Solving Physician Workforce Crisis Requires Multiple Solutions

FOR IMMEDIATE RELEASE: Tuesday, March 3, 2009

Contact: Leslie Champlin, 1-800-274-2237, ext. 5224, lchamplin@aafp.org

WASHINGTON, DC - Resolving America’s primary care physician shortage will require multiple solutions that boost programs to help medical students repay their education debt, narrow the payment gap between primary care physicians and subspecialists, change medical school admissions procedures and ensure the survival of primary care training programs.

Those are the conclusions in “Specialty and Geographic Distribution of the Physician Workforce: What Influences Medical Student & Resident Choices?” by Robert Phillips, Jr., MD, MSPH, and his research colleagues at the AAFP Robert Graham Center for Policy Studies in Family Medicine and Primary Care. The study was supported by the Josiah Macy, Jr., Foundation.

The U.S. health care system is grappling with a substantial decline in medical student interest in primary care careers, with a shortage of physicians in rural areas, and an inadequate physician pipeline to staff safety net clinics. There is an expansion of medical school positions underway; however, simply increasing the number of medical students will fail to meet the nation’s need for additional, appropriately distributed primary care physicians.

“Sizeable growth of the physician workforce in the last two decades has not resolved the maldistribution, and current efforts to simply train more physicians are unlikely to help,” Phillips and his coauthors write. “Even as States demonstrate a willingness to fund expansion of physician training, there is remarkably little direction or funding to purposefully tailor the output to future needs. Meanwhile, the miniscule but critical Federal funding designed to affect physician distribution is in real jeopardy. Market forces alone will not prepare our nation to care for the Baby Boom generation or expand the health care safety net to a growing un- and underinsured population.”

Phillips and his colleagues examined 30 years of medical education data, Medicare data, and physician workforce data to identify the income, debt, demographic, and educational dynamics that affect medical students’ specialty and practice location choices. They found several important factors: specialty income gap, educational experiences, student altruism, federal support for primary care education and options to trade debt for service.

“The income gap between primary care and subspecialists has an impressive negative impact on choice of primary care specialties and of practicing in rural or underserved settings,” the researchers write. “Over a typical physician career, this payment disparity produces an even greater gap in return on investment: 265% between primary care and the midpoint of income for subspecialists.”

Equally important are the students’ personal and educational background. Rural birth, interest in serving underserved or minority populations, exposure to Title VII-funded programs, and rural or inner-city training experiences significantly increase the likelihood of students choosing primary care, rural and underserved careers, Phillips and his colleagues reported.

“This study reaffirms the positive relationship between Title VII funding and most of our study outcomes despite decades of slowly declining Title VII investment in real dollars and the severe reductions in funding over the last decade,” the researchers write. “ … We found clear evidence that the student selection process and curriculum are very important in producing primary care physicians and physicians willing to serve in rural and underserved settings. … In general, public schools do a better job of producing primary care, rural and health center physicians.”

Moreover, students who accept loan repayment through service with the National Health Service Corps, military obligations and other forms of obligated debt reduction, are much more likely to later practice and remain in primary care and underserved settings.

Phillips and his colleagues offered several recommendations:

Create more opportunities for students and young physicians to trade debt for service, through effective programs such as the National Health Service Corps.

Reduce or resolve disparities in physician income.

Admit a greater proportion of students to medical school who are more likely to choose primary care, rural practice, and care of the underserved.

Study the degree to which educational debt prevents middle class and poor students from applying to medical school and potential policies to reduce such barriers.

Shift substantially more training of medical students and residents to community, rural and underserved settings.

Support primary care departments and residency programs and their roles in teaching and mentoring trainees.

Reauthorize and revitalize funding through Title VII, Section 747 of the Public Health Service Act.

Study how to make rural areas more likely practice options, especially for women physicians.

New medical schools should be public with preference for rural locations.