Primary Care Workforce Years

Family medicine retains a consistent primary care contribution over decades. The nation would need to graduate 2 to 5 times as many graduates of any form of primary care to deliver the equivalent workforce of one family physician. For rural and for frontier workforce, even higher ratios of graduates would be required. Nations must decide issues of primary care and health access based on 30 years of services, not just the first few years. It is also a great benefit to have “natural” distribution rather than obligated distribution. Estimates of primary care workforce over a 30 year period can be generated from the current literature and data from the Masterfile.

All of the above lose 2 – 4% to teaching. Some lose more than this to administration. Pediatric losses are timed shortly after residency graduation with relative retention in generalist primary care for the 70% remaining. International medical graduates lose 20% back to home nations at the completion of training.3 The remaining IMG group includes a small percentage with concentration in underserved areas due to J-1 Visa obligations. The office based internal medicine IMG physicians provide the best distribution, but IMG internal medicine has the lowest levels of office based generalist primary care retention of any form of primary care. Physician assistants are the youngest of all primary care workforce, but transitions to emergency care, subspecialties, and other major medical center careers limit primary care contributions. Nurse practitioners add late entry into training and lower levels of rural location to the PA obstacles. Medicine pediatric numbers are generated from the Masterfile with less than 20% or less than 30 in number remaining in medicine pediatrics for each match year from 1987 – 1990 compared those remaining listed in medicine pediatrics for the 1987 – 1990 graduates. To contribute to primary care in a superior way, a practitioner must stay in specialty, stay in primary care, and avoid major medical centers. Each of the above violates one or more of these principles and all concentrate graduates at 70% or more in major medical centers.

The impact of retention within specialty and within generalist primary care can be seen in family medicine where a 30 year estimated work career results in 0.85 FTE of primary care per 1 FTE of physician. It is a great advantage to family medicine to remain outside of major medical centers at 50% or greater levels.  This basic study does not fully consider supervision needs, gender issues, fewer hours, part time work, inactivity levels, multiple duties and locations, or poor utilization that decrease actual primary care, rural, and underserved workforce for NPs and PAs and for all with a number of duties and locations within major medical centers. These factors would also tend to improve family medicine contributions relative to other providers.

A survival curve can be constructed to compare to 1960 medical school graduates to see if any of the forms of primary care do better than this detailed study reporting 57% retention in primary care.4 A 57% final retention rate translates to 0.7 FTE of primary care over a 30 year career. Only family medicine at 0.85 exceeds this level of primary care. With losses in all other forms, family medicine contributions as a percentage of total primary care workforce increase, basically doubling family medicine share over the 30 years of workforce to levels of 30 - 50%. For the most rural and the rural and underserved areas, family medicine contributions begin at this level or higher.

The current environment transitions all susceptible forms away from primary care and steadily toward major medical center careers and locations over time. This is not surprising since major medical centers enjoy the highest levels of all revenue lines of support in multiple dimensions: state, federal, foundation, corporate, and other sources. Family medicine distributes differently and has retained this distribution over decades. Over 45 years of interventions have explored many possible solutions. Only one answer consistently addresses primary care and this choice also retains top levels of distribution to rural and to underserved areas.

1.         Goolsby MJ. 2004 AANP National Nurse Practitioner Sample Survey, part I: an overview. J Am Acad Nurse Pract. Sep 2005;17(9):337-341.

2.         American Academy of Physician Assistants. Data and Statistics.  http://www.aapa.org/research/index.html . Accessed October 26, 2006, 2006.

3.         American Medical Association, International Medical Graduate Section, International Medical Graduates in the US Workforce Discussion paper http://www.ama-assn.org/ama1/pub/upload/mm/18/workforce2006.pdf  . Chicago 2007.  The 20% loss of IMGs back to home nations over a 10 year period is from Salsberg's presentation. Also " In 2002, 22,230 IMGs were in residency training or clinical fellowships, 4,000 were American citizens, 8,200 were immigrants and permanent U.S. residents, 8,900 were on an exchange visitor visa and planned to return to their country unless the INS granted them a waiver because of a need to provide care to the American public. Over half (approximately 55%) of IMG physicians were American citizens or lawful immigrants."

4.         Swanson AG. AAMC longitudinal study of 1960 medical school graduates: a 20-year effort in 28 schools, 1956-1976. J Med Educ. Dec 1986;61(12):991-992.

AMA and IMG Section http://www.ama-assn.org/ama/pub/category/211.html

Distribution: Index Concentrations of Physician Distribution

Primary Care Health Policy

Primary Care Retention

Service Orientation

Academic Medicine's Season of Accountability and Social Responsibility

Workforce Issues

Physician Workforce Studies

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