Using the Residency Matched Method and Intent to Practice Method to Estimate Primary Care Workforce Production.

RECENT REPORTS HAVE WARNED OF A CRISIS RELATED to a shortage of primary care physicians. However, much of the current concern seems to have stemmed from articles in the medical literature specifically reporting that fewer internal medicine residents are choosing to pursue primary care and that fewer medical students are choosing family medicine residencies. Hauer et al found, among a national sample of fourth-year medical students, that only 22% planned careers in internal medicine and just 2% intended to practice general internal medicine. Ebell hypothesized that fewer medical students are choosing primary care specialties as a result of lower salaries relative to other specialties. It is important to note that the results of his trend-line analysis showed this was true only for family physicians. There has not been an appreciable change in the proportion of pediatric residents who choose primary care pediatrics. Thus, the concerns expressed regarding primary care should really only focus on the care of adults. While this is a large and important patient population, adults are not the only group served by primary care physicians. Historically, primary care has encompassed internal medicine, pediatrics, and family medicine; in some instances, obstetrics/gynecology is included. These groups are similar with respect to their primary care roles, but they are markedly different in many other ways, including workforce projections. For these reasons, it is disappointing that national discussions about the “crisis in primary care” have moved beyond the valid concerns regarding a shortage of physicians providing primary care to adults and have somehow come to imply a shortage of all primary care physicians. Multiple government reports also fail to distinguish among the primary care specialties when reporting on the crisis in primary care. For example, in its February 2008 report to Congress, the Government Accounting Office reported findings predicting a shortage of primary care physicians in 2018, without reference to specific specialties. Assessments by those tasked with determining sufficiency of training the physician workforce are no more specific. A 2005 report by the Council on Graduate Medical Education did not distinguish among the primary care specialties when assessing the future training needs of the country in this important area. The need to understand primary care workforce issues in a specialty-specific manner is critical, because any policy changes or economic incentives that affect the proportion of physicians pursuing primary care will likely have a differential effect across the primary care specialties. For example, it might be viewed as positive if the number of internal medicine residents who pursue primary care were to double. Indeed, a November 2008 American Medical Association news release reported a new policy aimed at “increasing the ranks of primary care physicians” without any reference to specific primary care specialties. However, the most recent published data regarding pediatric residents completing training in 2008 demonstrated that 40% were planning to pursue a career in primary care, with 10% still undecided. Similar findings were seen among senior residents scheduled to complete their training in 2009 (G.L.F. and J.A.S., unpublished data, 2008). Thus in pediatrics, a doubling or substantial increase of the proportion entering primary care could result in a possible oversupply of primary care pediatricians, likely at the expense of needed pediatric subspecialists. Markedly increasing the number of primary care pediatricians in the pipeline could create more such physicians than jobs available, resulting in the opposite effect of any intended legislation or other policy solution aimed at primary care. In contrast, the idea that there is a shortage of primary care pediatricians—or that, relative to the past, there are fewer primary care pediatricians to care for the current population of children—is contrary to published workforce and population data. While the absolute number of children in the United States has remained relatively stable, the number of pediatricians has increased substantially (FIGURE). This has resulted in an increase in the number of primary care pediatricians, from 32 to 78 per 100 000 children in the period 1975 to 2005. Similarly, there has been an increase in

A shortage of primary care physicians exists in the US, and medical schools are investigating factors that influence specialty choice. To better understand the factors associated with medical students choosing primary care specialties, a longitudinal annual survey from 2013 to 2019 was administered to students at the University of Iowa Carver College of Medicine, starting pre-matriculation. A logistic regression model examined factors of interest. Matching into a primary care specialty (family medicine, internal medicine, pediatrics) for residency was the primary outcome. Our study compared factors students reported in annual surveys: demographics, mentorship, debt, and lifestyle. Factors significantly associated with primary care specialty included pre-medical and medical school research, a family member in primary care, student age and gender. 28% of men chose primary care, and 47% of women. Although there was no gender difference in rates of medical education debt (N = 286,χ2(1) = 0.28, p = 0.60), men were more likely to report being influenced by debt (N = 278, χ2(1) = 10.88, p = 0.001), and students who reported debt-influenced specialty choice were one-third as likely to enter primary care (N = 189, 95% CI [0.11–1.06], p = 0.06). For men, potential salary was negatively associated with entering primary care (p = 0.03). Women were more likely to have a mentor in primary care (N = 374, χ2(1) = 13.87, p < 0.001), but this was not associated with an increased likelihood of entering primary care for men or women. Having a family member who practices primary care was associated with a 2.87 times likelihood of entering primary care (N = 303, 95% CI [1.14–7.19], p = 0.03). The decision to enter primary care is influenced by many factors; a key gender differentiator is that men’s specialty choice is more negatively influenced by financial concerns.

When I was young, I wanted to become a physician because I was interested in human beings and curious to know more about the biology and psychology of these creatures. If you are interested in people, there is no better job than that of a GP. Many young medical students share my enthusiasm for their career, yet few of them would like to specialize in general practice. As a teacher of medical students, I have noticed that during the first years of study general practice seems to be a possible choice for them, yet the longer the studies continue, the more a good many of them prefer a career in a narrower, hospital-based specialty. A recent article in this journal surveyed fifth-year medical students’ opinions on general practice [1]. While students respected GPs’ versatile and challenging work, they were concerned that the work was too hasty and pressing. The majority of the students (82%) considered that the most important aim of the GP's work is to identify serious diseases in order to refer patients for specialized care, which means that they overlooked the GP's important role in public health, i.e. the aim of better health for all people. Another concern among medical students was that GPs have to deal too much with non-medical problems. Bureaucratic duties such as sickness certification take up a large part of a GP's day, and GPs often consider these tasks problematic [2]. We need a continuous discussion about which jobs GPs should and should not do. As generalists, we are needed for many different tasks; however, not all of them are considered efficient use of the GP's time nor do they contribute to achieving the main aims of the GP's work. In Helsinki, the general practice training has been updated to help young doctors cope with the current challenges of primary care. General practice courses now get more positive feedback than before, and the number of young doctors wanting to specialize in general practice has increased. Nevertheless, young doctors who choose a career in primary care still face several barriers. The shortage of primary care physicians seems to continue, and young doctors often tend to leave after their mandatory period in general practice. In Finland, a primary care reform has been planned for several years, and one initiative was launched in 2012. However, it is based on municipalities as organizers of primary health care, and the initiative is strongly linked to a parallel reform of the number of municipalities. Few believe that this reform is going to solve the problems of primary care in Finland. GPs play a decreasing role in the leadership of primary care. High demands and limited resources challenge their role as primary care leaders, a similar situation to what was lately described in rural primary care in Norway [3]. Recently, three enthusiastic young physicians described their vision of future primary care in an editorial in the New England Journal of Medicine [4]. They emphasized multi-professional teams, quality-improvement cycles, patient groups, and the use of new technologies in communication with patients. Some of these ideas, such as teamwork and focus on quality, seem familiar in Scandinavia. Many countries, including the United States, Norway, and Finland, are simultaneously carrying out primary health care reforms. Despite the challenges, the many good practices and innovations in primary health care in Scandinavia are important models for the current reforms. Times are interesting for the transforming of primary care systems. The number of young physicians who choose a career in primary care serves as a good measure for the success of transformation. A journal like this plays an important part in letting us read and write about the importance of primary care and the successful innovations that are made in the few well-functioning systems. All this knowledge is useful for the GPs who are taking the lead in re-imaging the future of primary care.

Purpose: Primary care (PC) career choice has been declining among U.S. medical graduates and residents since the 1990s. 1,2 By 2034, an estimated shortage of 17,800–48,000 PC physicians is expected. 2 Some medical schools have developed programs to increase students’ interest in PC specialties and practice in underserved areas. 3,4 To our knowledge, the durability of early PC-specialty preference for long-term PC practice has not been reported. Method: The Association of American Medical Colleges provided linked, deidentified data for a national cohort of 48,533 U.S. MD-granting medical school matriculants from 1998–1999 through 2000–2001. Data from the Student Records System (sex, race/ethnicity, and graduation year), Matriculating Student Questionnaire (MSQ; specialty board certification plans and attitudinal variables: importance of prestige and social responsibility in choosing a medical career), Graduation Questionnaire (GQ; total debt, plans to practice in underserved areas, and student ratings [excellent vs not excellent] of PC and non-PC clerkship experiences), and American Medical Association (AMA) Physician Masterfile practice data through May 2020 were used. The outcome was office-based practice in a specialty from the AMA Physician Masterfile, categorized as follows: (1) general-PC (i.e., internal medicine, pediatrics, family practice, general practice, internal medicine/pediatrics, or internal medicine/family practice as primary specialty, with another general-PC or unspecified secondary specialty), (2) PC-subspecialty (i.e., general-PC primary and PC-subspecialty secondary specialty, or PC-subspecialty as primary specialty), and (3) non-PC specialties (i.e., non-PC primary specialty). Multivariable logistic regression models identified variables independently associated with general-PC vs each of PC-subspecialty and non-PC-specialty practice. Results: Of 46,698 graduates in 2002–2013, 30,435 (65.2%) had complete data for analysis (7,700 [25.3%] general-PC physicians, 5,327 [17.5%] PC subspecialists, and 17,408 [57.2%] non-PC specialists). Female (vs male) students, and students with plans to practice in underserved areas (vs no plans) were more likely to report general-PC (vs PC-subspecialty) practice. Underrepresented racial/ethnic minorities in medicine (URiM), Asian/Pacific Islander (Asian/PI) students (each vs White), and students planning to pursue non-PC specialties or no board certification (each vs PC board certification plans) on the MSQ were each less likely to report general-PC (vs PC-subspecialty) practice. In the second model, female students and students reporting plans to practice in underserved areas (vs no plans), endorsing higher importance of social responsibility, or rating only PC clerkships excellent (vs rating both PC and non-PC clerkships excellent) were each more likely to report general-PC (vs non-PC-specialty) practice. URiM, Asian/PI students, students planning to pursue non-PC or no board certification, and students endorsing higher importance of prestige were each less likely to report general-PC (vs non-PC-specialty) practice. Discussion: Several factors were associated with future PC practice. The greater likelihood of women and lower likelihood of URiM graduating students to choose PC specialties on the GQ has been reported. 1 We extend this work, finding lower likelihood of URiM and A/PI physicians to be in general-PC practice. Importantly, early preference for PC specialties was positively associated with general-PC practice in both models. This may reassure medical schools considering early specialty preferences for admissions or entry into early, PC-pathway programs. Although clerkship experiences might influence students to change specialty interests, 5 to our knowledge, associations between clerkship experiences and PC practice have not been examined. We observed that students reporting excellent PC-clerkship experiences were more likely to report general-PC (vs non-PC) practice. Greater importance of social responsibility in choosing medicine also was positively associated with general-PC (vs non-PC) practice. Significance: Medical school experiences that are amenable to intervention were associated with greater odds of general-PC practice. Admitting students with early interest in PC specialties or who highly value social responsibility, fostering students’ plans to practice in underserved areas, 3,4 and improving PC-clerkship experiences may help mitigate the PC-physician shortage. Acknowledgments: The authors thank Hershel Alexander, PhD, Marie Caulfield, PhD (retired), David Matthew, PhD, and Lindsay Roskovensky, at the Association of American Medical Colleges (AAMC), for their efforts to obtain and prepare the deidentified datasets from various sources and their assistance with data coding; the National Board of Medical Examiners (NBME) Office for Research Strategy for permission to use Step 1 licensing examination data; Kristy Vanderplow at MMS, Inc., for provision of the American Medical Association (AMA) Physician Masterfile data; and Maria Pérez, MA, at Washington University School of Medicine, for data management and preparation of the data for analysis.

Expanded roles of registered nurses in primary care delivery of the future

To the Editor: The series of articles by Drs Schuman et al1-3 address an important issue in the training of family medicine (FM) doctors in occupational and environmental medicine (OEM). The teaching of OEM is variable in medical education throughout the world.4,5 In many countries, and OEM gap is apparent at both the undergraduate level in medical school, as well as the postgraduate level in FM training. We would like to share our experience on how this gap is bridged in Singapore. In the medical school in Singapore, both disciplines are taught primarily by the Department of Community, Occupational and Family Medicine. OEM training of medical undergraduates consists of a series of lectures based on an organ-systems approach. This is supplemented by small group tutorials on patients likely to be encountered in primary care and hospital practice, eg, those with contact dermatitis, anemia detected during pre-employment examination,6 and a visit to a workplace. One objective is to ensure that students are able to identify occupational factors in the causation of disease and recognize the need to consider occupational factors in the management of all patients. Another aim is for students to be aware of the importance of preventive measures for work-related illness and the promotion of health at work. The undergraduate FM curriculum includes formal teaching as well as practical training. In the practical training, there is a one-week posting to a family practice and another week at a government primary health care center. Cases seen during the postings are logged and discussed with the clinical tutor. In the teaching sessions, the impact of the work environment on disease etiology and management is discussed whenever relevant. At the postgraduate level, FM training is conducted by the School of Postgraduate Medical Studies of the university. In the curriculum, care of special groups of patients, including the worker, is specifically listed in the training requirements booklet. A module on OEM is mandatory in the training program. The OEM teaching, which is jointly given by OEM and FM physicians, includes slide quizzes on clinical cases seen in primary care practice. Subsequent discussion of these case studies centers around the clinical and OEM aspects. In addition, over 500 FM practitioners in the country (about one quarter of all FM practitioners) have undergone formal postgraduate training in OEM. This is because of a national statutory requirement for medical examinations among workers exposed to prescribed hazards (eg, noise, some heavy metals and chemicals). These FM practitioners have to complete an examinable 72-hour course in OEM successfully before they can register as Designated Factory Doctors (DFDs). In 1998, this course will be replaced with a 100-hour course leading to a postgraduate diploma in occupational medicine. Statutory medical examinations and certification for fitness to work in some occupations can only be performed by DFDs. As such, many employers prefer to appoint a DFD as their company contract doctor. While an OEM gap in medical and FM training may exist in many situations throughout the world, the experiences in South Carolina and in Singapore demonstrate that the problem is not insurmountable. An integrated clinical case-study approach in the training appears to be an effective way to reduce the OEM gap in primary care doctors. David Koh, MBBS, MSc, PhD Sin-Eng Chia, MBBS, MSc, MD Department of Community, Occupational and Family Medicine; Faculty of Medicine; National University of Singapore

The principal goals of health care reform are to improve quality, increase access, and contain costs. In this issue, Pham and colleagues calculated that a typical primary care clinician must coordi...

Exploring the Generalist-Subspecialist Interface in Internal Medicine

A shortage of primary care physicians (PCP) is present nationally and within Kentucky. The shortage is expected to worsen, unless a dramatic increase occurs in the generation of additional primary care clinicians. Geographical maldistributions of PCP also exist. Whereas 20% of the US population resides in rural areas, only 10% of physicians practice in these areas. This study explores factors that influence medical students’ decisions to select primary care residency training programs, and to practice in rural areas. Specifically, the levels of debt among 1391 graduates from University of Louisville School of Medicine (ULSOM) during 2001-2010 were examined in association with their selection of categories of residency training programs. Similarly, levels of debt among 1180 ULSOM graduates during 2001-2008 were examined in association with rural practice locations. Statistical methods included evaluations of receiver-operating curves (ROC) and multiple logistic regression analyses. The ROC analyses showed no association was present for any level of debt with either selection of primary care residency programs or rural practice sites. Multiple logistic regression analyses showed a statistically significant, positive association was present between the two extreme quintiles of medical students’ debt, whereby medical students in the lower quintile of debt were more likely select a primary care residency, compared to those students within the highest quintile. No statistically significant association was found for students’ debt with rural practice location. Multiple policy options to increase the primary care workforce were examined, including raising physicians’ reimbursements, shortening time for medical training, and altering how medical schools finance medical education. Policy makers may also consider the affinity model, whereby increasing medical school admissions among applicants from rural areas may result in greater numbers of PCP that are more likely to return to practice in rural areas. Similarly, programs to better support rural pipeline programs may be considered. Other policy solutions may include allowing nurse practitioners and other clinical personnel to work at the full scope of their training as well as a fuller utilization of health information technology. Addressing population health through the Triple Aim may provide novel solutions.

Introduction: Primary care physicians serve on the front lines of care and provide comprehensive care to patients who may have difficulty accessing subspecialists. However, not enough students are entering residency in primary care fields to meet the primary care physician shortage. The authors sought to compare primary care match rates among graduates of medical schools in the state of North Carolina from 2014 to 2018. Methods: The 4 allopathic medical schools in the state of North Carolina were selected for this study: East Carolina University (ECU) Brody School of Medicine, University of North Carolina (UNC) Chapel Hill, Duke School of Medicine, and Wake Forest School of Medicine. Primary care specialties were defined as family medicine, internal medicine, pediatrics, and internal medicine/pediatrics. The proportion of students matching to a residency in any of these fields, and in each specific field, was compared across schools. Results: Over 2014-2018, 214 ECU Brody School of Medicine graduates, 386 UNC graduates, 165 Duke graduates, and 196 Wake Forest graduates matched to a primary care specialty. ECU had the highest proportion of its graduates match in a primary care specialty (53%, compared with 34% to 45% at other schools; P < .001), and was particularly distinguished by having the highest proportions of graduates match to residencies in family medicine (18%) and pediatrics (16%). Conclusion: During the study period of 2014-2018, the ECU Brody School of Medicine matched more medical students into primary care specialties than the other medical schools in the state. This school’s community-driven mission and rural location, among other characteristics facilitating sustained student commitment to primary care careers, can inform the development of new medical schools in the United States to overcome the primary care physician shortage.

Registered nurses in primary care: A value proposition

In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu

Physician Assistants als Zukunftsmodell in der hausärztlichen Versorgung – Erfahrungen, Bedarfe, Potenziale und Hürden

This paper deals with the some of the important variable factors relating to health care in Saudi Arabia, with special emphasis on primary health. Other aspects considered are the financial influen...

The contributions of primary care to improvements in many aspects of population and individual health are well documented (Starfield, Shi, and Macinko 2005). In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population subgroups. The findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs. Studies within countries, including both industrialized as well as middle income and developing countries, are consistent in showing greater improvements in health consequent to legislative and administrative policy initiatives directed at strengthening primary care, including increases in the supply and use of primary care practitioners and clinical improvements in primary care practice. The special and critical features of primary care are well known and include first contact access and use of primary care facilities and practitioners; person-focused (not disease-focused) care over time; comprehensiveness of services available and provided within primary care; and coordination of services when they are needed elsewhere (Starfield, Shi, and Macinko 2005).