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Opinion

Primary Care Physician Workforce Aided by Innovations in GME

The Teaching Health Center Graduate Medical Education Program (THCGME), by any measure, has been highly successful.  Since its inception in 2011, there has been a rapid expansion in both the number of THCs, but more importantly, there has been an increase in the number of physicians being trained in primary care specialties.  Today, there are 60 THCs, operating in 24 states, and training more than 550 primary care physicians and dentists. These programs are training physicians in the most needed shortage specialties of family medicine, internal medicine, pediatrics, psychiatry, general dentistry, and geriatrics.   In addition to providing meaningful and appropriate training opportunities for primary care physicians, these programs have expanded access to millions of underserved individuals in some of nation’s most vulnerable communities – rural and urban.

Our current GME system was created in the mid-20th century.  Its centralized education model was consistent with the “best practices” of the times.  However, much has changed in medicine and care delivery since, most notably is the fact that care delivery has transitioned predominantly to ambulatory settings.  The Ecology of Medical Care first demonstrated by Kerr White in the 1960’s and updated by the Robert Graham Center, demonstrates that in any given month, of 1,000 people 327 will consider seeking health care services.  Of those 327 people who consider seeking care, 217 will go to a physician, 113 will go to a primary care physician, 21 will go to a hospital clinic, 14 will receive home health, 13 will go to the emergency department, 8 will be admitted to a hospital, and less than 1 will go to an academic health center. If this is the case, why do we centralize training in the care site least sought by patients?  And, more importantly, why do we provide financial incentives to those sites least used by our population?

De-centralizing our graduate medical education system from the legacy hospital-based system, especially for primary care physicians, is a theme that has emerged from the Institute of Medicine, the Council on Graduate Medical Education, the Medicare Payment Advisory Commission, as well as numerous academic and physician organizations.  The reasons these organizations support such a shift in GME policy is quite simple – the concept of training our entire physician workforce in hospital settings is no longer accepted as a best practice and is likely not an appropriate investment of taxpayer dollars.

According to the Health Resources Services Administration (HRSA), primary care physicians trained in a community-based setting are three times more likely to practice in community-based settings as compared to physicians trained in the traditional hospital-based system. The IOM report also noted the inherent inequities in the geographic distribution of GME positions and funding.  Currently, most GME funding is aimed at urban hospitals.

Sadly, despite decades of research which has demonstrated the value of community-based medical education, specifically for primary care specialties, the legacy hospital-based model remains the accepted standard for training an overwhelming majority of our nation’s physician workforce.  The one bright spot that is contradicting this trend are Teaching Health Centers.

This program is a success.  It has trained over 550 primary care physicians in 4 years, in settings most applicable to their future practice environment.  Additionally, it has expanded access to millions of patients in communities ranging from urban Lawrence, MA to rural Yakima, WA.

Reauthorizing and fully funding the THCGME Program provides an opportunity to directly confront the nation’s primary care physician workforce shortage while providing medical and dental health care services to underserved communities across the country in highest need areas.  Congress should not only reauthorize this program, but look for ways to rapidly expand it and provide it stable, long-term financial support.

 

Shawn Martin is the Vice President for Practice Advancement and Advocacy at American Academy of Family Physicians