Primary Care Workforce

Atul Grover, MD, PhD, FCCPCenter for Workforce Studies

Academy HealthJune 3, 2007

Specialty and Geographic Distribution Are Important Workforce Issues

“Specialism has developed so extensively in the larger communities mainly because it is easier, more satisfying, more highly regarded by the public, and more profitable than general practice.

These and other factors have been responsible for the concentration of specialists in the cities, but the increase in their numbers beyond what is necessary to care for the people in any community is unsound and costly in the long run.”

…But Not New (AAMC Rappleye Report, 1932)

Specialties Reporting Shortages(relative to “need” or “demand”)

• Family Medicine, 2006• Allergy and Immunology, 2004 • Cardiology, 2004 • Dermatology, 2004• Medical Genetics, 2004 • Radiology, 2004• Geriatric Medicine, 2003 • Neurosurgery, 2003 • Psychiatry, 2003 • Critical Care, 2006• Pediatric Subspecialties, 2000• Endocrinology, 2002

Physician Supply per Capita

MDs to 100,000

175

125 140

202

276 283

0

50

100

150

200

250

300

1900 1930 1960 1980 2000 2010

Year

Blumenthal, NEJM 2004. 350;17

Proportion of Total Physicians in Primary Care Remains Stable (33%)

AMA DataPrimary Care Physicians

Non-Primary Care Physicians

0

100,000

200,000

300,000

400,000

500,000

600,000

1975 1980 1985 1990 1995 2000 2004

Year

Nu

mb

er o

f P

hys

icia

ns

Primary Care Non-Primary Care Physicians

Source: 2005 AMA Masterfile

Physicians by Degree Type

81.4% 62.2% 70.2% 70.1%

10.0%

4.2%

14.9%6.1%

8.6%

33.6%

14.9%

23.8%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

EM IM FM All Specialties

Specialty

Pe

rce

nt

of

Ph

ys

ica

ns

in S

pe

cia

lty

MD DO IMG

IMGs Account for One-Third of IM Physicians

Source: Physician Characteristics and Distribution in the US, 2007 Edition

Physicians - Percent Change, by Specialty

158.3%

63.2%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

120.0%

140.0%

160.0%

180.0%

1985 1990 1995 2000 2005

Year

Per

cen

t ch

ang

e fr

om

198

5

EM IM FM All Specialties

Number of ACGME PGY 1 Filled Positions, 1993-2005

0100020003000400050006000700080009000

10000Internal Medicine

Family Medicine

Pediatrics

Source: GME Census (AAMC/AMA)

% US MDs & DOs Currently Practicing as Generalists By Year of UME Graduation

Source: 2005 AMA Masterfile Data

Graduation Year

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Gen

eral

ists

as

a P

erce

nt o

f G

rad

uat

es

DO USMD

US MDs Entering Family Practice Training Through the NRMP

USMD

0

500

1,000

1,500

2,000

2,500

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Source: NRMP

Percent of New PAs Entering Family Medicine Parallels the Rise and Fall of MDs Going into Family Practice 1991-2005

0%

10%

20%

30%

40%

50%

60%

1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Year

Sources: AAPA Membership Census Survey, 1991-1995; AAPA Physician Assistant Census Survey, 1996-2005.

*PAs graduating in year immediately preceding the census reference year are considered New Graduates.

Family Medicine

Number and Percentages of Graduates Practicing as Family Practitioners, by Graduation Year and Degree

Graduation

year

Total

family

practice

M.D.s

Family Med as %

of M.D. grads in

year

Total

family

practice

D.O.s

Family Med as

% of D.O.

grads in year

1990 1,741 11.2 489 32.6

1991 1,748 11.2 490 32.2

1992 1,891 12.0 569 37.2

1993 2,099 13.3 561 35.3

1994 2,367 15.0 660 37.8

1995 2,559 15.8 632 34.6

1996 2,654 16.5 644 34.1

1997 2,656 16.5 642 32.1

1998 2,480 15.4 698 33.6

1999 2,125 13.8 519 24.0

2000 2,018 12.8 551 24.7

AMA Masterfile Data

IMGs as a Percent of Residents in FM Rising

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Year

Internal Medicine

Pediatrics

Family Practice

Source: Annual JAMA Medical Education Issues

Percent of PGY 1 Positions Filled by IMGs

Subspecialization Rates Going Up

Ratio of 1st Year Fellows to Residency Completers

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

20042003200220012000

Pediatrics Int Medicine Psychiatry Surgery

Source: JAMA Medical Education Issues

Internal Medicine Fellows by Year of Training

Percentage of First-Year Internal Medicine Fellows who are Female

ABIM Data

Fewer Than One-Fourth of IM Residents Plan to Practice as Generalists or Hospitalists

Internal Medicine In-Training Examination (ACP, APM, and APDIM), Ibrahim

Generalist

Hospitalist

24%23%

19%

16%

3%5% 5%

7%

0%

5%

10%

15%

20%

25%

30%

2002 2003 2004 2005

Career Plans for Residents (2005 ITE) Number Percent

Geriatrics 156 0.90%

Other Career (Not Internal Medicine) 411 2.38%

Rheumatology 424 2.46%

Other Internal Medicine Specialty 563 3.26%

Medicine-Pediatrics 591 3.42%

Infectious Diseases 596 3.45%

Endocrinology 689 4.00%

Undecided Internal Medicine Specialty 906 5.25%

Nephrology 945 5.48%

Pulmonary/Critical Care 1,013 5.87%

Hospital Medicine 1,122 6.50%

Hematology/Oncology 1,297 7.52%

Gastroenterology 1,473 8.54%

Undecided Career 2,116 12.26%

Cardiology 2,232 12.93%

General Internal Medicine 2,724 15.78%

Total 17,258 100.00%

Internal Medicine In-Training Examination (ACP, APM, and APDIM), Ibrahim

HRSA Report—Primary Care in Balance

…but doesn’t account for increasing specialization

Okay, We Built It…Why haven’t they come?

• Money?

• Lifestyle?

• Prestige?

• Educational bias?

Med Students Have Better Experiences in Primary CareMedical Students Who Rated

ClerkshipExcellent or Good

in 2003

Residency PositionsFilled by USMGs

in 2004

Internal medicine 87.9% 56.6%

Pediatrics 78.4% 71.3%

Surgery 78.4% 84.8%

Family medicine 77.8% 41.4%

Emergency medicine 76.8% 77.5%

Psychiatry 73.7% 62.8%

Obstetrics/gynecology 67.6% 65.1%

Neurology 62.4% 52.3%

Radiology (PGY-2) 60.6% 80.8%

AAMC, NRMP, and Ibrahim

Time for Family/Personal Life Most Important Factor in Desirable Position For Physicians Under 50

% Very Important

Time for family/personal 69%

Adequate support staff and services 41%

Long term income potential 39%

Practice income 37%

Health insurance coverage 34%

Flexible scheduling 33%

No or very limited on-call 28%

Adequate patient volume 28%

Opportunity to advance professionally 27%

Source: 2006 AAMC Survey of Physicians Under 50 (preliminary data)

Not interested in working more hours to earn more money

Willing to work longer hours for more pay

66% NO

Would reduce hours if could afford to

80% YES

Currently working/interested in part-time hours

43% YESSource: 2006 AAMC Survey of Physicians Under 50 (preliminary data)

Specialists are More Likely to be “Very Satisfied” with Their Specialty Than Primary Care Physicians

Results of the AAMC Survey of Physicians Over Age 50

0

10

20

30

40

50

60

70

VerySatisfied

SomewhatSatisfied

Neutral SomewhatDissatisfied

VeryDissatisfied

Primary Care Specialties

Primary Care Income Less Than Most Other SpecialtiesMedian Salary by Specialty in thousands of dollars

Source: MGMA Physician Compensation and Production Survey 2001-2006

$50 $100 $150 $200 $250 $300 $350 $400 $450

Family Medicine/General Practice

General Pediatrics

General Internal Medicine

Psychiatry

Emergency Medicine

OB/GYN

General Surgery

Opthalmology

Dermatology

Pathology

Otolaryngology

Orthopedic Surgery

Radiology & Diagnostic Radiology

Urology

Anesthesiology

There Will be Primary Care and Specialty Physician Shortages in the Next 20 Years

• Primary care shortages may be greater if different models of care adopted, increased sub-specialization

• Reimbursement a major factor in specialty choice but how is patient demand linked to physician payment?

• US Medical Schools are likely to expand enrollment 18% by 2012

• Osteopathic schools report 45% expansion likely over same time period

• What will the expanded workforce look like? Will they abandon generalism?