Why don't graduate medical education programs produce the doctors America needs?

In 2010, Fitzhugh Mullan and others from the George Washington University, with collaborators from the American Academy of Family Physicians' (AAFP) Robert Graham Policy Research Center, published the seminal article “The social mission of medical education: ranking the schools” in the Annals of Internal Medicine (discussed in this blog on June 10, 2010 in A New Way of Ranking Medical Schools: Social Mission).  This paper looked at the production of medical schools in the US in terms of whether their graduates were in 3 categories associated with social mission: practice in an underserved area, practicing a primary care specialty, and having a higher percentage of graduates who were members of underrepresented minority groups.  It was the first time such data had been published, and the results showed that most medical schools don’t do very well, and that, in general, those that do the worst are those most often identified as “top” schools by criteria such as National Institutes of Health (NIH) funding or rankings by US News. This is not surprising; enrolling students from high income families who have had top grades at the most elite private and suburban schools, training them in a setting in which the mix of doctors is heavily skewed to the most subspecialized and research-intensive, located in a densely populated urban area, is the precisely wrong formula for recruiting physicians from underserved backgrounds and training them to practice primary care in areas of need. Unfortunately, although there have been small programs implemented at many schools, this model has not seen any significant change in most medical schools, particularly those “most elite”.

This year, this group from the Graham Center and George Washington, with collaborators from the the American Board of Family Medicine (ABFM), take the next obvious step in examining the production of the nation’s doctors. In “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,[1] in Academic Medicine (not available free on-line; abstract at http://www.ncbi.nlm.nih.gov/pubmed/23752037), Candice Chen and her colleagues look at how institutions that sponsor GME (and, importantly, get very large amounts of money from Medicare and Medicaid -- $9.3 billion and $3.18 Billion, respectively, in 2009) do in producing specialists in short supply: primary care physicians (defined as family medicine, general internal medicine (GIM), general pediatrics, internal medicine–pediatrics, internal medicine geriatrics, and family medicine geriatrics), general surgeons, obstetrician - gynecologists and psychiatrists. Identifying which program produced who is quite a bit harder than when looking at medical school outcomes; while a medical school is a medical school, GME-sponsoring institutions can be consortia of a medical school and one or more hospitals, and may often sponsor more than one residency program in the same specialty.

As in all measures of primary care production, the big complication is in graduates of internal medicine programs, the majority of whose graduates go into subspecialty (e.g., cardiology, gastroenterology, pulmonary and critical care) fellowships rather than remaining in primary care/general internal medicine (GIM). Chen’s work accounts for this, but explicitly notes that they are unable to account for the percent of GIM graduates who do not go on to subspecialty training but work as hospitalists. These are clearly not in primary care, and by many accounts may represent a majority of those completing the basic internal medicine training but not going on to fellowship. The authors note that, by their calculations, the average for primary care was 25.2%,”… this overestimates primary care production, as we could not account for primary care physicians practicing as hospitalists.”

Just as with medical schools, there was a wide variation in the percent of graduates of different sponsoring institutions who entered these specialties-in-need. Of 759 sponsoring institutions, they ‘…found that 158 institutions produced no primary care graduates, and 184 institutions produced more than 80%; the latter tended to be smaller institutions.” Again no surprise; the larger, more elite and famous sponsoring institutions (most often hospitals associated with elite medical schools) did a terrible job, while the smaller sponsoring institutions -- often hospitals with one (usually family medicine) or a few residencies, in smaller cities and towns, and affiliated with Federally-Qualified Health Centers (FQHCs) or Area Health Education Centers (AHECs), based in in underserved urban and rural communities, did well. The Robert Graham Center website provides interactive tools to allow you to map the density of primary care physicians by state, county and other areas, the output of each institution producing residents in terms of location and specialty, and the footprint of graduates from each GME program.

Let me restate: 158 institutions sponsoring graduate medical education produced NO primary care graduates! Let’s add some other numbers from the study: 198 institutions (more than 25% of the total) produced NO rural physicians, while only 10 institutions had all graduates go to rural areas; the average percentage of graduates providing direct patient care in rural areas was 4.8%. 283 institutions (37%) produced NO physicians practicing in FQHCs or rural health clinics (RHCs); 479 (63%!) institutions produced no National Health Service Corps (NHSC; a program for sponsoring physicians for underserved areas) physicians. This performance can be described by a single, simple word: ABYSMAL!

Elite academic medical centers have values that lead them to attract and select students and trainees with characteristics that are the opposite of those needed for training physicians to meet the needs of the American people. They value caring for rarer and highly specialized tertiary and quarternary conditions, which both are highly reimbursed and provide the basis for research in narrow areas of disease (and almost never of health). They value receiving large sums of money from the National Institutes of Health (NIH) for research, most of which is basic laboratory research. These are not bad values; they are, in fact, necessary. We need research, including basic laboratory research and first-in-human studies, for medical science to advance (although we also need a lot more funding for population-based research into the causes of health and disease, and community-based efforts to address them). We need tertiary-care medical centers where rarer or more complex conditions can be most effectively treated by physicians and surgeons whose narrower expertise makes them more experienced and effective.

The problem is that concentrating all these subspecialists in the very places where students and residents are trained gives those learners a very skewed idea of the ratio of subspecialists to primary care doctors, and makes the teachers want to get the “best” students to go into their narrow, subspecialized areas. In addition, selection for medical school (and to a large extent for residencies that are more competitive because they have fewer slots) tend to be for students who have the characteristics that help them to do well in basic science courses, standardized tests, and possibly in laboratory research. These students tend to come from the highest income families of professionals, in the largest metropolitan areas, from elite public or suburban schools. They look a great deal like the people who have plenty of doctors to care for them, and very little like the people whose communities suffer from a dearth of physicians in inner city and rural areas. I have previously noted that, while about 20% of Americans live in rural areas, only about 9% of doctors practice in such areas; this study shows it is actually much worse, with only 4.8% of graduates in rural practice!

The situation is exacerbated by the inequity in income between primary care doctors and subspecialists, an inequity also seen (albeit at a higher level) for general surgeons vs. subspecialty surgeons, especially when hours of work are considered. Thus, students, generally selected from a population not representative of the American people, who have increasing debt (even for those from upper-middle-income, not to mention middle-income and the rare student from low income families), are attracted to specialties that pay the most; if assessments of “lifestyle” are added to the calculus, those that pay the most for the least work (or whose income/work ratios are the highest). This is a formula to continue what we have, not to make things better.

The authors of the paper say that “Primary care physician production of 25.2% and rural physician production of 4.8% will not sustain the current workforce, solve problems of maldistribution, or address acknowledged shortages. The relatively small number of physicians choosing to work in RHCs, FQHCs, HPSAs, and the NHSC will not support a doubling of the capacity of safety net services envisioned by the

Affordable Care Act.” They have that right. Medical schools and GME-sponsoring institutions have for too long been allowed to continue being self-serving, with the biggest institutions being entirely pitiful in terms of producing the doctors America needs. It needs an immediate, far-reaching, large-scale change, where the biggest training programs see themselves in the business of producing primary care doctors for underserved people.

Why would they do that? Well, there is the $9.5 billion in Medicare and $3.18 billion in Medicaid GME funding that could be withheld if they don’t, for a start…

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[1] Chen C, et al., “Toward Graduate Medical Education (GME) Accountability: Measuring the Outcomes of GME Institutions”,  Academic Medicine, Vol. 88, No. 9 / September 2013