SMART Primary Care : Family Practice Contributions

Specific in primary care is a source that remains in primary care closest to 100% for a career contribution.

Not Specific and therefore not SMART is a source that is flexible with graduates that serve less than one-third of their careers in primary care delivery.

Without specific retention within primary care, it is difficult to measure primary care delivery. Flexible primary care training sources do not remain in primary care and result 75% in non-primary care workforce. Internal medicine, nurse practitioner, and physician assistant graduates steadily depart primary care during training, at graduation, and each year after graduation. Flexible primary care sources are difficult to assess with regard to career primary care contributions, especially in the past 15 years of changes. During periods of declining primary care retention, all methods overestimate primary care delivery including the Standard Primary Care Year method.

Most permanent sources such as family medicine result in the most specific translation of annual graduates into reliable and measurable and achievable primary care delivery.

Primary care recovery requires SMART in at least 4 dimensions - retention in primary care for a career at closest to 100%, activity in practice at closest to 100%, years in a career closest to 40 years (age 25 to 65),and volume at or greater than the top volume sources such as pediatrics or family medicine.

Measurable involves estimates based on a tool such as the Standard Primary Care Year. The SPCYr is the product of career estimates of years in a career, % in primary care, % active in US workforce (or any specific location type), and volume set relative to 100% for FM and PD. Sources of primary care least specific  in years, PC retention, activity, and volume are least specific, difficult to measure, and deliver the least priamry care during a career.

SMARTest for primary care is family medicine with 85% retention, 34 years, 85% active, and 100% volume. Caribbean, US MD, US DO, and non-citizen international graduate FM all have 20 - 26 Standard Primary Care Years per graduate. This is a measure that is relative or comparative to other sources.

Nurse practitioners with 25 years, 70% active as direct clinicians, 35% of direct clinicians in primary care, and lowest volume at 70% (wide range) represent least primary care delivery per generic nurse practitioner graduate for only about 4 Standard Primary Care Years per graduate. By specific type of training, the family nurse practitioner can be expected to deliver about 6 to 7 SPCYrs over a career due to higher retention. All other nurse practitioner graduates combined deliver less than 2 Standard Primary Care Years per graduate or less than graduates of Yale or Harvard or other prestigious medical schools. Family medicine residency graduates in their careers will deliver 4 to 8 times more primary care than nurse practitioner graduates. Medical schools missing in family medicine career choice also miss out on primary care delivery for the United States.

Physician assistants have declined to 28% entering primary care, 75% active, 33 years, and 75% of the volume for about 5 Standard Primary Care Years per graduate. In the 1990s graduates with over 50% primary care and lower costs of training, the PA was a bargain in training cost and primary care delivery.

The last doubling of annual PA graduates resulted in a 200% increase in non-primary care entry and a 30% increase in primary care entry numbers - a level that will be negated by departures after graduation. PA annual graduates increased 100% but will have about zero increase in primary care delivery. PA leaders are not at fault. Physician assistants mirror physician designs and policies that shape only 25% of physicians entering primary care shape PAs the same way. Flexible designs cannot fight policy constructs. Only permanent designs can result specifically in primary care during periods of poorly supportive of primary care as in all recent decades other than 1970 - 1980.

SMART is possible for non-physician clinicians but only with required retention within family practice. Distribution is optimal as well as noted in family practice DO, MD, NP, and PA sources that distribute at maximum levels to those in need of care. If NP and PA matched the 95% retained in family practice of family physicians, NP and PA graduates would contribute 3 to 4 times more primary care per graduate and the combination of FM, NP, and PA would be optimal for primary care recovery. Regardless of the source, permanent family practice is required for recovery to have sufficient primary care and to distribute primary care where needed.

Only family practice solutions work for nearly all Americans
for basic health access needs for nearly all of the years of their lives
delivered in nearly all locations.

Internal medicine is not SMART with lack of specificity the major SMART failure. Only 20% of graduates indicate primary care entry with departures in the years after graduation. Highest cost of training defeats medicine and medicine pediatrics as sources. Internal medicine also concentrates in top concentrations of people, income, and health professionals. Non-citizen international graduates do tend to chose internal medicine (about 35% of total IM). Delays in entry, limited distribution, lack of retention in primary care, and departures from the United States.

Pediatric residency expansions are contraindicated for the purpose of increasing US primary care delivery. Saturation of pediatric primary care workforce has been known for a decade. Expansions of annual graduates have bounced away from primary care and toward academic and part time positions. Pediatric graduates crowd into academic and highest workforce concentrations (similar to origins and training) where 70% are already found. Fewer have been locating in rural and underserved locations (Randolph, Committee on Pediatric Workforce).

In summary, primary care that stays in family practice is SMART. Family practice provides the bulk of primary care and even greater shares of primary care where it is most needed.

Non-family practice sources are more likely to depart primary care and are more likely to crowd into top workforce concentration locations with the most specialized and the most concentrated. Even the most general still are found at 75% - 80% inside of existing workforce concentrations.

Family practice is found about 50 - 55% outside of concentrations where 65% of the population is found in 30,000 zip codes. All other sources are found 70 - 92% inside of concentrations - 3400 zip codes clustered together in 4% of the land area with 35% of the population.

Sources that are more specific than current family medicine are required for efficient and effective primary care recovery. Generic is not measurable and is actually not achievable with regard to primary care recovery. Permanent primary care that is predominantly family practice is required - 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 and he is the author of the World of Rural Medical Education, and Physician Workforce Studies
SMART – Specific, Measurable, Achievable, Realistic, Timely


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