All True GME Reforms Point to Family Medicine

The United States has 30 states in need of clinicians, needs primary care, and needs clinicians to locate practice where 40 - 50% of Americans are most in need of care. These same locations also are increasing most in population and have higher shares of populations growing faster in demand for primary care and basic services. All true reform for graduate medical education leads to family medicine specific expansions of GME positions. 

Primary Care Trained Graduates for Primary Care Result for a Career
  • Only family medicine training leads to 90% primary care result for a career.
  • Declines down below 15% primary care result for IM training and less than 40% for pediatric training represent failure for primary care. 
  • Less than 50% for primary care for nurse practitioners and less than 30% for physician assistant graduates is also failure for primary care

Clinician Workforce Where Needed
  • Only family physicians have population based distribution across their careers. This is a 1 to 1 distribution such as 20% of family physicians found in rural locations where 18% of the population is found. Family physicians are 36% found where 40% of Americans are found in the 2621 counties lowest in clinician concentrations.
  • 0.9 to 1.1 ratios are required for recovery of clinician services where needed and only family medicine reaches these ratios
  • 0.4 to 0.62 ratios or far less than 1.0 as in population based are not specific to services where needed. Far less is the result for all types of positions filled other than family practice

Training location also shapes clinician practice locations. Studies indicate that training locations where care is needed help to shape such locations in practice. Residency programs tend to fill up workforce in the 60 miles around the residency training program - especially in family medicine. For practical purposes, training in a certain county fills up graduates for a 2 or three surrounding county radius. 

Packing resident training into just a few counties that represent the centroid of top concentrations of physicians is the primary problem 
with regard to distribution of care where needed. 

Care where needed requires that training be established at sites in need of clinicians with nearby counties filling up with needed clinicians - by design.

The combination of poor retention in primary care plus poor distribution defeats all types of clinicians as sources of health access recovery other than family physicians. 

Clinicians for Thirty States in Need of Clinicians

The past decades of designs have favored 6 states with top concentrations of clinicians. Residency positions are not surprisingly concentrated in these states. Physicians that desire to remain in the 30 states in need of physicians often cannot do so because of aberrant GME design - they are forced to go to top concentration states and this shapes US physicians away from states in need and away from locations in need of physicians. The influence is particularly adverse with regard to international graduate physicians because their only influences are instate specific to states with top concentrations and in counties with top concentrations. 

The Instate Multiplier for States in Need - Across the 30 states in need of workforce, instate residency training is a 20 to 40 times multiplier of practice location using all active physicians (over 700,000) in the AMA Masterfile 2013 and controlling for state origins, state medical school, specialty, and other origin variables. 


In Conclusion, the Optimal Solution 
  1. Training in 30 states in need
  2. Training in family medicine
  3. All preparation and training in locations in need of workforce

This is also the solution for the following populations:
  • Elderly, oldest of the elderly, Medicare, Medicaid, Dual Eligible populations,  that are over 40% found in 2621 counties with 40% of the population
  • Veterans in need of care that are over 40% outside of lowest clinician concentration counties
  • Working poor, poor, rural, underserved, uninsured, underinsured, lesser employed, unemployed populations

So Why Do Our Leaders Promote the Following as Solutions

Generic expansions of MD, DO, NP, and PA
Generic expansions of physician primary care training
Generic advanced nursing

The Answer May Well Be That Generic Expansions Are Best for Employers, Institutions, Hospitals, Practices, and Facilities that 
  • already have higher concentrations of clinicians
  • already receive greater revenue by design

And those doing best want even more - from the generic workforce supplied to them, often with government and foundation dollars that are supposed to go for primary care and for workforce where needed. 

Will Teaching CHC Sites Deliver on the Promise of Health Access? - not if they do not remain specific to states in need, locations in need of workforce, and family medicine training (note, not all CHC sites are underserved or will result in distribution of family medicine residency graduates to surrounding counties lower in clinician concentrations)

Improving Graduate Medical Education - Especially in Family Medicine 

The best way to improve GME is to have a better medical student. 9 - 12 months in the third or fourth year spent in continuity sites where care is needed is the best of preparation for GME - especially for primary care and surgical careers as the Minnesota RPAP has demonstrated for decades. The third year dedicated to efficient and effective learning facilitates accelerated training. By the same process, all preparation and training immersed in communities in need of workforce is the optimal solution for health access recovery.

Avoiding the Distortion of Longer Graduate Medical Education Training (especially in FM)


Longer GME should be avoided. For example, a fourth year of FM GME 
  • Consumes more GME positions
  • Decreases the slots per year in a residency program by 12 - 20%
  • Decreases the number of family medicine graduates per year by 12 - 20%
  • Results in fewer years in a career (3% loss of workforce)
  • Delays and decreases income and increases debt at a time when family medicine residency graduates need increases in income, decreased debt and more income earning years
  • Is likely to result in declines in distribution (unless the 4th year of GME is specific to c-sections, surgery, and other procedural practices

More Evidence of GME Reform Failure

Chen et all demonstrate failure of the past decade of legislated GME reforms for the states in need, for primary care, and for rural training

GME Changes in Academic Medicine by Jolly - 11% annual increases in sub subspecialty positions, 4% annual increases in subspecialty fellowship positions - translates to shrinkage of the physicians remaining in core specialties, the physicians most associated with basic services, primary care, and care where needed.

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings - Those least likely to gain admission are the most likely to choose family medicine, the most likely to be found in primary care, and the most likely to distribute to counties in most need of care. Why does our national design so distort physicians away from health access recovery.


Global Fails Local But Local Focus Succeeds Globally

Domino Decline By Design - as ERs Close, Those Nearby Face Challenges, as Small or Rural Hospitals Close or Practices Where Needed...

Declines in Health Care Delivery Despite Increases in Health Spending - If We Keep Accelerating Non-Delivery Costs, We Can Continue to Remain Behind Health Care Demand


Blogs indicate that primary care can be recovered and should be recovered.

Dr. Bowman is the North American Co-Editor of Rural and Remote Health. He was the founding chair of the Rural Medical Educators Group of the National Rural Health Association and the long term chair of the STFM Group on Rural Health.

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