Physician Workforce Projections in an Era of Health Care Reform (Annual Review of Medicine Book 63)

Physician supply forecast: better than peering in a crystal ball?

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According to the AAPA survey, about 40 percent of PAs work in solo or group practice physician offices, about 10 percent in clinics, nearly 7 percent in health maintenance organizations, and about 25 percent in hospitals. This is a pattern not unlike that for NPs see above. In —, almost one-half 49 percent were in the East, one-third 34 percent in the North and South Central regions, and one-sixth 17 percent in the West. First-contact providers such as dentists, optometrists, and pharmacists play an important role in the provision of basic health care services.

The committee did not have the resources to track trends in supply of these types of providers, but in general it did not foresee a significant shift in either their numbers or their roles in the near term. With respect, however, to the role of the dental professions in overall health care in this country, a recent IOM report on dental education IOM, a calls attention to the following broad health objective p. This committee is generally in agreement with these views.

More broadly, the committee encourages greater coordination between these types of first-contact professionals and primary care clinicians. It believes that a continuation of the typical roles of first-contact providers is not likely to affect the demand for primary care clinicians to any meaningful degree in the near term, and thus it did not explore issues relating to these types of practitioners further. The history of workforce projection in health care is not encouraging.

Reviews of projection methodologies reveal many difficulties inherent in the projection of adequacy of supply and need or demand i. The IOM report on the U. Among the trends that complicate forecasting today are the following Feil et al. In the committee's view, drawing inferences about the expected adequacy of supply relative to requirements must be done with considerable caution, especially for the more distant future, and especially for NPs.

As noted by Scheffler Appendix E , estimates of the overall impact of NPs and PAs on the size and composition of the future health workforce vary widely because of the different assumptions that forecasters make about patient utilization rates, physician delegation rates, the extent to which HMOs and other managed care organizations are willing to use NPs and PAs, and other variables. The varying assumptions about managed care organizations reflect the fact that so far, researchers have been able to obtain detailed data on physician and nonphysician staffing patterns for only a handful of HMOs, and staffing patterns vary widely among those HMOs that have made data accessible to researchers Weiner, , The case study conducted by Scheffler for the committee compared staffing patterns in two mature HMOs.

He found, first, that merely counting physicians and specialist physicians does not provide a useful staffing analysis in a managed care world. Researchers must also examine the use of PAs, NPs, and other. Second, to make inferences about productivity, researchers cannot merely compare the number of health professionals used by the plan to the total plan enrollment. They need to investigate differences in enrollee and other plan characteristics, including enrollee age and sex distribution, patient severity of illness, patient outcomes, staff productivity, and the organizational structure of the clinical practice.

Third, staffing numbers alone cannot reveal some important health workforce parameters, such as complementarity and substitution possibilities within health care teams. Another salient issue regarding workforce estimates is the lack of current knowledge of the content of clinicians' practices—whether physicians, NPs, or PAs. Regardless of the disciplines in which they receive training, we know little about the proportion of their practice that is, in fact, primary care. Although clearly the numbers of NPs and PAs will increase in the years ahead, their roles in an evolving health care system are uncertain.

They may well be used in both specialty care and primary care, for example, making the size of their representation within the primary care clinician category quite problematic at this stage. Taking all the figures cited above in the admittedly difficult-to-predict context of health care restructuring in this country, the committee concluded that, at the moment, the nation probably has a modest aggregate shortage of primary care clinicians.

Aggregate, in this instance, refers to the combination of physicians, NPs, and PAs in primary care. In the near term, the aggregate "shortages" may disappear because of several factors. Some relate to demand for health care; others involve current supply and production of various types of primary care professionals. Market-driven changes will affect the effective economic demand for primary care clinicians. These changes include the growth of managed care, the development by some managed care organizations of innovative models of personnel substitution, and the increased use of primary care teams.

All have the potential to affect the demand for primary care clinicians. Because some changes may increase demand and others decrease it, it is difficult to predict the net effect. Furthermore, the cutbacks in Medicare and Medicaid that can be expected in coming years may attenuate the rate of growth in demand at least per capita demand from the elderly population.

Certainly the demand for provision of health care services to low-income, disabled, and disadvantaged populations can be expected to drop, if federal entitlements to the Medicaid program are eliminated. The rise in the number of persons underinsured or uninsured in any one year will also affect demand for health care services.

So, too, will increases in mandatory out-of-pocket costs, such as higher health care premiums, higher deductibles and copayment requirements, and cutbacks in coverage of certain services such as those for mental health. Economic demand for health care services is not equivalent to potential need for such services. As Tarlov , p. The committee is under no illusions: Developing a national consensus about service requirements—i. Changes on the supply side can be expected to help eliminate shortages in the future.

Among these changes are the probable increase in the number of specialists and subspecialists who expand their delivery of primary care services, a rising interest in primary care careers on the part of medical students, and continued rapid growth in training of NPs and PAs. In general, the committee supports these trends, but it remains unconvinced that the supply of well-prepared primary care clinicians will be sufficient to meet the demand for their services, at least in the short term.

In the longer term, of course, these steps may well suffice, but the committee is not persuaded that, collectively, they will produce adequate numbers of appropriately competent personnel able to function in the model of a primary care team and to provide adequate quality of care.

To address these concerns, the committee has two points it wishes to emphasize concerning the future of programs that produce primary care physicians, PAs, and NPs. The committee recommends a that the current level of effort to increase the supply of primary care clinicians be continued and b that these primary care training programs and delivery systems focus their efforts on improving the competency of primary care clinicians and on increasing access for populations not now receiving adequate primary care.

In the committee's judgment, the nation does still have an imbalance in the supply of primary care clinicians relative to clinicians chiefly physicians in specialty and subspecialty disciplines. Its language about the output of current training programs is, therefore, chosen advisedly. That is, the committee believes that the present levels of production of primary care physicians, NPs, and PAs should be maintained—not accelerated, but also not diminished. The committee does not recommend the introduction of major new initiatives aimed at increasing the aggregate supply of primary care clinicians.

Rather, as noted just below, the aim is to improve access to primary care for all Americans, taking into account expertise, geographic distribution, ethnic and cultural representation within the primary care workforce, or other factors important to the delivery of high-quality primary care.

The committee's further focus with respect to primary care training programs is on improving primary care competencies. These issues are explored more fully in Chapter 7 on training and education and are touched on in Chapter 8 with respect to accountability for quality of care. This committee, like others at the IOM, endorses the IOM's stated position about universal access to health care coverage for all Americans IOM, and has explicitly offered its own recommendation in this area Recommendation 5.

Fulfilling this aim is regarded as especially pertinent for primary care, because of the centrality of primary care to well-rounded, integrated health care, access to appropriate specialists, and better patient outcomes. It is even more important for those populations that do not now receive adequate primary care. Thus, the committee is especially concerned that training programs be configured so as to prepare students for careers in the full range of settings needed to serve all the American people.

These points are also addressed more fully in Chapter 7 in discussions of undergraduate medical education in primary care sites see Recommendation 7. The committee also wishes to go on record as supporting special initiatives that will increase the percentage of underrepresented minorities in the health professions, including primary care. This is in keeping with recent recommendations of other IOM committees, especially one on minority representation in the health professions IOM, and another on aggregate physician supply IOM,. Specifically, the committee would like to see the ethnic and cultural mix of the present and future supply of primary care clinicians be modified over time by an increase in the proportion of minorities.

In this regard, the committee draws attention not only to the problems of underrepresentation among practitioners i. Ensuring Racial and Ethnic Diversity in the Health Professions IOM, , the committee is sensitive to the need for health professions schools to develop programs that reflect genuine appreciation and respect for students' various backgrounds, values, and perspectives. It also underscores the need for health professions schools and professional organizations to engage in more outreach to prospective students at the university indeed, at the high school level.

This view dovetails with the discussion in the next chapter about the need for training programs, professional organizations, and similar groups to emphasize cultural sensitivity and appropriate communication skills see Recommendation 7. The committee recommends that state and federal agencies carefully monitor the supply of and requirements for primary care clinicians.

In keeping with the increasingly interdisciplinary nature of primary care, the committee urges that state and federal agencies compile a composite database of primary care clinicians—including physicians, NPs, and PAs providing primary care services. This would help analysts, policymakers, educators, and others understand the changing requirements for primary care clinicians and monitor utilization patterns of employment, geographic distribution, and insurance status of patients served.

Market forces may be able in the future to correct the modest shortage of primary care clinicians. The restructuring presently taking place, however, remains fluid so that the committee cannot be certain that market forces will induce and maintain appropriate responses in training and practice choices. Moreover, the committee remains concerned about the rapid changes taking place in the health care sector as a whole.

It concludes that ongoing monitoring of supply and requirements is essential to ensure that appropriate public policy and private career decisions can be made. The committee endorses their efforts and notes the recommendations from a parallel IOM committee IOM, a on the same point. Specifically, that panel advocated p. Clearly, those recommendations pertain to physicians and to all physicians, not just those in primary care. This committee would extend that advice to include nurses especially advanced practice nurses or NPs and PAs see IOM, b, for a detailed discussion of the needs for better data on the nurse workforce.

The analogous collaboration and cooperation would be sought with a wide array of professional associations, including but not limited to the American Academy of Physician Assistants, American Association of Colleges of Nursing, the American Association of Physician Assistants, American Nurses Association, the National League for Nurses, and the National Organization of Nurse Practitioner Faculties. Apart from general monitoring of the several professions relevant to primary care e. Of particular interest are patterns of substitution across physicians, NPs, and PAs and the impact of the complex interactions of these practitioners on health care costs, access, and quality of care.

These points are revisited in Chapter 8 with respect to a primary care research agenda. The committee is concerned by the continuing geographic maldistribution of the primary care workforce; there are too few clinicians in inner cities and rural areas. Despite many attempts to address this shortage, the nation simply has not adequately improved access to primary care services in these underserved areas. The last are identified on the basis of several variables, including low physician-to-population ratios, high rates of adverse health events such as infant deaths, and poor access to care.

More information on HPSAs and on the entire effort to designate underserved areas and to address their health care professional needs can be found in Lee , Desmarais , and Mullan, The latest, dramatic evidence of this for physicians was presented by Cooper , cited earlier; equivalently detailed information for NPs and PAs is not available.

The incompatibility between articulated public policy goals and objectives and the financing mechanisms put in place to support them have created an expansion of the physician supply without actually achieving an adequate workforce supply in underserved areas. Neither ''trickle-down" physician workforce policy nor market forces to date have been notably successful in alleviating the problems of inequitable distribution of primary care services and clinicians, across the nation.

The committee has dealt—essentially throughout this report—with the widely recognized issues of maldistribution of physicians by generalist or specialty training and practice. The problem of maldistribution by geographic location is another, and troubling, matter. The committee regards the goal of overcoming imbalances in the geographic distribution of primary care clinicians as an especially significant one.

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It also believes that, with the rapid changes now taking place in the private sector, managed care organizations and integrated health delivery systems have a significant duty to address this question head-on. The committee recommends that federal and state governments and private foundations fund research projects to explore ways in which managed care and integrated health care systems can be used to alleviate the geographic maldistribution of primary care clinicians. For purposes of this recommendation, the committee regards rural and inner city jurisdictions as appropriate targets for such projects and for specific attempts to redress the shortage of primary care clinicians in these areas.

Clearly, as between rural areas and the core metropolitan areas, the problems, the likely solutions, and the types of personnel and configurations of primary care teams are all likely to differ. In fact, rural areas themselves will vary along these dimensions, as will inner cities. The committee believes that managed care organizations may be able to deal with some maldistribution problems where earlier efforts have not worked.

For instance, integrated delivery systems that wish to expand their businesses into previously uncovered catchment areas, whether rural or inner city, can provide financial incentives, collegial relationships, and telecommunications capabilities that will attract physicians as well as NPs and PAs into those areas.

Academic health centers may also operate community or school clinics or other types of ambulatory care networks, especially in poor sections of metropolitan areas, that essentially also represent good business and expanded catchment opportunities. The inducements may include acceptable practice sites, competitive salaries, hospital privileges, professional relationships and backup, and appropriate referral networks, but the growing scarcity of practice openings in more affluent areas should not be discounted.

The precise combinations of fiscal and professional incentives that might work best for particular types of underserved areas are clearly not known today. Thus, demonstration and evaluation of current efforts would be particularly useful, in the committee's view. The committee did not call for testing or evaluation of specific approaches that managed care and integrated systems might use to address the geographic maldistribution problems of these areas.

Consistent with the principles laid out in Chapter 2 , however, the committee notes that it would not subscribe to solutions that were based solely on one type of primary care clinician; it believes that innovative programs involving physicians, NPs, and PAs are more desirable, and indeed it would advocate that strategies involving the entire primary care team be investigated.

Finally, this recommendation is couched in terms of research projects and thus should be considered in conjunction with the broad research agenda laid out in Chapter 8. The committee advances it here to underscore the policy issues—specifically, a very uneven presence of primary care clinicians across the states that severely hinders any efforts to bring greater parity in access to health care services to large portions of the U.

Because managed care organizations and integrated systems are gaining such a prominent role in the whole restructuring of the nation's health care system, it was felt that demonstration and evaluation projects conducted by them or under their auspices would shed the most light on how best to address this access issue. In short, the committee believes that as managed care plans and approaches expand, they bring opportunities to improve access to primary care in rural and inner city areas; that efforts to encourage that possibility are called for; and that the successes and failures of such efforts should be thoroughly understood.

PAs are permitted to do. Collectively, these laws constitute a crazy quilt of permitted or disallowed practices and activities. Thus, the legal restrictions on the scope of practice for NPs and PAs in some states seriously impede the involvement of these types of personnel in primary care in some settings and circumstances. This fact has a number of health care policy and delivery implications.

For example, for managed care enterprises that operate in more than one state, the configurations they can use to organize their primary care teams may be different, depending on the state in question. It is not clear to this committee why different structures for the delivery of high-quality primary care ought to turn on what may be quite idiosyncratic or outmoded state practice acts.

The committee recommends that state governments review current restrictions on the scope of practice of primary care nurse practitioners and physician assistants and eliminate or modify those restrictions that impede collaborative practice and reduce access to quality primary care. The committee is concerned that state statutes presently on the books create obstacles to innovative collaboration among members of primary care teams and that those ordinances by default hinder the provision of effective and efficient health care. These limitations may involve the degree and nature of supervision such as the requirement in some states for on-site supervision of PAs , the ability to prescribe pharmaceuticals, or the ability to order other services needed by the patient without a physician's case-by-case approval.

A recent analysis of the practicing environment in 10 states for NPs and PAs assigned weighted scores regarding scope of practice, requirements for physician supervision, prescriptive and dispensing authority, reimbursement, and so forth. It found total average scores of Similarly, PAs scores in the same states averaged The committee believes that more freedom to structure the divisions of duties and responsibilities should be given to the primary care team.

Clearly, reconsideration by the states of these practice acts might also enable some to address their shortage-area problems discussed earlier more creatively as well, in part by enabling managed care organizations and integrated delivery systems to develop efficient models of primary care practice that work within their own. This chapter has reviewed trends in the supply of the principal types of primary care clinicians—physicians, NPs, and PAs—taking care to observe the great difficulties of developing reliable and valid estimates of supply and, especially, requirements for clinicians or clinicians' services.

It also briefly comments on the education and training infrastructure for such personnel, which leads into the next chapter. The present chapter then advances four recommendations concerning important directions that, in the committee's view, the production and use of primary care clinicians ought to take. These involve 1 continuing the current level of effort to increase the supply of primary care clinicians but ensuring that primary care training programs and delivery systems focus their efforts on improving the competency of primary care clinicians and on increasing access for populations not now receiving adequate primary care; 2 encouraging state and federal agencies to carefully monitor the supply of and requirements for primary care clinicians; and 3 exploring ways in which managed care and integrated health care systems might be used to alleviate the geographic maldistribution of primary care clinicians; and 4 examining how state practice acts for NPs and PAs might be amended to eliminate outmoded restrictions on practices that currently impede efficient and effective functioning of primary care teams and that reduce access to needed health care.

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Work Force and Educational Issues. National Academy Press, b. Nursing, Health, and the Environment: Strengthening the Relationship to Improve the Public's Health. National Academy Press, c. The Nation's Physician Workforce: Options for Balancing Supply and Requirements. Nursing Staff in Hospitals and Nursing Homes: Appendix II, Table 1. Physician Assistants and Health System Reform: The Elusive Generalist Physician. Current Approaches to Shortage Area Designation. Journal of Rural Health 7 4 Supl. The Registered Nurse Population: Government Printing Office, The National Health Service Corps: The Josiah Macy, Jr.

Health, United States, and Prevention Profile, Government Printing Office, December Where Have All the Doctors Gone? The Geographic Distribution of Physicians: Is the Conventional Wisdom Correct? Volume 1, Graduate Education in Nursing. Advanced Practice Nursing Pub. Pew Health Professions Commission. Pew Health Professions Commission, Annual Report to Congress, The Changing Labor Market for Physicians. Chapter 14 in Annual Report to Congress, Report and Recommendations to Congress, March 1, Directions for the 21st Century.

Final Report Deliverable Item Research Triangle Park, N. RTI, July 7, Social Science and Medicine New England Journal of Medicine American Association of Colleges of Osteopathic Medicine, Estimating Physician Workforce Requirements. The Devil Is in the Assumptions. Assessing the Impact of Managed Care on the U.

Policy paper commissioned by the Bureau of Health Professions of the U. Forecasting the Effects of Health Reform on U. How Many Miles to the Doctor? Ask for a definition of primary care, and you are likely to hear as many answers as there are health care professionals in your survey. Primary Care fills this gap with a detailed definition already adopted by professional organizations and praised at recent conferences. This volume makes recommendations for improving primary care, building its organization, financing, infrastructure, and knowledge base--as well as developing a way of thinking and acting for primary care clinicians.

Are there enough primary care doctors? Are they merely gatekeepers? Is the traditional relationship between patient and doctor outmoded? The committee draws conclusions about these and other controversies in a comprehensive and up-to-date discussion that covers. This volume discusses the needs of special populations, the role of the capitation method of payment, and more. Recommendations are offered for achieving a more multidisciplinary education for primary care clinicians. Research priorities are identified. Primary Care provides a forward-thinking view of primary care as it should be practiced in the new integrated health care delivery systems--important to health care clinicians and those who train and employ them, policymakers at all levels, health care managers, payers, and interested individuals.

Based on feedback from you, our users, we've made some improvements that make it easier than ever to read thousands of publications on our website. Articles Apr 15, Howard K. Boulger, PhD; Matthew L. Hunsaker, MD; James J. Diamond, PhD; Fred W. Comprehensive medical school rural programs RPs have made demonstrable contributions to the rural physician workforce, but their relative impact is uncertain.

This study compares rural primary care practice outcomes for RP graduates within relevant states with those of international medical graduates IMGs , also seen as ameliorating rural physician shortages. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. Hunsacker, MD; James J.

The shortage of physicians in rural areas is one of the most persistent problems in the U. Articles Mar 15, Andrew W. Makaroff, DO; James C. Health care reform will add millions of Americans to the ranks of the insured; however, their access to health care is threatened by a deep decline in the production of primary care physicians.

Poorer access to primary care risks poorer health outcomes and higher costs. Meeting this increased demand requires a major investment in primary care training. Title VII, Section of the Public Health Service Act previously supported the growth of the health care workforce but has been severely cut over the past 2 decades. New and expanded Title VII initiatives are required to increase the production of primary care physicians; establish high-functioning academic, community-based training practices; increase the supply of well-trained primary care faculty; foster innovation and rigorous evaluation of these programs; and, ultimately, improve the responsiveness of teaching hospitals to community needs.

This amount represents a small investment in light of the billions that Medicare currently spends to support graduate medical education, and both should be held to account for meeting physician workforce needs. Expansion of Title VII, Section with the goal of improving access to primary care would be an important part of a needed, broader effort to counter the decline of primary care. Failure to launch such a national primary care workforce revitalization program will put the health and economic viability of our nation at risk.

One Pagers Jan 01, Elizabeth J. Warshaw, MD; Stephen M. Petterson, PhD; Imam M. Xierali, PhD; Andrew W. The current number of geriatricians cannot keep up with the health care needs of the growing number of older adults. To fill the gap, more geriatricians should focus on training primary care and other specialty physicians to care for older adults. One Pagers Dec 15, Howard K. Hunsaker, MD; Fred W. Markham, MD; James J.

Health insurance expansion expected from the Affordable Care Act is likely to exacerbate the long-standing and critical shortage of rural and primary care physicians over the next decade. Comprehensive medical school rural programs, from which most graduates ultimately enter primary care disciplines and serve rural areas, offer policy makers an interesting potential solution.

Xierali; Jason Rinaldo; Larry A. Green; and James C. Provisions for Medicare bonus payment specified in the health care reform bill the Patient Protection and Affordable Care Act used a narrow definition of primary care that inadvertently offers family physicians disincentives to delivering comprehensive primary care. Articles Nov 15, Andrew W. Puffer; and Larry A. The authors measured institutions' production of primary care physicians and general surgeons on completion of first residency versus two to four years after graduation to inform debate and explore residency expansion and physician workforce implications.

Production of primary care physicians and general surgeons was assessed by retrospective analysis of the American Medical Association Masterfile, which includes physicians' training institution, residency specialty, and year of completion for up to six training experiences. The authors measured production rates for each institution based on physicians completing their first residency during in family or internal medicine, pediatrics, or general surgery. They then reassessed rates to account for those who completed additional training.

They compared these rates with proposed expansion eligibility thresholds and current workforce needs. Of , physicians completing their first residency, 54, At two to four years out, only 29, physicians Residency expansion thresholds that do not account for production at least two to four years after completion of first residency overestimate eligibility.

The overall primary care production rate from GME will not sustain the current physician workforce composition. Articles May 15, Imam M. Xierali, PhD; Jason C. Rinaldo, PhD; Larry A. Newton, MD; and James C. Participation in this voluntary process must be broad-based and balanced for MOC to have any practical national impact on health care.

To investigate characteristics associated with differential participation in MOC by family physicians, we performed a cross-sectional comparison of all active family physicians using descriptive and multinomial logistic regression analyses. Large numbers of family physicians are participating in MOC. The significant association between practicing in underserved areas and lapsed board certification, however, warrants more research examining causes of differential participation. The penetrance of MOC engagement shows that MOC has the potential to convey substantial practice-relevant medical information to physicians.

Thus, it offers a potential channel through which to improve health care knowledge and medical practice. Presentations May 15, Robert L. One Pagers May 01, Veerappa K. Hospital readmission after discharge is often a costly failing of the U. Increasing the number of family physicians FPs is associated with significant reductions in hospital readmissions and substantial cost savings.

To determine the distribution of geriatricians across the rural-urban continuum from to and to compare with primary care physicians in County-level analysis of physician data from the American Medical Association Physician Masterfile for , , and merged with U. Physicians in the United States. Number of physicians per county elderly population. The number of self-identified geriatricians nationwide increased from 5, to 7, from to In , the number of geriatricians per 10, older adults declined as rurality increased from 1.

General internal medicine physicians are more plentiful in urban counties and declined as rurality increased from In contrast, family physicians were more evenly distributed with the elderly population across the rural-urban continuum Small numbers of geriatricians combined with a growing elderly population poses a challenge and an opportunity. Healthcare systems and policy-makers will need to modify care models to better use the skill of geriatricians in concert with other providers to provide quality care for older rural and urban Americans.

Presentations Apr 15, Robert L. Meta description must not be left blank. See Content Tab under the Meta section Creation date must not be left blank. See Content Tab under the Content Review section. Dodoo, PhD; Robert L. These income disparities dissuade medical students from selecting primary care and should be addressed to ensure sufficient patient access to primary care. Articles Aug 15, Shannon K. Bolon and Robert L. The future of family medicine is closely tied to the strength of family medicine research.

Physicians with fellowship training have been shown to be more productive researchers than those without fellowship training. Fellowship programs available to family physicians were identified by Internet searches and confirmed by telephone or e-mail. Directors of identified fellowships received a item survey exploring research training provided by their program. Descriptive statistics were used to evaluate the quantitative data. Survey comments were analyzed qualitatively to identify themes. We confirmed that of identified research fellowships are available to family physicians.

Fellowships with and without a research focus are providing research training. They are threatened, however, by weak research infrastructure, inadequate funding, and attitudinal biases against family medicine research.

There are many fellowship and research training opportunities for family physicians. But in many programs, research training is tenuous, and support for researchers is low. We recommend expanding research advocacy efforts within family medicine, Congress, and funding institutions. One Pagers Jul 15, Nicholas A. Weida, BA; Robert L. Dodoo, PhD; Stephen M. This decline will further exacerbate the current primary care shortage and severely affect future projections of primary care shortage. The basic purpose of medical schools is to educate physicians to care for the national population. Fulfilling this goal requires an adequate number of primary care physicians, adequate distribution of physicians to underserved areas, and a sufficient number of minority physicians in the workforce.

To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions. The percentage of graduates who practice primary care, work in health professional shortage areas, and are underrepresented minorities, combined into a composite social mission score. The contribution of medical schools to the social mission of medical education varied substantially. Three historically black colleges had the highest social mission rankings.

Public and community-based medical schools had higher social mission scores than private and non-community-based schools.

National Institutes of Health funding was inversely associated with social mission scores. Medical schools in the northeastern United States and in more urban areas were less likely to produce primary care physicians and physicians who practice in underserved areas. The AMA Physician Masterfile has limitations, including specialty self-designation by physicians, inconsistencies in reporting work addresses, and delays in information updates.

The public good provided by medical schools may include contributions not reflected in the social mission score. The study was not designed to evaluate quality of care provided by medical school graduates. Medical schools vary substantially in their contribution to the social mission of medical education. School rankings based on the social mission score differ from those that use research funding and subjective assessments of school reputation.

These findings suggest that initiatives at the medical school level could increase the proportion of physicians who practice primary care, work in underserved areas, and are underrepresented minorities. Articles Feb 15, Nicholas A. Teaching hospitals have favored higher revenue generating specialty training over primary care positions. General internal medicine positions increasingly serve as channels for revenue generating subspecialty programs, leaving fewer internal medicine positions dedicated to primary care. Policy makers hoping to realize the superior health outcomes and decreased costs associated with greater access to primary care may find this trend alarming.

Our findings support the concern expressed by the COGME that instead of responding to policy aims to correct shortage in the primary care pipeline, hospitals are instead training to meet hospital goals. Articles Jan 15, Andrew W. Xierali, PhD, Stephen M. Petterson, PhD, Robert L. Rinaldo, PhD, James C. Puffer, MD and Larry A. In its recent shift to a Maintenance of Certification for Family Physicians MC-FP paradigm, the American Board of Family Medicine provides diplomates completing 3 self assessment modules SAMs in the first 3 years or first stage of MC-FP a pathway to extend their recertification cycle to 10 years provided additional requirements are met, versus a 7-year cycle for "non-completers.

We merged data from MC-FP files, association workforce files, and the US Census and completed cross-sectional spatial, descriptive, and regression analyses of the uptake and timely completion of SAMs during a 3-year period. Specifically, we explored characteristics of diplomates who did not meet first-stage MC-FP requirements within 3 years versus those who did. The cohort comprised 10, participants who passed their certification or recertification examination in , of which The population of patients older than 65 years is projected to increase substantially in the coming years, particularly in rural areas.

Family physicians are essential providers of geriatric care, especially in rural areas, but need payment reform to improve their capacity to meet the needs of older patients. House draft bill H. Since then it has undergone committee consideration and a mark-up session. It shows the widely variable but important impact. The US Senate Finance Committee and the Medicare Payment Advisory commission have both proposed incentive payments for primary care physicians who meet certain thresholds of "primary care-ness. This suggests that a substantial bonus may influence more primary care physicians to deliver more primary care.

But because it excludes more rural physicians than urban, these threshold codes may also be excluding physicians doing a broader scope of appropriate primary care. We do not yet suggest additional codes to be considered but suggest that Congress and the Administration need to re-evaluate their choices to avoid the unintended consequence of overly restricting the range of services needed for the Patient Centered Medical Home. Medical school expansion, primary care, and policy: Engaging primary care educators in evidence-based advocacy.

The chasm between knowledge and practice decried by the Institute of Medicine IOM is the result of other chasms that have not been addressed. They include the chasm between what we know and what we need to know to improve care; the chasm between those who provide primary care and those who do not fund, study, support, or publish practical primary care studies; and the chasm between research and quality improvement QI.

These chasms are a result of problematic concepts, attitudes, traditions, time frames, and financing approaches among the various participants. These changes include the following: Articles Mar 15, Sean C. Purposive sampling identified 13 key informants at NIH for open-ended, semi-structured interviews. Evaluation was by content analysis. NIH officials expressed the perception that family physicians have strong relationships with patients and communities and focus on interdisciplinary collaboration but that they do limited research and have weak research infrastructure. They also indicated that NIH has repackaged its stated focus, to include areas of research that might be applicable to family medicine, but whether this represents real change is questionable; NIH still emphasizes basic science and exclusionary trials.

While NIH officials suggested that family physicians still have no obvious NIH home, they also suggest that family physicians are well-poised to recruit patients and inform questions, if not lead research. Family physicians have opportunity with Clinical and Translational Science Awards CTSAs but need areas of expertise and additional formal research training to succeed with greater research participation.

NIH key informants generally appreciated family medicine clinically but viewed family medicine research as underdeveloped. Some identified opportunities for family medicine to lead, particularly CTSAs. We studied the spending effects of having different usual sources of care, focusing on variations associated with the type of facility or physician specialty. Based on analyses of data from the — Medical Expenditure Panel Surveys, we found significant differences in annual spending, especially for adults. Use of and spending for subspecialists were similar to those for general internists, and both were significantly higher than those for family physicians.

Variation in spending might be the result of training differences among primary care specialties. Presentations Mar 15, Robert Graham Center. A compendium of slides for public use that includes original and adapted analyses, commentary, and annotation from the staff of the Robert Graham Center. Specialty and geographic distribution of the physician workforce: Family medicine is challenged to develop its own research infrastructure and to inform and contribute to a national translational-research agenda.

Toward these ends, understanding family medicine's engagement with the National Institutes of Health NIH is important. We descriptively analyzed NIH grants to family medicine from through and the current NIH advisory committee memberships. These values represented only 0. Ten of the nation's departments of family medicine 7. Representatives from family medicine were on 6. Departments of family medicine, and family physicians in particular, receive a miniscule proportion of NIH grant funding and have correspondingly minimal representation on standing NIH advisory committees.

Family medicine's engagement at the NIH remains near well-documented historic lows, undermining family medicine's potential for translating medical knowledge into community practice, and advancing knowledge to improve health care and health for the US population as a whole. Despite increasing data demonstrating the positive impact primary care has on quality of care and costs, our specialty faces uncertainty.

Its popularity among medical students is declining, and the income gap is growing between primary care and other specialties. Congress has the power to intervene in this impending crisis. If we want to influence lawmakers' actions, we need to know how they are thinking about these issues.

Using a set of questions covering several physician payment topics, we interviewed 14 congressional staff aides 5 aides on Medicare-oversight committees, 9 general staff aides and one representative from each of 3 governmental agencies: Interviewees revealed that issues in primary care are not high on the congressional agenda, and that Medicare's Sustainable Growth Rate SGR is the physician-payment issue on the minds of congressional staff members. Attempts to solve primary care's reimbursement difficulties should be tied to SGR reform. Community health centers CHCs are a critical component of the health care safety net.

President Bush's recent effort to expand CHC capacity coincides with difficulty recruiting primary care physicians and substantial cuts in federal grant programs designed to prepare and motivate physicians to practice in underserved settings. We then conducted retrospective analyses to compare the proportions of physicians working in CHCs among physicians who either had or had not attended Title VII-funded medical schools or residency programs and to determine the association between having attended Title VII-funded residency programs and subsequent NHSC LRP participation.

Policy options for recruiting and retaining primary care physicians to HPSAs, and new HPSA criteria that support access to primary care practices, should be considered. National workforce models fail to capture the regional effect of residency programs, despite local control over decisions to open or close training sites. We report on a novel approach to measuring the regional effect of residency training programs closures using a combination of quantitative and spatial methods.

American Medical Association Physician Masterfile records and residency graduate registries for 22 of 37 family medicine residency programs that closed between were analyzed to determine regional patterns of physician practice, as well as the effect of graduates from closed programs on areas that otherwise would be Health Professional Shortage Areas HPSAs. Program graduate data from two sampled programs were mapped using geographic information system software to display the distribution "footprint" of graduates regionally.

Without the graduates of these programs, there would have been additional full HPSA counties in 15 states. The spatial distribution of the graduates of two closed programs demonstrates their effect across multiple counties and states. The effect of closing family medicine residency programs is likely to go undetected for many years. Decisions regarding the fate of family medicine programs are often made without benefit of a full assessment. Local and regional effects on physician access are often recognized only after the fact. Novel approaches to analysis and display of local effects of closures are essential for policy decisions concerning physician workforce training.

Rural areas have fewer physicians compared to urban areas, and rural emergency departments often rely on community or contracted providers for staffing. The emergency department workforce is composed of a variety of physician specialties and clinicians. To determine the distribution of emergency department clinicians and the proportion of care they provide across the rural-urban continuum.

Cross-sectional analysis of secondary data. The distribution of clinicians who provide emergency department care by county was determined using the Area Resource File. The percentage of emergency department care provided by clinician type was determined using Medicare claims data. Logistic regression analyses assessed the odds of being seen by different clinicians with a patient's rurality when presenting to the emergency department. The bulk of the remainder of emergency department care is largely provided by family physicians and general internists, with the percentage increasing with rurality.

The likelihood of being seen by an emergency physician in the emergency department decreases 5-fold as rurality increases, while being seen by a family physician increases 7-fold. Nonemergency physicians provide a significant portion of emergency department care, particularly in rural areas.

Medical specialties must cooperate to ensure the availability of high-quality emergency department care to all Americans regardless of physician specialty. GIS and General Practice: Where are we going and when will we get there? The Patient Centered Medical Home: History, seven core features, evidence and transformational change.

The shortage of physicians in U. Two medical student characteristics that predict eventual practice in rural settings are clear: Articles Apr 15, Robert L. Fryer Jr, Walter Rosser. A physician shortage has been declared in both Canada and the United States. We sought to examine the migration pattern of Canadian-trained physicians to the United States, the contribution of this migration to the Canadian physician shortage and policy options in light of competing shortages in both countries.

We describe the migration pattern of Canadian medical school graduates to the United States, the number of Canadian-trained physicians in the United States in , the proportion who were in active practice, the proportion who were practising in rural or underserved areas and the annual contribution of Canadian-trained physicians to the US physician workforce.

Two-thirds of the 12, Canadian-educated physicians living in the United States in were practising in direct patient care, in rural areas. About , or 1 in 9, Canadian-educated physicians from each graduating class joined the US physician workforce providing direct patient care. Canadian-educated physicians are more likely than US-educated physicians to practise in rural areas. Minimizing emigration, and perhaps recruiting physicians to return to Canada, could reduce physician shortages, particularly in subspecialties and rural areas.

In light of competing physician shortages, it will be important to consider policy options that reduce emigration, improve access to care and reduce reliance on physicians from developing countries. Satisfaction among both physicians and patients is optimal for the delivery of high-quality healthcare. Although some links have been drawn between physician and patient satisfaction, little is known about the degree of satisfaction congruence among physicians and patients living and working in geographic proximity to each other. We sought to identify patients and physicians from similar geographic sites and to examine how closely patients' satisfaction with their overall healthcare correlates with physicians' overall career satisfaction in each selected site.

We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study CTS Household and Physician Surveys , , , a nationally representative telephone survey of patients and physicians. We studied randomly selected participants in the 60 CTS communities for a total household population of , patients and a total physician population of 37, Both physicians and patients were asked a variety of questions pertaining to satisfaction. Satisfaction varied by region but was closely correlated between physicians and patients living in the same CTS sites.

Physician career satisfaction was more strongly correlated with patient overall healthcare satisfaction than any of the other aspects of the healthcare system Spearman's rank correlation coefficient 0. Patient trust in the physician was also highly correlated with physician career satisfaction 0. Despite geographic variation, there is a strong correlation between physician and patient satisfaction living in similar geographic locations. Further analysis of this congruence and examination of areas of incongruence between patient and physician satisfaction may aid in improving the healthcare system.

Little is known about the epidemiology of new skin lesions seen in primary care. Our primary objective was to determine the percentage of the skin lesions that improved after evaluation by family physicians.

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Secondarily, we sought to determine patient satisfaction with their care, as well as diagnostic concordance between family physicians and dermatologists in diagnosing and treating skin lesions. A prospective cohort study was done in two practice-based research networks. Patients with new skin lesions were eligible. Digital photographs, lesion descriptions and brief patient histories were collected in the family physician's office and independently reviewed by two dermatologists.

Patients were administered a telephone survey at days 7, 28 and 84 after the visit to assess the status of lesions and their overall satisfaction with care. Our study demonstrates that most skin lesions seen by office-based family physicians resolve within three months, patients are generally satisfied with the care they receive, and the diagnostic and treatment decisions made by primary care physicians are not significantly different from those of their dermatologic colleagues.

Articles Sep 15, Donald E. Beyond providing temporary staffing, National Health Service Corps NHSC clinicians are believed by some observers to contribute to the long-term growth of the non-NHSC physician workforce of the communities where they serve; others worry that NHSC clinicians compete with and impede the supply of other local physicians. To assess long-term changes in the non-NHSC primary care physician workforce of rural underserved counties that have received NHSC staffing support relative to workforce changes in underserved counties without NHSC support.

Using data from the American Medical Association and NHSC, we compared changes from to in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: From to , counties staffed by NHSC clinicians experienced a mean increase of 1. The finding of greater non-NHSC primary care physician to population mean ratio increase in NHSC-supported counties remained significant after adjusting for baseline county demographics and health care resources P Articles Sep 15, Robert L.

Dodoo, PhD; Scott A. Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected U. These analyses do not fully consider the role of family medicine in the care of children. Family medicine's role in children's health care is more stable in rural communities, for adolescents, and for underserved populations. For these populations, in particular, family medicine's role remains important. The erosion of the proportion of visits to family medicine is likely caused by the rapid rise in the number of pediatricians relative to a declining birth rate.

Between and , the general pediatrician population grew at 7 times the rate of the U. The number of clinicians caring for children meets or exceeds most estimates of sufficiency; however, the workforce distribution is skewed, leaving certain populations and settings underserved.

More than 5 million children and adolescents live in counties with no pediatrician. Unmet need, addressing health in the context of families and communities, and tackling "millennial morbidities" represent common ground for both specialties that could lead to specific, collaborative training, research, intervention, and advocacy.

Articles Sep 15, Robert L. Dovey, Deborah Graham, Nancy C. Elder and John M. To test whether family doctors, office staff, and patients will report medical errors and to investigate differences in how and what they report. Clinicians, staff, and patients in 10 family medicine clinics of the American Academy of Family Physicians National Research Network representing a diversity of clinical and community settings were invited to report errors they observed.

They were asked to report routinely during 10 weeks and to report every error on 5 specific days.

Background

They submitted anonymous reports via a Web site, paper forms, and a voice-activated phone system. Staff reported more errors in patient flow and communication; clinicians reported more medication and laboratory errors. Patients submitted reports, 18 of which included errors. Clinicians and staff offer different and independently valuable lenses for understanding errors and their outcomes in primary care, but both predominantly reported process- or system-related errors.

There is a clear need to find more effective ways to invite patients to report on errors or adverse events. These findings suggest that patient safety organizations authorized by recent legislation should invite reports from a variety of health care workers and staff. Fryer, PhD; Jessica L. Dodoo, PhD; Larry A. Articles Jun 15, Amanda L. The number of international medical graduates IMGs entering family medicine in the United States of America has steadily increased since Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations.

The objective of this study is to determine, at the time when a large influx of IMGs into family medicine began, whether differences existed between USMG and IMG family physicians in regard to personal and professional characteristics and attitudes that may have implications for the health care system resulting from the increasing numbers of IMGs in family medicine in the United States. This is a secondary data analysis of the Community Tracking Study CTS Physician Survey comparing United States medical graduates and international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week.

Fryer, PhD, Robert L. Nationwide, family physicians FPs deliver a smaller proportion of the outpatient care of children than they did 10 years ago. Millions of children depend on FPs for care. Family medicine should reevaluate how it will contribute to the care of the nation's children. Ensuring access to emergency care in rural areas remains a challenge. High costs and low patient volumes make percent staffing of rural emergency departments EDs by emergency medicine residency—trained physicians EPs unlikely. As rurality increases, so does the dependence on family physicians FPs to provide quality emergent care.

The United States has never had a more robust primary care workforce, but dysfunctional financing schemes and inability to compete for the hearts and minds of the next generation of young doctors threaten its future. Many of the problems are a direct result of the market approach to health care. Innovation is needed in how primary care functions are financed, protected, organised, and taught in order to identify options for a stable and robust health system built on primary care.

Physician supply forecast: better than peering in a crystal ball?

At least three models have been used to project the future physician workforce, and each produces different results. No physician workforce predictions can be relied on until there is more consideration of and agreement on desired health outcomes and what physicians must do to achieve them. The baby boom generation will place large demands on the Medicare program and the U.

These demands may be extended by a large legal immigrant population that will become Medicare-eligible soon after the baby boom generation does. The physician assistant PA and nurse practitioner NP workforces have realized explosive growth, but this rate of growth may be declining. Most PAs work outside primary care; however, the contributions of PAs and NPs to primary care and interdisciplinary teams should not be neglected. Most people in the United States consult a general physician each year, and some see other subspecialists.

However, the proportion of people consulting a general physician who sees adults and children appears to be declining. In the past quarter century, the number of office visits to physicians in the United States increased from million per year to million per year, with slightly more than one half of total visits since being made to primary care physicians.

Most visits to primary care physicians were made to family physicians FPs and general practitioners GPs until the mid s, when visits to general internists and general pediatricians exceeded visits to FPs and GPs. Historically, osteopathic physicians have made an important contribution to the primary care workforce. More than one half of osteopathic physicians are primary care physicians, and most of these are family physicians. However, the proportion of osteopathic students choosing family medicine, like that of their allopathic peers, is declining, and currently is only one in five.

Overall fill rates in July have been relatively stable at approximately 94 percent. Family medicine has become reliant on international medical graduates IMGs , who in made up 38 percent of first-year residents. Policy makers and workforce planners should consider how changes in the production of FPs would affect these programs. People living outside metropolitan areas, especially those living in rural counties, depend on family physicians. Resolving the disparities in physician distribution nationwide will require solutions to make rural practice a viable option for more health care workers.

In , there were 91, family physicians FPs and general practitioners GPs and , primary care physicians actively caring for patients, one for every 1, persons. These primary care physicians represent the largest and best-trained primary care physician workforce that has ever existed in the United States. Departing from past reports, the latest Council on Graduate Medical Education COGME report warns of a physician deficit of 85, by and recommends increases in medical school and residency output.

COGME notes that contributions of other clinicians and changes in how medical care is delivered in the future would likely offset physician deficits but chose not to modify their recommendations. COGME offers a relatively minor workforce correction in an otherwise flawed system of health care; however, the nation awaits a reassessment of its physician workforce based on what the nation wants and needs from physicians working in modern systems of care.

Great caution should be exercised in expanding the physician workforce. Producing a physician surplus could be far worse than wasted, because the investment required and resulting rise in health care cost may harm, not help, the health of people in the United States. Instead, these resources could be applied in ways that improve health.

Articles Mar 15, Donald E. Fryer, PhD; Larry A. Green, MD; and Robert L. This study assesses whether the National Health Service Corps's legislated goals to see health improve and health disparities lessen are being met in rural health professional shortage areas for a key population health indicator: In a descriptive study using a pre-post design with comparison groups, the authors calculated age-adjusted mortality rates at baseline and follow-up for the populations of rural whole-county health professional shortage areas arrayed into 3 groups based on the number of study years they were staffed by National Health Service Corps physicians, physician assistants, and nurse practitioners terms of 1 to 7, 8 to 11, and 12 to 15 years.

The authors compared changes over time in age-adjusted mortality rates in the 3 county groups that had National Health Service Corps staffing with rate changes in whole-county rural health professional shortage areas and non-health professional shortage area rural counties that had no National Health Service Corps.

At baseline age-adjusted mortality was higher in all 4 health professional shortage area county groups than in the non-health professional shortage area county group. Age-adjusted mortality rates improved with time in all groups, including health professional shortage area counties both with and without National Health Service Corps support, and non-health professional shortage area counties. Essentially, baseline differences in age-adjusted mortality rates between health professional shortage areas and non-health professional shortage area counties did not diminish with time, whether or not there was National Health Service Corps support.

From the early s through the mids, the National Health Service Corps's goal to see health improve in rural health professional shortage areas was met, but its goal to diminish geographical health disparities was not. Because age-adjusted mortality rates improved in all county groups, the authors conclude that improvement was likely due to a variety of factors, including decreasing poverty and unemployment rates and increasing primary care physician-to-population ratios, to which the National Health Service Corps may have contributed.

Dodoo, PhD; Jessica L. Fryer, PhD; Lisa S. Green, MD; Martey S. Fryer, PhD; Robert L. Chiropractors are the largest source of office-based care in the United States that does not involve a physician, but people do not view chiropractors as primary providers of health care or advice.

Unlike the care given by primary care providers, the majority of care provided by chiropractors is limited to musculoskeletal problems. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

Graduate Medical Education That Meets the Nation's Health Needs.

The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty and trust. Articles Apr 15, George E. There is general consensus that the size of the US physician workforce now exceeds the health care needs of the American public. There is a greater proportion of specialists than primary care physicians, a specialty mix different from that of most other developed countries.

The Colorado Board of Medical Examiners sent a one-page questionnaire to all physicians licensed to practice in the state. It contained the question: Just under half

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