Why are 2008 HRSA Projections of Primary Care Workforce indicating substantial increases when the reality is decreases in primary care?

Primary care workforce is substantially less than annual graduate numbers depict due to departures from primary care during primary care training, at graduation, and each year after graduation.

The Health Resources and Services Administration projection of 2020 physician primary care was last posted in 2010. This document indicates increases in primary care that are impossible for internal medicine and family practice. To properly guide the nation, HRSA must not wait for new data or studies. It should remove the erroneous projections. This major document represents much good work tainted by the primary care projections.

	Family Medicine	Internal Medicine	Pediatrics
Annual Graduates since 1980	3000 and steady for zero growth for 30 yrs	About 1% annual growth to 7200	About 2% annual growth to 3200
% Primary Care Entry	85% - surveys, office based retention, COGME 91%	20 - 25% for senior resident surveys and COGME	44% for senior resident surveys and COGME
2010 Primary Care	100,000	80,000 – 90,000	45,000 – 50,000
2020 Primary Care	100,000	60,000 – 70,000	45,000 – 50,000
2030 Primary Care	100,000	40,000 – 50,000	45,000 – 55,000
Steady State 30 yr Entry	3000 per year	1400 per year	1400 - 1600 per year
HRSA 2020 Primary Care Projection Exhibit 18	143,350 family/general practice	155,330 IM Primary Care	72,730 for PD Primary Care
Past Entry into Primary Care in recent years	2500 - 3000	3000 – 3500	1200 - 1400
Annual Primary Care Entry 2010 to 2020 to reach HRSA 2020 Projections	Double from 3000 to 6000 FM Grads 2010 to 2020	Five times entry requiring all 7000 IM Grads to stay in PC	Double the current annual entry to 2600 each year 2010 to 2020

Family medicine has not changed and given 30 years of zero growth, is not likely to change. Internal medicine primary care retention has been cut in half in primary care entry in the past 15 years and 20,000 internists, typically those younger, have entered the hospitalist workforce in recent years. The decline in primary care internal medicine is a worst case scenario for the elderly doubling 2010 to 2030. Any increase in annual graduates in family medicine would have been most specific for the elderly, poor, near poor, rural, CHC, and other populations in most need of primary care.

Pediatric experts have indicated saturations of pediatric primary care in the locations where pediatricians locate primary care practices (Cull, Committee, Freed). Because PD primary care is saturated, increased pediatric annual graduates have resulted in lower proportions remaining in primary care. Expansions of PD annual graduates have demonstrate lack of an ability to increase primary care via expansion. 

Government and foundation reports indicate nurse practitioner and physician assistant contributions to be made in primary care. It is true that primary care contributions have increased, but it now takes 2 to 3 times more graduates for the same primary care, rural primary care, and underserved primary care delivery since 1980. This is because fewer remain in family practice employment – the predominant primary care, rural, and underserved delivery vehicle.

Government and foundation reports also are not specific and the media reports of these efforts are even worse. The reports imply indicate "nurse substitution for physicians" or "nursing as a solution" or "nurse practitioners as solutions." Generic solutions such as more nurses or more nurse practitioners are not specific primary care solutions. Specific solutions for primary care are only 1 in 50 nursing school graduates and only 1 in 4 nurse practitioner graduates that are specific to employment in family practice as a direct care clinician.

Retention in family practice for MD, DO, NP, and PA graduates

is the only significant primary care, rural primary care,

and underserved primary care solution.

Retention in primary care is required

for any source of primary care to result in primary care workforce.

How can viable workforce discussions proceed if major association, foundation, and government reports are in error? Getting beyond agendas to people in need of basic health access is the specific requirement for primary care to be able to address basic health access.

Projection methods for primary care fail when graduates fail to remain in primary care. Projection methods fail when assumptions intercede and displace reality. Common sense tests must be applied to be sure that projections during rosier times (such as the 1990s for primary care) do not result in inflated projections.

Studies must encompass entire careers of contributions using realistic estimates such as those based on years in a career, primary care retention, and activity levels. With only 30% of primary care graduates serving in primary care careers and wide variations in activity and years in a career, the folly of depending upon annual gradutes is quite apparent.

SMART measuring tools are required that assign future workforce to the class year of graduation. This is illustrated in the Standard Primary Care Year – a method that can Specifically Measure Achievable primary care in a Realistic and Timely way.