Number One Two Three in Health Access

Solutions for health access primary care workforce
  • Enter primary care practices at highest proportions after training
  • Stay in primary care practice at highest proportions in the years after graduation
  • Have the longest health professional career lengths
  • Remain active in practice during a career at the highest percentages
  • Deliver the highest volume of primary care when active in primary care delivery.
  • Are most likely to be found in 30,000 zip codes with 200 million Americans and only 25% of total workforce (Practice Locations Outside of Concentrations) and
  • Are least likely to be found in 1000 zip codes with only 11% of the population and 50% of the workforce (Super Center Concentrations).
Only family medicine residency graduates meet all of these criteria for graduates past, present, and future. Only family medicine residents have not been increased beyond the 3000 annual graduates first reached in 1980. The US primary care design has also not changed for primary care numbers since 1980 while the non-primary care design has doubled each 15 years since 1965.
Only a broadest generalist primary care source can best meet the needs of over 65% of elderly, poor, near poor, rural, underserved, lower income, middle income, disadvantaged, children in need of health care workforce, and shortage area populations.
Number 1 is United States Origin Family Medicine from a US Medical School

25 Standard Primary Care Years
Estimated Range of 23 – 30 Standard Primary Care Years depending upon age at workforce entry, gender, retention in primary care
Number 2 is United States Origin Family Medicine from a non-US Medical School
22 - 25 Standard Primary Care Years
A slight delay in entry to practice is likely to result in the potential for lesser workforce, but there may be no difference
Number 3 is non-US Origin Family Medicine from a non-US Medical School

20 – 22 Standard Primary Care Years (but broad range)
Medical education in other nations commonly results in younger age but those working toward US training and practice face delays that result in older age entry to US workforce

Standard Primary Care Years Estimates for 2012 
First career and practice location choices are simply insufficient to assess primary care sources. The Standard Primary Care Year is an important estimate of future primary care delivery assigned to the class year of graduation. 

Pediatric and Medicine Pediatrics
10 – 14 SPCYrs
Less than half and likely less than 40% will remain in primary care.
Physician Assistant Beginning Family Practice
12 SPCYrs
Steady departures over the years after graduation limit outcomes.
Nurse Practitioners Trained as Family Nurse Practitioners
6 – 8 SPCYrs
Half will be active as direct care clinicians in family practice employ. Fewest years and lowest volume result in substantially fewer SPCYrs.
Internal Medicine
3 – 5 SPCYrs
Few enter primary care and departures continue after graduation.
Physician Assistant not Starting in Family Practice
1 - 3 SPCYrs
Family practice is the predominant PA primary care vehicle
Nurse Practitioners not FNP trained
1 – 2 SPCYrs
Family nurse practitioners are the predominant NP primary care vehicle


Nurse practitioner and physician assistant contributions to rural or underserved locations in need of workforce are multiple times greater when employed in family practice as compared to NP and PA not family practice employed. NP and PA graduates not employed in family practice remain below average in needed practice locations. About 25% of NP and PA workforce are found active as family practice clinicians although declines could result in fewer.
Comments by any number of “workforce experts” about family medicine from any US origin or non-citizen source should be supportive about expansion, about selection specific to family practice, and about training specific to family practice. This entire blog was posted because non-citizen family medicine has received comments and even testimony to Congress that has not been flattering. What matters is health access delivery where needed. Even if only 7% of non-citizens average family medicine choice, this choice is an important one for 200 million Americans left behind and about to have even more difficulty.
Generic expansions of health professional training not specific to permanent family practice (MD, DO, NP, and PA) should be understood as solutions for non-primary care and practice locations that already have top concentrations. Flexible designs fail for primary care and for 200 million Americans. Flexible designs are represented by NP, PA, and IM training that can result in any number of non-primary care careers. For nurse practitioner or physician assistant training to be SMART Basic Health Access Solutions, they would have to find a way to permanent family practice by a permanent design change. Generic and flexible is failed health access.
Specific family practice is the SMART solution for health access for 200 million Americans left behind and falling further behind by design.
Thanks to all 12,000 who have visited Basic Health Access in 2011.

Robert C. Bowman, M.D.        Basic Health Access Web    Basic Health Access Blog

Dr. Bowman is the North American Co-Editor of Rural and Remote Health and a Professor in Family Medicine at A T Still University School of Osteopathic Medicine. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association, he was the long term chair of the STFM Group on Rural Health, he is the founding director of Priority Infrastructure at http://www.infrastructureamerica.org/ and he is the author of the World of Rural Medical Education, and Physician Workforce Studies

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