Robert C. Bowman, M.D. Major Graphics on Primary Care Retention Illustrating Primary Care Training That Is No Longer Primary Care
The United States is losing primary care steadily over time. While workforce leaders scheme for more specialist physician graduates and more graduate medical education positions that are converted steadily to vehicles to specialty care, the fact is that the United States has made more than the necessary changes to meet specialty workforce needs. What remains is a decade or two of graduates to resolve whatever limited shortage of specialists remains. The situation for primary care is a different matter. While US MD and DO schools have increased specialty workforce production by 50% each, this has come at a cost of primary care.
New physicians enter primary care at 20 - 30% levels and more schools move below 20%. These measures are true primary care measures, not just measures of new primary care graduates such as internal medicine that fail primary care delivery 90% of the time. Losses of internal medicine are 90%, losses of pediatric graduates are approaching 50%, and medicine pediatrics losses are so rapid to subspecialization and other careers that the departures cannot be tracked by typical methods.
Only family physicians remain 85% or more in primary care, remain active at 85%, remain for 35 year careers, and deliver the top volume of any primary care source. Family physicians remain over 95% in the broad generalist family practice mode which is critical for rural and for underserved contributions, Nurse practitioners and physician assistants in practice have declined to 20 - 25% in family practice mode and the rural, primary care, and underserved contributions depart when NP and PA depart family practice.
This decline and losses of NPs and PAs and declines in generalist internal medicine choice are the result of failed health policy with all sources of primary care prevented from actually choosing primary care or converted away from primary care months or years after training.
The NRMP Match is not intended to be used for calculations of primary care workforce although it has often been used in predictions. Primary care workforce levels are poorly predicted by the NRMP Match because internal medicine, pediatric, and medicine pediatric graduates fail to remain in primary care. Only those choosing family medicine actually remain reliably in primary care. All other primary care careers represent maximum values at the match or soon after with a deterioration with time distance from medical school graduation. Internal medicine and medicine pediatrics losses are the most significant. Office-based levels, a reasonable reflection of generalist primary care, also tend to deteriorate over time in all primary care specialties as physicians choose teaching, research, administration, inactivity, or hospital forms of care. Primary care retention is an important concept that has rarely been considered.
Primary Care Career Changes 1987 - 1999 US MD Grads as of 2005 Masterfile Careers
|All Listed in Masterfile||14||11||22||20||38||67||132||189||248||249||290||292||255|
% in Office MPD
US Seniors in NRMP
% Office / Match
|Steady losses over time with loss to subspecialties|
|All Listed in Masterfile||3628||3679||3498||3373||3231||3398||3382||3566||3836||3875||3953||4016||3835||47270|
|% in Office IM||44%||42%||41%||41%||47%||49%||53%||49%||49%||47%||44%||40%||37%||45%|
|IM, Prelim, Primary||4450||4703||4603||4416||4295||4258||4030||4086||4072||3984||4052||4249||4266||55464|
|% in Office IM||36%||33%||31%||31%||36%||39%||45%||42%||46%||46%||43%||38%||33%||38%|
|IM Plus Primary Only||3419||3525||3291||3047||2897||2913||2705||2848||3009||3083||3206||3306||3209||40458|
|% Office / Match||47%||44%||43%||46%||53%||58%||67%||61%||63%||59%||55%||49%||44%||52%|
|declines||recovery with policy||steady declines with more to come|
|All Listed in Masterfile||1380||1324||1288||1331||1419||1431||1584||1690||1864||1992||2069||2141||2073||21586|
|% in Office Peds||68%||66%||65%||67%||68%||66%||68%||63%||63%||65%||62%||58%||58%||64%|
US Seniors in NRMP
% Office / Match
|fairly stable over time after graduation|
|All Listed in Masterfile||1847||1633||1633||1662||1667||1778||2010||2285||2484||2622||2636||2459||2201||26917|
|% in Office FP||88%||89%||89%||88%||88%||85%||87%||86%||87%||90%||91%||89%||88%||88%|
|US Seniors in NRMP||1729||1493||1468||1418||1374||1398||1636||1850||2081||2276||2340||2179||2024||23266|
|% Office / Match||94%||97%||100%||104%||106%||109%||107%||106%||104%||104%||102%||101%||96%||102%|
|Additions after the Match|
For an interpretation of the changes over time by major careers and specialties, see Changes in Specialty Choice 1987 - 1999
Many studies have focused on retention in rural or in underserved areas, but few studies compare retention within primary care. In order to distribute to rural and underserved areas and to provided any consistent primary care, providers must be retained in their original choices, must remain active, and must be retained in primary care. Primary care ends for an increasing number of primary care types within a few short years with sustained levels of active providers below 40%. The standard for physician retention is over 95% remaining active and in their primary care specialty with 90% in office based care and also as much as possible away from major medical centers (over 57% outside of MMCs) where actual primary care capacity is limited by teaching, administration, hospital, and other duties. Away from major medical centers also means distribution to underserved and rural populations, preferably distribution above the rural workforce average of 11% or the rural population average of 20% and also double the 7% underserved physician average. Only one group of physicians or providers satisfies all of these criteria and is likely to continue doing so.
Internal medicine (IM) residency graduates peaked with the 1978 graduating class. Since that time declines in numbers and percentages have been progressive with the exception of managed care. After falling as low as 44%, generalist internal medicine increased back above 50% for the 1993 medical school class. Now less than 20% of interns plan careers in generalist IM 1and further declines are likely with each passing year. Pediatric office based primary care remains relatively steady at 66%. Over 69% of both PD and IM physicians remain in major medical centers (MMCs) for practice and less than 10% are found in rural areas. IM and PD rural distributions do not exceed the rural born component. Rural born US MD Grads have declined below 10%.
Medicine pediatrics attracted 3100 in the matches of 1987 – 1999. Less than half remain in generalist primary care. For the earlier 1987 – 1990 grads, less than 20% can be found with medicine pediatrics as their primary specialty. Medicine pediatrics has twice the rural distribution of IM or PD at 16%, but this shrinks to less than 10% when the denominator includes all who matched into medicine pediatrics.
Nurse practitioner data is often inadequate for national comparisons. Many studies involve surveys or selected subgroups. What is consistent for NPs is loss of half of graduates to primary care. For 39000 graduates surveyed, some 21000 FTE in primary care were produced and this is a broader definition of primary care than most. Numerous part time NPs and NPs with only part of their activities as primary care had to be summed up to obtain this total. The total does not allow for inactive NPs, other part time NPs, lower productivity, or continuing losses in primary care over time. The actual full time primary care NPs are lower. This and other data at AANP.org. Health policy, graduate degree focus, subspecialization, and MMC influences appear to have replicated physicians and their tendencies to avoid primary care and distribution.
Physician assistants (PAs) have achieved Money Magazine ranking as the 5th best occupation in America. PAs are predicted to be in the top 10 in job growth in census projections to 2014. PA popularity may be a major reason for declines in primary care choices below 40%. Hospitals, surgeons, emergency rooms, and a host of subspecialists have discovered their utility. PAs are still undervalued by current employers and have discovered that it pays to switch employers. Higher income gains consistently above 10% are associated with changing away from primary care. Another interpretation is that lower paid (rural or underserved) PC practices are not able to pay enough to retain PAs. About 10% of PAs are inactive and 40% remain in PC. These losses may also be tracked by changes in supervising physicians. PAs working for FPGP physicians have declined from 40% to 28.5% in the past ten years and rural choices have declined from 25% to 17%. (http://www.aapa.org/research/index.html) These are significant steady declines in the distributions of all PAs that are likely to continue with current policies. The earliest PA and NP programs admitted a broad range of students, trained broadly and outside of MMCs (usually with FPs), and distributed. The efficiencies of larger classes and student recruitment have forced changes.
Head to Head: Physician Assistants in 2000 Compared to Family Physicians in State and National Location - Includes table of primary care types in national studies. Since this time period, physician assistant primary care levels have been cut in half with only 20% beginning in the family practice mode that is the only form of physician assistants to have the isolated rural, small rural, community health center, and other rural and underserved contributions above the PA averages.
Family medicine contributions remain consistent with 98% remaining in FP and 90% remaining in PC. FPs have 20% rural location nationwide or twice the 9% of recent US MD Grads of 1987 - 1999 and over 14% underserved distribution or twice the national physician average of 7%.
The FP difference involves the lack of connection to concentrations of physicians. FPs remain outside of physician concentrations with 53% of graduates while all other physicians have 70% or greater MMC location. PAs and NPs are increasingly connected to major medical centers. Other primary care types remain 70% in MMCs.
FPs are only 10% of the physicians in urban areas, their lowest concentration. This allows FPs to maintain a steady equilibrium of 24% in rural areas (2 times the 11% physician average) and 12.8% to underserved areas outside of MMCs (also nearly 2 times the 7% average). The rural levels double for rural origin FPs and the underserved levels double for lower income origin FPs.
The FP distributions are no accident. FPs are more likely to have origins outside of MMCs, they are excluded from elite schools that distribute poorly, they have the broadest scope that allows full expression of birth origins influences, they face less competition outside of MMCs than inside and serve populations that are familiar with FPs, they have greater ability to improve finances by doing procedures or obstetrics in locations away from MMCs, and costs are lower outside of the most urban locations.
FPs increase in percentage with declining levels of income, education, population density, health facilities, and health providers. FPs increase from 10% of physicians in urban areas to 30% in rural areas to 67% in lower income isolated rural areas. FPs are 50% of the physicians in Community Health Centers and 61% of the physicians in rural CHCs. They are outnumbered only by registered nurses.2 The RN plus FP model is the nation’s choice for efficient, effective primary health care.
Top levels of distribution, the one time PC choice that acts as a natural resistance to poor health policy, greater distance from MMC influences, origins outside of MMCs, and declines in every other form of PC with current health policy make family medicine a best choice.
Match levels remain an excellent predictor of primary care contributions of FPs. FP losses of 10 – 12% to teaching, administration, and military careers are balanced by the same 10 - 12% late additions to FP in the first years after medical school graduation for osteopathic, Caribbean, and allopathic transfers. Many persisted in their desire to become family physicians even when rejected by allopathic public schools, a more common situation. Others had little exposure to family medicine in life and during medical school and came late.
One thing is certain. Calculations of all other forms of primary care require major adjustments for loss of capacity in numbers and in duties consistently over time.
Match levels or even graduation levels of other PC forms are inaccurate measures of workforce.
1. Garibaldi RA, Popkave C, Bylsma W. Career plans for trainees in internal medicine residency programs. Academic Medicine. May 2005;80(5):507-512.
2. Rosenblatt RA, Andrilla CH, Curtin T, Hart LG. Shortages of medical personnel at community health centers: implications for planned expansion. Jama. Mar 1 2006;295(9):1042-1049.
The Standard Primary Care Year
The One Per Cent Solutions that Resolve Distribution Problems
Retention Within FP
Distributional Medical Schools
Changes in Specialty Choice 1987 - 1999