Generic Expansions Are Not Smart

Medical and medical education associations want generic expansions of graduate medical education positions. Billions taken from health care diverted to medical education will not address primary care deficits SMARTly. 

Generic expansion fails for the purpose of primary care. Generic is not SMART - specific, measurable, achievable, realistic, or timely. Obviously the added GME positions outside of primary care will not result in primary care. IM and PD graduate increases have been countered by decreases in the percentages remaining in primary care for no gain. Both are mired at about 1400 - 1600 entering primary care and this is likely to remain so. Both have primary care graduates most likely to crowd their practice location in top concentrations of primary care already.

Specific family medicine expansions could help, but gains of positions could result in conversions of family medicine training to non-primary care positions. What is most likely is that family medicine will remain at 3000 annual graduates as it has for the last 30 years. After 30 years family medicine has reached a peak with 100,000 as a primary care workforce. Internal medicine and pediatric primary care with both be about 50,000 or together about 100,000. HRSA 2008 projections of substantially more are in error as the projections assume retention of primary care graduates within primary care, something lacking in US primary care for decades with more to come.

Only expansions specific to primary care with permanent primary care result for a career are SMART.


Nurse practitioner and physician assistant annual graduates have doubled in number each 6 - 12 years since 1980 but the primary care results have been limited due to departures form primary care and family practice during training, at graduation, and after graduation. The last doubling of physician assistants from 3000 to 6000 resulted in a 30% increase in those entering primary care in 2008 but a 200% increase in non-primary care. Conversions of primary care to non-primary care will result in no gain in primary care and over a tripling of non-primary care.

Generic expansions of osteopathic schools have not increased family medicine numbers. Before 1970 the family practice component was 70%, in the 1990 decade it averaged 35%, and recently the AOA study noted 17%. Each increase in annual graduates has been countered by a decrease in FM proportion resulting in the same 500 - 600 family medicine DO graduates.

Over time the international medical graduate numbers have increased, but the preference has been internal medicine resulting in the least primary care yield. Caribbean annual graduate increases have resulted in forced primary care choice to return to the US via residency programs, but generic expansions of GME will allow more to bypass primary care - negating the expansion. Ross is the number one US source of primary care with by far the most annual graduates and with 26% family medicine and with over 50% primary care training program entry, but more GME positions will allow a bypass of primary care choice.

US MD expansions also fail to increase primary care. The 30% increase in annual graduates seems impressive. Unfortunately the proportion remaining in primary care continues to decline with 7% for family medicine, 4 - 5% for internal medicine, and 6% for pediatrics with 20% or less as a total. Departures from primary care and conversions of family medicine to other positions negate generic GME expansion. Also with generic expansion, graduates choosing FM or IM as a backup plan are more likely to get their higher priority subspecialty choices.

For a SMART primary care result, generic should be avoided and the focus should be specific, measurable, achievable, realistic, and timely. Even with a change to a totally SMART primary care design, it will take 30 class years of sufficient permanent primary care graduates (about 14,000 a year). About 2050 or 2060 the US could have sufficient primary care just as it chose in 1980 to have too little for 2010 to 2030 - by design.


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