The Comparative Anatomy of Primary Care Contributions for the 2009 Graduates By Type of Training

Robert C. Bowman, M.D.

Using data posted on medical school web sites regarding the 2009 Match results, the following future estimates of primary care can be made.

SPC Years per Grad	Future Primary Care Over the Careers of 2009 Graduates from 2009 – 2044
16	Duluth Medical School graduates from 1971 creation to the 2008 class year with 42 – 52% family medicine choice in 55 – 58 graduates a year selected specifically for rural family practice and with 30 graduates a year trained for 9 months with rural family physicians in the 3^rd and most important clinical year.
12.6	Duluth graduates in 2009 with 36% family medicine choice and still a true 60% in primary care, but the decline at Duluth in 2009 gives evidence that optimal selection and training cannot compensate for primary care policy declines destroying and diverting primary care in the United States
9.50	U of Illinois Rockford – This is the specific contribution of the Rockford segment of the University of Illinois dedicated to health access. The 9.5 SPC years is a decline from the previous 13 – 14 SPC years in the past decade when the nation supported primary care at much higher levels.
9.25	University of North Texas Health Sciences – this Texas osteopathic school maintains a reasonable primary care contribution with 28% family medicine graduates in 2009, but the level of primary care has declined from the 35 – 40% family medicine choice range of a decade ago with over 12 SPC years per graduate.
9.11	Ross University in the Caribbean leads all schools in family medicine graduates with 115 entering family medicine residencies. With by far the greatest number of total medical school graduates at 469 and the top primary care production per graduate set in place by 115 family medicine graduates, Ross is the single greatest primary care contributor to the US workforce. Ross contributes more primary care than all of the allopathic medical schools in New York with 1700 graduates and all of the 1100 graduates of allopathic schools in Illinois. Ross University is outside of the United States yet admits the medical students who are US citizens that have not been selected by US schools. Ross has continued to generate a fair amount of attention for a variety of reasons, but without the Ross family medicine graduates more family medicine residency programs would have had to close. Major family medicine programs in states such as Texas depend upon two main sources of medical students – U of North Texas/Texas College of Osteopathic Medicine and Ross University. Caribbean schools in general do tend to admit students with more exclusive origins consistent with more exclusive children having multiple chances for admission (early, regular, late, allopathic private, allopathic public, osteopathic, Caribbean, International). Of course the pecking order regarding US residency programs tends to shift physicians with “less prestigious training” in US or international schools to careers lower on the board score scale (away from plastics and dermatology and toward family medicine, women’s health, and primary care residency choices). The theme of most needed health access resulting from origins and training outside and the theme of most needed health access as the result of exclusion is supported.
7.49	Kirksville College of Osteopathic Medicine is the original osteopathic school. Kirksville maintains reasonable rural workforce above 20% and 15% of graduates in underserved locations. Both contributions are steady over the class years and are twice the levels of US physician workforce in rural (9 – 10%) and in underserved (7 – 8%) areas.
6.73	U of Arkansas
6.71	Lake Erie College of Osteopathic Medicine LECOM (out of 141 2009 grads reported so far)
6.3 – 6.6	U of Missouri, Wright State
6.3	University of Nebraska Medical Center – Declines in family medicine choice have been substantial for graduates with family medicine choice more than cut in half in the past decade. The internal medicine and pediatric primary care contributions continue to decline with lower primary care retention. Family medicine choice is 3% for those with origins in Omaha and Lincoln, 10% for large rural cities, and 25 – 30% for the rest of the state. Primary care contributions are estimated at 2.4 SPC per grad for Lincoln area origins, 5 for Omaha area origins, 6 for large rural origins, and 11 and greater for origins in small or isolated towns
5.6 – 6	U of Iowa, U of New Mexico, U of Nevada, Texas Tech, U of Colorado
5 - 5.3	Florida State, U of Florida, U of Alabama, U of Minnesota Main Campus (not including Duluth), Creighton (a leading allopathic private school in health access)
4.3 – 4.7	U of South Florida, U of Oklahoma, Ohio State, UC Davis, U of Louisville
4	Mercer has had the most dramatic descent in primary care, rural, and underserved contributions with a move from a top rated family medicine level over 32% to less than 8%. This is a decline from a health access school rating with 14 SPC years to the current contribution of 4 SPC years per graduate. Because of the dramatic decline in family practice the decline is even greater for rural (30% for FM to less than 12% for Mercer grads for other specialties) and for underserved (over 24% for FM to less than 15% for Mercer grads for other specialties) workforce.
3.7 - 3.9	Medical College of Wisconsin, Dartmouth, Brown, SUNY Buffalo, VCU Virginia
2.8 – 3.3	U of Rochester, U of Miami, UCLA, Tufts, U of South Carolina, U of Michigan, Yeshiva Einstein, New York Medical
2.4 – 2.7	Temple, Chicago Pritzker
2.1 – 2.2	Vanderbilt, U of Pennsylvania
1.5 - 1.8	Columbia (1.3 without the 2 choosing family medicine), Johns Hopkins, Cornell , Yale

The estimates of future primary care should be considered just that – estimates. Actual primary care delivery could be better or worse. If internal medicine and pediatric residency graduates continue to depart primary care choices, matters could be even worse for primary care. Some schools do have internal medicine or pediatric trained graduates that have greater primary care retention. Because the family medicine contributions remain relatively stable, there is greater reliability in medical schools with more family medicine graduates. Also about 5 – 10% of family medicine graduates enter from a residency program rather than directly from medical school.

Generally the rural and the underserved location rates of schools near the bottom of the table are half of the national averages. The lowest primary care contributions are coupled with the lowest percentages found in rural and in underserved locations. This is why a graduate of Duluth at the top contributes 64 times more primary care compared to graduates of the 20 schools at the bottom of the table or the top 20 MCAT schools. Many medical schools attempt to become “Harvard.” None move toward Duluth and 1970s created medical schools such as Mercer and osteopathic schools make lower primary care contributions now compared to a few years ago. Osteopathic schools with 60% family medicine had optimal health access. The rate declined to 35 – 40% by the 1990s and was just over 20% for the 2004 graduates. Current levels are likely to be around 15%. A doubling of osteopathic graduates from 2004 – 2017 is likely to result in no increased primary care delivery due to lower percentages in family medicine and primary care.

More normal in admission, in training, and in career choice combine for top health access contributions in the top health access schools. Exclusive in selection, scores, training, and career choice contributes to lowest health access contributions for those at the bottom of the table.

Reference Table from 1 to 35 Standard Primary Care Years

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 more 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
9 – 14	Medical schools (allopathic or osteopathic) with health access focus in training and more family medicine graduates
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
	·
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.

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.^{1, 2} Expansions of specialty and hospital can result in decreases in primary care production without proper coordination and supervision.

Medical School Type and Career Choice and Most Needed Health Access

1. Sox H. Career Changes in Medicine: Part II. Ann Intern Med. Nov 21 2007;145(10):782-783.

2. Sox HC. Leaving (internal) medicine. Ann Intern Med. Jan 3 2006;144(1):57-58.