What Could Have Been: Maximal Primary Care Training Capacity

 Robert C. Bowman, M.D.

The United States has created a number of different types of primary care practitioners. Federal and state governments have invested billions of dollars for programs, faculty, faculty development, trainees, and other costs. Unfortunately the nation is apparently willing to sit and watch as much of this investment is wasted. Careers outside of health care and primary care have claimed tens of thousands of primary care graduates with more to come.

The primary care graduates of 1960 delivered 71% levels of primary care over a 30 year period. Current forms of primary care will deliver less than 50%. The only newer model that exceeds this 71% is family medicine with 88% levels.

If the primary care designs insured that 100% remained in their primary care choice and 100% remained active and 90% remained in office based care the nation could depend upon future supply and direct primary care to maximize health care delivery. Without a stable primary care base and with increasing rewards for convenience care, urgent care, and emergency services, the nation will not be able to address cost, quality, or access. It will not be able to recover a sagging economy or address increasing debt or problems in business, education, or any other area crippled by increasing health care costs.

A nation unwilling to support changes in health policy must maximize existing primary care capacity. The nation has choices.

1. Terminate forms of primary care that are not reliable and that provide no unique benefits.
2. Restructure existing forms to prevent future losses.
3. Shift resources in favor of more permanent forms of primary care.
4. Tailor training program openings to favor more permanent forms.

Rather than preserve maximum primary care capacity, the nation has not structured primary care in ways that prevent leaks. With each passing year and with each class year after graduation, the nation has fewer remaining in primary care for nurse practitioners, physician assistants, internal medicine, and medicine pediatrics. Pediatric general practice levels decline primarily for about 30% that subspecialize at graduation from initial residency training. Family medicine levels remain stable for decades after graduation. All forms of primary care donate 1 – 3% for military service, about 3 - 4% for teaching, and 1 – 4% for research, administration, or hospital based activities. This leaves about 87 – 90% that are classified as office based, the best measure of direct patient primary care. Even so, the levels vary within each group. Rural PAs deliver a higher percentage of primary care. All forms of primary care deliver greater levels of office based care in rural areas, up to 95% for family medicine. The NP and PA literature repeatedly documents the problems of major medical center location with distractions away from primary care. The same applies to NPs and PAs in major medical centers who also have more duties and distractions. Family medicine, with only 50% in major medical centers, holds an advantage in better productivity outside of major medical centers. These are not the FPs studied in comparative studies, however.

Each of the forms of primary care has unique characteristics such as areas of influence, distribution, or emphasis. Influences of health policy and major medical center hiring practices have shaped certain practitioners away from primary care. The following table is a comparison of maximal production of primary care compared to current and predicted production.

Family medicine remains a consistent 98% in family medicine and 90% in primary care. For this comparison the optimal levels were 18% of total physician graduates. This level has been exceeded during the 1990s policies, but this particular period was stimulated beyond just health policy. The managed care reports and predictions resulted in a non-legislated limitation of graduate medical education positions that was far out of proportion to the actual situation. Family medicine is now a smaller contributor, but its long term retention, highest percentages of rural distribution, and underserved distributions at top levels means greater proportions over the time after graduation compared to all other types.

Internal medicine residency graduates have maximized office based choices at 55% when compared to a denominator of all internal medicine residency graduates who remained in internal medicine or an internal medicine subspecialty. This was evident during peak Medicare and Medicaid health reform periods in the 1970s and 1990s.

Pediatrics has remained with a consistent 63 – 70% of residency graduates in office based general pediatrics. Pediatrics remains in balance with supply and demand and is increasing proportionally to need currently. Obstetrics-gynecology contributions were also considered to be steady and were not used in the calculations.

Increases in nurse practitioner and physician assistant programs and numbers of graduates each year have been steady, but health policy and major medical center hiring practices move more away from primary care, rural areas, and underserved locations with each passing year.

Medicine pediatric numbers remain small and poor retention within medicine pediatrics makes the primary care contribution insignificant.

Distributions of primary care practitioners were categorized by type and class year. The actual distributions were combined with estimates to cover the years from 1970 – 2015. The data sources included the American Medical Association Masterfile and information from the HRSA Bureau of Health Professions National Center for Health Workforce Analysis: U.S. Health Workforce Personnel Factbook

Current1 estimates (individual physician calculations based on the Masterfile) and Current2 estimates (HRSA physician estimates) used different data sources but were in agreement. Maximal capacity for primary care involved a total of primary care workforce resulting from 55% of internal medicine in office care, 18% of physicians in family medicine, 70% of pediatricians remaining in generalist practice, and 100% of nurse practitioners and physician assistants in primary care. “Loss” is the difference between Current2 and Maximal. The % Max was the percentage of primary care workforce (Current2) obtained compared to the denominator of maximal values.

Internal medicine office based retention and choice of family medicine as a career are at record lows, are expected to continue to decline although slowly, and not expected to change without major policy reforms. Pediatricians remain committed to generalist practice and are slowly increasing. Physician assistant and nurse practitioner levels are at maximum and although some expect some decline, the real driver involves benefits to major medical centers, who also control the training levels. For these reasons no change was listed and there is still potential for more programs and graduates. Each of the values is impacted by the percent remaining in primary care. Increased NP and PA graduates are balanced by declines in primary care retention. Lower levels of family medicine choice and retention of IM, PA, and NP would increase losses and lower the efficiency beyond the levels shown below. The predicted declines are laid out in Changing Primary Care Contributions for examination. 

Results

Maximal Primary Care Production Capacity

Overall primary care training capacity continues to increase although this is driven by NP and PA increases. Pediatric increases have been steady and may be related to increases in females admitted to medical school up to and even beyond parity in many schools. Females in nearly all groups explored so far are also more likely to be found in major medical centers.

Minimal loss and maximal efficiency is related to health policy in the 1970s and 1990s. Internal medicine retention in office based practice was maximal at this time, family medicine choice was at or near the 18% levels, and primary care attrition rates for NPs and PAs were lower.

Discussion

Continued declines in efficiency are likely from all primary care sources for many years without changes in health policy.

Optimal health policy would likely prevent the need for major changes, however health care needs in lower income, middle income, and rural areas will not wait. Health policies also have a way of being incomplete, compromise, distorted, unreliable, poorly interpreted in implementation, and temporary when it comes to areas outside of major medical centers.

For these reasons the nation should consider other options that would complement future primary care capacity, with or without changes in policy.

Termination of primary care training programs

Medicine pediatrics training should be radically changed or terminated. Those remaining in medicine pediatrics decline to less than 20%. Some specialty programs reject more of their fellows than this and the rejects result in 20 – 25% primary care choice for the specialty. The deteriorations make it difficult to call medicine pediatrics primary care. No disrespect is intended to those who remain, however the specialty choice is being abused by schools, faculty, student interest groups, and those interested in new subspecialty programs. Most of the funding intended for primary care is being wasted. Studies demonstrate that the other possible choices considered along with medicine pediatrics would deliver better levels of primary care. Medicine pediatrics has gained a reputation among students for having an advantage when applying for subspecialty programs. In Masterfile data only MPD graduates who are older or those graduating from medical schools with strong family medicine components stay around to contribute significantly to primary care. 

If medicine–pediatrics was not an option, most applicants would have chosen internal medicine (39%), pediatrics (24%), and family medicine (23%) - Robbins, Ostrovsky, Relgar.

Primary care retention in generalist internal medicine also presents much the same options with primary care retention down below 20%. (Academic Medicine. 80(5):507-512, May 2005. Garibaldi, Richard A. MD) Expanding internal medicine residency positions clearly will not result in needed increases in primary care. The major medical center focus of internal medicine may be too great to change. Even those leaving major medical centers for generalist care tend to transition to major medical center locations and careers over time. Sharing call and adequate patient numbers present a problem for smaller areas. Without different training emphasis, different training location, and more difficulty leaving primary care, it may be difficult to reverse the current declines.

Primary Care Retention

Not Terminating Some Programs

Termination also needs reconsideration in some areas. It is sad workforce policy that has allowed accelerated family medicine training programs to be terminated while far less productive primary care types are promoted. An investigation would reveal poor study of the model, general lack of outcomes studies, bickering between community-based and academic programs stemming from poor matches, and poor leadership at all levels including support by medical education, family medicine leaders, and accrediting bodies. Accelerated programs came as close to optimal outcomes as any primary care program. The programs were also replicated in enough locations to assure that the model made the difference and not local influences. Accelerated programs selected twice as many older graduates. These were mature students committed to family medicine that delivered the highest levels of rural and underserved primary care workforce of any training program or school without bias in rural or underserved training or background. Over 40% of accelerated graduates were found in optimal careers and locations: small rural, isolated rural, underserved, military, or teaching careers (not major medical center, large rural, or urban served locations). This 40% level is the same level as graduates of Historically Black medical schools, Duluth, or Mercer; family physicians born in whole county shortage areas, high poverty counties, or the most rural areas; or family physicians who were Native American, Black, or Mexican American.  These levels are far above the 24% for typical family medicine, and 12 – 16% for other types of physicians.

Accelerated Family Medicine Training Programs

Top Workforce Outcomes Rankings

Restructure Existing Forms: Programs

The nation has had choices in the designs of family medicine, nurse practitioners, and physician assistants.

Family medicine – In the creation of family medicine some favored 2 years of training, a choice that may well have led to even greater distribution outside of major medical centers. Requirements for 3 years of training in many hospitals has limited location choice in general practitioners. In the early phases of family medicine training, experts in Minnesota (Jack Verby) and Arkansas (Tom Bruce) noted that the early graduates did not appear as likely to distribute.

The design of 3 years of training was an attempt to remain equal in status with internal medicine and pediatric training, an attempt that may not have been entirely successful not due to length of training but more due to acceptance as a specialty. However the current top levels of primary care retention with 50% of graduates remaining outside and top levels of rural and underserved location seems to have worked out. However there are limitations in the current model.

The first limitation is that family medicine depends upon a medical school admissions process that fails to admit those most likely to choose family medicine. The same problem exists for the National Health Service Corps who is forced to take what medical schools admit rather than choosing the candidates for admission that would best meet the needs of lower and middle income populations. Older graduates, lower and middle income origin students, and those with only slightly lower scores are more likely to choose family medicine and are more likely to distribute. Older graduate levels remain steady after slow acceptance over the past 3 decades. Rural origin students have declined to their lowest levels now crossing below 10% even with over 20% rural population. The effect of admissions on choice of family medicine can be best seen in neutral health policy periods as noted in graphic comparisons of rural born admissions and choice of family medicine in the 1978 – 1990 class years, a period of slow decline with the two lines parallel to one another. More significant admissions changes have impacted the last decade. For the 16000 matriculants to allopathic schools, the nation admits 1500 fewer lower income and 1500 fewer middle income medical students now compared to 10 years ago. Declines in rural background, white, and male students impact family medicine choice and distribution to rural areas which depend upon rural white male students.

Restructure Existing Forms: Medical Schools

The training in medical education has also come to a crossroads. Access to primary care demands a reliable near 100% source of primary care. The best generic rural or lower income admissions can only generate 25% choice of family medicine. Specialized selection efforts maximize at 40 – 50% family medicine choice. The nation needs a school with 100% rates of primary care graduation. Family medicine seems the most likely suspect and training based on the accelerated model appears to be a winning combination with less cost, same or better quality, and greatly enhanced distribution. The older graduates are available for admission and many could be nurse practitioners and physician assistants or others with health care experience.

A compromise would involve major changes in existing medical schools to allow 2 or 3 different tracks such that the entire 7 or more years of medical education can be used for maximal preparation. Medical schools have become places where medical students can decide on a career, but are not the highest level education that can greatly enhance medical training by constantly increasing the responsibilities of medical students under appropriate levels of supervision. Those penalized by the current system are at either end of a broad spectrum. At one end are the dermatology, plastic surgery, and subspecialty focused careers that need much more involving research and academic focus. Also those most interested in careers involving people, primary care, low income populations, rural areas, and the biopsychosocial model fail to receive optimal training. The evaluations of the rural interested students reveal that twice as many are dissatisfied with their medical school preparation (7% vs 3%). They are clearly less satisfied with curricular elements and self-design their own experiences outside of major medical centers whenever possible. (rural int)

Other nations have begun to address this fragmentation with different medical schools for primary care and for rural careers in Australia. Again, the accelerated model could fit the need. The accelerated design impacted the clinical years of medical school and residency training. A specific admissions component focused on family medicine (older, service oriented, previous health career experience, lower or middle income origin, rural background) and a first two years focused on preparing a physician for family medicine and distribution would complement the older and service oriented types admitted with a specific interest in a lifetime in family medicine. The final years of training could address many barriers to primary health care in rural, lower income, and middle income areas depending on the particular needs of the state location.

It is already two late to prevent severe shortages. Health policy impacts such as declines in primary care and family medicine, losses of rural born admissions, and losses of international graduate requirements for rural service will mean great and growing gaps in a variety of primary care and secondary care areas. Enhanced family medicine training could fill primary care needs, basic mental health needs, and the more common secondary procedures.

The lessons of recent years are clear. A less than challenging medical education leads to poor distribution. Overtraining specialty physicians leads to subspecialization. Overtraining family physicians leads to enhanced distribution. Those who seek the skills and gain the confidence and competence involved are often forced to locate in smaller areas to practice all of these skills. The older, mature, committed accelerated family medicine graduates provide great workforce flexibility for a nation with fewer and fewer options.

Hypermobility syndrome in nurse practitioners and physician assistants – Within weeks or months it is possible for nurse practitioners or physician assistants to switch to a specialty far beyond their previous training and experience. One major concern would be the quality of care provided by a PA or NP new to a specialty. Erecting barriers to transitions away from primary care might slow the departures. More punitive measures could be established for specific locations or careers if needed to slow departures. As always, the best measures involve improvements in primary care support, however the nation appears to be less willing to deal with needed health reform.

Nurse practitioners - The early designs for nurse practice also included forms with less formal training and increased distribution. The nation chose more formal training, graduate degrees, increased status, independence for practitioners, and training that eventually centralized in major medical centers. This is a great contrast to forms of advanced nurse training as in Great Britain where nurses retain their patients and their local focus of care, upgrade their skills, and assume greater levels of local supervision. This was possible because the primary care patient panel is the focus of care in the UK.

In the United States, the focus of health care is major medical centers. As long as the United States maintains this focus, any new or existing model or intervention will be distorted this direction. As long as the most revenue streams and the highest reimbursed revenue streams flow to major medical centers, they will be able to adapt to any scenarios.

The situation with NPs and PAs was mutually beneficial for nearly all involved. NPs and PAs have not been recognized for their full worth. Major medical centers have discovered that NPs and PAs are an excellent vehicle to replace costly physicians (salary, benefits, other costs), increase their revenue generation capability, or make their care ever more efficient. Other corporate entities have also discovered their value.  NPs and PAs are more dependent, more appreciative, and are easier to control. Now that major medical centers have discovered PAs and NPs, the declines in primary care will not cease, even with health policy changes. NPs and PAs are one of the more recent of a long line of health policy interventions that have been redirected to assist major medical centers. Given indigent care burdens, increasing costs of delivering care, and declining support for health professions education; major medical centers have little choice but to maximize revenue sources, minimize costs, shed distractions, and improve productivity.

The list of health policy interventions replicated by major medical centers is long and near complete. The list includes capital building programs, prospective payment, bonus payments for shortage areas for visiting subspecialists, geographic and cost manipulations of rural health clinics, abuses of Medicare teaching funds and resident uses, and use of the federal shortage designation process to expand and replicate of urban Community Health Centers (deflect costs), use National Health Service Corps personnel, and recruit physicians from other nations as faculty with Visa programs and loopholes. Medicare and Medicaid expenditures are also constantly shifting to major medical center forms of care. Urban major medical centers are also increasing in physicians. The closest competitors to major medical centers are urban locations outside of major medical centers and rural major medical centers are losing physicians and the market share that follows the physicians.

Increased pay tied to clinical activities has also made it difficult to retain faculty to train nurses, nurse practitioners, and physician assistants. Physician assistants have also been discovered by major medical centers and those outside of formal primary care. An initial design for nurse practitioners and physician assistants that involved licensure, reimbursement, or specific location outside of major medical center locations would have resulted in different training, different training location, and maximal impact on primary care, rural, and underserved locations. Now nurse practitioners and physician assistants are more and more divided in location and specialty. Now they are more centralized in major medical center practices where 75% of physicians and over 90% of the health resources of the nation are concentrated. Unified purpose, primary care emphasis, or a focus on areas outside of major medical centers is increasingly difficult for NP and PA associations.

Hoping for the best is possible, but preparing for the worst is important. In the current climate, declines in primary care support are more likely than major health reforms. Any major reforms are likely to be even shorter in duration than the recent managed care period of influence. Compromised and divided primary care associations will not help in accomplishing this needed effort. Who will support distributions to lower and middle income populations that must come from cuts in funding to major medical centers when most are employed and trained there?

Medicine and pediatrics are already 70 – 75% tied to major medical center locations, already depend upon revenue shifting from subspecialists to maintain support, and join all forms of primary care in major medical centers as loss leaders with a focus on market share, developing a referral base, and increasing the revenues for pathology and radiology services. No major medical center form of primary care will have enough standing to accomplish needed changes as long as health policy penalizes primary care reimbursement, defeats independent primary care accreditation, and prevents independent funding of primary care training. 

Attempts to restructure existing forms are likely to be met with tremendous resistance.

Shifting Existing Resources to More Permanent Primary Care

Family medicine choice is at record lows, mainly because of poor primary care health policy and failure to hire family physicians at the major medical center level. Supply and demand is set by major medical centers for all physicians, even family medicine with the lowest levels at 50%. During the class years impacted by health policy reforms, major medical centers increased from 1200 to 1950 physicians. This was one of the greatest number and percentage increase for any family medicine location. With declines in health policy, with decreased major medical center hiring of family physicians (associated with lower status), with the costs of delivering care far outstripping reimbursement, and with primary care having the highest overhead cost, medical students see less point in choosing a permanent form of primary care.

The changes in family medicine choice with changing health policy also reveals much. The lower income, middle income, and older graduates that increased only 30% during the 1995 – 1997 class years still remain choosing family medicine. Those most committed to subspecialty careers continue to avoid family medicine (elite schools, elite scores, youngest age, foreign born). The West Coast schools and the Historically black schools increased the most and declined the most. These are the schools with some of the highest levels of diversity in the nation and the students in such schools may be leery of fighting even more adversity after decades of past experience to gain admission. One of the largest impacts of health policy involved those with connections to medical schools by birth or practice. Those born in the same county as their medical school and those found in practice in the same county as their medical school had 65 – 80% increased choice. Their career decision may be shaped by 30 years of life experience contact with family, friends, and colleagues. The health reform/managed care forced them to choose between specialty career and practice location, and they clearly chose for location and family medicine. When health policy does not favor primary care such that major medical centers are hiring, there is little point of family medicine choice. Their 30 years of experience has also taught them that it is difficult for any types of physicians to compete with the superior organization and the multiple lines of support of major medical centers.

Tailor training program openings to favor more permanent forms.

The worst case scenario for primary care for 2007 is opening up graduate medical education positions outside of family medicine. Many medical students enter family medicine as a second or third choice. These students and others forced to choose family medicine during managed care changes still retain choice of family medicine, primary care, and distribution. The loss of more US MD Grads from this form of primary care that manages to resist poor primary care health policy for decades would be devastating. Medical educators proposing increased GME positions should be sent back to the drawing board to be sure that their plans include lower and middle income and rural populations, not just major medical center needs.

A more stringent measure may be needed. The nation could reward and punish medical schools and training programs based on outcomes. The medical schools, the residency programs, the nurse practitioner programs, and the physician assistant programs that fail to meet workforce goals would face warnings and then mandatory reductions. There is little need to attempt to detail all the fine points of distribution. The FTE of continuity primary care and the FTE provided outside of major medical centers would be the only requirement. Those that provide the most primary care years and the most distribution outside of major medical centers would receive greater support and more positions. The schools and programs that pack the most into major medical centers would face more challenging requirements. Schools or programs would be free to change preadmissions, admissions, or training to improve their ability to meet national or state workforce goals, or they could choose to train fewer students or residents.

Market forces distributions work for those in major medical centers, who have little choice other than a major medical center.

Market forces works when the “market forces” help drive primary care where it is most needed, to lower and middle income populations.

Health care is needed most outside of major medical centers and in primary care which receives the least market forces stimulation and suffers the most consequences in a nation that concentrates economics, income, wealth, education, and medical training in major medical center locations.

Changing health policy makes the most sense, however in the absence of the courage to make these changes, the professionals who lead the nation in government and in health care better figure out strategies that will improve production of primary care types that will stay in primary care and lower and middle income locations.

Head to Head: Physician Assistants in 2000 Compared to Family Physicians in State and National Location

Family Medicine Central: National Comparisons of Workforce

Physician Workforce Studies

www.ruralmedicaleducation.org