Primary Care Workforce:

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Primary Care Workforce

• Cathleen Morrow MD
• Department of Community and Family Medicine
• Dartmouth Medical School

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Goals and Objectives

• To review some background about workforce data
  nationally and in NE.
• To attempt to create some context and perspective
  on workforce issues.
• To make the case for the centrality of education
  to workforce dilemmas and solutions.
• To attempt to convince you that the expansion of
  your health centers interface with education is
  in your long term interests.

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Background

• Board of Access to Medical Education Comm of FAME
  (Finance Authority of ME)
• Legislative Commission on Primary Care Workforce
  Development - State of NH

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Primary Care Workforce

• 97,752 family physicians
• 1 for every 3, 081 persons
• 92,257 general internists
• 1 per 2,443 adults
• 48,930 general pediatricians
• 1 for 1,548 children and adolescents
• 238,939 primary care physicians
• 1 for every 1,260 persons

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Primary Care Shortage?

• Currently a problem of distribution
• 239,000 primary care physicians (2007)
• 1 for every 1,260 people in the US
• Still concentrated in desirable areas
• Relative shortage in underserved areas
• True for physicians, NPs and Pas
• 20 of the population living in rural areas 9
  of the doctors.

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Primary Care Shortage

• Real shortage and greater distribution problem
  possible
• Substantial decline in US student interest
• Increased reliance on international students
• Increased interest in specialization and
  alternative careers
• Contraction of training programs
• Majority of PAs now sub specialize NPs?
• Current physician expansion effort not promoting
  primary care - AAMC

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Status check Family Medicine
Family Medicine Positions March, 2008
Filled by US Graduates
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Reliance on International Medical Graduates
Change in Number of IMGs in Training 2002-2006
Source JAMA Medical Education Issues, Ed
Salsberg, AAMC
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Student Interest

• General Internal Medicine 2.0
• Med/Peds 2.7
• Family Medicine 4.9
• General Pediatrics 11.7
• Total 21.3

K. E. Hauer et al. Choices Regarding Internal
Medicine Factors Associated With Medical
Students' Career JAMA. 2008300(10)1154-1164
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M. H. Ebell. Future Salary and US Residency Fill
Rate RevisitedJAMA. 2008300
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Primary care losing ground GME

• Between 2002 and 2007
• Residency positions grew 7.9
• Subspecialty positions grew 24.7
• Primary care positions grew 2.3
• Howeverthe estimated number of graduates going
  on to practice primary care fell 15 (from
  28.1 to 23.8)

E. Salsberg et al. US Residency Training Before
and After the 1997 Balanced Budget Act. JAMA.
2008300(10)1174-1180.
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Summary

• We may have enough primary care physicians (all
  physicians too)
• Need to improve distribution and access
• Pipeline in trouble for future
• Need to fix income gap
• Schools need to choose and train wisely
• GME priorities, payments, and places need updating

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Primary Care Vacancies

• NH 17 Family physicians
• 13 Internists
• 12 NP/PAs
• 5 Dentists
• VT - 20 Family physicians
• 9 Internists
• 7 NP/PAs
• 4 Pediatricians
• 1 Dentist

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Primary Care Vacancies

• Maine - 50 Family physicians
• 2 Pediatricians
• 27 Internists
• 9 NP/PAs

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NH Dartmouth Residency

• 2004 - 62
• 2005 - 50
• 2006 - 70
• 2007 - 50 NH 25 Ma.
• 2008 - 83
• 2009 - 70 NH 30 Ma.
• 2010 100 say they are staying.

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More from NH Dartmouth

• The graduates have actually mostly gone south -
  Manchester, Derry, Londonderry, Nashua, Hudson, a
  few in Concord area. One of our 2002 graduates
  went to Littleton because her family is there.
  During the resident practice management series in
  the fall of 3rd year, we have the Bi State
  Primary Care Association folks come and talk with
  them. They outline loan repayment options, talk
  about using their recruitment center, and talk
  about the north country practices

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MMC FM Residency - Portland

• Over the past five years
• 75 have stayed in Maine
• 81 have stayed in New England (including
  those who stayed in Maine)
• Of those who stayed in Maine, 16 have gone
  to more rural (north or west) and 84 have stayed
  in Greater Portland, Lewiston, or southern Maine.

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EMMC FM Residency - Bangor

• Graduation year Maine Total
• 2004 5 8
• 2005 5 6
• 2006 5 8
• 2007 2 8
• 2008 4 7
• 2009 10 10
• TOTAL 31 47
• 66
• My recollection is that we are around 50 for
  the entire life of the
• Residency

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CMMC Lewiston ME

• 2005 50 ME 50 NE (Ma, VT, RI)
• 2006 28 ME
• 2007 65 ME
• 2008 50 ME and NH
• 2009 85 ME and NH
• Graduated 1st rural track resident in 2008
  fill 2 positions/yr in Rumford, ME.

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Maine Dartmouth FM Residency

• 57 of graduates remain in practice in Maine
• Overall total since the beginning of the program
  (1973)

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Jessie Reynolds story

• Grew up in Indiana, small town pop 500
• Went to Middlebury College
• Did a Jan. term in Wells River VT with Steve
  Genereaux MD
• Taught 7th grade science went to Indiana
  University Medical School
• Matched in CMMC Rural Track Residency Program in
  Rumford, ME
• Now in Wells River, VT practicing at a FQHC
  offered positions at 2 x salary.

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Macy Foundation StudyApril 2009

• Born in a rural area
• 2.5x more likely to practice in rural area
• 2x more likely to go into FM.
• Attend a public medical school
• 2x more likely to go into FM
• 2x practice in rural area

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Macy Foundation

• NHCS recipient
• 4x more likely to work in a FQHC
• If you express interest in serving underserved
  pop 3 x more likely to be in a FQHC and 4x more
  likely to practice in a rural area.
• Conclusion Rotations in these environments
  matter! Growing your own matters!

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Workforce Future and Present
Practice Culture
Trainees Students and Residents
Patient Needs
Productivity
EHR
Regulatory Demands
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Training Obstacles

• Largest Lack of practicum placements no
  reimbursement, administrative costs of placement,
  slowing down already overbooked providers
  Medicare regulations regarding documentation.
• Faculty shortages
• EMRs- lack of standardization/ challenges for
  learners
• Certification obstacles e.g. VA, background
  checks

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Macy Foundation Report

• New entities, to be called teaching community
  health centers should be established. These
  centers would serve as sites for the training of
  healthcare professionals and would work with
  primary care practices to raise standards of
  care. These teaching CHCs will require strong
  collaborative ties with teaching hospitals
  continuing the theme that collaboration is
  essential for better patient care and for
  preventing disease.

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Educational Home

• Create an educational environment such that
  students and learners of all kinds feel welcomed
  and embraced
• Workforce that feels always responsible for
  teaching/learning
• Teaching/learning is intrinsic to patient care
  patients enjoy it engage in a sense of ownership
  Im helping this student to learn, I am
  providing value here as well as obtaining medical
  care.

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Educational Home

• Education is so intrinsic to the environment that
  the process of permission asking is not such an
  ordeal.
• Buy in from staff is critical.
• Clear permissions to not engage is also critical.

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Ideals of Learners

• Making a difference
• Making a difference
• Making a difference
• My work matters what I do is important I am
  contributing to the outcome of this patient, this
  practice, this institution, this community.

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Positioning Your Institution

• Pipeline development grow your own
• Loan repayment
• 3rd and 4th year medical student electives
• Rural Scholars programs
• Creating an educational home within your
  institution

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Educational Home and Recruitment

• Physician burnout/compassion fatigue is real.
• Majority of people entering primary care want to
  teach.
• The opportunity to teach offers you a recruiting
  advantage.
• Time to teach must be a component of a realistic
  offer.

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Macy Foundation Report

• AHECs should be designated and well supported to
  coordinate the educational experiences of health
  professions students and primary care residents
  in teaching CHCs and in other primary care
  community based clinical settings.

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Macy Foundation Report

• Title VII of the US Public Health Service Act
  must be expanded to direct more financial support
  to education in the primary care professions.

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Macy Foundation Report

• Private and federal insurance program payment
  policies must be changed to reduce income
  disparities between primary care providers and
  other specialists.

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Macy Foundation Report

• The NHSC, with substantially increased funding,
  should become a focus of efforts to alleviate the
  burden of debt that discourages medical students
  from selecting primary care as a specialty and to
  increase the numbers and diversity of primary
  care professionals who practice and teach in
  underserved communities.

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Macy Foundation Report

• Criteria for admission to medical school should
  be changed to attract a larger and more diverse
  mix of students who are likely to choose primary
  care and to care for patients in inner cities,
  small towns, and rural areas.

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Macy Foundation Report

• The graduate medical education system needs to be
  better aligned to meet the physician workforce
  needs of the country.

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Taking Care of One Another

• Burn-out and compassion fatigue are real and
  contributing significantly to our challenges in
  recruitment and retention.
• An angry, resentful provider is the worst
  recruiter to primary care imaginable (and
  patients and co-workers suffer too!)
• Our work in primary care is important, hard, and
  good work we must also take care of each other.