Primary Care Workforce Atul Grover, MD, PhD, FCCP Center for Workforce Studies Academy Health June 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 Blumenthal, NEJM ;17

Proportion of Total Physicians in Primary Care Remains Stable (33%) AMA Data Primary Care Physicians Non-Primary Care Physicians

Source: 2005 AMA Masterfile IMGs Account for One-Third of IM Physicians

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

Internal 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

US MDs Entering Family Practice Training Through the NRMP Source: NRMP

Percent of New PAs Entering Family Medicine Parallels the Rise and Fall of MDs Going into Family Practice Sources: AAPA Membership Census Survey, ; AAPA Physician Assistant Census Survey, *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 AMA Masterfile Data

IMGs as a Percent of Residents in FM Rising Source: Annual JAMA Medical Education Issues Percent of PGY 1 Positions Filled by IMGs

Subspecialization Rates Going Up 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

Career Plans for Residents (2005 ITE)NumberPercent Geriatrics % Other Career (Not Internal Medicine) % Rheumatology % Other Internal Medicine Specialty % Medicine-Pediatrics % Infectious Diseases % Endocrinology % Undecided Internal Medicine Specialty % Nephrology % Pulmonary/Critical Care1, % Hospital Medicine1, % Hematology/Oncology1, % Gastroenterology1, % Undecided Career2, % Cardiology2, % General Internal Medicine2, % Total17, % Internal Medicine In-Training Examination (ACP, APM, and APDIM), Ibrahim

HRSA ReportPrimary Care in Balance …but doesnt account for increasing specialization

Okay, We Built It… Why havent they come? Money? Lifestyle? Prestige? Educational bias?

Med Students Have Better Experiences in Primary Care Medical Students Who Rated Clerkship Excellent or Good in 2003 Residency Positions Filled by USMGs in 2004 Internal medicine87.9%56.6% Pediatrics78.4%71.3% Surgery78.4%84.8% Family medicine77.8%41.4% Emergency medicine76.8%77.5% Psychiatry73.7%62.8% Obstetrics/gynecology67.6%65.1% Neurology62.4%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/personal69% Adequate support staff and services41% Long term income potential39% Practice income37% Health insurance coverage34% Flexible scheduling33% No or very limited on-call28% Adequate patient volume28% Opportunity to advance professionally27% 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% YES Source: 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

Primary Care Income Less Than Most Other Specialties Median Salary by Specialty in thousands of dollars Source: MGMA Physician Compensation and Production Survey

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?