Through its research efforts, the Robert Graham Center for Policy Studies in Family Medicine and Primary Care seeks to help inform policy solutions to the questions facing today’s primary care workforce. The Graham Center remains a leader in workforce analysis and application development intended to reveal the following: variations in primary care workforce; primary care provider-to-population ratios that optimize outcomes and align with need; factors that influence health care professionals’ decisions to practice in a primary care setting; maldistribution of physicians after they complete their training; and effectiveness of policies meant to expand and alter the primary care workforce.

Workforce Projections

Primary care physician (PCP) workforce shortages challenge the long-term viability of U.S. primary care. Using state and national data, the Graham Center projects to 2030 the state PCP workforce necessary to maintain current primary care utilization rates, accounting for increased demand due to aging, population growth, and an increasingly insured population due to the Affordable Care Act.

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Workforce at the State Level

Many decisions that affect the health care workforce occur at the state level. The Graham Center has been called upon to help states and regions plan for the best and most efficient health care workforce, provide the best access to care for local populations, and contribute to improving health in communities. Communities that the Graham Center has worked with include New Orleans, Louisiana; Rhode Island; and North Carolina.

Primary Care Physician Mapper

This mapping program illustrates the distribution of primary care physicians by state, county, or census tracts in metropolitan areas. The physician data source is the National Provider Identifier (NPI), maintained by the Centers for Medicare & Medicaid Services (CMS). Any provider who bills Medicare, Medicaid, or certain private insurance companies is counted in the NPI dataset.

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Narrow Results:

  • Opting Out of Medicaid Expansion May Cost States Additional Primary Care Physicians

    One Pagers | Jan 01, 2015 | Mark W. Lin, MD; Stephen Petterson, Phd; Claire Gibbons, Phd; Sean Finnegan, MS; Andrew Bazemore, MD, MpH

    States currently electing not to expand Medicaid possibly forego the opportunity to expand their primary care workforces by a total of 1,525 physicians. Increased demand from expansion states and a limited primary care physician pool may provide a pull across state lines to the disadvantage of nonexpansion states.

  • Trends in Office-Based Care for Reproductive-Aged Women According to Physician Specialty: A Ten-Year Study

    Articles | Dec 23, 2014 | Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSHP; and William Rayburn, MD

    The anticipated increase in access to health care has prompted an interest in where women go for their office-based care. The objectives of this study were to examine which types of office site are chosen by reproductive-aged women for their health care and to compare the reasons for their visits among these sites.

  • Do Residents Who Train in Safety Net Settings Return for Practice?

    Articles | Dec 15, 2014 | X

    This study examines the relationship between training during residency in a federally qualified health center (FQHC), rural health clinic (RHC), or critical access hospital (CAH) and subsequent practice in these settings.

  • Trends in Physician House Calls to Medicare Beneficiaries

    Articles | Nov 30, 2014 | Lars Peterson, MD, PhD; Stephen Landers, Andrew Bazemore, MD, MPH

    House calls (HCs) to older adults seemed to be headed for extinction in recent decades. HCs may be a tool to ensure access and reduce institutionalization of the elderly population. This study determines the number and distribution of HCs by physician specialty over time and analyzes associations of providing HCs with physician and area-level characteristics.

  • General internists and family physicians: Partners in geriatric medicine?

    Commentaries & Editorials | Nov 30, 2014 | James W. Mold, MD, MPH, Larry A. Green, MD, and George E. Fryer, PhD

    General internists and family physicians: Partners in geriatric medicine?

  • Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions 

    Articles | Sep 15, 2014 | Candice Chen, MD, MPH; Stephen Petterson, PhD; Robert L. Phillips, MD, MSPH; Fitzhugh Mullan, MD; Andrew Bazemore, MD, MPH; and Sarah D. O’Donnell, MPH.

    This study developed and tested candidate GME outcome measures related to physician workforce. The findings can inform educators and policy makers during a period of increased calls to align the GME system with national health needs.

  • Factors Influencing Family Physicians’ Contribution to the Child Health Care Workforce

    Articles | Sep 15, 2014 | Laura A. Makaroff, DO; Imam M. Xierali, PhD; Stephen M. Petterson, PhD, MPH; Scott A. Shipman, MD, MPH; James C. Puffer, MD; and Andrew W. Bazemore, MD, MPH

    This article explores demographic and geographic factors associated with family physicians’ provision of care to children.

  • One in Fifteen Family Physicians Principally Provide Emergency or Urgent Care

    Articles | Aug 01, 2014 | Stephen Petterson, PhD; Lars Peterson, MD, PhD; Robert L. Phillips, MD, MSHP; Miranda Moore, PhD; Sean Finnegan, MS; Megan Coffman, MS; and Andrew Bazemore, MD, MPH

    A small but nontrivial proportion of US family physicians devote most of their time providing emergency or urgent care. With considerable attention focused on expanding access to primary care, it is important to account for providers principally working outside of traditional primary care.

  • Doctors Treating Their Families

    Commentaries & Editorials | Jun 15, 2014 | Douglas Kamerow, MD, MPH

    The American Medical Association states that “physicians generally should not treat themselves or members of their immediate families.” Reasons cited include the doctor’s possible lack of professional objectivity, potential failure to probe sensitive topics or perform an intimate examination, and possible feeling of obligation to perform care for which he or she is unqualified. Despite these stated—and oftentimes valid—concerns, many doctors in America admit to treating their families, neighbors, and friends.

  • Making the Case: Family Medicine for America's Health53 page PDF

    Presentations | Apr 15, 2014 | Andrew Bazemore, MD, MPH

  • Trends in Family Physicians Performing Deliveries, 2003-2010

    Articles | Mar 15, 2014 | William F. Rayburn MD, MBA; Stephen M. Petterson PhD; and Robert L. Phillips MD, MSPH

    This observational study examined the proportion of family physicians continuing to perform deliveries from 2003–2010. Presented at the 9th annual Association of American Medical Colleges Physician Workforce Research Conference, Alexandria, Virginia, USA, May 2, 2013.

  • Patients with High-Cost Chronic Conditions Rely Heavily on Primary Care Physicians

    Articles | Jan 15, 2014 | Manisha, Sharma, MD; Newton Cheng, MS; Miranda Moore, PhD; Megan Coffman, MS; and Andrew Bazemore, MD, MPH

    Today’s US physician workforce principally comprises specialists trained in the care of specific chronic conditions in the outpatient setting. However, a majority of patients seeking care for most of 14 high-cost chronic conditions were more likely to see a primary care physician than a specialist physician.

  • Migration After Family Medicine Residency: 56% of Graduates Practice Within 100 Miles of Training

    One Pagers | Nov 15, 2013 | E. Blake Fagan, MD; Sean C. Finnegan, MS; Andrew W. Bazemore, MD, MpH; Claire B. Gibbons, Phd, MpH; And Stephen M. Petterson, Phd

    Using the 2009 American Medical Association Physician Masterfile, this one-pager notes that 56% of family medicine residents stay within 100 miles of where they graduate from residency.

  • Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends.

    Articles | Nov 15, 2013 | Sebastian Tong, MD, MPH; Laura Makaroff, MD, MPH; Imam Xierali, PhD; James Puffer, MD; Warren Newton, MD; and Andrew Bazemore, MD, MPH

    Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010.

  • State Patterns in Medical School Expansion, 2000-2010: Variation, Discord, and Policy Priorities

    Articles | Oct 15, 2013 | Adler, Benjamin; Biggs, Wendy S. MD; Bazemore, Andrew W. MD, MPH

    This study used established national health workforce and training site datasets to compare total medical school enrollment (2000-2010) with change in population, medical student retention in state (those returning to practice in the state where they graduated), and primary care supply.

  • Historic Growth Rates Vary Widely Across the Primary Care Physician Disciplines

    One Pagers | Oct 01, 2013 | Laura A. Makaroff, DO; Larry A. Green, MD; Stephen M. Petterson, PhD; James C. Puffer, MD; Robert L. Phillips, MD, MSPH; and Andrew W. Bazemore, MD, MPH.

    With continued population aging trends, low annual birth rate, and expected health insurance expansion, it is vital that physician workforce policy be aimed at meeting population needs to deliver optimal primary care. To better understand trends in the primary care physician workforce, we have examined the growth of family physicians, general pediatricians, and general internists providing direct patient care.

  • Relying on NPs and PAs Does Not Avoid the Need for Policy Solutions for Primary Care

    One Pagers | Aug 15, 2013 | Stephen M. Petterson, PhD; Robert L. Phillips, Jr., M.D., MSPH; Andrew W. Bazemore, M.D., MPH; Bridget Teevan Burke, MPH, MS; Gerald T. Koinis, BA

    Physician assistants (PAs) and nurse practitioners (NPs) are often proposed as solutions to the looming shortage of primary care physicians. However, a large and growing number of PAs and NPs now work outside of primary care, which suggests that innovative policy solutions to increase access to primary care are still needed.

  • A Needs-Based Method for Estimating the Behavioral Health Staff Needs of Community Health Centers

    Articles | Jul 15, 2013 | Bridget Teevan Burke, Benjamin F Miller, Michelle Proser, Stephen M Petterson, Andrew W Bazemore, Eric Goplerud and Robert L Phillips.

    Federally Qualified Health Centers are expanding to increase access for millions of more Americans with a goal of doubling capacity to serve 40 million people. Health centers provide a lot of behavioral health services but many have difficulty accessing mental health and substance use professionals for their patients. To meet the needs of the underserved and newly insured it is important to better estimate how many behavioral health professionals are needed.

  • Factors Influencing Family Physician Adoption of Electronic Health Records (EHRs)

    Articles | Jul 15, 2013 | Xierali IM, Phillips RL Jr, Green LA, Bazemore AW, Puffer JC.

    Physician and practice characteristics associated with family physician adoption of electronic health records (EHRs) remain largely unexplored but may be important for tailoring policies and interventions. Variation in EHR adoption is associated with physician and practice characteristics that may help guide intervention.

  • Unequal Distribution of the U.S. Primary Care Workforce

    One Pagers | Jun 01, 2013 | Stephen M. Petterson, PhD; Robert L. Phillips, Jr., MD, MSPH; Andrew W. Bazemore, MD, MPH; Gerald T. Koinis, BA

    The United States is facing a primary care physician shortage, but the most pressing problem is uneven distribution, particularly in poor and rural communities. Providing adequate access to care for the nearly 30 million uninsured people living in these communities will require potent incentives and policy.

  • The Association Between Global Health Training and Underserved Care: Early Findings From Two Longstanding Tracks

    Articles | Apr 15, 2013 | Liaw W, Bazemore A, Xierali I, Walden J, Diller P, Morikawa MJ.

    Global health tracks (GHTs) improve knowledge and skills, but their impact on career plans is unclear. The objective of this analysis was to determine whether GHT participants are more likely to practice in underserved areas than nonparticipants. In this retrospective cohort study, using the 2009 American Medical Association Masterfile, we assessed the practice location of the 480 graduates from 1980--2008 of two family medicine residencies-Residency 1 and Residency 2. The outcomes of interest were the percentage of graduates in health professional shortage areas (HPSAs), medically underserved areas (MUAs), rural areas, areas of dense poverty, or any area of underservice.

  • Trends in Physician Supply and Population Growth

    Articles | Apr 15, 2013 | Makaroff LA, Green LA, Petterson SM, Bazemore AW.

    The physician workforce has steadily grown faster than the U.S. population over the past 30 years, context that is often absent in conversations anticipating physician scarcity. Policy makers addressing future physician shortages should also direct resources to ensure specialty and geographic distribution that best serves population health.

  • Family Physicians Are Essential for Mental Health Care Delivery

    Articles | Apr 15, 2013 | Imam M. Xierali, PhD, Sebastian T. Tong, MD, MPH, Stephen M. Petterson, PhD, James C. Puffer, MD, Robert L. Phillips Jr., MD, MSPH and Andrew W. Bazemore, MD, MPH

    As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing mental health care, especially in rural and underserved areas. However, the proportion of family physicians who report providing mental health care is low. Policy barriers such as payment for mental health services should be explored to ensure access to mental health care for patients across the urban to rural continuum.

  • Trends in Physician Supply and Population Growth

    One Pagers | Apr 01, 2013 | Laura A. Makaroff, Do; Larry A. Green, Md; Stephen M. Petterson, Phd; Andrew W. Bazemore, Md

    The physician workforce has steadily grown faster than the U.S. population over the past 30 years, context that is often absent in conversations anticipating physician scarcity. Policy makers addressing future physician shortages should also direct resources to ensure specialty and geographic distribution that best serves population health.

  • The Redistribution of Graduate Medical Education Positions in 2005 Failed to Boost Primary Care or Rural Training

    Articles | Jan 15, 2013 | Chen C, Xierali I, Piwnica-Worms K, Phillips R.

    Graduate medical education (GME), the system to train graduates of medical schools in their chosen specialties, costs the government nearly $13 billion annually, yet there is little accountability in the system for addressing critical physician shortages in specific specialties and geographic areas. Medicare provides the bulk of GME funds, and the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 redistributed nearly 3,000 residency positions among the nation's hospitals, largely in an effort to train more residents in primary care and in rural areas. However, when we analyzed the outcomes of this recent effort, we found that out of 304 hospitals receiving additional positions, only 12 were rural, and they received fewer than 3 percent of all positions redistributed. Although primary care training had net positive growth after redistribution, the relative growth of nonprimary care training was twice as large and diverted would-be primary care physicians to subspecialty training. Thus, the two legislative and regulatory priorities for the redistribution were not met. Future legislation should reevaluate the formulas that determine GME payments and potentially delink them from the hospital prospective payment system. Furthermore, better health care workforce data and analysis are needed to link GME payments to health care workforce needs.

  • A Small Percentage of Family Physicians Report Time Devoted to Research

    Articles | Jan 15, 2013 | Voorhees JR, Xierali IM, Bazemore AW, Phillips RL Jr, Jaén CR, Puffer JC.

    Despite calls by family medicine organizations to build research capacity within the discipline, few family physicians report research activity. Policy that supports efforts in family medicine research and increases awareness of opportunities for primary care research in the practice setting is essential for family medicine to expand its scholarly foundations.

  • Engagement of Family Physicians in Maintenance of Certification Remains High

    Articles | Dec 15, 2012 | James Puffer, MD; Andrew Bazemore, MD, MPH; CR Jaén CR, Imam Xierali, PhD; Robert Phillips, MD, MSHP; and SM Jones

    Maintenance of Certification for Family Physicians was created to enhance the quality of care delivered by family physicians but risked decreasing their engagement due to the increased burden of meeting additional requirements to remain board-certified. Participation by family physicians in Maintenance of Certification remains higher than predicted.

  • Projecting US Primary Care Physician Workforce Needs: 2010-2025

    Articles | Nov 15, 2012 | Stephen M. Petterson, PhD; Winston R. Liaw, MD, MPH; Robert L. Phillips, Jr, MD, MSPH; David L. Rabin, MD, MPH; David S. Meyers; Andrew W. Bazemore, MD, MPH.

    Researchers project the United States will need 52,000 additional primary care physicians by 2025 — a 25 percent increase in the current workforce — to address the expected increases in demand due to population growth, aging, and insurance expansion following passage of the Affordable Care Act. Analyzing nationally representative data, the researchers conclude population growth will be the single greatest driver of increased primary care utilization, requiring approximately 33,000 additional primary care physicians by 2025, while 10,000 additional physicians will be needed to accommodate population aging. Insurance expansion, they estimate, will require approximately 8,000 additional primary care physicians, a 3 percent increase in the current workforce.

  • The Percentage of Family Physicians Attending to Women's Gender-Specific Health Needs is Declining

    Articles | Jun 15, 2012 | Imam M. Xierali, PhD; James C. Puffer, MD; Sebastian T. C. Tong, BA; Andrew W. Bazemore, MD, MPH; and Larry A. Green, MD

    As the largest and most widely distributed of primary care physicians, family physicians have an important role in providing women's health care, especially in rural and underserved areas. The proportion of family physicians who are attending to women is declining. Policy intervention may be needed to help family physicians maintain the comprehensiveness of care necessary to address the wide range of medical problems of women they encounter within their practices.

  • Communities of Solution: The Folsom Report Revisited

    Articles | May 15, 2012 | Sarah Lesko, MD, MPH; Kim S. Griswold, MD, MPH; Sean P. David, MD, SM, DPhil; Andrew W. Bazemore, MD, MPH; Marguerite Duane, MD, MHA; Thomas Morgan, MD; John M. Westfall, MD, MPH; C. Everett Koop, MD, SciD; Betsy Garrett, MD; James C. Puffer, MD; and Larry A. Green, MD

    Efforts to address the current fragmented US health care structure, including controversial federal reform, cannot succeed without a reinvigoration of community-centered health systems. A blueprint for systematic implementation of community services exists in the 1967 Folsom Report—calling for “communities of solution.” We propose an updated vision of the Folsom Report for integrated and effective services, incorporating the principles of community-oriented primary care. The 21st century primary care physician must be a true public health professional, forming partnerships and assisting data sharing with community organizations to facilitate healthy changes. Current policy reform efforts should build upon Folsom Report’s goal of transforming personal and population health.

  • Proportion of Family Physicians Providing Maternity Care Continues to Decline

    Articles | May 15, 2012 | Sebastian T. C. Tong, BA; Laura A. Makaroff, DO; Imam M. Xierali, PhD; Parwen Parhat, MA; James C. Puffer, MD; Warren P. Newton, MD, MPH; and Andrew W. Bazemore, MD, MPH

    Family physicians traditionally have played an integral role in delivering babies as a component of the comprehensive care they provide for women. The proportion of family physicians who report providing any maternity care continues to decrease. This trend is particularly concerning because family physicians are the most widely distributed specialty and are essential to health care access in rural areas.

  • Medical School Rural Programs: A Comparison with International Medical Graduates in Addressing State-Level Rural Family Physician and Primary Care Supply

    Articles | Apr 15, 2012 | Howard K. Rabinowitz, MD; Stephen Petterson, PhD; James G. Boulger, PhD; Matthew L. Hunsaker, MD; James J. Diamond, PhD; Fred W. Markham, MD; Andrew Bazemore, MD, MPH; and Robert L. Phillips, Jr. MD, MSPH

    Purpose: 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. Method: Using data from the 2010 American Medical Association Physician Masterfile, the authors identified all 1,757 graduates from three RPs (Jefferson Medical College's Physician Shortage Area Program; University of Minnesota Medical School Duluth; University of Illinois College of Medicine at Rockford's Rural Medical Education Program) practicing in their respective states, and all 6,474 IMGs practicing in the same states and graduating the same years. The relative likelihoods of RP graduates versus IMGs practicing rural family medicine and rural primary care were compared. Results: RP graduates were 10 times more likely to practice rural family medicine than IMGs (relative risk [RR] = 10.0, confidence interval [CI] 8.7-11.6, P <.001) and almost 4 times as likely to practice any rural primary care specialty (RR 3.8, CI 3.5-4.2, P <.001). Overall, RPs produced more rural family physicians than the IMG cohort (376 versus 254). Conclusions: Despite their relatively small size, RPs had a significant impact on rural family physician and primary care supply compared with the much larger cohort of IMGs. Wider adoption of the RP model would substantially increase access to care in rural areas compared with increasing reliance on IMGs or unfocused expansion of traditional medical schools.

  • The Next Phase of Title VII Funding for Training Primary Care Physicians for America's Health Care Needs

    Articles | Mar 15, 2012 | Robert L. Phillips Jr, MD, MSPH, and Barbara J. Turner, MD, MSED

    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 747 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. To accomplish these goals, Congress should act on the Council on Graduate Medical Education's recommendation to increase funding for Title VII, Section 747 roughly 14-fold to $560 million annually. 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 747 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.

  • Declining Numbers of Family Physicians are Caring for Children

    Articles | Mar 15, 2012 | Andrew W. Bazemore, MD, MPH; Laura A. Makaroff, DO; James C. Puffer, MD; Parwen Parhat, MA; Robert L. Phillips, MD, MSPH; Imam M. Xierali, PhD; and Jason Rinaldo, PhD

  • Refocusing Geriatricians’ Role in Training to Improve Care for Older Adults

    One Pagers | Jan 01, 2012 | Elizabeth J. Bragg, PhD, RN; Gregg A. Warshaw, MD; Stephen M. Petterson, PhD; Imam M. Xierali, PhD; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr., MD, MSPH

    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.

  • Comprehensive medical School Rural Programs Produce Rural Family Physicians

    One Pagers | Dec 15, 2011 | Howard K. Rabinowitz, MD; Stephen Petterson, PhD; James G. Boulger, PhD; Matthew L. Hunsaker, MD; Fred W. Markham, MD; James J. Diamond, PhD; Andrew Bazemore, MD, MPH; Robert L. Phillips, Jr., MD, MSPH

    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.

  • Research Productivity of Senior General Practice Academicians in Australia, Canada, England/Wales, New Zealand, Scotland, and the U.S.22 page PDF

    Presentations | Nov 15, 2011 | Susan Dovey, PhD; Andrew W. Bazemore, MD, MPH; Winston Liaw, MD, MPH; Robert L. Phillips, Jr., MD, MSPH

  • What Services Do Family Physicians Provide in a Time of Primary Care Transition?

    Articles | Nov 15, 2011 | Andrew W. Bazemore; Stephen Petterson; Nicole Johnson; Imam M. Xierali; Robert L. Phillips, Jr.; Jason Rinaldo; James C. Puffer; and Larry A. Green.

    The Future of Family Medicine Report envisioned a new model of practice “committed to providing the full basket of clinical services offered by Family Medicine.” In actuality, variation in that basket is considerable and may influence patients’ access to care as much as supply and distribution of physicians does in the wake of health care reform.

  • Rewarding Family Medicine While Penalizing Comprehensiveness? Primary Care Payment Incentives and Health Reform: The Patient Protection and Affordable Care Act (PPACA)

    Articles | Nov 15, 2011 | Stephen Petterson; Andrew W. Bazemore; Robert L. Phillips, Jr.; Imam M. Xierali; Jason Rinaldo; Larry A. Green; and James C. Puffer.

    Family physicians’ scope of work is exceptionally broad, particularly with increasing rurality. 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.

  • Family Physician Participation in Maintenance of Certification

    Articles | May 15, 2011 | Imam M. Xierali, PhD; Jason C. B. Rinaldo, PhD; Larry A. Green, MD; Stephen M. Petterson, PhD; Robert L. Phillips Jr, MD, MSPH; Andrew W. Bazemore, MD, MPH; Warren P. Newton, MD; and James C. Puffer, MD

    Purpose: The American Board of Family Medicine has completed the 7-year transition of all of its diplomates into Maintenance of Certification (MOC). Participation in this voluntary process must be broad-based and balanced for MOC to have any practical national impact on health care. This study explores family physicians’ geographic, demographic, and practice characteristics associated with the variations in MOC participation to examine whether MOC has potential as a viable mechanism for dissemination of information or for altering practice. Methods: 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. Results: Eighty-five percent of active family physicians in this study (n = 70,323) have current board certification. Ninety-one percent of all active board-certified family physicians eligible for MOC are participating in MOC. Physicians who work in poorer neighborhoods (odds ratio [OR] = 1.105; 95% confidence interval [CI], 1.038–1.176), who are US-born or foreign-born international medical graduates (OR = 1.221; 95% CI, 1.124–1.326; OR = 1.444; 95% CI, 1.238–1.684, respectively), or who are solo practitioners (OR = 1.460; 95% CI, 1.345–1.585) are more likely to have missed initial MOC requirements than those from a large, undifferentiated reference group of certified family physicians. When age is held constant, female physicians are less likely to miss initial MOC requirements (OR = 0.849; 95% CI, 0.794–0.908). Physicians practicing in rural areas were found to be performing similarly in meeting initial MOC requirements to those in urban areas (OR = 0.966; 95% CI, 0.919–1.015, not significant). Conclusion: 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.

  • Evidence About the Role of the PCMH and ACOs in Improving Quality and Safety36 page PDF

    Presentations | May 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • Innovations in Family Medicine Education: Early Learnings from the P4 Initiative18 page PDF

    Presentations | May 15, 2011 | Samuel M. Jones, MD; Warren Newton, MD, MPH

  • Accounting for Graduate Medical Education production of primary care physicians and general surgeons: Timing of measurement matters

    Articles | May 15, 2011 | S Petterson; M Burke; RL Phillips; and B Teevan

    PURPOSE: Legislation proposed in 2009 to expand GME set institutional primary care and general surgery production eligibility thresholds at 25% at entry into training. 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. METHOD: Production of primary care physicians and general surgeons was assessed by retrospective analysis of the 2009 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 2005-2007 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. RESULTS: Of 116,004 physicians completing their first residency, 54,245 (46.8%) were in primary care and general surgery. Of 683 training institutions, 586 met the 25% threshold for expansion eligibility. At two to four years out, only 29,963 physicians (25.8%) remained in primary care or general surgery, and 135 institutions lost eligibility. A 35% threshold eliminated 314 institutions collectively training 93,774 residents (80.8%). CONCLUSIONS: 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.

  • FPs Lower Hospital Readmission Rates and Costs

    One Pagers | May 01, 2011 | Veerappa K. Chetty, PhD; Larry Culpepper, MD, MPH; Robert L. Phillips, Jr., MD, MSPH; Jennifer Rankin, PhD, MPH, MS, MHA; Imam Xierali, PhD; Sean Finnegan, BS; and Brian Jack, MD

    Hospital readmission after discharge is often a costly failing of the U.S. health care system to adequately manage patients who are ill. Increasing the number of family physicians (FPs) is associated with significant reductions in hospital readmissions and substantial cost savings.

  • Rural-Urban Distribution of the U.S. Geriatrics Physician Workforce

    Articles | Apr 15, 2011 | LE Peterson; A Bazemore; EJ Bragg; I Xierali; and GA Warshaw

    OBJECTIVES: To determine the distribution of geriatricians across the rural-urban continuum from 2000 to 2008 and to compare with primary care physicians in 2008. DESIGN: County-level analysis of physician data from the American Medical Association Physician Masterfile for 2000, 2004, and 2008 merged with U.S. Census data on the number of older (≥65) county residents. Descriptive statistics for each year were stratified according to 2003 Rural Urban Continuum Codes (RUCCs). SETTING: United States. PARTICIPANTS: Physicians in the United States. MEASUREMENTS: Number of physicians per county elderly population. RESULTS: The number of self-identified geriatricians nationwide increased from 5,157 to 7,412 from 2000 to 2008. The number of geriatricians increased in each RUCC level, with nearly 90% of geriatricians residing in urban areas in all years. In 2008, the number of geriatricians per 10,000 older adults declined as rurality increased (from 1.48 in the most-urban areas to 0.80 in the most rural). General internal medicine physicians are more plentiful in urban counties and declined as rurality increased (from 27.29 to 3.85 per 10,000 older adults in 2008). In contrast, family physicians were more evenly distributed with the elderly population across the rural-urban continuum (22.02 to 14.27 per 10,000 older adults in 2008). CONCLUSION: 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.

  • Paul Ambrose Spring Forum: Primary Care Present and Future43 page PDF

    Presentations | Apr 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • Establishing a Baseline: Health Information Technology Adoption Among Family Medicine Diplomates

    Articles | Mar 15, 2011 | A Bazemore; M Burke; I Xierali; S Petterson; J Rinaldo; LA Green; and J Puffer

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  • Evidence About Your Value (and the Return on Investment)43 page PDF

    Presentations | May 15, 2011 | Robert L. Phillips, Jr., MD, MSPH

  • Primary Care and Health Care Reform43 page PDF

    Presentations | Sep 15, 2010 | Kevin Burke and Andrew Bazemore, MD, MPH

  • Income Disparities Shape Medical Student Specialty Choice

    One Pagers | Sep 15, 2010 | Venis Wilder, MD; Martey S. Dodoo, PhD; Robert L. Phillips, Jr., MD, MSPH; Bridget Teevan, MS; Andrew W. Bazemore, MD, MPH; Stephen M. Petterson, PhD; and Imam Xierali, PhD

    Currently, a gap of more than $135,000 separates the median annual subspecialist income from that of a primary care physician, yielding a $3.5 million difference in expected income over a lifetime. These income disparities dissuade medical students from selecting primary care and should be addressed to ensure sufficient patient access to primary care.

  • Building the Research Culture of Family Medicine with Fellowship Training

    Articles | Aug 15, 2010 | Shannon K. Bolon and Robert L. Phillips, Jr.

    Background and Objectives: 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. This study’s objectives are to (1) identify fellowship programs available to family physicians, (2) explore how family medicine fellows are taught research skills, and (3) identify obstacles to enhancing research training in fellowships. Methods: Fellowship programs available to family physicians were identified by Internet searches and confirmed by telephone or e-mail. Directors of identified fellowships received a 33-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. Results: We confirmed that 247 of 328 identified research fellowships are available to family physicians. Survey response rate from those 247 fellowships was 65%. 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. Conclusions: 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.

  • Loss of Primary Care Residency Positions Amidst Growth in Other Specialties

    One Pagers | Jul 15, 2010 | Nicholas A. Weida, BA; Robert L. Phillips, Jr., MD, MSPH; Andrew W. Bazemore, MD, MPH;, Martey S. Dodoo, PhD; Stephen M. Petterson, PhD; Imam Xierali, PhD; and Bridget Teevan, MS

    Since the 1997 Balanced Budget Act capped funding for graduate medical education (GME) programs, overall growth in GME has continued (+7.8 percent), but primary care specialties have experienced a substantial decline in their number of programs and residency positions. This decline will further exacerbate the current primary care shortage and severely affect future projections of primary care shortage.

  • The Social Mission of Medical Education: Ranking the Schools

    Articles | Jun 15, 2010 | Mullan F; Chen C; Petterson S; Kolsky G; and Spagnola M

    BACKGROUND: 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. OBJECTIVE: To develop a metric called the social mission score to evaluate medical school output in these 3 dimensions. DESIGN: Secondary analysis of data from the American Medical Association (AMA) Physician Masterfile and of data on race and ethnicity in medical schools from the Association of American Medical Colleges and the Association of American Colleges of Osteopathic Medicine. SETTING: U.S. medical schools. PARTICIPANTS: 60,043 physicians in active practice who graduated from medical school between 1999 and 2001. MEASUREMENTS: 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. RESULTS: 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. LIMITATIONS: 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. CONCLUSION: 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.

  • Does Graduate Medical Education Also Follow Green?

    Articles | Feb 15, 2010 | Nicholas A. Weida, BA; Robert L. Phillips Jr, MD, MSPH; and Andrew W. Bazemore, MD, MPH

    Teaching hospitals have favored higher revenue generating specialty training over primary care positions. Expansion of positions in the “R.O.A.D.” disciplines (radiology, ophthalmology, anesthesia, and dermatology) and emergency medicine over the last 10 years parallels losses in family medicine, general pediatrics, and general internal medicine. 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.

  • American Board of Family Medicine (ABFM) Maintenance of Certification: Variations in Self-Assessment Modules Uptake Within the 2006 Cohort

    Articles | Jan 15, 2010 | Andrew W. Bazemore, MD, MPH, Imam M. Xierali, PhD, Stephen M. Petterson, PhD, Robert L. Phillips, Jr, MD, MSPH, FAAFP, Jason C.B. Rinaldo, PhD, James C. Puffer, MD and Larry A. Green, MD

    Introduction: 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 use geographic information systems to report on variations in SAM participation and completion in a single cohort of diplomates followed during their first stage of MC-FP to better understand the communities impacted, barriers to uptake, and urban-rural differences. Methods: We merged data from 2006 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. Results: The cohort comprised 10,812 participants who passed their certification or recertification examination in 2005, of which 30.5% did not complete their MC-FP requirements by the end of 2008. Noncompleters were more likely to be older (P < .01), men (P < .0001), and from areas of dense poverty (P < .01) and underserved areas (P < .05). There were no significant differences in MC-FP completion across the rural-urban continuum (P = .7108). Conclusions: More than two-thirds of eligible, certified family physicians completed stage-one MC-FP requirements. Concerns that technical aspects of the new MC-FP paradigm would leave parts of a widely distributed, poorly resourced primary care workforce disadvantaged may hold true for providers in some underserved areas, but differential completion among rural and remote physicians was not found. Understanding barriers to uptake is essential if the specialty boards are to meet their obligations to the public to promote quality of care through Maintenance of Certification for all physicians.

  • Family Physicians' Present and Future Role in Caring for the Elderly

    One Pagers | Nov 15, 2009 | Lars E. Peterson, MD, PhD; Andrew W. Bazemore, MD, MPH; Robert L. Phillips Jr., MD, MSPH; Bridget Teevan, MS; Martey S. Dodoo, PhD; Imam Xierali, PhD; and Stephen M. Petterson, PhD

    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

  • Estimated Effects of "America's Affordable Health Choices Act of 2009"10 page PDF

    Monographs & Books | Sep 15, 2009 | Robert Graham Center

  • Are Medicare GME Policies Adequate to Meet the Rising Need for Primary Care Physicians?22 page PDF

    Presentations | Aug 15, 2009 | Bob Phillips, MD, MSPH

  • Effects of proposed primary care incentive payments on average physician Medicare revenue and total Medicare allowed charges14 page PDF

    Monographs & Books | May 15, 2009 | Robert Graham Center

  • What influences medical student and resident choices?41 page PDF

    Presentations | Apr 15, 2009 | Bridget Teevan, MS

  • Is Colorado Ready for a Primary Care-based Health Care System?72 page PDF

    Presentations | Apr 15, 2009 | Bob Phillips, MD MSPH and Andrew Bazemore, MD MPH

  • Medical school expansion, primary care, and policy: Engaging primary care educators in evidence-based advocacy68 page PDF

    Presentations | Apr 15, 2009 | Andrew Bazemore, MD, MPH; Julie Phillips, MD, MPH; Amy McGaha, MD; Hope Wittenberg, MA

  • The Robert Graham Center Update: A Primary Care Perspective on Health Care Workforce and Expenditures50 page PDF

    Presentations | Mar 15, 2009 | Robert Graham Center

  • Health Care: The Next Mortgage Crisis32 page PDF

    Presentations | Mar 15, 2009 | ichael Fine, MD, and Shannon Brownlee, MS

  • Usual Source of Care: An Important Source of Variation in Health Care Spending

    Articles | Mar 15, 2009 | Bob Phillips, MD, MSPH; Martey Dodoo, PhD; Larry A Green, MD; George E Fryer, PhD; Andrew Bazemore, MD, MPH; Kristin McCoy; and Stephen Petterson, PhD

    Health care spending varies in unexplained ways, and physicians’ behavior is thought to explain much of the variation. 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 2001–2004 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.

  • What Influences Medical Student & Resident Choices?102 page PDF

    Monographs & Books | Mar 15, 2009 | Robert Graham Center

  • How Can Primary Care Cross the Quality Chasm?

    Articles | Mar 15, 2009 | Solberg LI; Elward KS; Phillips WR; Gill JM; Swanson G; Main DS; Yawn BP; Mold JW; and Phillips RL Jr

    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. If we are to facilitate the production and use of the knowledge needed for primary care to cross IOM’s chasm, major changes are needed. These changes include the following: (1) admission by all primary care professions that we have quality problems that require our unified attention and action; (2) conversion of the paradigm from “translate research into practice” to “optimizing health and health care through research and QI”; (3) development and facilitation of more partnerships among clinicians, researchers, and care delivery leaders for engaged scholarship in both research and QI; (4) modification of the agendas and methods of funders and researchers so they emphasize the problems of patients and patient care and support practical time frames and research designs; and (5) facilitation by funders and journals of the dissemination and implementation of lessons from QI and practical research.

  • Family Medicine, the NIH, and the Medical-Research Roadmap: Perspectives from Inside the NIH

    Articles | Mar 15, 2009 | Sean C. Lucan, MD, MPH; Frances K. Barg, PhD, MEd; Andrew W. Bazemore, MD, MPH; and Robert L. Phillips, Jr, MD, MSPH

    PURPOSE: Family medicine has had little engagement with the National Institutes of Health (NIH), and it is unclear what NIH officials think about this. METHODS: Purposive sampling identified 13 key informants at NIH for open-ended, semi-structured interviews. Evaluation was by content analysis. RESULTS: 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. CONCLUSIONS: 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. Greater self-advocacy, research training, and developing areas of expertise may improve family medicine’s engagement with NIH.

  • Universal Primary Care34 page PDF

    Presentations | Mar 26, 2009 | Michael Fine, MD, and Shannon Brownlee, MS

    Universal Primary Care - Health Care. Reform. Shovel Ready Now

  • What the Federal Government Should Do to Revitalize the Primary Care Practice Infrastructure & Quality in the United States37 page PDF

    Presentations | Jan 15, 2009 | Kevin Grumbach, MD

  • Off the Roadmap? Family Medicine's Grant Funding and Committee Representation at NIH

    Articles | Nov 15, 2008 | Sean Lucan, Bob Phillips and Andrew Bazemore

    PURPOSE: 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. METHODS: We descriptively analyzed NIH grants to family medicine from 2002 through 2006 and the current NIH advisory committee memberships. RESULTS: Grants (and dollars) awarded to departments of family medicine increased from 89 ($25.6 million) in 2002, to 154 ($44.6 million) in 2006. These values represented only 0.20% (0.15% for dollars) and 0.33% (0.22% for dollars), respectively, of total NIH awards. Nearly 75% of family medicine grants came from just 6 of NIH's grant-funding 24 institutes and centers. Although having disproportionately fewer grant continuations (62% vs 72%) and R awards (68% vs 74%)-particularly R01 awards (53% vs 84%)-relative to NIH grantees overall, family medicine earned proportionately more new (28% vs 21%) and K awards (25% vs 9%) and had more physician principal investigators (52% vs 15%). Ten of the nation's 132 departments of family medicine (7.6%) earned almost 50% of all family medicine awards. Representatives from family medicine were on 6.4% of NIH advisory committees (0.38% of all members); family physicians were on 2.7% (0.16% of members). CONCLUSIONS: 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

  • Impact of Title VII Training Programs on Community Health Center Staffing and National Health Service Corps Participation

    Articles | Sep 15, 2008 | Diane Rittenhouse, Ed Fryer, Bob Phillips, Thomas Miyoshi, Christine Nielson, David Goodman, Kevin Grumbach

    PURPOSE: 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. This article examines the association between physicians' attendance in training programs funded by Health Resources and Services Administration (HRSA) Title VII Section 747 Primary Care Training Grants and 2 outcome variables: work in a CHC and participation in the National Health Service Corps Loan Repayment Program (NHSC LRP). METHODS: We linked the 2004 American Medical Association Physician Master-file to HRSA Title VII grants files, Medicare claims data, and data from the NHSC. 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. RESULTS: Three percent (5,934) of physicians who had attended Title VII-funded medical schools worked in CHCs in 2001-2003, compared with 1.9% of physicians who attended medical schools without Title VII funding (P<.001). We found a similar association between Title VII funding during residency and subsequent work in CHCs. These associations remained significant (P<.001) in logistic regression models controlling for NHSC participation, public vs private medical school, residency completion date, and physician sex. A strong association was also found between attending Title VII-funded residency programs and participation in the NHSC LRP, controlling for year completed training, physician sex, and private vs public medical school. CONCLUSIONS: Continued federal support of Title VII training grant programs is consistent with federal efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity.

  • Primary Care's Eroding Earnings: Is Congress Concerned

    Articles | Sep 15, 2008 | Yoshi Laing, Thomas Bodenheimer, Bob Phillips, and Andrew Bazemore

    PURPOSE: 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. METHODS: 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: the Medicare Payment Advisory Commission, Congressional Budget Office, and Government Accountability Office. RESULTS: 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. CONCLUSION: Attempts to solve primary care's reimbursement difficulties should be tied to SGR reform.

  • Residency Footprints: Assessing the Impact of Training Programs on the Local Physician Workforce and Communities

    Articles | May 15, 2008 | Reese VF, McCann JL, Bazemore AW, Phillips RL J

    BACKGROUND AND OBJECTIVES: National workforce models fail to capture the regional effect of residency programs, despite local control over decisions to open or close training sites. In the last 5 years, 37 (nearly 8% of total) family medicine residency programs have closed. We report on a novel approach to measuring the regional effect of residency training programs closures using a combination of quantitative and spatial methods. METHODS: American Medical Association Physician Masterfile records and residency graduate registries for 22 of 37 family medicine residency programs that closed between 2000-2006 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. RESULTS: Of the 1,545 graduates of the 22 programs, 21% of graduates practice in rural locations, and 68% are in full-county or partial-county HPSAs. Without the graduates of these programs, there would have been 150 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. CONCLUSIONS: 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.

  • Physician Distribution and Access: Workforce Priorities

    One Pagers | May 15, 2008 | Xingyou Zhang, PhD; Bob Phillips, MD MSPH; Andrew Bazemore, MD MPH; Martey Dodoo, PhD; Stephen Petterson, PhD; Imam Xierali, PhD, and Larry A. Green, MD

    Most Primary Care Health Professional Shortage Areas (HPSAs) exceed federal population-to-physician designation criteria, yet struggle to maintain access to primary care physicians. 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.

  • Non-emergency Medicine-Trained Physician Coverage in Rural Emergency Departments

    Articles | Apr 15, 2008 | Peterson LE, Dodoo M, Bennett KJ, Bazemore A, Phillips RL Jr.

    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. PURPOSE: To determine the distribution of emergency department clinicians and the proportion of care they provide across the rural-urban continuum. METHODS: Cross-sectional analysis of secondary data. The distribution of clinicians who provide emergency department care by county was determined using the 2003 Area Resource File. The percentage of emergency department care provided by clinician type was determined using 2003 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. FINDINGS: Board-certified emergency physicians provide 75% of all emergency department care, but only 48% for Medicare beneficiaries of the most rural of counties. 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. CONCLUSION: 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?41 page PDF

    Monographs & Books | Jan 15, 2008 | Dr. Paul Grinzi, Department of General Practice, University of Melbourne, Australia

  • Building a Primary Care Workforce in the 21st Century40 page PDF

    Monographs & Books | Aug 15, 2008 | Robert Graham Center

  • The Patient Centered Medical Home: History, seven core features, evidence and transformational change32 page PDF

    Monographs & Books | Nov 15, 2007 | Robert Graham Center

  • Rural Origins and Choosing Family Medicine Predict Future Rural Practice

    One Pagers | Jun 01, 2007 | JL Hyer, MB; Andrew Bazemore, MD, MPH; RC Bowman; Xingyou Zhang, PhD; Stephen Petterson, PhD; Robert Phillips, MD, MSPH

    The shortage of physicians in U.S. rural practice may impact access to health care for one in five citizens. Two medical student characteristics that predict eventual practice in rural settings are clear: being born in a rural county and choosing a residency in family medicine.

  • The Distribution of IMGs in US: The Interplay of Poverty, Rurality, and Length of Practice12 page PDF

    Presentations | May 15, 2007 | Xingyou Zhang, PhD Martey Dodoo, PhD Stephen Peterson, PhD Andrew Bazemore, MD, MPH Bob Phillips, MD, MSPH

  • Impact of Title VII Funding on Community Health Center Staffing and the National Health Service Corps12 page PDF

    Presentations | Apr 15, 2007 | Bob Phillips, MD, MSPH, and Diane R. Rittenhouse, MD, MPH

  • The Canadian Contribution to the U.S. Physician Workforce

    Articles | Apr 15, 2007 | Robert L. Phillips Jr, Stephen Petterson, George E. Fryer Jr, Walter Rosser

    BACKGROUND: 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. METHODS: We performed a cross-sectional analysis of the 2004 and 2006 American Medical Association Physician Masterfiles, the 2002 Area Resource File and data from the Canadian Institute for Health Information, the Canadian Medical Association and the Association of Faculties of Medicine of Canada. 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 2006, 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. RESULTS: Two-thirds of the 12,040 Canadian-educated physicians living in the United States in 2006 were practising in direct patient care, 1023 in rural areas. About 186, 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. INTERPRETATION: 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.

  • The NHSC in Rural Counties: A historical review and impact assessment25 page PDF

    Presentations | Mar 15, 2007 | Robert Phillips, MD, MSPH, and Andrew Bazemore, MD, MPH

  • How Well Do Family Physicians Manage Skin Lesions?

    Articles | Jan 15, 2007 | Dan Merenstein, David Meyers, Alex Krixst, Jose Delgado, Jessica L. McCann, Stephen Petterson and Robert L. Phillips

    PURPOSE: 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. 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. METHODS: 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. RESULTS: After 7 days, 84% of lesions were "much better" or "better." After 28 and 84 days, 89% and 94% of lesions respectively were rated similarly. Overall, patients were satisfied with the dermatologic care provided by their family physician, with 55% of patients reporting highest satisfaction level and 34% reporting second highest on a five point scale at day 7. At days 28 and 84, 93% of the patients reported the two highest levels of satisfaction. Overall diagnostic agreement was 72% between dermatologists and family physicians, with over 80% agreement for the more common diagnoses. CONCLUSION: 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.

  • Congruent Satisfaction: Is There Geographic Correlation Between Patient and Physician Satisfaction?

    Articles | Jan 15, 2007 | Jennifer DeVoe, George E. Fryer, Alton Straub, Jessica McCann, Gerry Fairbrother

    CONTEXT: 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. OBJECTIVE: 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. METHODS: We undertook a cross-sectional analysis of data from 3 rounds of the Community Tracking Study (CTS) Household and Physician Surveys (1996-1997, 1998-1999, 2000-2001), 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 179,127 patients and a total physician population of 37,238. Both physicians and patients were asked a variety of questions pertaining to satisfaction. Results: 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 0.628, P < 0.001). Patient trust in the physician was also highly correlated with physician career satisfaction (0.566, P < 0.001). CONCLUSIONS: 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.

  • Access Granted: The Primary Care Payoff24 page PDF

    Monographs & Books | Aug 15, 2007 | Robert Graham Center

  • National Health Service Corps Staffing and the Growth of the Local Rural Non-NHSC Primary Care Physician Workforce

    Articles | Sep 15, 2006 | Donald E. Pathman, George E. Fryer, Robert L. Phillips, John Smucny, Thomas Miyoshi and Larry A. Green

    CONTEXT: 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. PURPOSE: 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. METHODS: Using data from the American Medical Association and NHSC, we compared changes from 1981 to 2001 in non-NHSC primary care physician to population ratios in 2 subsets of rural whole-county health professional shortage areas: (1) 141 counties staffed by NHSC physicians, nurse practitioners, and/or physician assistants during the early 1980s and for many of the years since and (2) all 142 rural health professional shortage area counties that had no NHSC clinicians from 1979 through 2001. FINDINGS: From 1981 to 2001, counties staffed by NHSC clinicians experienced a mean increase of 1.4 non-NHSC primary care physicians per 10,000 population, compared to a smaller, 0.57 mean increase in counties without NHSC clinicians. 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 < .001). The estimated number of "extra" non-NHSC physicians in NHSC-supported counties in 2001 attributable to the NHSC was 294 additional physicians for the 141 supported counties, or 2 extra physicians, on average, for each NHSC-supported county. Over the 20 years, more NHSC-supported counties saw their non-NHSC primary care workforces grow to more than 1 physician per 3,500 persons, but no more NHSC-supported than nonsupported counties lost their health professional shortage area designations. CONCLUSIONS: These data suggest that the NHSC contributed positively to the non-NHSC primary care physician workforce in the rural underserved counties where its clinicians worked during the 1980s and 1990s.

  • Learning from Different Lenses: Reports of Medical Errors in Primary Care by Clinicians, Staff, and Patients

    Articles | Sep 15, 2006 | Robert L. Phillips, Susan M. Dovey, Deborah Graham, Nancy C. Elder and John M. Hickner

    OBJECTIVES: To test whether family doctors, office staff, and patients will report medical errors and to investigate differences in how and what they report. METHODS: 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. They submitted anonymous reports via a Web site, paper forms, and a voice-activated phone system. RESULTS: Four hundred one clinicians and staff reported 935 errors within 717 events, 37% (265) of which came from the 5 intensive reporting days and 61% (440) from routine reports. Staff made 384 (53%) reports, and clinicians, 342 (47%) reports. Most (96%) errors reported were process errors, not related to knowledge or skill. Staff reported more errors in patient flow and communication; clinicians reported more medication and laboratory errors. Reports suggest that patients with complex health issues (31% versus 20%, P = 0.013) are vulnerable to more severe outcomes. Patients submitted 126 reports, 18 of which included errors. CONCLUSIONS: 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.

  • Family Physicians in the Child Health Care Workforce: Opportunities for Collaboration in Improving the Health of Children

    Articles | Sep 15, 2006 | Robert L. Phillips, MD, MSPH; Andrew W. Bazemore, MD, MPH; Martey S. Dodoo, PhD; Scott A. Shipman, MD, MPH; Larry A. Green, MD

    Pediatric workforce studies suggest that there may be a sufficient number of pediatricians for the current and projected U.S. child population. These analyses do not fully consider the role of family medicine in the care of children. Family physicians provide 16% to 26% of visits for children, providing a medical home for one-third of the child population, but face shrinking panels 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 1981 and 2004, the general pediatrician population grew at 7 times the rate of the U.S. population, and the family physician workforce grew at nearly 5 times the rate. 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.

  • The U.S. Medical Liability System: Evidence for Legislative Reform

    Articles | Jun 15, 2006 | Janelle Guirguis-Blake, MD, George E. Fryer, PhD, Robert L. Phillips Jr, MD, MSPH, Ronald Szabat, JD, LLM, Larry A. Green, MD

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  • International Medical Graduates in Family Medicine in the United States of America: An Exploration of Professional Characteristics and Attitudes

    Articles | Jun 15, 2006 | Amanda L. Morris, Robert L. Phillips, Jr., George E. Fryer, Jr., Larry A. Green, Fitzhugh Mullan

    BACKGROUND: The number of international medical graduates (IMGs) entering family medicine in the United States of America has steadily increased since 1997. Previous research has examined practice locations of these IMGs and their role in providing care to underserved populations. To our knowledge, research does not exist comparing professional profiles, credentials and attitudes among IMG and United States medical graduate (USMG) family physicians in the United States. 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. METHODS: This is a secondary data analysis of the 1996-1997 Community Tracking Study (CTS) Physician Survey comparing 2360 United States medical graduates and 366 international medical graduates who were nonfederal allopathic or osteopathic family physicians providing direct patient care for at least 20 hours per week. RESULTS: Compared to USMGs, IMGs were older (p < 0.001) and practised in smaller (p = 0.0072) and younger practices (p < 0.001). Significantly more IMGs practised in metropolitan areas versus rural areas (p = 0.0454). More IMG practices were open to all new Medicaid (p = 0.018) and Medicare (p = 0.0451) patients, and a greater percentage of their revenue was derived from these patients (p = 0.0020 and p = 0.0310). Fewer IMGs were board-certified (p < 0.001). More IMGs were dissatisfied with their overall careers (p = 0.0190). IMGs and USMGs did not differ in terms of self-rated ability to deliver high-quality care to their patients (p = 0.4626). For several of the clinical vignettes, IMGs were more likely to order tests, refer patients to specialists or require office visits than USMGs. CONCLUSION: There are significant differences between IMG and USMG family physicians' professional profiles and attitudes. These differences from 1997 merit further exploration and possible follow-up, given the increased proportion of family physicians who are IMGs in the United States.

  • Examining the Impact of Closing Family Medicine Residency Programs4 page PDF

    Presentations | May 15, 2006 | Jessica McCann, MA Valerie Reese, MD Andrew Bazemore, MD, MPH Robert Phillips, MD, MSPH

  • Recent Studies of the Family Physician Workforce: Implications for Education and Training8 page PDF

    Presentations | May 15, 2006 | Bob Phillips, MD, MSPH Andrew Bazemore, MD, MPH Martey Dodoo, PhD Perry Pugno, MD

  • The Diminishing Role of FPs in Caring for Children

    One Pagers | May 01, 2006 | Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSPH; Martey Dodoo, PhD; Jessica McCann, MD; Lawrence Klein, PhD; Larry Green, MD

    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.

  • Family Medicine Training: Time to be Counterculture Again7 page PDF

    Presentations | Apr 15, 2006 | Bob Phillips, MD, MSPH

  • Family Physicians Help Meet the Emergency Care Needs of Rural America

    One Pagers | Apr 01, 2006 | Laura Peterson; Andrew Bazemore, MD, MPH; Martey Dodoo, PhD; Robert Phillips, MD, MSPH

    Ensuring access to emergency care in rural areas remains a challenge. High costs and low patient volumes make 100 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.

  • Access, Health, and Wealth: Impact of the National Health Service Corps in Rural America49 page PDF

    Monographs & Books | Sep 15, 2006 | George E. Fryer, PhD; Jessica L. McCann, MA; Martey S. Dodoo, PhD; Larry A. Green, MD; Thomas Miyoshi; Robert L. Phillips, MD, MSPH

  • Primary care in the United States: problems and possibilities

    Commentaries & Editorials | Dec 15, 2005 | Robert L. Phillips, Jr., MD, MSPH

    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.

  • Excess, Shortage, or Sufficient Physician Workforce: How Could We Know?

    One Pagers | Nov 01, 2005 | Martey Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Ginger Ruddy, MD; Jessica McCann, MD; Lawrence Klein, PhD

    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.

  • Physician Workforce: Legal Immigrants will Extend Baby Boom Demands

    One Pagers | Oct 15, 2005 | Martey Dodoo, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Ginger Ruddy, MD; Jessica McCann, MD; Lawrence Klein, PhD

    The baby boom generation will place large demands on the Medicare program and the U.S. health care system. These demands may be extended by a large legal immigrant population that will become Medicare-eligible soon after the baby boom generation does. The U.S. health care system should be prepared for sustained stress from this aging population.

  • Physician Assistant and Nurse Practitioner Workforce Trends

    One Pagers | Oct 01, 2005 | Jessica McCann, MD; Robert Phillips, MD, MSPH; Edward O'Neil, MD; Ginger Ruddy, MD; Martey Dodoo, PhD' Lawrence Klein, PhD

    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.

  • Number of Persons who Consulted a Physician, 1997 and 2002

    One Pagers | Sep 15, 2005 | Ed Fryer, PhD; Martey Dodoo, PhD; Larry Green, MD; Robert Phillips, MD, MSPH; Ginger Ruddy, MD; Jessica McCann, MD

    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.

  • Patterns of Visits to Physicians' Offices, 1980 to 2003

    One Pagers | Sep 01, 2005 | Marey Dodoo, PhD; Ed Fryer, PhD; Larry Green, MD; Robert Phillips, MD, MSPH; Ginger Ruddy, MD; Jessica McCann, MD

    In the past quarter century, the number of office visits to physicians in the United States increased from 581 million per year to 838 million per year, with slightly more than one half of total visits since 1980 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 1990s, when visits to general internists and general pediatricians exceeded visits to FPs and GPs.

  • Osteopathic Physicians and the Family Medicine Workforce

    One Pagers | Aug 15, 2005 | Ginger Ruddy, MS; Robert Phillips, MD, MSPH; Lawrence Klein, MD; Jessica McCann, MD; Martey Dodoo, PhD; Larry Green, MD

    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.

  • Who Filled First-Year Family Medicine Residency Positions from 1991 to 2004?

    One Pagers | Aug 01, 2005 | Lawrence Klein, MD; Ginger Ruddy, MD; Robert Phillips, MD, MSPH; Jessica McCann, MS; Martey Dodoo, PhD; Larry Green, MD

    Graduates of U.S. allopathic schools have filled less than one half of the family medicine positions offered in the National Resident Matching Program (NRMP) Match since 2001. 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 2004 made up 38 percent of first-year residents.

  • Physician Workforce: The Special Case of Health Centers and the National Health Service Corps

    One Pagers | Jul 15, 2005 | Robert Phillips, MD, MSPH; Ed Fryer, PhD; Ginger Ruddy. MD; Jessica McCann; Martey Dodoo, PhD; CS Klein

    Federally funded health centers and the National Health Service Corps (NHSC) depend on family physicians (FPs) and general practitioners (GPs) to meet the needs of millions of medically underserved people. Policy makers and workforce planners should consider how changes in the production of FPs would affect these programs.

  • The Family Physician Workforce: The Special Case of Rural Populations

    One Pagers | Jul 01, 2005 | Ginger Ruddy MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Larry Green, MD; Martey Dodoo, PhD; Jessica McCann, MD

    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.

  • Family Physicians and the Primary Care Physician Workforce in 2004

    One Pagers | Jun 15, 2005 | Larry Green, MD; Ed Fryer, PhD; GR Ruddy; Martey Dodoo, PhD; Robert Phillips, MD; MSPH; Jessica McCann

    In 2004, there were 91,600 family physicians (FPs) and general practitioners (GPs) and 222,000 primary care physicians actively caring for patients, one for every 1,321 persons. These primary care physicians represent the largest and best-trained primary care physician workforce that has ever existed in the United States.

  • COGME's 16th Report to Congress: Too many physicians could be worse than wasted

    Commentaries & Editorials | May 15, 2005 | Robert L. Phillips, Jr., MD, MSPH; Martey Dodoo, PhD; Carlos R. Jaen, MD, PhD; and Larry A. Green, MD

    Departing from past reports, the latest Council on Graduate Medical Education (COGME) report warns of a physician deficit of 85,000 by 2020 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.

  • Changes in Age-Adjusted Mortality Rates and Disparities for Rural Physician Shortage Areas Staffed by the National Health Service Corps: 1984-1998

    Articles | Mar 15, 2005 | Donald E. Pathman, MD, MPH; George E. Fryer, PhD; Larry A. Green, MD; and Robert L. Phillips, MD, MSPH.

    OBJECTIVE: 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: age-adjusted mortality. METHODS: In a descriptive study using a pre-post design with comparison groups, the authors calculated age-adjusted mortality rates at baseline (1981-1983) and follow-up (1996-1998) for the populations of 448 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 172 whole-county rural health professional shortage areas and 772 non-health professional shortage area rural counties that had no National Health Service Corps. RESULTS: 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. CONCLUSIONS: From the early 1980s through the mid-1990s, 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.

  • Report to the Task Force on the Care of Children by Family Physicians79 page PDF

    Monographs & Books | Jan 15, 2005 | Robert L. Phillips, Jr., MD, MSPH; Martey S. Dodoo, PhD; Jessica L. McCann, MA; Andrew Bazemore, MD; George E. Fryer, PhD; Lisa S. Klein; Michael Weitzman, MD; Larry A. Green, MD

  • The Phsyician Workforce of the United States: A Family Medicine Perspective197 page PDF

    Monographs & Books | Oct 15, 2004 | Larry A. Green, MD; Martey S. Dodoo, PhD; Ginger Ruddy, MD; George E. Fryer, PhD; Robert L. Phillips, MD, MSPH; Jessica L. McCann, MA; Edward H. O’Neil, MPA, PhD, FAAN; Lisa S. Klein

  • Chiropractors Are Not a Usual Source of Primary Health Care

    One Pagers | Jun 01, 2004 | Jessica McCann, MD; Robert Phillips, MD, MSPH; Larry Green, MD; Ed Fryer, PhD

    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.

  • Few People in the United States can Identify Primary Care Physicians

    One Pagers | May 15, 2004 | Mary Stock Keister, MD; Larry Green, MD; Norman Kahn, MD; Robert Phillips, MD, MSPH; Jessica McCann. MD; Ed Fryer, PhD

    Almost one decade after the Institute of Medicine defined primary care, only one-third of the American public is able to identify any of the medical specialties that provide it, and only 17% were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

  • What People Want from Their Family Physician

    One Pagers | May 15, 2004 | Mary Stock Keister, MD; Larry Green, MD; Norman Kahn, MD; Robert Phillips, MD, MSPH; Jessica McCann, MD; Ed Fryer, PhD

    The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty and trust. If the U.S. healthcare system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture, relationships people have with their primary physician.

  • Specialist Physicians Providing Primary Care Services in Colorado

    Articles | Apr 15, 2004 | George E. Fryer, Jr.; Rachel Consoli; Thomas J. Miyoshi; Susan M. Dovey; Robert L. Phillips, Jr.; and Larry A. Green

    BACKGROUND: 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. METHODS: The Colorado Board of Medical Examiners sent a one-page questionnaire to all physicians licensed to practice in the state. It contained the question: "How many hours in the last week did you provide primary care services, defined as either preventive care, routine physical exams, or treatment of common ailments?" The responses of physicians who reported non-primary-care medical specialties were analyzed with respect to their personal and practice characteristics. RESULTS: Just under half (46.5%) of the 2745 specialist respondents reported having provided primary care services. As a group, however, 27.9% of specialist physicians’ direct patient care time was devoted to primary care activities. The amount of primary care services being provided was greater among those not board-certified in their specialties, osteopathic physicians, and specialists spending less time in direct patient care. CONCLUSION: Additional evaluation is needed with a more comprehensive definition of primary care than used in this article, which includes important but difficult-to-measure elements, such as the integration of services, a sustained partnership with patients, and practice in the context of family and community. To the extent possible, this definition should not rely on physician self-definition of which examinations are routine and which ailments are common. However, the contribution of specialists should be considered in future primary care needs assessments, and specialists who experience low demand for their particular specialties may be especially inclined to provide primary care services.

  • The New Model of Primary Care: Knowledge Brought Dearly24 page PDF

    Monographs & Books | Mar 15, 2004 | Robert L. Phillips, Jr., MD, MSPH; Larry A. Green, MD; George E. Fryer, Jr., PhD; Jessica McCann, MA

  • The U.S. Primary Care Physician Workforce: Undervalued Service

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, MD; Robert Phillips, MD MSPH; Janelle Guirguis-Blake, MD; Ed Fryer, PhD

    Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.

  • The U.S. Primary Care Physician Workforce: Persistently Declining Interest in Primary Care Medical Specialties

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, MD; Robert Phillips, MD; MSPH; Janelle Guirguis-Blake, MD; Ed Fryer, PhD

    A persistent, six-year trend in the choice of specialty training by U.S. medical students threatens the adequacy of the physician workforce of the United States. This pattern should be reversed and requires the attention of policy makers and medical educators.

  • The U.S. Primary Care Physician Workforce: Minimal Growth 1980-1999

    One Pagers | Oct 15, 2003 | Holly Biola, MD; Larry Green, PhD; Robert Phillips, MD, MSPH; Janelle Guirguis-Blake, MD; ED Fryer, PhD

    Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care.

  • Family Physicians Are an Important Source of Newborn Care: The Case of the State of Maine

    One Pagers | Aug 15, 2003 | Donna Cohen, PhD; Janelle Guirguis-Blake, MD; David Jack, MD; V.K. Chetty, PhD; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians (FPs) provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine’s commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs.

  • Family Physicians Make a Substantial Contribution to Maternity Care: The Case of the State of Maine

    One Pagers | Aug 01, 2003 | Donna Cohen, PhD; Janelle Guirguis-Blake, MD; David Jack, MD; V.K. Chetty, PhD; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians provided nearly 20 percent of labor and delivery care in Maine in the year 2000. A substantial proportion of this care was provided to women insured by Medicaid and those delivering in smaller, rural hospitals and residency-affiliated hospitals. As family medicine explores its future scope, research identifying regional variations in the maternity care workforce may clarify the need for maternity care training in residency and labor and delivery services in practice.

  • International Medical Graduates and the Primary Care Workforce for Rural Underserved Areas

    Articles | Mar 15, 2003 | Fink KS, Phillips RL, Fryer GE, Koehn N

    The proportion of international medical graduates (IMGs) serving as primary care physicians in rural underserved areas (RUAs) has important policy implications. We analyzed the 2000 American Medical Association Masterfile and Area Resource File to calculate the percentage of primary care IMGs, relative to U.S. medical graduates (USMGs), working in RUAs. We found that 2.1 percent of both primary care USMGs and IMGs were in RUAs, where USMGs were more likely to be family physicians but less likely to be internists or pediatricians. IMGs appear to have been no more likely than USMGs were to practice primary care in RUAs, but the distribution by specialty differs.

  • Family Physicians' Declining Contribution to Prenatal Care in the United States

    One Pagers | Dec 15, 2002 | Janelle Guirguis-Blake, MD; Ed Fryer, PhD; Mark Deutchman, MD; Larry Green, MD; Susan Dovey, MD, MPH; Robert Phillips, MD, MSPH

    There has been a substantial decline in prenatal care by family physicians over the past 20 years in all geographic regions of the country. Even so, during the past two decades, FP/GPs have provided over two million prenatal visits per year. As the field re-explores future scope, it should consider the erosion of the provision of prenatal care, its effect on the U.S. population and the specialty, and possibilities for revitalization of prenatal care in residency curricula and practice.

  • Can Nurse Practitioners and Physicians Beat Parochialism into Plowshares?

    Articles | Sep 15, 2002 | Robert L. Phillips Jr.; Doreen C. Harper; Mary Wakefield; Larry A. Green; and George E. Fryer Jr.

    Nurse practitioners have evolved into a large and flexible workforce. Far too often, nurse practitioner and physician professional organizations do not work together but rather expend considerable effort jousting in policy arenas. Turf battles interfere with joint advocacy for needed health system change and delay development of interdisciplinary teams that could help patients. A combined, consistent effort is urgently needed for studying, training, and deploying a collaborative, integrated workforce aimed at improving the health care system of tomorrow. The country can ill afford doctors and nurses who ignore one another's capabilities and fail to maximize each other's contributions cost-effectively.

  • Family Practice in the United States: Position and Prospects

    Articles | Aug 15, 2002 | Green LA, Fryer GE

    Family practice became the 20th U.S. medical specialty in 1969. It has delivered on its promise to reverse the decline of general practice and care for people with diverse problems in all areas of the country. But many important health care problems remain unsolved, in part because of poor role delineation for family physicians, poor differentiation of family practice from other fields, and insufficient changes in the cultural and political environment. Family practice's problems include confusion about whether it is a reform movement or an incumbent specialty; disagreement about its role in controlling and assuring care; confusion about whether family physicians are generalists or specialists; lack of clarity about family practice as vital for all versus a possible option for some; misunderstanding about the knowledge requirements for family practice; and inadequate business models. Family practice's mistakes include expending much effort on justification and less on assuring practical means to accomplish its work; permitting an erosion of public trust; failing to strengthen relationships with interfacing specialties and organizations; and neglecting research. Nonetheless, there are promising opportunities to improve health and health care through strengthening family practice that depend in part on redesigning the family practice setting, defining carefully critical interactions with other elements of the health care system, fostering discovery of family practice, and further differentiating family practice as a scientific and caring field. Another period of adaptation by family practice is already under way; this may be the first time in history that its ambitious aspirations are actually achievable.

  • Title VII Funding is Associated with More Family Physicians and More Physicians Serving the Underserved

    One Pagers | Aug 15, 2002 | David Meyers, MD; Gregory Krol, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH; Larry Green, MD

    Title VII funding of departments of family medicine at U.S. medical schools is significantly associated with expansion of the primary care physician workforce and increased accessibility to physicians for the residents of rural and underserved areas. Title VII has been successful in achieving its stated goals and has had an important role in addressing U.S. physician workforce policy issues.

  • The Increase in International Medical Graduates in Family Practice Residency Programs

    Articles | Jun 15, 2002 | Koehn NN, Fryer GE, Phillips RL, Miller JB, Green LA

    BACKGROUND AND OBJECTIVES: The number of filled positions in family practice residency programs decreased by 18.6% from 1997–2001. This study sought to determine the degree of reliance on international medical graduates (IMGs) to fill family practice residency positions and the relative proportion of US citizen IMGs. METHODS: We analyzed the 1992–2001 National Resident Matching Program results, the 2000 American Medical Association Masterfile, and the 1992–2001 American Academy of Family Physicians Annual Survey of Family Practice Residency Programs. RESULTS: The percentage of IMGs matching in family practice remained stable between the years of 1992–1996 (10.0%–11.8%) but since 1997 has increased to a high of 21.4% in 2001. This rise in IMGs corresponds with a drop in the total percentage of family practice residency positions filled in the Match from 90.5% in 1996 to 76.3% in 2001. Despite the drop in Match numbers, the percentage of first-year family practice positions filled in July has remained in the range of 95.5%–97.8% since 1996. IMGs account for an increasing percentage of post-Match fills from 16.7% in 1996 to 47.9% in 2001. In 1999, a majority of family practice programs (279 [55.6%]), had at least one IMG. Of these, 48 programs (9.6%) had at least 50% of residents who were IMGs, and eight programs (1.6%) were entirely composed of IMGs. In five states (Connecticut, Illinois, Michigan, New Jersey, and New York), more than 25% of family practice residents were IMGs. CONCLUSIONS: Family practice is becoming increasingly reliant on IMGs to fill residency positions.

  • Making choices about the scope of family practice

    Commentaries & Editorials | May 15, 2002 | Phillips RL, Green LA.

    Making choices about the scope of family practice

  • Does Career Dissatisfaction Affect the Ability of Family Physicians to Deliver High-Quality Patient Care?

    Articles | Mar 15, 2002 | DeVoe J, Fryer GE, Hargrave JL, Phillips RL, Green LA

    OBJECTIVES: A usual source of care is associated with better health outcomes. Dissatisfaction among family physicians and general practitioners (FP/GPs) may compromise the accessibility of a usual source of care and the quality of services. We examined the association between FP/GP dissatisfaction and an inability to deliver high-quality care. STUDY DESIGN: We performed a secondary analysis of the Community Tracking Study (CTS) Physician Survey (1996-1997). POPULATION: The study included a nationally representative sample of more than 12,000 non-federal physicians practicing direct patient care in the United States. OUTCOMES MEASURED: We measured associations of career dissatisfaction with physicians’ perceptions of their ability to provide high-quality care as defined by 6 survey items. Multivariate analysis controlled for the effects of personal, professional, and practice characteristics. RESULTS: Among FP/GPs in 1996-1997, more than 17% were dissatisfied. Age was the most significant personal factor associated with dissatisfaction; 25.1% of those aged 55 to 64 years reported dissatisfaction compared with only 10.1% of those younger than 35 years. Other personal or professional characteristics significantly associated with FP/GP dissatisfaction included osteopathic training, graduation from a foreign medical school, full practice ownership, and an income of less than $100,000. Physicians dissatisfied with their careers were much more likely to report difficulties in caring for patients, strong disagreeing (vs strong agreeing, odds ratio [OR] 1.0) that they had enough clinical freedom (OR 7.89; 95% confident interval [CI], 4.86-12.83); continuous patient relationships (OR 7.11; 95% CI, 4.90-10.33); no financial penalties for clinical decisions (OR 4.44; 95% CI, 3.13-6.31); adequate time with patients (OR 4.42; 95% CI, 2.84-6.87); ability to provide quality care (OR 4.26; 95% CI, 2.88-6.31); and sufficient communication with specialists (OR 3.57; CI 2.20-5.80). CONCLUSIONS: An inability to care for patients is significantly associated with career dissatisfaction. This relationship has implications for the achievement of policy objectives related to access, having a usual source of care and quality.

  • The delicate task of workforce determination

    Commentaries & Editorials | Mar 15, 2002 | Dovey SM, Green LA, Phillips RL, Fryer GE

    The delicate task of workforce determination

  • It takes a balanced health care system to get it right

    Commentaries & Editorials | Dec 15, 2001 | Green LA, Dovey SM, and Fryer GE

    It takes a balanced health care system to get it right

  • Uncoordinated Growth of the Primary Care Workforce

    One Pagers | Nov 01, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    Family physicians, nurse practitioners and physician assistants are distinctly different in their clinical training, yet they function interdependently. Together, they represent a significant proportion of the primary care work force. Training capacity for these three professions has increased rapidly over the past decade, but almost no collaborative work force planning has occurred.

  • Trumping Professional Roles: Collaboration of Nurse Practitioners and Physicians for a Better U.S. Health Care System

    One Pagers | Oct 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Professional turf battles have yielded variations in the scope of practice for nurse practitioners (NPs) obstructing collaboration with physicians that would enhance patient care. Patients would be better served if NPs and physicians worked together to develop better combined models of education and service that take advantage of the benefits of both professions' contributions to care.

  • The Contemporary Ecology of U.S. Medical Care Confirms the Importance of Primary Care

    One Pagers | Sep 15, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD; Robert Phillips, MD, MSPH

    More women, men, and children receive medical care each month in the offices of primary care physicians than any other professional setting. There is an urgent need for health policies that encourage further innovation and implementation of first-rate primary care for everyone.

  • The United States Relies on Family Physicians, Unlike Any Other Specialty

    One Pagers | May 01, 2001 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD

    Designation of a county as a Primary Care Health Personnel Shortage Area (PCHPSA) depends on the number of primary care physicians practicing there. Without family physicians, an additional 1332 of the United States' 3082 urban and rural counties would qualify for designation as primary care HPSAs. This contrasts with an additional 176 counties that would meet the criteria for designation if all internists, pediatricians and ob/gyns in aggregate were withdrawn. The United States relies on family physicians, unlike any other specialty.

  • Practice based primary care research networks: They work and are ready for full development and support

    Commentaries & Editorials | Mar 15, 2001 | Green LA, Dovey SM

    Practice based primary care research networks: They work and are ready for full development and support