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While the workforce measures in this report are focused on primary care, the training measures are focused on all physician trainees as recommended by the NASEM committee. Seeing the entire physician training picture, and not just the primary care picture, is important when considering how graduate medical education in the United States may be contributing to primary care workforce shortages or maldistribution.
The distribution of physician residents does not match the areas where physicians are entering primary care. In 2022, the Northeast had the highest density of physicians-in-training (residents) overall, and the western states and Alaska had the lowest (Figure 6). Yet in much of the Northeast, the proportion of physicians entering primary care is among the lowest in the country (Figure 2).
The mismatch between training opportunities and PCP supply signals that graduate medical education (GME) funding is not set up to support the growth of primary care but instead encourages subspecialty fields. In fact, most GME funding is allocated to the sponsoring institution (usually a hospital)25 even though primary care occurs in the community rather than the inpatient setting.26
Although less is known about the distribution of NP and PA training programs, the largest proportion of postgraduate NP training also occurs within hospitals or large health systems.27
Community-based training initiatives, such as the Teaching Health Center (THC) program, have been shown to produce graduates who are more likely to care for underserved patients and work in rural areas.28 The NASEM report recommended that these alternative training and funding models for GME continue to be supported.
By Emily M. Hawes, Jacob Rains, Candice Chen, and Erin Fraher
Authority Health’s Teaching Health Center (THC) is transforming primary care delivery in urban and rural Michigan. Seventy eight medical residents across four specialties (internal medicine, family medicine, pediatrics, and psychiatry) have increased access to primary care, providing 80,000 patient visits a year that would not exist without the THC program. Residents deliver primary care to patients through a multidisciplinary group-practice model integrating doctors with nurses, social workers, and other health professionals in community-based settings. Through preventive health and chronic disease management, Authority Health specializes in training residents to meet the needs of populations at risk for conditions such as opioid use disorder and diabetes. In addition, the THC residency program has allowed Authority Health to expand the availability of evening care, assist patients with insurance enrollment, and integrate residents into nonclinical settings via a community medicine rotation.
The THC program specializes in growing the primary care workforce in underserved areas and retaining graduates to continue to provide whole-person care to patients. Since the Authority Health THC’s inception in 2013, 49% of graduates have stayed in Michigan and 62% are practicing in a medically underserved area. These data align with recent nationwide findings showing that THC graduates are more likely than other graduates to care for medically underserved populations (35.2% vs. 18.6%) and practice in federally qualified health centers (26.70% vs. 11.69%). THC graduates are also more likely to provide behavioral health care, buprenorphine prescribing, and outpatient gynecological procedures to their patients.
Authority Health. Graduate Medical Education (GME). 2023. https://authorityhealth.org/graduate-medical-education-2/ Davis CS, Roy T, Peterson LE, Bazemore AW. Evaluating the Teaching Health Center graduate medical education model at 10 years: practice-based outcomes and opportunities. J Grad Med Educ.2022;14(5):599-605. doi:10.4300/JGME-D-22-00187.1
There is large state variation in the availability of training in medically underserved areas and rural counties, which are more likely to offer community-based training. To build a robust and evenly distributed primary care workforce, the NASEM report called for primary care teams in all states to have training in community-based settings where most primary care occurs. Yet, some states train only 5.9% of physician residents in MUAs or rural counties, while other states expose all physician residents to these settings (Figure 7).
Johns Hopkins University runs two urban health residency programs – a combined internal medicine-pediatrics program and a primary care track internal medicine program – that are based out of a local federally qualified health center (FQHC). Over 90% of the graduates of these programs have stayed in primary care, and about 75% of them have stayed in Baltimore. Program officials attribute the program’s success in retaining students in primary care to (1) conducting a rigorous interview process to ensure they are picking people who are committed to primary care, (2) building a community around these residents that fosters their interest in primary care, (3) focusing on the wellness of their residents, and (4) giving them an enjoyable primary care experience. Being a part of an FQHC has served as a draw in terms of recruiting residents who are interested in the mission of urban health for underserved populations. The residency programs were also able to make strides in recruiting residents underrepresented in medicine by creating an associate program director position dedicated to diversity, equity, and inclusion to help recruit these residents and support them once they are in the program. As a result, in recent years, about half the class of residents has been made up of those who are underrepresented in medicine.
Reprinted from: Kona M, Houston M, Clark J, and Walsh-Alker E. Assessing the Effectiveness of Policies to Improve Access to Primary Care for Underserved Populations: A Case Study Analysis of Baltimore, Maryland. Milbank Memorial Fund. August 15, 2022.
Community-based training locations such as community health centers contribute to the training of residents as well but are not represented in these maps given limitations of the data. According to 2021 HRSA national data reports, approximately 572 PAs, nearly 2,000 NPs, and nearly 6,000 physicians a year receive some postgraduate training in community health centers.29
By Christine Haran
Nicole Henry-Dindial, MD
Like many other primary care physicians, family medicine physician Nicole Henry-Dindial, MD, of New Jersey, has worked for larger and larger organizations over time. Her independent physician association (IPA) of 23 family medicine physicians merged with Summit Medical Group, a multispecialty organization encompassing over 200 physicians.
Summit Medical Group later merged with CityMD through the help of a private equity investor, to form Summit Health, employing over 1,500 providers. Less than three years later, they are undergoing an acquisition by another entity, VillageMD, which is financed by Walgreens and CIGNA.
Twenty-five years ago, Dr. Henry-Dindial attended CUNY Medical–Sophie Davis School of Biomedical Education in New York City, which offers positions to about 70 medical students from historically underrepresented groups who, like her, want to go into primary care. She was drawn to family medicine because of the diversity of the practice. “I like being able to go in one room and manage someone’s mental health problem, go into another room and take care of an infant and talk about milestones, and then see another patient for GYN care.”
As a student, she trained at an academic medical center, but because it was difficult for her as a nonspecialist to gain experience with then-common family-medicine procedures like placing central lines to assist with surgery, she chose a community-based residency at Overlook Medical Center.
Dr. Henry-Dindial’s original IPA had a patient-centered medical home model, and as a part of Summit Health, further evolved into team-based care. She and her fellow physicians now draw on the organization’s resources such as case managers and pharmacy and behavioral health departments. Her office also has a transition of care program with care management nurses that reach out to patients within two or three days of a hospital discharge. They help patients with discharge instructions, coordinating follow-up care and helping avoid medication errors.
Still, Dr. Henry-Dindial struggles with what she calls the “trifecta” of low reimbursement; administrative hurdles like “never-ending” charting and preauthorization for medications, tests, and procedures; and the loss of autonomy associated with being an employed doctor.
“When we called the shots in our practice, we could make the decision to say, ‘Okay, I’m going to see fewer patients and spend more time with each one,’ but owning the decisions that affect our revenue,” she says. “Now, when you’re employed, you’re told you need to see a certain number of patients within a certain time frame.”
Dr. Henry-Dindial also observes that prior to the pandemic, physicians could exchange some patient hours for teaching medical students and residents as part of the tradition of physicians teaching the next generation. But as individual practices become incorporated into larger entities, they dissuade non-revenue generating activities, says Dr. Henry-Dindial, who was directed to “volunteer to teach on her own time.”
In addition, the company stopped her office from serving as a clinical family medicine site for first- and third-year students initially due to safety concerns with the pandemic but now because they don’t see the value in it to their profits. The dwindling availability of clerkship sites for students to rotate through adversely affects the ability to recruit new primary care doctors. In addition, it’s the loss of an activity that can help prevent physician burnout, she argues.
Dr. Henry-Dindial sees the need for more investment in primary care medical education, particularly for students from historically underrepresented groups – and in primary care practices. “Resources need to be spent to help the family physician, pediatrician, and the internal medicine physician, be they solo practitioners or in large groups, be able to care for the increased needs of patients,” Dr. Henry-Dindial said. “Because when we send them to the specialist, it costs both the patient and the health care system more money.”
25. Mullan F, Chen C, Steinmetz E. The geography of graduate medical education: imbalances signal need for new distribution policies. Health Aff (Millwood). 2013:32(11):1914-1921. doi:10.1377/hlthaff.2013.0545 26. Chen C, Petterson S, Phillips RL, Mullan F, Bazemore A, O’Donnell SD. Toward graduate medical education (GME) accountability: measuring the outcomes of GME institutions. Acad Med. 2013;88(9):1267-1280. doi:10.1097/ACM.0b013e31829a3ce9 27. Martsolf GR, Nguyen P, Freund D, Poghosyan L. What we know about postgraduate nurse practitioner residency and fellowship programs. J Nurse Pract. 2017;13(7):482-487. doi:10.1016/j.nurpra.2017.05.013 28. Davis CS, Roy T, Peterson LE, Bazemore AW. Evaluating the teaching health center graduate medical education model at 10 years: practice-based outcomes and opportunities. J Grad Med Educ. 2022;14(5):599-605. doi:10.4300/JGME-D-22-00187.1 29. 2021 Health Center Data. Health Resources and Services Administration; 2021.https://data.hrsa.gov/tools/data-reporting/program-data/national/table?tableName=WFC&year=202
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