Less than 25 percent of new doctors go into primary care and less than 5 percent establish practices in rural areas, according to a recent study recently in Academic Medicine.
U.S. residency programs are not producing the right kinds of doctors in the right places to address the nation’s physician-workforce needs, researchers found.
“If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse,” said lead study author Candice Chen, MD, an assistant research professor of health policy at the George Washington University School of Public Health and Health Services in a statement. “The study’s findings raise questions about whether federally funded graduate medical education institutions are meeting the nation’s need for more primary care physicians.”
However, John Peter Smith Hospital in Fort Worth doesn’t have that problem. It ranked sixth nationally in the study for producing primary-care graduates, with more than 44 percent of its graduates in primary care.
“The mission of the family practice residency at JPS has always been about meeting the needs of the population. We believe in that,” said Dr. Josephine Fowler, vice president of academic affairs and chief academic officer at JPS Health Network.
Its family practice residency program, which opened in 1973, is the largest of nine residencies at JPS and trains more family medicine physicians annually than any other U.S. program. And those who complete their family practice residencies in Texas tend to stay.
“Even those who go off to do fellowships tend to return to Texas,” Fowler said.
Among the JPS graduating class of 2012, 74 percent planned to practice medicine in Texas, and 41 percent planned to practice in rural areas.
Fowler challenged the study’s suggestion that demanding greater accountability of GME programs is the solution to the shortage of primary care physicians. She said residency programs do not dictate which specialty a doctor chooses.
“The training institution has to promote a culture that supports primary care, which we do, but institutions do not dictate which specialty a physician will choose. It’s an individual decision,” she said.
The U.S. GME system relies on public funding, including nearly $10 billion from the Medicare program and another $3 billion from Medicaid. Many experts, however, say that the federal government does not hold residency programs accountable for producing physicians trained to serve in rural or underserved areas.
The researchers studied the careers of nearly 9,000 physicians who graduated from 759 medical residency sites from 2006 to 2008. They analyzed data to find out where these new physicians ended up practicing three to five years after graduation, and found that about one out of four worked as primary care physicians, a number that includes hospitalists.
In addition, the researchers found that about one out of three medical schools produced no rural physicians during the study period. And another one out of three graduated no doctors practicing in federally qualified health centers—often located in remote or impoverished urban areas.
The study underscores the disconnect between federal funding to pay for residency programs and the nation’s shortage of primary care doctors.
The study’s top 20 primary care producers trained 1,658 primary care doctors out of a total of 4,044, or 41 percent. These sites received just $292 million in GME funding. In contrast, the bottom 20 programs produced only 684 primary care graduates out of 10,937 or 6.3 percent. According to the study, those sites received $842 million in GME payments. The researchers pointed out that nearly two-thirds of $10 billion in annual Medicare GME funding goes to 200 hospitals—and those sites perform poorly when it comes to producing primary care doctors.
The GME programs at UT Southwestern and Baylor University Medical Center were ranked among the lowest producers of primary-care graduates at 10 percent and 8.8 percent, respectively.
UTSW is the largest GME program in Texas, training more than 1,500 clinical residents annually. It offers four family practice programs. UTSW officials point out that Texas also has shortages in numerous specialties.
According to the Texas Medical Association, Texas has physician shortages in 36 of the top 40 medical specialties, compared with the national average for each.
There were 16,830 Texas primary-care physicians in 2009. The state had 69 per 100,000 residents, compared with 81 per 100,000 nationally in 2009. Nearly half of Texas counties are classified as health professional shortage areas, and 29 counties have no primary-care physicians.
Baylor’s GME program has 220 residents or fellows, and has hired about 30 percent have been joined its health system over the past 15 years.
In response to the study, William Sutker, MD, Baylor director of medical education, said, “I agree that it is reasonable for the government to look at outcomes to guide how they spend funds for medical education.”
Steve Jacob is editor of D Healthcare Daily and author of the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us. He can be reached at firstname.lastname@example.org.