The nation’s medical education system — and the graduate medical education funding that supports it — are failing to produce the primary care physician workforce needed by Americans, particularly those who live in rural areas, according to research in today’s Academic Medicine.
The research, “Towards Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions” by researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care and the George Washington University School of Public Health and Health Services, found that some medical schools graduated no primary care physicians. The percentage of graduates going into primary care overall was less than 25 percent. Fewer than 5 percent practiced in rural areas.
Researchers analyzed data on 8,977 physicians who graduated between 2006 and 2008 to identify their ultimate specialty five years after they completed residency training. Only 25.2 percent of those physicians were practicing primary care medicine, and only 4.8 percent practice in rural, underserved areas.
“Primary care physician production of 25.2 percent and rural physician production of 4.8 percent will not sustain the current workforce, solve problems of maldistribution or address acknowledged shortages,” wrote lead author Candice Chen, MD, MPH, assistant research professor of health policy at SPHHS, and her colleagues. Their data showed:
- Of 759 academic health center institutions, 158 produced no primary care graduates and 198 institutions produced no rural physicians.
- 479 institutions — more than half of those institutions — produced no National Health Service Corps graduates, the federal program designed to improve access to care in underserved rural and urban areas.
- 283 institutions produced no physicians practicing in Federally Qualified Health Center or Rural Health Clinics, which are designed to provide health care to underserved, low-income urban and rural patients.
Moreover, the data showed graduate medical education funding provides more support to subspecialty programs than primary care programs. Teaching hospitals that produced the most primary care physicians received $550 million less than institutions that produced new primary care graduates. The top 20 primary care producers graduated 1,658 primary care physicians — 41 percent of their total 4,044 graduates. They received of $292 million in total Medicare GME payments. The bottom 20 primary care producers graduated 684 primary care physicians — 6.4 percent of their total 10,937 graduates. They received $842 million in Medicare GME funding.
“These results highlight the challenges we face in producing the workforce we need in the current graduate medical education system,” said co-author Andrew Bazemore, MD, MPH, director of the Robert Graham Center. “National calls for more primary care physicians, general surgeons, psychiatrists and providers in rural and urban underserved areas are thwarted by federal funding that continues to support training programs without requiring measurement of, much less accountability for, what they produce. Not surprisingly, this results in a physician workforce directed more by potential earnings and hospital service lines than social needs.”
Taxpayers invest in the physician workforce through GME funding provided through Medicare, which provides nearly $10 billion, and Medicaid, which provides $3 billion. The money compensates teaching health centers for the extra costs associated with teaching future physicians. In an era of budget restraint, Congress has questioned whether GME is meeting the nation’s current and future physician workforce needs.
“These measures of social accountability are neither perfect nor comprehensive, but they do begin to inform decades of calls to link GME funding to the products of that funding,” said Bazemore. “A public that invests in graduate medical education, might expect a return on that investment to at least include physicians working in the areas and specialties where there is greatest need. This is particularly important amid national discussions of expanding graduate medical education, and debate over how much funding to offer, what the taxpayer should demand in return, and how we measure those demands.”
Accompanying the article and further revealing the results of their analysis, the geospatial team at the Robert Graham Center also created the GME Outcomes Mapper. Visitors to the site can click on a map of all residency training institutions in the country to see how many residents each trains and the proportion of those residents entering underserved areas or primary care specialties.
The research was support by a grant from the Josiah Macy Foundation.
(Source: AAFP. The information and opinions contained in research from the Graham Center do not necessarily reflect the views or policy of the AAFP.)