The Robert Graham Center conducts graduate medical education (GME) research with a focus on the primary care pipeline and uneven distribution of physicians to high needs areas. Despite current investment in GME, there is emerging evidence that the nation has unmet needs in a variety of medical fields including primary care, psychiatry, general surgery, and certain pediatric subspecialties. Further, the nation lags well behind other industrialized nations in population outcomes in spite of outsized health care expenditures.
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The Graham Center provides evidence that supports a number of GME stakeholders, including MedPAC, COGME, and the 2014 Institute of Medicine. One recent example is the 2014 IOM report, “Graduate Medical Education That Meets the Nation’s Health Needs.”
Articles | Sep 11, 2019 | Brian Beachler, MD; Yalda Jabbarpour, MD; Douglas B. Kamerow, MD, MPH; Elizabeth Wilkinson, BS; Zachary Levin, BS; and Andrew Bazemore, MD MPH
The first significant expansion of allopathic medical schools since the 1970s was anticipated to produce more physicians capable of addressing the nation's current and projected primary care shortages. However, our analysis of the early outputs of new allopathic medical schools suggests that these students were nearly 40% less likely to specialize in family medicine than existing schools.
Practice Intentions of Family Physicians Trained in Teaching Health Centers: The Value of Community-Based Training
Articles | Mar 15, 2019 | Zachary Levin, BS; Peter Meyers, MD; Lars Peterson, MD, PhD; Andy Habib, MPH; and Andrew Bazemore, MD, MPH
Family medicine residents who graduate from Federally Qualified Health Center–aligned Teaching Health Center (THC) training residencies are nearly twice as likely to pursue employment in safety-net settings compared with non-THC graduates.
Factors Associated With Successful Research Departments: A Qualitative Analysis of Family Medicine Research Bright Spots
Articles | Oct 31, 2018 | Winston Liaw, MD, MPH; Aimee Eden, PhD, MPH; Megan Coffman, MS; Meera Nagara; and Andrew Bazemore, MD, MPH
Inadequate resources have led to family medicine research divisions at varying stages of development. The purpose of this analysis was to identify the factors that family medicine research “bright spot” departments perceive to be crucial to their success.
Articles | Oct 12, 2018 | Julie Phillips; Carrie Fahey; A Wendling; and B Mavis
To assess the effect of community-based medical education as implemented by Michigan State University College of Human Medicine on the physician workforce in the six communities in which clinical campuses were initially established.
Thirty Years Training Rural Physicians: Outcomes from Michigan State University College of Human Medicine Rural Physician Program
Articles | Oct 12, 2018 | Julie Phillips; Carrie Fahey; A Wendling; B Mavis; and W Short
There is a shortage of primary care and rural physicians in the United States. In 1974, Michigan State University College of Human Medicine created the Rural Physician Program to address these issues and increase primary care physicians in Michigan's Upper Peninsula. The authors describe the program and analyze 30 years of outcomes.
Articles | Jul 10, 2018 | Meera Nagaraj; Megan Coffman, MS; and Andrew Bazemore, MD, MPH
Rising educational debt may discourage entry into primary care and practice in safety net settings, but little is known about participation in loan repayment programs that are thought to be part of the solution. A survey of 2052 recent family physician residency graduates found that 30% pursued loan repayment, only a portion of which is tied to service obligations, suggesting opportunities for research and areas for the attention of policymakers.
Articles | Mar 14, 2018 | Lars E. Peterson, MD, PhD; Bo Fang, PhD; James C. Puffer, MD; and Andrew W. Bazemore, MD, MPH
Substantial gaps have been found between preparation for, and practice of, early career family physicians in nearly all clinical practice areas. With reported intentions of graduates for a broad scope of practice, gaps between practice and preparation suggest family physicians early in their careers may not be finding opportunities to provide comprehensive care.
Barriers and Solutions to the Single Accreditation System: A Survey Study of AOA Family Medicine Residency Program Directors24 page PDF
Reports | Oct 23, 2017 | Julie Petersen Marcinek; Megan Coffman; Zachary Levin; Winston Liaw, MD, MPH; and Andrew Bazemore, MD, MPH
In 2014, the AOA and ACGME announced they would be transitioning from two separate GME accreditation systems to a unified Single Accreditation System (SAS). This survey was designed to assess the attitudes, confidence, and progress of family medicine residencies accredited by the AOA alone during this transition.
Changes in Primary Care Graduate Medical Education Are Not Correlated With Indicators of Need: Are States Missing an Opportunity to Strengthen Their Primary Care Workforce?
Articles | Sep 05, 2017 | Coutinho, Anastasia J. MD, MHS; Klink, Kathleen, MD; Wingrove, Peter; Petterson, Stephen, PhD; Phillips, Robert L. Jr MD, MSPH; and Bazemore, Andrew MD, MPH
Federal and state graduate medical education (GME) funding exceeds $15 billion annually. It is critical to understand mechanisms to align undergraduate medical education (UME) and GME to meet workforce needs. There is little relationship between PCGME trainee growth and state need indicators. States should capitalize on opportunities to create explicit linkages between UME, GME, and population need; strategically allocate Medicaid GME funds; and monitor the impact of workforce policies and training institution outputs.
Funding Instability Reduces the Impact of the Federal Teaching Health Center Graduate Medical Education Program
Articles | May 09, 2017 | Troy Kurz, BS; Winston Liaw, MD, MPH; Peter Wingrove, BS; Stephen Petterson, PhD; and Andrew Bazemore, MD, MPH
The Accreditation Council of Graduate Medical Education and federal data reveal that the THCGME program accounted for 33% of the net increase in family medicine residency positions between 2011 and 2015. However, amid concerns about the program's stability, the contribution of the THCGME program to the net increase fell to 7% after 2015.
Commentaries & Editorials | Jan 23, 2017 | Winston Liaw, MD, MPH and Jack Westfall, MD, MH
PCORI needs to examine its role in addressing the complex primary care needs of patients.
Articles | Jan 17, 2017 | Imam M. Xierali, PhD; Marc A. Nivet, EdD, MBA; Anne H. Gaglioti, MD; Winston R. Liaw, MD, MPH; and Andrew W. Bazemore, MD, MPH
The diversity of medical school faculty has failed to keep up with the demographics of students and the overall American population.
Characteristics and Distribution of Graduate Medical Education Training Sites: Are We Missing Opportunities to Meet U.S. Health Workforce Needs?
Articles | Mar 29, 2016 | Janice Blanchard, MD; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Fitzhugh Mullins, MD
This study characterizes the distribution of residency training sites in different settings for three high-need specialties-family medicine, internal medicine, and general surgery.
Status of Underrepresented Minority and Female Faculty at Medical Schools Located Within Historically Black Colleges and in Puerto Rico
Articles | Mar 02, 2016 | Emily M. Mader, MPH, MPP; José E. Rodríguez, MD; Kendall M. Campbell, MD; Timothy Smilnak; Andrew W. Bazemore, MD, MpH; Stephen Petterson, PhD; and Christopher P. Morley, PhD, MA, CAS
This article examines the impact of medical school location in Historically Black Colleges and Universities (HBCU) and Puerto Rico (PR) on the proportion of underrepresented minorities in medicine (URMM) and women hired in faculty and leadership positions at academic medical institutions.
Commentaries & Editorials | Dec 01, 2015 | Stephen Petterson, PhD
Past efforts to curb unnecessary, costly care decisions by physicians, particularly under the guise of managed care, were often interpreted by physicians and patients alike as a tradeoff between quality and cost. Absent incentives to the contrary, physicians tend to choose aggressive treatments and quickly adopt new diagnostic and therapeutic procedures, without full consideration of the value to patients.
Are Time-Limited Grants Likely to Stimulate Sustained Growth in Primary Care Residency Training? A Study of the Primary Care Residency Expansion Program
Content Type, Articles | Jul 14, 2015 | Melissa Rossan Chen,MD, MSc; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Kevin Grumbach, MD
This article contains results from a survey that examines the perceived likelihood of sustaining new residency positions funded by five-year (2010-2015) Primary Care Residency Expansion (PCRE) grants.
Articles | Jun 05, 2015 | Christopher P. Morley, PhD, MA; Emily M. Mader, MPH, MPP; Timothy Smilnak; Andrew Bazemore, MD, MPH; Stephen Petterson, PhD; José E. Rodríguez, MD; Kendall M. Campbell, MD
Mission statements of medical schools vary considerably. These statements reflect institutional values and may also be reflected in the outputs of their institutions. The authors explored the relationship between US medical school mission statement content and outcomes in terms of graduate location and specialty choices.
Articles | May 18, 2015 | Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; and Jennifer Rankin, PhD
Providers and educators lack the tools and models necessary to address community problems. We describe an online curriculum intended to teach learners how to adapt established Community-Oriented Primary Care (COPC) principles for an age of ready access to clinical and population data and geospatial technology.
Articles | May 01, 2015 | Hehua Zhang, PhD; Imam Xierali, PhD; Laura Castillo-Page, PhD; Marc Nivet, EdD, MBA; and Sarah Conrad, MS
The top ten positive or very positive factors in choosing a medical school are reviewed here, with specialty attention to the priorities of students from racial and ethnic minorities.
Presentations | May 01, 2015 | Melanie Raffoul, MD; Jennifer Rankin, PhD; Elena Cohen, BA; Robert Phillips, Jr., MD, MSPH
215 American Association of Medical Colleges Health Workforce Research Conference
Presentations | May 01, 2015 | Melanie Raffoul, MD; Stephen Petterson, PhD; William Rayburn, MD, MBA; and Andrew Bazemore, MD, MPH
2015 American Association of Medical Colleges Health Workforce Research Conference
Estimating the Residency Expansion Required to Avoid Projected Primary Care Physician Shortages by 2035
Articles | Mar 16, 2015 | Stephen M. Petterson, PhD; Winston R. Liaw, MD, MPH; Carol Tran, MD; and Andrew W. Bazemore, MD MPH
The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes.
Articles | Mar 02, 2015 | Shokar Navkiran, MD, MPH; GeorgeBergu, MD; Andrew Bazemore, MD, MPH; Randall Clinch, DO, MS; Andrew Coco, MD, MS; Betsy Jones, EdD; Arch Mainous III, PD; Dean Seehusen, MD, MPH; and Vijay Singh, MD, MPH
The current state of affairs is that as a specialty, we underperform in scholarly and research output compared with our peers in other specialties, and although this has been acknowledged for a while, improvements in research productivity have been slow. Many barriers remain to the generation of research and scholarly output from departments of family medicine.
Family Medicine Graduate Proximity to Their Site of Training: Policy Options for Improving the Distribution of Primary Care Access
Articles | Feb 16, 2015 | Blake Fagan, MD; Claire Gibbons, PhD; Sean C Finnegan, MS; Stephen Petterson, PhD; Lars Peterson, MD, PhD; Robert L Phillips Jr, MD, MSHP; and Andrew Bazemore, MD, MPH
The US Graduate Medical Education (GME) system is failing to produce primary care physicians in sufficient quantity or in locations where they are most needed. Decentralization of GME training has been suggested by several federal advisory boards as a means of reversing primary care maldistribution, but supporting evidence is in need of updating. We assessed the geographic relationship between family medicine GME training sites and graduate practice location.
Articles | Dec 15, 2014 | Phillips, Robert L. MD, MSPH; Petterson, Stephen PhD; Bazemore, Andrew MD, MPH
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.
Spending Patterns in Region of Residency Training and Subsequent Expenditures for Care Provided by Practicing Physicians for Medicare Beneficiaries
Articles | Dec 15, 2014 | Candice Chen, MD; Stephen Petterson, PhD; Robert Phillips, MD, MSHP; Andrew Bazemore, MD, MPH; and Fitzhugh Mullan, MD
Graduate medical education training may imprint young physicians with skills and experiences, but few studies have evaluated imprinting on physician spending patterns.
A Retrospective Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States
Articles | Nov 17, 2014 | Julie Phillips; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; and Robert Phillips, MD, MSHP
A retrospective analysis of the relationship between medical student debt and primary care practice in the United States
Articles | Oct 13, 2014 | Winston Liaw, MD, MPH; Andrew Bazemore, MD, MPH; Ranit Mishori, MD, MHS; Philip Diller, MD, PhD; Inis Bardella, MD; Newton Cheng, MS
Interest in global health among medical students and residents has increased. According to recent surveys, medical school graduate participation in global health has increased from 20.2% in 2002 to 30.4% in 2012. Despite this growth, over a third of graduates (35.6%) rate their global health instruction as “inadequate.”
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.
Impact of Global Health Experience During Residency in Graduate Practice Location: A Multiple Cohort Study
Articles | Sep 01, 2014 | Winston Liaw, MD; Andrew Bazemore, MD, MPH; Imam Xierali, PhD; John Walden, MD; and Phillip Diller, MD, PhD
The impact of global health experiences on practice location is not clear. Graduates of programs with global health experiences were more likely to practice in an underserved or rural area. Making these experiences available may affect participants and nonparticipants.
Articles | Sep 01, 2014 | Laura Makaroff, DO; Xierali Imam, PhD; Stephen Petterson, PhD; Scott Shipman, MD, MPH; Andrew Bazemore, MD, MPH; and James Puffer, MD
We wanted to explore demographic and geographic factors associated with family physicians' provision of care to children. We analyzed the proportion of family physicians providing care to children using survey data collected by the American Board of FamilyMedicine from 2006 to 2009. Using a cross-sectional study design and logistic regression analysis, we examined the association of various physician demographic and geographic factors and providing care of children.
Articles | Sep 01, 2014 | Imam Xierali, PhD; Laura Castillo-Page, PhD; Kehua Zhang, PhD; Kathryn Gampfer, MS; and Marc Nivet, EdD, MBA
The US is experiencing a demographic shift towards more diversity, while the US workforce is diversifying at a much lower rate. Policy makers should prioritize measures to increase diversity in the physician workforce.
Articles | Jun 05, 2014 | Lars Peterson, MD, PhD; Peter Carek, MD; Eric Holmboe MD; James Puffer MD; Eric Warm, MD; and Robert Phillips MD, MSPH
The authors propose that ABMS boards and the ACGME deepen their existing relationship to better assess residency training outcomes. ABMS boards have a wealth of data on physicians collected as a by-product of MOC and business operations.
Articles | Apr 15, 2014 | William Rayburn, MD; Stephen Petterson, PhD; Newton Cheng, MS
Expansion of medical school enrollment in the 1960s through 1980s has led to more baby boomer physicians reaching retirement age. The objectives were to determine the number of obstetrician-gynecologists nearing retirement age and how eventual retirement will affect the future supply of obstetrician-gynecologists
Presentations | Apr 15, 2014 | Andrew Bazemore, MD, MPH
Making the Case: Family Medicine for America’s Health
Projected Impact of the Primary Care Residency Expansion Program Using Historical Trends in Graduate Placement
One Pagers | Apr 01, 2014 | Rossan M Chen, MD, MSc; Stephen M. Petterson, PhD; and Andrew Bazemore, MD, MPH
The Primary Care Residency Expansion (PCRE) program was created by the Health Resources and Services Administration in 2010 to help address the shortage of primary care physicians. If historical graduate placement trends for funded programs remain stable, the PCRE program would have a potential impact of more than 600 new physicians working in primary care.
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.
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.
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.
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.
One Pagers | Feb 01, 2013 | Erica C. Brode, Md, Mph; Stephen M. Petterson, Phd; And Andrew W. Bazemore, Md, Mph
National Institutes of Health (NIH) funding to family medicine departments is very low and has an inverse association with the production of family physicians at these medical schools. Clinical and Translational Science Awards and other efforts to include primary care in NIH research priorities should be considered to increase the family medicine workforce.
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.
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.
A Large Retrospective Multivariate Analysis of the Relationship Between Medical Student Debt and Primary Care Practice in the United States22 page PDF
Presentations | Dec 12, 2012 | Julie Phillips, MD, MPH; Stephen Petterson, PhD; Andrew Bazemore, MD, MPH; Robert Phillips, MD, MSPH.
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.
Medical School Rural Programs: A Comparison With International Medical Graduates in Addressing State-Level Rural Family Physician and Primary Care Supply
Articles | Apr 01, 2012 | Howard Rabinowitz, MD; Stephen Petterson, PhD; James Boulger, PhD; Matthew L. Hunsacker, MD; James J. Diamond, PhD; Fred W. Markham, MD; Andrew Bazemore, MD, MPH; and Robert L. Phillips, MD, MSPH
The shortage of physicians in rural areas is one of the most persistent problems in the U.S. health care system, with serious implications for access to care. This shortage is especially critical regarding generalist physicians, with rural areas having only 63% of the per capita primary care physician supply that urban areas have—despite the similar need for locally available primary care.
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.
Increasing Graduate Medical Education (GME) in Critical Access Hospitals (CAH) could enhance physician recruitment and retention in rural America
Articles | Jan 15, 2012 | mam M. Xierali; Sarah A. Sweeney; Robert L. Phillips, Jr.; Andrew W. Bazemore; and Stephen M. Petterson, PhD
Critical Access Hospitals (CAHs) are essential to a functioning health care safety net and are a potential partner of rural Graduate Medical Education (GME) which is associated with greater likelihood of service in rural and underserved areas. Currently, very little Medicare funding supports GME in the CAH setting, highlighting a missed opportunity to improve access to care in rural America.
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.
Calling All Scholars to the Council of Academic Family Medicine Educational Research Alliance (CERA)
Articles | Jul 15, 2011 | Navkiran Shokar; George Bergus; Andrew Bazemore; C. Randall Clinch; Andrew Coco; Betsy Jones; Arch G. Mainous III; Dean Seehusen; and Vijay Singh.
The mission of CERA is to set within family medicine a standard for medical education research that is rigorous and generalizable, to provide mentoring and education to junior researchers, to facilitate collaboration between medical education researchers, and to guide the specialty by providing leadership and vision in the arena of medical education research.
An International Health Track is Associated with Care for Underserved US Populations in Subsequent Clinical Practice
Articles | Jun 15, 2011 | Andrew W. Bazemore, Linda M. Goldenhar, Christopher J. Lindsell, Philip M. Diller, and Mark K. Huntington
Background: Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States. Methods: In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population. Results: IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5 years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings, and they had higher percentages of uninsured and non–English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5 years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice. Conclusions: Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.
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.
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.
Presentations | Apr 15, 2011 | Robert L. Phillips, Jr., MD, MSPH
Primary Care Present and Future
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.
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.
One Pagers | Jan 15, 2010 | Bridget Harrison, MD, MPH; Diane R. Rittenhouse, MD, MPH; Robert L. Phillips Jr., MD, MSPH; Kevin Grumbach, MD; Andrew W. Bazemore, MD, MPH; and Martey S. Dodoo, PhD
Community health centers (CHCs) and the National Health Service Corps (NHSC) are essential to a functioning health care safety net, but they struggle to recruit physicians. Compared with physicians trained in residency programs without Title VII funding, those trained in Title VII-funded programs are more likely to work in CHCs and the NHSC. Title VII funding cuts threaten efforts to improve access to care for the underserved.
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.
One Pagers | Oct 15, 2009 | Bridget Harrison, MD MPH; Andrew Bazemore, MD MPH; Martey S. Dodoo, PhD; Bridget Teevan, MS; Hope R. Wittenberg, MA; and Robert L. Phillips, Jr. MD MSPH
Title VII, Section 747 is a source of federal funding intended to strengthen the primary care workforce. Despite evidence that Title VII has been successful, its funding has declined over the past three decades, threatening the production of primary care physicians.
Presentations | Aug 15, 2009 | Bob Phillips, MD, MSPH
Are Medicare GME policies adequate to meet the rising need for primary care physicians?
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
Medical school expansion, primary care, and policy: Engaging primary care educators in evidence-based advocacy
Presentations | Apr 15, 2009 | Bridget Teevan, MS
What influences medical student and resident choices?
Monographs & Books | Mar 15, 2009 | Robert Graham Center
Specialty and geographic distribution of the physician workforce: What influences medical student & resident choices?
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
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.
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.
Articles | Oct 15, 2007 | Heck JE, Bazemore A, Diller P
BACKGROUND: Rapid growth in medical volunteerism in resource-poor countries presents an opportunity for improving global health. The challenge is to ensure that the good intentions of volunteers are channeled effectively into endeavors that generate locally acceptable, sustainable changes in health. METHODS: Started in Honduras in 1990, Shoulder to Shoulder is a network of partnerships between family medicine training programs and communities in Honduras and other resource-poor countries. The program involves short-term volunteering by US health professionals collaborating with community health boards in the host countries. The program has been implemented in seven US family medicine training programs and is supported by a small international staff. RESULTS: During the 16 years of program operation, more than 1,400 volunteers have made visits to host countries, which include Honduras, Ecuador, and Tanzania. Clinics have been established, school-based food programs and community-based water filtration programs developed, and cancer screening and pregnancy-care programs put in place. These and other programs have been implemented on a budget of less than $400,000, raised through donations and small grants. CONCLUSIONS: The Shoulder to Shoulder model allows health care professionals to channel short-term medical volunteerism into sustainable health partnerships with resource-poor communities. The resulting network of partnerships offers a powerful resource available to governments and foundations, poised to provide innovative interventions and cost-effective services directly to poor communities.
Articles | Oct 15, 2007 | Evert J, Bazemore AW, Hixon A, Withy K
Medical students and residents have shown increasing interest in international health experiences. Before attempting to establish a global health training program in a family medicine residency, program faculty must consider the goals of the international program, whether there are champions to support the program, the resources available, and the specific type of program that best fits with the residency. The program itself should include didactics, peer education, experiential learning in international and domestic settings, and methods for preparing learners and evaluating program outcomes. Several hurdles can be anticipated in developing global health programs, including finances, meeting curricular and supervision requirements, and issues related to employment law, liability, and sustainability.
One Pagers | Jul 15, 2007 | JL Hyer; Andrew Bazemore MD, MPH; R Bowman; Xingyou Zhang, PhD; Stephen Petterson, PhD; Robert Phillips, MD, MSPH
The first expansion of allopathic medical education in 35 years is under way; this could eliminate rural physician shortage areas if students more likely to practice in rural areas are preferentially admitted and supported.
One Pagers | Jun 01, 2007 | D Lindsay; Andrew Bazemore, MD, MPH; R Bowman; Stephen Petterson, PhD; Lerry Green, MD; Robert Phillips, MD, MSPH
The racial/ethnic composition of U.S. medical schools does not reflect the U.S. population. With proper planning, the current medical school expansion could improve physician diversity and reduce health disparities.
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
The distribution of IMGs in the U.S.: The interplay of poverty, rurality, and length of practice
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
Impact of Title VII funding on community health center staffing and the National Health Service Corps
Presentations | Mar 15, 2007 | Robert Phillips, MD, MSPH, and Andrew Bazemore, MD, MPH
The National Health Service Corps in rural counties: A historical review and impact assessment
Articles | Dec 15, 2006 | Lars E. Peterson, Hillary Johnson, Perry A. Pugno, Andrew Bazemore, Robert L. Phillips Jr.
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Presentations | May 15, 2006 | Bob Phillips, MD, MSPH Andrew Bazemore, MD, MPH Martey Dodoo, PhD Perry Pugno, MD
Recent studies of the family physician workforce: Implications for education and training
Presentations | May 15, 2006 | Jessica McCann, MA Valerie Reese, MD Andrew Bazemore, MD, MPH Robert Phillips, MD, MSPH
Examining the impact of closing family medicine residency programs
Presentations | Apr 15, 2006 | Bob Phillips, MD, MSPH
Family medicine training: Time to be counterculture, again
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.
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.
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.
Commentaries & Editorials | May 15, 2005 | Marguerite Duane, MD, MHA, and Robert L. Phillips, Jr., MD, MSPH
Four-year residency training for the next generation of family physicians
Articles | Sep 15, 2004 | Marguerite Duane, MD, MHA; Susan M. Dovey, PhD; Lisa S. Klein, and Larry A. Green, MD
Advances in medical technology and knowledge combined with increasing restrictions on resident work hours and decreasing medical student interest invite reconsideration of how family physicians are trained. METHODS: We resurveyed 442 third-year family practice residents who had participated in a prior study in 2000 to determine whether their opinions about the length and content of residency had changed and whether they would still choose to be a physician and a family physician.
Geographic Retrofitting: A Method of Community Definition in Community-Oriented Primary Care Practices
Articles | Jun 15, 2004 | Fitzhugh Mullan, MD; Robert L. Phillips, Jr, MD, MSPH; Edward L. Kinman, PhD
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Monographs & Books | Mar 15, 2004 | Robert L. Phillips, Jr., MD, MSPH; Larry A. Green, MD; George E. Fryer, Jr., PhD; Jessica McCann, MA
The new model of primary care: Knowledge bought dearly
Articles | Jan 15, 2004 | Robert L. Phillips, Jr, MD, MSPH; George E. Fryer, PhD; Frederick M. Chen, MD, MPH; Sarah E. Morgan, MD; Larry A. Green, MD; Ernest Valente, MA, PhD; and Thomas J. Miyoshi, MSW
BACKGROUND: We wanted to evaluate the most recent, complete data related to the specific effects of the Balanced Budget Act of 1997 relative to the overall financial health of teaching hospitals. We also define cost report variables and calculations necessary for continued impact monitoring. METHODS: We undertook a descriptive analysis of hospital cost report variables for 1996, 1998, and 1999, using simple calculations of total, Medicare, prospective payment system, graduate medical education (GME), and bad debt margins, as well as the proportion with negative total operating margins. RESULTS: Nearly 35% of teaching hospitals had negative operating margins in 1999. Teaching hospital total margins fell by nearly 50% between 1996 and 1999, while Medicare margins remained relatively stable. GME margins have fallen by nearly 24%, however, even as reported education costs have risen by nearly 12%. Medicare+Choice GME payments were less than 10% of those projected. CONCLUSIONS: Teaching hospitals realized deep cuts in profitability between 1996 and 1999; however, these cuts were not entirely attributable to the Balanced Budget Act of 1997. Medicare payments remain an important financial cushion for teaching hospitals, more than one third of which operated in the red. The role of Medicare in supporting GME has been substantially reduced and needs special attention in the overall debate. Medicare+Choice support of the medical education enterprise is 90% less than baseline projections and should be thoroughly investigated. The Medicare Payment Advisory Commission, which has a critical role in evaluating the effects of Medicare policy changes, should be more transparent in its methods.
Articles | Nov 15, 2003 | Robert L. Phillips, Jr, MD, MSPH; Katherine A. Phillips, PhD; Frederick M. Chen, MD, MPH; and Allegra Melillo, MD, MS.
BACKGROUND AND OBJECTIVES: This study's objective was to learn what student applicants to family practice residency programs in 2002 understood about National Resident Matching Program guideline violations, whether they experienced violations, and how they were affected by perceived violations. METHODS: We used qualitative analysis of in-depth interviews with 15 key informant students. RESULTS: Only six of the 15 students believed that they had experienced a violation. Only two students had experienced an actual Match guideline violation, and two more experienced potential violations. There was substantial confusion about what constituted a violation. The sources of confusion involved failure to attend Match orientation, lack of clarity in published information, confusing messages from programs, rumors and word-of-mouth, and students' own personal moral values. Equal Employment Opportunity Commission violations were interpreted by some as Match violations. Some students judged programs based on threats to the integrity of the Match, whether or not they experienced actual violations. CONCLUSIONS: Real and potential Match violations did occur, but there is also considerable confusion about what constitutes a violation. There are opportunities to investigate violations, train students to recognize and deal with violations, and clarify actual violation definitions and for programs to avoid the real and perceived violations that affect their recruiting.
Articles | Nov 15, 2003 | English H. Gonzalez, MD, MPH; Robert L. Phillips, Jr, MD, MSPH; and Perry A. Pugno, MD, MPH, CPE.
BACKGROUND: Between July 1, 2000, and July 1, 2002, the Residency Review Committee for Family Practice had received requests for voluntary withdrawal from 27 residency programs. This number represents a significant increase in the rate of program closure over previous years. OBJECTIVES: We compared descriptive data on these closing programs and explored factors contributing to the closure. METHODS: Descriptive program data were collected from the Accreditation Council for Graduate Medical Education, National Resident Matching Program, the American Academy of Family Physicians, and the American Board of Family Practice. Program directors from closing programs were invited to participate in a semi-structured interview to discuss factors contributing to the closure of their program. RESULTS: Seventy-five percent of closing programs were community based, median program age was 11 years, board pass rate averaged 98%, and 69% cared for underserved communities. Financial, political, and institutional leadership changes were most frequently cited by program directors as primary reasons for program closure. CONCLUSIONS: The rate of program closure is increasing, affecting programs that meet most measures of high quality. Quality programs are being lost, and the ultimate impact is yet to be seen. Program directors offer warning signs and advice that is generally applicable to other family practice residency programs.
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.
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.
Articles | Feb 15, 2003 | Schneewiss R, Rosenblatt RA, Dovey S, Hart LG, Chen FM, Casey S, Fryer GE
BACKGROUND AND OBJECTIVES: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States. METHODS: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis. RESULTS: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 year between 1988-1997 to 4.8 per year in the 4 years following passage of the BBA. CONCLUSIONS: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.
Articles | Sep 15, 2002 | Chen FM, Phillips RL, Schneeweiss R, Andrilla, CHA, Hart G, Fryer GE, Casey S, Rosenblatt RA
BACKGROUND AND OBJECTIVES: Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding. METHODS: Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs' knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare. RESULTS: A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME funding they received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%). CONCLUSIONS: More than half of family practice training programs do not know how much GME funding they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.
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.
Commentaries & Editorials | Aug 15, 2002 | Robert L. Phillips, Jr., MD, MSPH; George E. Fryer, Jr. PhD; and Larry A. Green, MD
GME financing reform: The saga continues
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.
The Association of Title VII Funding to Departments of Family Medicine with Choice of Physician Specialty and Practice Location
Articles | Jun 15, 2002 | George E. Fryer, Jr, PhD; David S. Meyers, MD; David M. Krol, MD; Robert L. Phillips, MD, MSPH; Larry A. Green, MD; Susan M. Dovey, MPH; and Thomas J. Miyoshi, MSW
BACKGROUND: Title VII predoctoral and departmental grants for departments of family medicine are intended to increase the number of family and primary care physicians in the United States and increase the number of practices in rural and underserved communities. This study assessed the relationships of Title VII funding with physicians' choices of practice specialty and location. METHODS: Non-federal direct patient care physicians who graduated from US medical schools from 1981-1993 were identified in the 2000 American Medical Association Masterfile. A grant history file was used to annotate Masterfile records with Title VII funding data for the physicians' 4-year medical school enrollment. Characteristics of the county in which they practice were taken from the Area Resource File. Title VII funding variables were then related to practice specialty and location. RESULTS: Predoctoral training and departmental development funding were strongly related to attainment of each of the Title VII program objectives evaluated. CONCLUSIONS: Title VII has been successful in achieving its stated goals and legislative intent and has had an important role in addressing US physician workforce policy issues.
Articles | Mar 15, 2002 | Marguerite Duane, MD, MHA; Larry A. Green, MD; Susan Dovey, MPH, PhD; Sandy Lai, MD; Robert Graham, MD; and George E. Fryer, PhD
BACKGROUND: Family practice residency programs are based largely on a model implemented more than thirty years ago. Substantial changes in medical practice, technology, and knowledge necessitate reassessment of how family physicians are prepared for practice. METHOD: We simultaneously surveyed samples of family practice residency directors, first year residents, and family physicians due for their first board recertification to determine, using both quantitative and qualitative methods, their opinions about the length and content of family practice residencies in the United States. RESULTS: Twenty seven percent of residency directors, 32% of residents, and 28% of family physicians favored extending family practice residency to four years; very few favored 2 or 5 year programs. There was dispersion of opinions about possible changes within each group and among the three groups. A majority of all three groups would be willing to extend residency for more training in office based procedures and sports medicine, but many were unwilling to extend training for more training in surgery or hospital based care. Residents expressed more willingness to change training than program directors or family physicians. Barriers to change included disagreement about the need to change; program financing and opportunity costs, such as loss of income and delay in debt repayment; and potential negative impact on student recruitment. CONCLUSION: Most respondents support the current three year model of training. There is considerable interest in changing both the length and content of family practice training. Lack of consensus suggests a period of elective experimentation may be needed to assure that family physicians are prepared to meet the needs and expectations of their patients.
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.
Direct Graduate Medical Education Payments to Teaching Hospitals by Medicare: Unexplained Variation and Public Policy Contradictions
Articles | May 15, 2001 | Fryer GE, Green LA, Dovey SM
PURPOSE: To comprehensively examine both inter - and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services. METHOD: Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria fro moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined by the Area Resource File. RESULTS: Variations in inter - and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAs. CONCLUSION: Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to US physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.
One Pagers | Jul 01, 2000 | Susan Dovey, MD, MPH; Larry Green, MD; Ed Fryer, PhD
Accredited family practice rural training tracks place their graduates in rural settings at very high rates: 76% overall and 88% among programs implemented in the last ten years. Favorable, immediate results could be expected from their continuation and expansion, permitted by adjustments in the Balanced Budget Act of 1997.
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