U.S. Medical Schools Still Underproducing Family Physicians
It marks the 35th year of an AAFP undertaking that involves researching statistics from all residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME).
Read the results of that work in an article titled "Entry of US Medical School Graduates Into Family Medicine Residencies: 2015-2016(stfm.cmail2.com)" in the October issue of Family Medicine.
Corresponding author Stan Kozakowski, M.D., director of the AAFP Division of Medical Education, told AAFP News the study provides insight into a longstanding problem in the U.S. graduate medical education system.
"This annual study is important because it represents one outcome measure of the efforts made by U.S. medical schools to produce family physicians," said Kozakowski. "It serves much like a barometer or dashboard dial to compare changes in this production over time."
The 2016 report offered a new twist that sets it apart from previous iterations.
"This is the first time that we have specifically looked at the production of family physicians by the medical schools in each state, including osteopathic medical schools," said Kozakowski.
"Our intention is to spark curiosity at a local level. We want state leaders to begin conversations about all their medical schools so they can learn from each other and try different approaches."
Healthy competition can be a positive motivator for learning and action, he added.
Kozakowski and his team noted in the article that the annual report is "one measure of the effectiveness of medical schools to produce a primary care workforce, a key measure of social responsibility, as measured by their production of graduates entering into family medicine."
They noted that primary care has been proven to improve patient outcomes, reduce health disparities and lower per-capita health care costs.
They pointed out that some states -- and certain medical schools -- do better when it comes to producing family physicians and can serve as models for other programs that need to implement strategies aimed at increasing the number of students who choose primary care and family medicine.
"The move toward a single graduate medical education accreditation system by 2020 presents an opportunity to facilitate the creation of an annual residency census for all U.S. family medicine residency programs," they wrote.
According to the study authors, in 2015, 3,594 medical school graduates entered ACGME-accredited family medicine residency programs as first-year residents. Of those
- 48 percent were graduates of U.S. M.D.-granting schools,
- 23 percent were from U.S. D.O.-granting schools and
- 29 percent were international graduates.
Authors pointed out that the percentage of U.S. M.D. graduates in residencies accredited by the ACGME has remained steady for a decade. However, they noted a reciprocal shift in numbers for the other two groups.
D.O. graduates increased by about 1 percent each year during the 10-year span (from 16 percent in 2005 to 23 percent in 2015), and international graduates decreased by 1 percent each year (from 38 percent in 2005 to 29 percent in 2015).
When the authors looked at the production of graduates who chose family medicine, U.S. D.O.-granting medical schools racked up nearly twice the percentage (15.5 percent of 5,314 graduates) compared to their M.D.-granting counterparts (8.7 percent of 18,929 graduates).
"There are four times as many M.D.-granting medical schools (134) as D.O.-granting medical schools (32)," wrote the authors, and yet "they produce only three and a half times as many total graduates compared to the DO-granting schools."
When combined, the schools graduated 24,243 medical students from July 2014 to June 2015, and of those, they produced 2,463 family medicine residents, or 10.2 percent of total graduates.
Furthermore, among the 134 M.D.-granting schools
- 10 schools accounted for 30 or more graduates entering family medicine,
- 70 schools produced 80 percent of new doctors who chose a family medicine residency, and
- six schools produced no family medicine residents.
The University of Minnesota Medical School in Minneapolis topped the list with 42 graduates choosing the specialty; the Uniformed Services University of the Health Sciences in Bethesda, Md., claimed the highest percentage at 19.8 percent.
D.O.-granting schools more than pulled their weight when it came to producing graduates pursuing family medicine. For instance,
- 19 of 32 schools with graduates in 2015 produced 80 percent of D.O. graduates entering the specialty;
- nine schools had 30 or more students enter family medicine;
- five international schools each produced 40 or more graduates entering family medicine residencies, and combined to account for 73 percent of the total number of international students choosing the specialty; and
- two of those international schools, Ross University School of Medicine in Portsmouth, Dominica, and St. George's University School of Medicine in True Blue, Grenada, each graduated more than 100 students who entered family medicine programs in 2015.
The authors singled out Des Moines University College of Osteopathic Medicine in Iowa as having both the most graduates (68) of any of the U.S. medical schools and the largest percentage of graduates (32.7 percent) entering family medicine.
In aggregate, schools located east of the Mississippi River had more than double the number of total graduates than did schools west of the river; they also counted 370 more graduates who entered family medicine.
However, pointed out the authors, schools west of the Mississippi had graduating students enter family medicine at a higher rate than their counterparts east of the river (10.8 percent versus 7.7 percent).
"States were ranked by the production of all medical students entering family medicine residencies from the M.D.- and D.O.-granting schools located within the state," said the researchers. They found that
- 51 percent of states and territories with medical schools produced 80 percent of the graduates entering ACGME-accredited family medicine programs,
- six states produced more than 100 such graduates, and
- seven states were below the national average of population-to-primary-care-physician ratio.
Those states -- Alabama, Florida, Georgia, Louisiana, Missouri, North Carolina and Ohio -- also claimed fewer than the national average of M.D.-medical school graduates choosing family medicine.
Iowa stood out as the only state with more than 20 percent of all graduates entering a family medicine program.
The article also sports numerous charts and graphs, including one that displays in ranked order U.S. M.D.-granting medical schools based on the past three years' average percentage of graduates who were family medicine residents.
The top five schools on that list are the University of Minnesota in Minneapolis, (19 percent) the University of Kansas in Lawrence, (17.8 percent), the University of North Dakota in Grand Forks (17.4 percent), East Carolina University in Greenville (16.7 percent), and the University of Washington in Seattle (16.6 percent).
The authors reiterated the widely known fact that most family medicine residents settle in to practice medicine within 100 miles of where they completed their residency training.
Notably, the percentage of students who graduated from M.D.-granting U.S. medical schools who remained in-state for residency ranged from a high of 68.8 percent in California to a low of 3.9 percent in Maryland.
Building the Primary Care Workforce
According to Kozakowski, "There continues to be widespread variation in the production of graduates choosing family medicine by region, state and school. In aggregate, our medical schools are failing to produce the physician workforce that this nation needs and deserves."
Moving forward, "There are opportunities to learn from those who seem to be more successful, try strategies implemented by successful schools and states, and measure the outcomes," he said.
Kozakowski would like to see the study data "activate" individuals across the country to recognize the success some schools and states have met, and then determine how to implement similar ideas in those less successful locations.
His take-home message for readers is that even though numerous studies have shown the value of family physicians in helping the country achieve the triple aim -- better health outcomes, better health care experiences and lower costs -- medical schools still lag behind in producing graduates who desire to practice family medicine.
"We need to get the right people into medical school, transform the training environment and improve the payment system," said Kozakowski.
The AAFP is doing its part to address all of these issues, but individual family physicians also have a role.
"Training the next generation of family physicians will require enthusiastic doctors who are able and willing to precept medical students in their practices," said Kozakowski. He acknowledged the demands of physicians' time and the "perceived burden" of inviting medical students into their practices.
"Students can and should add value to a practice. These students may turn out to be our future partners," he said.