Guest Editorial

Fix the Biggest Leak in the Primary Care Pipeline

March 27, 2020 01:39 pm Clif Knight, M.D.

We are in the midst of a health crisis unprecedented in modern history. The COVID-19 pandemic only amplifies what we already know: There is great need for an expanded primary care workforce, maybe more now than at any other time in our history. We're seeing positive changes from communities and health systems, as evidenced by the resilience of existing programs and growth of new family medicine residencies, as well as an increasing number of students pursuing family medicine. Only one sector of the residency pipeline isn't delivering: U.S. allopathic medical schools.

[headshot of Clif Knight, M.D.]

Clif Knight, M.D.

That needs to change immediately.

Residency opportunities are growing. The AAFP is working to help communities know the value of family medicine and initiate new graduate medical educations programs while growing existing ones. With this growth, especially, every sector of the undergraduate medical education pipeline needs to recruit, expose, support, prepare and graduate students into family medicine residencies in strong numbers. As I said after reviewing last week's National Resident Matching Program Main Residency Match results, it is shameful and unacceptable that the sector of the undergraduate medical pipeline that is the largest, receives the most taxpayer dollars and includes some of the most elite medical training institutions in the country -- U.S. allopathic medical schools -- graduates the smallest rate of students into family medicine. It is also the only sector where this rate is declining.

Our patients and communities can be thankful for the osteopathic pipeline, which, despite being smaller (less than one-third the number of graduates of U.S. allopathic schools), has graduated an increasing number of students into primary care specialties, especially family medicine, and sustained that rate through the rapid growth of their schools and class sizes in recent years. For every 10 U.S. allopathic seniors that matched to family medicine last week, nine osteopathic seniors did -- an astonishing figure when you consider the significantly smaller total number of D.O. graduates.

The pathway for students who complete their undergraduate medical education internationally, the vast majority of whom are U.S. citizens studying in Caribbean-based medical schools, has remained steady, with almost 28% of new family medicine residents graduating from these schools. As we grow family medicine residency programs and positions, it is important that these opportunities continue to exist for students who take this path, and it's laudable that these students and institutions continue to support the primary care workforce so significantly.

At the same time, there should be opportunities and strong incentives within our country for students to pursue family medicine and primary care. Although U.S. allopathic schools are failing to adequately meet our primary care workforce needs, the problem cannot be laid entirely on the shoulders of the medical schools themselves. It is a system problem, one that requires solutions that impact the entire system. The AAFP, in collaboration with eight other family medicine and multi-sector partners, is working to change the factors and systems that prevent truly meaningful growth of family medicine and primary care. This work involves enhancements in the pipeline of potential students, the process of medical education, health care delivery and practice reform, as well as health care payment transformation. Our system must achieve greater income parity between primary care physicians and their subspecialty colleagues.

In the pipeline, we are engaging a new national partnership with hopes of building a greater presence for family medicine in science, technology, engineering and mathematics -- or STEM -- education through a national network that includes most U.S. high schools. We are also working to educate and empower health professions advisers and educators, who are significant influencers for students early in their path to a career in medicine.

We have a strong tradition of engagement and support of medical students and educators, and we're strengthening these efforts. We are also creating a new platform to leverage the individuals, institutions and communities that are achieving the best results to spread promising interventions. There are amazing bright spots and true family medicine champions at medical schools across the country whose work should be spread and scaled up. Transformative change often starts at the local level, and our AAFP chapters across the country will be vital to achieving success.

We're calling for reform of graduate medical education funding to incentivize the appropriate balance of primary care training. In addition, creation of a national physician workforce commission would help meet the United States' true health care needs by ensuring the right mix of physician specialties and diversity.

In the words of our incoming CEO/EVP, Shawn Martin, we're writing our own history here. No one is going to do it for us. Our patients, communities and country need us to change the trajectory, a fact that's even more obvious in the midst of the COVID-19 pandemic.

Learn more about this work to grow the family medicine pipeline and, if you believe what we believe, do everything you can in your community to create this change. Stay informed and support national efforts for growth. Consider becoming a preceptor, becoming involved in your local AAFP chapter or reaching out to your community. Please join me in this campaign. It's going to take every one of us.

Clif Knight, M.D., is the AAFP's senior vice president for education.