Family Medicine Graduate Proximity to Their Site of Training: Policy Options for Improving the Distribution of Primary Care Access

摘要

Background and Objectives: The US Graduate Medical Education (GME) system is failing to produce primary care physicians in sufficient quantity or in locations where they are most needed. Decentralization of GME training has been suggested by several federal advisory boards as a means of reversing primary care maldistribution, but supporting evidence is in need of updating. We assessed the geographic relationship between family medicine GME training sites and graduate practice location.Methods: Using the 2012 American Medical Association Masterfile and American Academy of Family Physicians membership file, we obtained the percentage of family physicians in direct patient care located within 5, 25, 75, and 100 miles and within the state of their family medicine residency program (FMRP). We also analyzed the effect of time on family physician distance from training site.Results: More than half of family physicians practice within 100 miles of their FMRP (55%) and within the same state (57%). State retention varies from 15% to 75%; the District of Columbia only retains 15% of family physician graduates, while Texas and California retain 75%. A higher percentage of recent graduates stay within 100 miles of their FMRP (63%), but this relationship degrades over time to about 51%.Conclusions: The majority of practicing family physicians remained proximal to their GME training site and within state. This suggests that decentralized training may be a part of the solution to uneven distribution among primary care physicians. State and federal policy-makers should prioritize funding training in or near areas with poor access to primary care services.(Fam Med 2015;47(2):124-30.)Despite a $15 billion annual federal and state investment in graduate medical education (GME), a physician shortage is on the horizon.1 The Association of American Medical Colleges predicted that by 2025 the nation would need an additional 124,400 physicians of all specialty types.2 However, the number of GME-funded training positions was capped by the 1997 Balanced Budget Act, and from 1997 to 2008, only 7,869 new resident positions were created, mainly to train specialists by teaching hospitals.3 Moreover, the physician shortage is particularly acute among primary care physicians (PCPs) due to the Affordable Care Act and a declining production of primary care from US GME teaching hospitals.4 Recent projections estimate that the growth in the overall US population, the aging of the US population, and insurance expansion through various provisions of the Patient Protection and Affordable Care Act (ACA) will create a need for 35,000 to 52,000 more PCPs by 2025.5,6Equally important is the uneven geographic distribution of primary care physicians between urban and rural areas. Most states and primary care service areas have shortages because physicians most often practice in urban areas. There are on average 68 PCPs per 100,000 residents in rural areas, compared to 84 per 100,000 in urban areas.7 According to the Agency for Healthcare Research and Quality, 89.9% of general internal medicine physicians, 77.6% of pediatricians, and 91% of all physicians practice in urban areas.8,9 Of all the adult primary care physician specialties, family physicians are more likely to populate rural areas, with 77.5% in urban areas, 11.1% in large rural areas, 7.2% in small rural areas, and 4.2% in isolated rural areas.7,10Many factors have been shown to influence the ultimate location of physician practice, including family factors, birth location, training exposures, and even the location of training itself.11,12 As evidenced by significant public investment in regional expansion of medical schools, some policymakers and planners believe the location of training is an effective remedy to the unequal distribution of physicians in their states or regions. Evidence supporting this assumption, however, is scarce. A small number of studies have examined the relationship between training lo