Primary care shortfall could be worse than predicted

Less than a quarter of recently trained physicians are choosing primary care, and few are heading to underserved rural areas.

By — Posted July 17, 2013

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The U.S. appears to be falling behind in its effort to avert an impending primary care physician shortage, according to a recent study published in Academic Medicine that tracked the specialty choices of residents and fellows as they entered practice (link).

About a third of physicians who deliver patient care are family doctors, internists or pediatricians, according to the American Medical Association’s 2013 Physician Characteristics and Distribution in the U.S. Yet, the Academic Medicine study found that of the new doctors being trained by U.S. physician training programs, only 24% go on to practice primary care.

The Assn. of American Medical Colleges predicts that by 2025 there will be a shortfall of 65,800 primary care doctors to serve the country’s health care needs (link).

For the study in Academic Medicine, researchers mined the AMA Masterfile, the National Provider Identifier database, Medicare claims data and information from the National Health Service Corps and the Accreditation Council for Graduate Medical Education to follow nearly 9,000 doctors who did their training at 759 teaching hospitals between 2006 and 2008.

They then examined what kind of care they delivered three to five years after training. The study said the 24% figure probably overestimates the share of doctors entering primary care because the data sources did not distinguish between internists practicing office-based primary care and those working as hospitalists. The AAMC says 17% of internists self-identify as hospitalists. Meanwhile, just 5% of the tracked residents went on to practice in rural shortage areas, said the study, posted online June 7 (link).

“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 Candice Chen, MD, MPH, the study’s lead author. A pediatrician, she also is assistant research professor of health policy at the George Washington University School of Public Health and Health Services in Washington.

Wide gaps in residency programs

Behind the low share of trainees entering primary care lies great variation among residency programs, the study found. For example, 158 of the 759 training sites studied produced zero primary care physicians, while 184 saw 80% or more of their residents go on to practice in primary care.

“We talk about the primary care shortage a lot in the aggregate,” Dr. Chen said. “The reality is, it’s the decisions that each of these programs make on their own that makes up the aggregate. It’s worth looking at what each of these programs does on its own that affects the big picture on this.”

A teaching hospital medical culture that prizes primary care practice can persuade more internal medicine residents to enter primary care instead of subspecializing, Dr. Chen said. Further research should be done to determine the factors associated with the training sites that produce higher shares of primary care doctors, she added.

Nearly $13 billion in Medicare and Medicaid dollars go to graduate medical education annually. President Obama’s fiscal 2014 budget proposes to reduce Medicare’s contribution to GME by about 10% for a total cut of $11 billion during the next decade. The AMA opposes the cuts and has argued that the restrictions on Medicare GME funding that took effect in 1997 ought to be reversed.

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