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A look at primary care training in the US suggests that workforce supply is likely to worsen in the near future. While the number of medical residents for all other specialties has risen from 23 residents per 100,000 to 29 residents per 100,000 people in the past decade — representing a 26% increase — the number for primary care has grown from 14 to 17 residents per 100,000 people, representing a 21% increase (Figure 6). We were unable to track the training of PAs and NPs because of lack of data on their individual training pathways.
Only a small proportion of primary care residents end up practicing primary care three to five years after residency. In fact, nearly 90% of internal medicine residents subspecialize or go into hospitalist-only medicine.
Data Source: Analyses of Accredited Council of Graduate Medical Education program-level data to get counts for medical residents and Area Health Resource File for the population data, 2012–2021.Notes: Primary care specialties included family medicine, internal medicine, geriatrics, and pediatrics.
Moreover, only a small proportion of primary care residents end up practicing primary care three to five years after residency. In fact, nearly 90% of internal medicine residents subspecialize or go into hospitalist-only medicine.99 In addition, the number of pediatric residents who subspecialize is on the rise.100 By filtering out primary care physicians working in hospitals, we find, for the first time, the true share of primary care residents who ultimately practice outpatient primary care ranges from 11.7% to 15.5% (Figure 7). There is speculation that the jump in percentage of residents entering primary care outpatient practice in 2021 is a response to the pandemic and a reluctance to practice hospital-only medicine.49, 50 As we recalibrate to a postpandemic state, the erosion in outpatient practice seen between 2012 and 2020 is likely to continue.
Today, approximately 34% of all physicians currently practice outpatient primary care.51 If only 15% of all residents are entering outpatient primary care medicine, we have a shortage that is even worse than that predicted a decade ago (before researchers were unable to exclude hospitalists from their calculations).52
Data Source: Analyses of the 2023 American Medical Association Historical Residency File, the 2023 American Medical Association Masterfile, and the 2012–2021 Centers for Medicare and Medicaid Services Physician and Other Practitioners data.Notes: Primary care specialties included family medicine, general practices, internal medicine, geriatrics, pediatrics. Specialty for doctors of osteopathy (DOs) are not always included in the American Medical Association Masterfile, so these data may be an underestimation of the true workforce. (See limitations in Appendix for more details.)
To reduce the hemorrhaging of primary care residents to specialty or hospital-only care, NASEM reiterated the recommendations of the Institute of Medicine in 198953 to train more residents in the community, outside the hospital setting. Currently, most residency training occurs in the hospital setting, whereas most primary care is delivered in community settings.13
Currently, most residency training occurs in the hospital setting, whereas most primary care is delivered in community settings.
Training in the community can be defined in many ways. To classify a primary care resident as “community-trained,” we used two definitions. In the broader definition, any primary care resident who completed their training in a program that, according to the American Medical Association’s FRIEDA database, primarily trained outside of a hospital or large academic center was considered community trained. In the narrow definition, any primary care resident who trained in a Teaching Health Center (THC) or rural training track was considered community trained. The Teaching Health Center Graduate Medical Education (THCGME) Program has a stated mission of “training physicians and dentists in community-based settings with a focus on rural and underserved communities.” Similarly, rural training tracks offer a significant amount of their training in rural communities, as opposed to large urban academic centers and hospitals where most residents are trained. Both programs not only focus on training in the community, but also on training in the most medically vulnerable communities in the United States.
We found that between 2013 and 2021, the percentage of primary care residents being trained in a community-based setting has risen but remained low for both definitions of community based. When using the broad definition, 15% of all primary care residents trained in the community in 2021. When using a narrow definition, only 4.6% of primary care residents trained in the community — specifically in underserved communities — that year. Notably, these percentages are representative of all primary care residents. Specialty-specific numbers are likely to be vastly different as primary care specialties such as family medicine tend to be more outpatient and community-based as opposed to internal medicine, which has a larger focus on hospital settings.54
Given that traditional graduate medical education funds are disbursed to hospitals and not outpatient centers, it is no surprise that most primary care resident training occurs in hospitals, where a minority of the US population seeks care. Programs that do actually train residents in the community, such as the Teaching Health Center program, have unstable and low levels of funding,55 unlike traditional Medicare GME, which provides hospitals with nearly $24 billion yearly.55, 56 Not surprisingly, THC graduates, who train in underserved, outpatient settings, also work in underserved communities at higher rates than traditional GME graduates.57
Data Source: Analyses of Accredited Council of Graduate Medical Education program-level data for numbers of medical residents; FREIDA American Medical Association Residency and Fellowship Program Database; a rural residency program list from the RTT Collaborative; and Health Resources and Services Administration Teaching Health Center Graduate Medical Education program dashboards to identify community-based training programs, 2013–2021.*Notes: Community-based training was identified if (1) the majority of training did not take place in a university academic medical center or a hospital with a medical school affiliation (broad) or (2) it utilized programs with rural training track or a Health Resources and Services Administration Teaching Health Center Graduate Medical Education grant (narrow).
New Pathway Programs Are Widening the Circle of Medical Students
by Christine Haran
Data clearly show the impact a health care provider of the same race, and one who speaks the same language, has on patient-reported satisfaction and health outcomes.1 Moreover, clinicians of color are more likely to work in low-income, medically underserved communities in rural or urban areas. But there are many barriers to the creation of a diverse health care workforce,2 such as lack of exposure to medical careers, the cost of a medical education, and sometimes a lack of academic preparation, particularly for doctoral degrees.
Sunita Mutha, MD, director of the Health Workforce Center at the University of California, San Francisco, explains that even for students of color who work through the obstacles and get into medical school, staying can be a challenge. The creation of affinity groups or cohorts, Dr. Mutha says, can create a sense of community and provide mentorship. However, it still can be difficult to find role models. “Even in medical schools where the percentage of students of color has increased, you may have no or very few faculty of color,” she says.
That’s one reason why medical schools such as the University of California–Davis are investing in new pathway programs to recruit and retain medical students from underrepresented communities and prepare them for primary care residencies. “If not enough residency graduates are entering primary care, then we should look at who’s going into residency,” says Tonya Fancher, MD, vice chair of workforce diversity and associate dean of workforce innovation and education quality improvement at UC Davis. “And ultimately that goes back to who gets into medical school.”
For its pathway programs, UC Davis has reengineered admissions to be mission-driven, enabling them to recruit nontraditional students. With Dr. Fancher’s guidance, UC Davis created Accelerated Competency-based Education in Primary Care (ACE-PC), a three-year primary care program designed to mitigate student debt and provide extra supports, as well as a regional program with Oregon Health and Sciences University that helps fill workforce gaps in rural, tribal, and urban areas. She is currently developing a program to recruit from community colleges, whose graduates are more likely to be students of color, as well as more likely to practice family medicine.
More than 30 medical schools participating in the Consortium of Accelerated Medical Pathway Programs (CAMPP) have developed three-year or other accelerated curricula that lead to an MD degree. Catherine Coe, MD, a family medicine assistant professor at the University of North Carolina (UNC) Medical School, is on the CAMPP board of directors and is the former director of UNC’s Fully Integrated Readiness for Service Training (FIRST) program, which offers a three-year medical school curriculum to UNC medical students who agree to serve for three years in underserved or rural parts of the state after their residency. Clinicians who go to medical school and do their residencies in North Carolina have a 62% chance of practicing in the state.
Dr. Coe, who observes that fewer medical students are coming directly out of undergraduate programs but instead may be coming from other careers, suggests that the United States move toward a competency-based medical education framework, which can allow for shorter (or longer) pathways to residency as needed and can ensure that clinicians are patient-centered in their approach.
Notes:
North Dakota As of 2021, North Dakota is the highest-ranked state for training measures. Although North Dakota has fewer primary care residents per population, at 14.1 per 100,000 people, than the national average of 17 per 100,000 people, the state has a larger share of new physicians entering primary care (including hospitalists) (36.4%) annually than the nation (21.6%). North Dakota has also maintained a high rate of physicians, PAs, and NPs working in primary care at 26.6%, 44.2%, and 39.4%, respectively. These rates are similar or higher than the national averages of 26.6% PCPs, 29.7% PAs, and 34% NPs. Additionally, 27% of residents in North Dakota are trained in the community (using the narrow definition) compared to 2% nationally. For more state data, see the data dashboard.
