The serious shortage of primary care doctors in America will get much worse unless the country reforms its graduate medical education system, researchers from the George Washington University School of Public Health and Health Services (SPHHS) reported in Academic Medicine.

Less than 25% of newly qualified doctors go into primary care, and just 4.8% move into rural areas, the authors added. This serious problem will only get worse unless some fundamental changes are introduced.

Lead author, Candice Chen, MD, MPH, an Assistant Research Professor of Health Policy at SPHHS, said:

"If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse. The study's findings raise questions about whether federally funded graduate medical education institutions are meeting the nation's need for more primary care physicians."

The American GME (graduate medical education system) depends on public funding. It receives almost $10 billion from the Medicare program, plus $3 billion from Medicaid. Experts say that in spite of this large cash infusion, the federal government does not ask residency programs to make sure doctors are trained to work in rural or underserved areas of the country.

Medicare and Medicaid represent the major public investment in the US health force. Even so, in some geographical regions there are critical shortages of primary care doctors. There are also shortages in other specialties, including general surgery.

Dr. Chen and team gathered and examined data on the career pursuits of 8,977 doctors who graduated from 2006 to 2008 from 759 medical residency sites. They analyzed the data to determine where these recently qualified doctors were practicing three to five years later.

Overall, they found that just 25.2% of the 8,977 physicians ended up in primary care. Even this figure is probably an overestimate, the authors explained, because it includes graduates who practice as hospitalists.

Out of the 759 medical residency sites the researchers analyzed, 198 produced no rural doctors at all from 2006 to 2008. They also found that 283 sites produced no doctors practicing in Federally Qualified Health Centers, centers that provide medical care to low-income patients, among others. Many Federally Qualified Health Centers are located in struggling urban or remote areas.

The critical shortage in primary care physicians and clinics affects approximately 66 million Americans, about 1 in every 5 people. Chen added that the primary care shortage and inadequate access to proper and prompt care probably contributes to a higher incidence of more serious health conditions.

The USA is producing primary care physicians at an "abysmally low" rate. Unless something drastic is done soon, the shortfall will get desperately worse. As the Affordable Care Act pushes up demand for primary care services (millions of newly insured patients), large parts of America are set for a serious health care crisis. According to a study carried out at the Mongan Institute for Health Policy at Massachusetts General Hospital, a high percentage of primary care doctors probably won't care for the newly insured patients.

Finding and retaining primary care doctors is already a serious problem for urban clinics in underserved neighborhoods.

This new study underlines the huge void that exists between federal funding for residency programs and the country's dire shortage of primary care physicians.

The authors also reported that:
  • Forty-one percent of all primary care doctors came from 20 sites. They produced 1,658 primary care physicians. However, they only received $292 million in GME funding (out of the nearly $13 billion)

  • The bottom 20 programs produced just 684 primary care graduates, that is just 6.3% of 10,937 graduates, but they received $842 in GME payments.
Chen and team wrote that the GME federal funding distribution shows a total disregard for the country's serious primary care doctor shortage. All it ends up doing is "churning out highly paid specialists who typically practice in big cities or the suburbs."

The authors pointed out that nearly two-thirds of the almost $10 billion in Medicare funding for GME every year goes to 200 hospitals which have a poor record in producing primary care doctors.

America needs a more accountable GME system

America is in desperate need for a more accountable GME system. Policymakers need to completely change the existing system of skewed incentives which has led to the primary care crisis that exists today, the authors stressed.

Fitzhugh Mullan, MD, the Murdock Head Professor of Medicine and Health Policy at GW, said:

"Better balance in medical specialties and more primary care physicians will be essential to building an effective and affordable health system going forward."

There is an interactive map(American Academy of Family Physicians) that shows how well residency programs perform regarding primary care.

The study was sponsored by the Josiah Macy Jr. Foundation.

Boosting primary care does not guarantee better outcomes

Researchers from the Dartmouth Atlas Project explained in 2010 that a nation's primary care needs is not just a question of numbers.

Better outcomes cannot necessarily be guaranteed by increasing the number of primary care physicians, having more primary care services, or improving access to primary care, the authors wrote.

Lead author and co-principal investigator for the Dartmouth Atlas Project, David C. Goodman, M.D., M.S., said "Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage. Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."

Written by Christian Nordqvist