President's Message

It's Time to Hold Our Medical Education System Accountable for Producing the Right Workforce

April 09, 2013 03:20 pm Jeff Cain, M.D.

In my office at A.F. Williams Family Medicine Center in Denver, we have tremendous medical students and family medicine residents who are bright and passionate and who understand the value of family medicine and the patient-centered medical home.

[Jeffrey J. Cain, M.D., FAAFP]

Jeff Cain, M.D.

Nationally, we have more students than ever choosing family medicine as a career. Nearly 3,000 students matched into family medicine residencies last month, filling 96 percent of positions offered. The number of U.S. seniors (1,374) matching into family medicine was the highest in more than a decade.

It all sounds good, right?

Well, yes and no.

Although the overall number of students -- including U.S. seniors -- who choose family medicine is up, medical schools have been expanding their enrollments at an even faster pace, and new medical schools have opened. So, the reality is the percentage of U.S. seniors choosing family medicine actually has decreased.

To put it simply, the education system is failing to produce the workforce our nation needs. Increasing enrollment in our medical schools alone has not, and will not, translate into an increase in the percentage of U.S. seniors entering family medicine.

The Robert Graham Center for Policy Studies in Family Medicine and Primary Care projects( that the United States will need an additional 52,000 primary care physicians by 2025 -- a 25 percent increase in the current workforce -- to address the expected increases in demand due to population growth and aging and to insurance expansion following passage of the Patient Protection and Affordable Care Act.

Sadly, our nation isn't prepared to meet that demand. Our flawed medical education system has not offered students appropriate incentives to choose primary care, and we are not holding medical schools accountable for producing the number of primary care physicians our communities need.

A trio of special articles in the March issue of Family Medicine( shines a light on these problems and offers some interesting suggestions on how to fix them.

One of the articles(, written by Alan David, M.D., points out that 33 percent of students owe more than $200,000 and 15 percent owe more than $250,000 by the time they complete medical school. Meanwhile, the income gap between primary care physicians and our subspecialty colleagues has grown to more than $135,000 a year.

That gaps forces many students who entered medical school with an interest in family medicine to choose subspecialty medicine based on financial necessity.

Our government, which spends almost $13 billion a year on graduate medical education (GME), is in the midst of a financial crisis. Fiscal accountability is a popular topic, but our health care system is not getting what it needs from its 11-figure investment.

Now is the time to push for GME reform.

A few years ago, a grass-roots collaboration of leaders in family medicine residency training began work on recommendations to reform primary care training and financing. The recommendations of the GME Initiative are reviewed in a second special article( in the same issue of Family Medicine.

The initiative's recommendations are too numerous and complex to completely list here, but they are intriguing, and I'd like to share a few highlights, such as

  • amend federal regulations to support family medicine training in outpatient settings;
  • increase primary care GME positions; and
  • expand training in ambulatory, community and underserved sites.

The same article suggests reallocating existing GME funding based on workforce needs, requiring private payers to contribute to GME funding, and providing funding directly to accredited primary care programs. The authors also recommend increasing payments for primary care residents.

Moreover, the initiative calls for more accurate measuring of the real number of primary care physicians that medical schools are graduating because the majority of internal medicine and pediatric residents who initially enter primary care residencies ultimately go on to subspecialize. We need a better understanding of the proportion of graduating medical students that really go on to practice primary care.

Two years ago, the Council on Graduate Medical Education (COGME) issued a report to the HHS secretary and Congress that recommended increasing the percentage of primary care physicians from 32 percent to 40 percent of our total physician workforce to achieve optimal health care in the United States. For our country to reach that goal, COGME recommended( governmental reforms to both the medical education system and the way that we pay for primary care. Specifically, in addition to GME reforms, the council recommended that the gap between primary care physician income and that of subspecialists be reduced to attract more physicians to primary care.

Now, an IOM committee is developing recommendations( for policies to improve GME. According to the IOM, "specific attention will be given to increasing the capacity of the nation's clinical workforce that can deliver efficient and high-quality health care that will meet the needs of our diverse population."

Primary care is the foundation of an efficient and high-quality health care system. Investing in primary care has been proven to help us reach the triple aims of higher quality, lower costs and improved patient experience.

It is time for our country to hold our medical schools and GME system accountable if we are to produce the physician workforce that our country deserves.

Jeff Cain, M.D., is the president of the AAFP.