Promises of primary care are one thing. Actual delivery of primary care is another. Current workforce studies fail miserably for the purpose of national health access workforce. The reason is common sense. Graduates who are not in primary care are not delivering primary care. Graduates who are only 60% active (nurse practitioners) deliver less primary care than those 80 - 90% active (physicians). Most of all graduates with a low and a declining rate of primary care retention with each passing year are not reliable primary care workforce. Studies must consider all graduates to be considered for the role of health access. Most workforce studies only consider active full time graduates. These studies miss the most important determinants of actual primary care delivery.

Studies that fail to capture all graduates do not consider missing graduates (inactive, hospital careers), those part time, those who leave the country after graduation (over 20% of foreign origin international medical graduates), or the 65% - 90% of nurse practitioner, physician assistant, or internal medicine graduates that depart primary care during training, at graduation, or within a few years after graduation. Primary care trained graduates that are not in primary care do not deliver primary care.

· The number of years in a career, usually 27 years for age 38 – 65 (nurse practitioners, foreign origin international medical graduates) as compared to 35 years for age 30 – 65 contributions (US origin physicians, physician assistants)

· The percentage remaining in primary care for an entire career on average for all graduates in a class year – 10% for internal medicine, 25% PA, 33% NP, 50% PD, 90% for family medicine

· The percentage that remain active and in the United States delivering primary care, not part time or inactive graduates - 60% for nurse practitioners and foreign origin international medical graduates compared to 70% for physician assistants and 85% for physicians

Another problem with workforce is that measures of past contributions fail to anticipate future workforce. Numerous recent studies indicate deficits of tens of thousands of primary care physicians, but the question remains, “Which primary care physician?” The same situation involves proposals for more nurse practitioner or physician assistant primary care – which type, who remains, how active, how long.

This is a huge problem in the United States as primary care graduates melt away from primary care with each passing year. Estimates of future primary care contributions are needed such that future primary care delivery can be estimated. This must be specific to each source of primary care based on entire populations and specific to the class year of graduation.

One simple method is to multiply years in a career times primary care retention percentage times the percentage remaining active times the volume of primary care percentage compared to family physicians (35 years times 90% in primary care times 86% active times 100% for family physicians results in 27 Standard Primary Care Years).

	NP	PA	FM	IM	PD
% Primary Care for a Career	33.0%	25.0%	90.0%	10.0%	55.0%
Years in Career	27	35	35	35	35
% Remaining Active in a Career	60.0%	70.0%	86.0%	86.0%	84.0%
% Volume Relative to FM	60.0%	70.0%	100.0%	86.0%	95.0%
SPC Years Per Graduate	3.2	4.3	27.1	2.6	15.4
Rural SPC Years Per Grad	0.64	0.86	5.42	0.26	1.23
Underserved SPC Years Per Grad	0.48	0.64	4.06	0.26	1.54
Rural % of Primary Care Grads	20%	20%	20%	10%	8%
Underserved % of Primary Care	15%	15%	15%	10%	10%

The Standard Primary Care Year can also be used to estimate rural or underserved workforce in rural Standard Primary Care Years or underserved SPC years. This is possible as each source of primary care has a definite rural or underserved percentage that remains steady over time.

Some calculations are needed for the NP and PA forms that involve multiple specialties. The FP mode is the portion making the superior rural and underserved contributions. With NP and PA grads leaving the family practice mode during training and at graduation and each year after graduation, they are departing primary care, rural, and underserved contributions. Instead of a simple primary care loss, there is a combined primary care and rural loss.

A second method can be used to calculate the Standard Primary Care year over an entire lifetime in the career of a physician or non-physician. This can include the changes in the percentage that are active and the percentage remaining in primary care that also change over a lifetime. A graphic captures this best with the years in a career from age 30 to 65 on the horizontal axis and the vertical access representing the year to year primary care contributions using the product of primary care retention percentage, percentage active, and percentage volume.

The area under the curve represents the Standard Primary Care Year contributions specific to the specialty and to the class year of graduates.

This method tends to capture the greater contributions in the first years with lesser contributions in later years.

This gives a visual depiction of the different primary care contributions of the different sources of primary care.

The major determinant of primary care contribution is primary care retention. With 90% retention, family medicine contributions are greatest. Internal medicine graduates with 10% primary care retention contribute the least. Nurse practitioner contributions are lower due to 8 years delay in entry (complete nursing school, nurse practitioner training, 8 years experience as a nurse practitioner), the relatively constant 60% active seen in nurse derived careers, lowest volume at 60%, and only 33% remaining in primary care. Physician assistants come out with relatively the same Standard Primary Care year contribution, but the contribution begins at an earlier age, involves slightly more volume and activity, but loses ground with lower primary care retention at 25%. Foreign origin international medical graduates lose the most workforce with only 10% remaining in primary care, only 27 years remaining after delayed entry, only 60% remaining active in the United States, and 80% of the volume of a family physician. This is a significant loss as 45% of all internal medicine residency graduates are foreign origin IMG.

It is readily seen that the contributions of foreign origin international medical graduates is minimal. They have half of the workforce of US origin graduates due to 23% of primary care lost in delayed entry and 30% lost after graduation. Studies that only consider only the FIMG IM graduates active and in the United States miss the significant losses before and after. One solution for increasing workforce for little or no additional cost is to replace foreign origin international medical graduates with US origin graduates. This basically doubles the workforce contribution. Also without family medicine choice, graduates of US as well as international schools are not likely to deliver most needed health access. Medical School Type and Career Choice and Most Needed Health Access

The 3000 family medicine residency graduates each year at 25 SPC years per graduate will deliver 75,000 SPC years of primary care. The 8000 internal medicine graduates at 2 SPC years per graduate will contribute 16,000 SPC years. Both of the above figures are adjusted for the FIMG graduate component. The 7000 PA graduates will deliver about 25,000 SPC years. The 7000 NP graduates will deliver about 25,000 SPC years. The 3000 family medicine residency graduates will deliver more primary care than the 22,000 flexible primary care graduates – the combined total for IM, NP, and PA.

When it comes to primary care, remaining in primary care is the most important factor. Health policy now drives flexible forms away from primary care in this destructive policy period.

SPC Years per Grad	Reference Points for 2009 Graduates
Perfect Score of 35 SPC Years	A perfect score of 35 SPC years is an entire 35 year career from age 30 to age 65 with 100% primary care retention for the entire career, 100% active for the entire career, and the volume of a family physician with a 100% volume rating (top volume). A typical US origin family physician contributes 29 SPC years with a range from 25 for those in most urban areas and 30 – 31 for rural family physicians that have greater primary care retention and greater activity levels. They also tend to have greater volume but the volume for all family physicians is held constant at the 100% Standard compared to 95% for pediatrics, 86% for internal medicine, 70% for physician assistants, and a 60% volume rating for nurse practitioners
28 – 30	US origin family physicians (31 to 32 for some in rural areas with increased years, primary care retention, activity, and volume)
25	All 3000 family medicine residency graduates including adjustments for foreign origin IMG for a total of 75,000 SPC years as the family medicine primary care contribution for the class of 2009.
14 Range of 8 – 20	Pediatric residency graduates - higher levels with increased primary care retention found in more normal origin graduates, programs, and medical schools and not the graduates with the most exclusive origins, the most exclusive schools, and the most exclusive residency programs. If the graduates of a residency program or those tracked to a medical school remain in primary care at 25% levels, this is 6.8 SPC years At 15% primary care retentino, the contribution of pediatric graduates is 4 SPC years.
9 – 14	Medical schools (allopathic or osteopathic) with health access focus in training and more family medicine graduates Ross University is in the 9 Standard Primary Care Year per graduate range and with 469 graduates and 115 family medicine graduates, Ross is the number 1 source of primary care in the United States.
6 – 9	Average osteopathic graduates and graduates of Caribbean schools with predominantly US origins make significant primary care contributions as they are more likely to find their way to family medicine or primary care careers and stay in primary care. The US origin graduates also have twice the workforce contribution of foreign origin international medical graduates
4 – 7	Allopathic public school graduates
3 – 5	Allopathic public schools with fewer family medicine graduates
	Pecking order considerations in primary care · Some choice of primary care is deliberate and other primary care is dictated by prestige and examination scores. Psychiatry and women’s health careers also are commonly careers for graduates with more normal board scores rather than graduates with most exclusive board scores. · Graduates of medical schools with lower board scores and graduates from less prestigious medical schools are more likely to be found in family medicine, women’s health, and primary care careers. · Standardized scores can also be a factor in the internal medicine and pediatric graduates that specialize and those that remain in primary care. · Expansions of exclusive graduate medical education positions would be expected to deplete the graduates of all of the lower board scoring specialties which are most needed workforce in the United States. With more opportunities to select away from family medicine, fill rates of programs would be even lower. No longer would less exclusive graduates or graduates of less exclusive schools be forced into the most needed health access careers. The opposite effect was seen in the 1990s when assumptions of widespread managed care implementation frightened medical students away from radiology, anesthesiology, and radiology GME positions resulting in the loss of thousands of GME positions. In this climate family medicine and primary care choices reached all time peak levels. · Studies indicate that internal medicine primary care is often a result of graduates that intended specialty careers that did not materialize.^{7, 8} Expansions of specialty and hospital opportunities destroy primary care choice.
3 – 4	Nurse practitioner or physician assistant graduates have descended to half of the primary care retention of graduates of 10 – 15 years ago. Primary care deliver may actually be lower (2 - 3 SPC per grad range) because flexible primary care forms (internal medicine, physician assistant, and nurse practitioner) decline each year after graduation. This has forced Standard Primary Care estimates to be revised down in the past few years after initial class year estimates. There is a range of primary care outcomes based on different programs and different workforce environments. PA and NP programs that are decentralized with a focus on health access and graduates remaining in the family practice mode optimize primary care and distribution just like medical schools focused on health access. Sadly health access schools and programs are being displaced by specialty training focus. Family nurse practitioner programs in states with top health access policy can reach the 6 – 8 range for graduates and physician assistant primary care can be even higher. In states with lowest primary care, the levels of primary care are 1 – 2 per nurse practitioner or physician assistant graduate. Family physicians are found in lowest percentage in the same states that have top concentrations of specialists, physicians, and health resources. It is important to understand that the family practice broad generalist component has declined the most in non-physicians. The family practice mode has 25% or greater rural location rates compared to 15% or less for other specialties and 15% or greater underserved location rates compared to 10% or less for other specialties. When NPs and PAs steadily depart the family practice mode during training, at graduation, and each year after graduation, they depart primary care and the most needed practice locations. New physician assistants begin in family practice at only 20% and primary care in 28%. AAPA studies demonstrate that the family practice PA has 30% rural location compared to the PA average of 15% with less than 15% for all other types. The family practice PA is 6 – 7 times more likely to be found in a Community Health Center and 30 times more likely than other types of PAs to be found in a federally qualified rural health clinic. The major difference in physician and non-physician family practice forms is that physicians remain in family practice and in primary care at over 90% levels while non-physician family practice forms steadily depart most needed contributions.
1.5 – 2.5	Allopathic Private US Schools and all US medical schools that admit the most with highest MCAT scores also admit medical students with the lowest probability of family medicine choice and admit medical students with the lowest probability of remaining in primary care internal medicine or pediatrics. Also these SPC year estimates depend upon internal medicine primary care which is expected to continue to decline at graduation and each year after graduation
2.5	US origin internal medicine residency graduates have 10% primary care retention, 85% remaining active, 35 years in a career, and 86% of the volume of a family physician for 2.5 SPC years per graduate.
1.3	Foreign origin international medical graduate internal medicine graduates also are subject to the same 10% primary care retention dictated by policy but have only 60% remaining active in the US (over 20% depart the US), have 27 years for a US health career (8 year delay in entry), and 80% of the volume of a family physician. Claims of primary care contributions for the FIMG IM graduates that are 45% of internal medicine residency graduates are no longer true with so few remaining in primary care and fewer choosing obligations that require primary care and underserved obligations. Also international graduates have higher scores than US medical school graduates in internal medicine residency examinations. These examinations also shape access to specialty fellowships. The FIMG IM graduates are also more likely to face actions by licensure boards. The requirements to adjust to a new country, a new system, a new language, and a new culture represent challenges for physicians, the US system, and US patients. Standardized tests appear to the be easiest adjustment for physicians to make.