S. graduates entering ACGME-accredited family medicine programs increased by 78.8 percent (from 1,814 to 3,243 graduates);
- since 2005, the absolute number of allopathic students increased by 37.5 percent (from 1,350 to 1,856 graduates); and
- since 2005, the percentage of allopathic students choosing family medicine increased only slightly from 8.7 percent to 9.8 percent.
Researchers included a variety of charts and tables depicting their findings, including two tables that list "bright spots" -- both allopathic and osteopathic schools that have made long-term (2011-2017) and short-term (2015-2017) contributions to the family medicine workforce.
Des Moines University College of Osteopathic Medicine in Iowa stands out in 2011-2017 data as having both the highest number of graduates entering family medicine residences (412) and the highest percentage of graduates entering those residency programs (27.4 percent). Notably, the nine medical schools with the next highest percentages of students choosing family medicine were also osteopathic institutions.
A similar trend is apparent on the three-year list of schools, with Western University of Health Sciences/College of Osteopathic Medicine of the Pacific in Pomona, Calif., leading the pack in both the number of graduates entering family medicine programs (181) and the percentage of its graduates entering these programs (28.1 percent). And again, the remainder of the top 10 schools with the highest family medicine percentages on this list were all osteopathic medical schools.
Interestingly, the researchers noted that newer osteopathic medical schools sent fewer graduates to family medicine programs than older schools and that private osteopathic schools have a better track record in producing students who choose family medicine than do public osteopathic medical schools.
On the other hand, the authors reported that newer allopathic medical schools are sending more graduates to family medicine residencies than their older counterparts.
The researchers also pointed to a disturbing trend among osteopathic school graduates: "Declining osteopathic student interest in FM is of significant concern and deserves the full attention of our leadership," they wrote.
Conclusions, Next Steps
Study researchers concluded that although the number of U.S. medical school graduates matching to family medicine residency programs has increased in the past decade, the increase has been modest, with just 12.6 percent of combined allopathic and osteopathic graduates entering an ACGME-accredited family medicine residency program.
"Significant changes are needed for the specialty to reach a national goal of 25 percent of U.S. graduates choosing family medicine by 2030," wrote the authors. "A change in course of this magnitude will require substantial changes to undergraduate medical education in the United States."
Based on the research findings, "Multiple factors influence student choice, and we need to work on these issues simultaneously," said Phillips. Fulfilling the country's primary health care needs will require
- more residency positions in family medicine;
- additional residency programs with more capacity;
- stronger student interest;
- curriculum changes to better focus on family medicine; and
- pipeline and recruiting efforts that get the right students into medical school, specifically those who are interested in family medicine and committed to service.
"We need to make sure that every student has a robust family medicine experience," Phillips continued. "Evidence shows that training tracks that focus on primary care, rural health, underserved care or public health can help foster that interest in the specialty.
"And we need to recruit more family physicians into faculty positions and leadership roles in medical schools, where they can shape the curriculum and a culture that values primary care and family medicine."
Lastly, holding medical schools accountable for the nation's primary care workforce needs would be a major step forward in attaining these goals, said Phillips.
Related AAFP News Coverage
Family Medicine Tops the List in Osteopathic Match
2019 AOA Match Day Marks End of Era