Comparative Primary Care Delivery By Medical School and Training Type

Physicians and other clinicians have been moving steadily away from primary care. Specific measuring tools can indicate sources better and worse in the production of primary care. Unlike "wait and see" or projections based on annual graduates, the Standard Primary Care Year (SPCYR) is a more specific measuring tool. The SPCYR estimates the future primary care delivery at the time of graduation. Data regarding years in a career, clinical activity, and adjustments for differences in volume between primary care sources are already known. 

Career Years x Primary Care Retention x Clinician Activity x Volume Adjust  =  SPCYR

The career years times how that career was spent with adjustments for activity and volume differences yields the Standard Primary Career Year estimate.

The most recent primary care retention figures can be inserted or the steady declines of recent decades of class years can be projected. Recent primary care retention was used rather than projections for this ranking. Even less primary care delivery would be expected from recent graduates, especially in sources declining the most rapidly.

Spreadsheet calculations can be used to estimate primary care deliver (in SPCYRs) for each type of training. For medical school calculations, the Standard Primary Care Year result for graduates choosing family medicine, internal medicine, and pediatric training can be estimated and the results summed for each type of school for 100 average graduates of that type of school. Results below.

Summary of Primary Care Delivery Contributions by Training Type

Substantial declines in primary care delivery have occurred in the past 20 years across physician, physician assistant, and nurse practitioner sources of clinicians. The major reasons include fewer graduates entering primary care careers and fewer staying in primary care careers. As rewarded by health policy payment design, more graduates have entered new specialties and more have been added to each new specialty. The most specific losses have been in family practice and in primary care position result. 

Declines in family medicine in certain schools simultaneously reduce primary care delivery and workforce where most needed by multiple times. This is because family medicine residency graduates deliver 2 to 6 times more primary care and because family physicians distribute at 2 to 4 times greater levels than other sources not in family practice positions. This location multiplier applies across all locations in need of workforce and applies to the graduates of over 95% of medical schools 

Since family practice is about one-fourth of workforce where needed and since primary care is half of workforce where needed, the declines noted in the past twenty years for MD, DO, NP, and PA graduates indicate declines in workforce where needed. 

Sources with predominantly internal medicine training as the source of primary care (international, lowest FM choice schools) have declined substantially because so few internists remain in primary care after training. The 60% primary care result of 1980 internal medicine entry has fallen to less than 20%. In general, types of schools with greater FM choice also tend to have graduates with slightly better internal medicine primary care retention.

Overall Primary Care Delivery Result in SPCYRs for Recent Graduates 

Estimated Over Their Careers 2010 to 2045

• 12.1 Standard Primary Care Years per Graduate - Duluth medical school leads in primary care delivery per graduate due to 44% family medicine result for recent graduates and essentially 44% - 52% FM result for decades of class years.
• 9.2 - Caribbean school graduates deliver the most primary care per graduate due to about 25% family medicine and 36% internal medicine (reduced to 12% actual primary care for IM)
• 8.9 – Top osteopathic schools once led in primary care delivery with over 60% family practice result, but only the schools remaining at 30% family medicine continue this contribution.
• 7.0 - Physician assistants have declined to only 20% family practice position result with less than 30% active as primary care clinicians, but PA graduates remain above the average US DO and US MD graduate.
• 5.9 – International graduates other than from Caribbean schools have reduced primary care result due to only about 7% family medicine. The substantial internal medicine training choice of 45% is multiplied by only 30% retention in primary care to negate the primary care result.
• 4.7 - Nurse practitioners have also had declines in primary care retention. Family nurse practitioner graduates likely have the highest contributions with
• 4.4 - The US MD schools remain the major source of physicians for the United States. Declines in primary care delivery over the past two decades have been devastating for primary care result.
• 2.4 - The schools considered the most exclusive by the top MCAT scores of matriculants, by NIH research dollars awarded per year, or by subspecialty production have the lowest primary care production. Fewest family physicians and least internal medicine and pediatric primary care retention reduce the primary care delivery result.

The SMART Family Medicine Medical School

Specific - Failures and successes shaped predominantly by family medicine choice indicate a Specific solution for primary care and for workforce where needed. Bypassing the barriers to family medicine result such as current medical school preparation, admission, and training makes sense.

Measurable - A family medicine only medical school is Measurable at 25 Standard Primary Care Years or 2 times the best school and 10 times the primary care delivery of the worst schools 

Achievable - Flexible sources of primary care cannot achieve primary care because so few stay in primary care over their careers. Primary care recovery is achievable based on the number of annual graduates needed times the family medicine SPCYR number. 

Specific designs for just 3 years of preparation and 3 years of medical (not 4) would result in 27 Standard Primary Care Years - a design that requires less graduates for more primary care result. 

Realistic - Expecting primary care from sources with nearly 20 class year declines in primary care result is not realistic. The overall primary care result from 6 primary care sources is only about 33% retention in primary care. When primary care delivery is the specific focus, the realistic solution is the 90% primary care result as seen only in family medicine. NP or PA graduates, if forced to remain permanent in family practice positions over a career, could be realistic sources but this would require a reversal of the past 50 years of training and policy in 50 states.

Timely - Actually it is already too late for primary care recovery. Workforce changes toward primary care would take at least 15 class years and more likely 25, but SMART expansions are the most timely in terms of the result for primary care, for 40% of the nation left behind where 36% of family physicians are found, for the populations increasing most in these locations such as the elderly, and for those previously without insurance coverage, 

Defeating SMART Family Medicine

An increase in family medicine residency from 3 to 4 years would result in 23 Standard Primary Care Years and fewer funded GME positions per class year would result in a 12 - 18% decline in the number of family medicine graduates a year - a disaster for primary care and workforce where needed.

A two year longer training for a doctoral NP degree similarly would reduce workforce result by 10% including primary care delivery with a likely further reduction in annual graduates due to shortages of faculty and other elements of training. 

Recent Works

Too Many and the Wrong Clinicians - Additional consequences result from designs not specific to primary care or care where needed.

Starting to Solve Societal Inequities - Support for a SMART Start from the Very Beginning of Life

And the Next Victims of Cost Cutting: Dual Eligibles - Those Most Vulnerable and Least Able to Defend Themselves Are Next

ALS Disease Focus Is Not a Top Priority - Have fun, but Minor Incidence Diseases Are Below the Major Diseases, and Far Below Health Care Caused Disease, and Causes of Early Death, and the top 10 priorities for most Americans - and America as a Nation  

Information Technology Cannot Heal - Time to Get Out of the Way of Healing and Those Who Can Help Remove Barriers to Healing 

Best Beginnings for Health Access Clinicians - Shared Origins and Optimal Health Access Focus During Trainings

Family Medicine Needs a New Beginning - Current Preparation, Admission, and Medical School Plus Health Policy Interact To Prevent Family Medicine Choice - and Health Access Result

Hotspotting Has Many Spots To Consider - Simple Interpretations Are Inaccurate, Many Different Characteristics Shape the Outcomes, Not Just Geographic Location

Retail Clinic Recoil - Many Side Effects Can Be Anticipated, And More to Come

Global Fails Local But Local Focus Succeeds Globally

What Veterans Need Is Family Practice - No Other Type of Clinician Comes Close to the Location or the Scope

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

Perverse Health Payment Dividing US - More for Fewer and Less for More, and Penalties for Those Caring for Those Most in Need

How To Resolve Health Access for 40 States Behind By Design

Health Care Delivery Is No Laughing Matter - Political Cartoons are Nice, but...

Overcoming Barriers to Health Access Including Portions of ACA

Will Teaching CHC Sites Deliver on the Promise of Health Access?

How Bad Medicine is Sweeping The Country.

Preventing Rural Workforce By Design

The Worksheets

The first calculations involve an average 100 US MD graduates with typical activity, volume by specialty, and 35 career years in the 1990s 

US MD 1990s	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	83%	94%	100%	35	27.31	13%	359.99
IM	83%	60%	86%	35	14.99	25%	374.75
PD	83%	65%	95%	35	17.94	9%	161.45
					8.91		891.18

Fewer in family medicine plus primary care retention cut by one-third for internal medicine cuts primary care delivery per graduate from 8.91 to 4.43 Standard Primary Care Years. Minor changes include declines in activity and years in a career.

The US MD figure of 4.43 Standard Primary Care Years for recent graduates (2010) basically sets a low bar for primary care production from the dominant US source of clinician workforce.

US MD Recent Grads	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	90%	100%	34	24.48	8%	196
IM	80%	20%	90%	34	4.90	25%	122
PD	80%	44%	95%	34	11.37	11%	125
					4.43		443

Osteopathic medical schools have rapidly expanded with another doubling of graduates since the 1990s. Unfortunately the family medicine choice has been cut in half from 35% to 18%. Since family medicine is the predominant primary care source for US DO schools, the primary care result has also plummeted.

US DO	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	90%	100%	34	24.48	18%	441
IM	80%	28%	90%	34	6.85	14%	96
PD	80%	50%	95%	34	12.92	6%	78
					6.14		614

Caribbean schools have been expanding annual graduates at some of the fastest rates. This has raised some controversy, but it has also raised primary care production. Caribbean graduates have some of the highest rates of family medicine choice. Internal medicine choice also makes a contribution at 36% of Caribbean graduates, but this is reduced to a reality check 12% because of only 33% primary care retention.

Caribbean	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	90%	100%	34	24.48	23%	563
IM	80%	33%	90%	34	8.08	36%	291
PD	80%	42%	95%	34	10.85	6%	65
					9.19		919

International graduates are often considered a good source of primary care, but this may be because they are better than US MD graduates – slightly better. Graduates from schools in the Philippines stand out as superior in primary care and workforce where needed. This is somewhat limited to a few states. These figures do not correct for 20% - 25% that depart the United States after US residency training or lesser activity levels due to higher unemployment rates. These corrections would leave international graduates at the same low level as US MD graduates.

Inter-national	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	90%	100%	34	24.48	7%	171
IM	80%	30%	90%	34	7.34	45%	330
PD	80%	33%	95%	34	8.53	10%	85
					5.87		587

Success as indicated by consistent top primary care delivery result from the 1970s to the present is found at Duluth.  Even with some slight decline to 44% family medicine, Duluth remains a star. These results are also shown per 100 graduates although Duluth is just 60 per year.

Duluth	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	90%	100%	34	24.48	44%	1077
IM	80%	30%	90%	34	7.34	8%	59
PD	80%	50%	95%	34	12.92	6%	78
					12.13		1213

The top US DO schools continue with 30% family medicine choice. This is half of the level of all osteopathic schools before the 1970s, but the 30% level is still a mark to reach for any school to claim to be in the top echelon of primary care production. Schools in California (Western), West Virginia, and Texas lead. Newer schools such as Pacific Northwest and ATSU’s School of Osteopathic Medicine in Arizona have been consistent at 30% family medicine and should also rate at 8 – 9 Standard Primary Care Years per graduate.

Top US DO Schools	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	90%	100%	34	24.48	30%	734
IM	80%	20%	90%	34	4.90	16%	78
PD	80%	40%	95%	34	10.34	7%	72
					8.85		885

The schools considered the most exclusive by the top MCAT scores of matriculants, by NIH research dollars awarded per year, or by subspecialty production have the lowest primary care production. 

Top MCAT/ Research	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate	% of Grads	SPCYRs per 100 Grads
FM	80%	85%	100%	34	23.12	3%	69
IM	80%	15%	90%	34	3.67	21%	77
PD	80%	33%	95%	34	8.53	11%	94
					2.40		240

 This is the result of the lowest family medicine choice at less than 5%, slightly lower internal medicine choice at 21%, lowest internal medicine retention in primary care at less than 15%, and lowest pediatric retention in primary care at 33%.  Five times as many graduates of the most exclusive schools must be graduated to reach the primary care delivery of Duluth graduates. Most exclusive on physician origin, in selection, in training, and in graduate medical education choices (specialty, location) results in the least primary care delivery. Studies of 14 medical schools indicated only 2% of senior medical students planning internal medicine primary care. This translates to only about 8 – 10% of internal medicine trained graduates retained in primary care from these schools and not all are the most exclusive or have the worse primary care retention in physician databases.

Nurse practitioner and physician assistant primary care delivery can also be estimated. 

	Activity	Primary Care Retention	Volume	Career Years	Standard Primary Care Years per Graduate
NP	60%	50%	70%	23	4.83
PA	75%	40%	75%	31	6.98

Nurse practitioner activity as a clinician is limited due to fewer who become clinicians (part time, inactive, nursing staff, and other non-clinician employment). The primary care retention figures were taken from AHRQ studies using NPI (procedural code) data. Previous comparison studies were summarize for the volume adjustment that was used in the Standard Primary Care Year publication in 2008. AAPA data indicates the 31 year career of PA graduates. The 23 year NP career is the result of late graduation about age 41 or 42 leaving 23 years before retirement.

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Robert C. Bowman, M.D.        Robert.Bowman@DignityHealth.org

Basic Health Access Web    Basic Health Access Blog   World of Rural Medical Education

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.