Retention Within the Specialty of Family Practice

Robert C. Bowman, M.D.

Family physicians remain in family medicine and in primary care. Primary Care Retention It seems strange to have to document that a specialty really is a specialty and remains a specialty, but given deteriorations of all other primary care providers, it is necessary.

A review of other specialty types such as pediatrics would be a good consideration, since pediatrics seems to remain about 66% in generalist primary care.

Constant deteriorations in internal medicine make comparisons a problem with the probability that less than 20% of a lower number of internal medicine residency graduates will remain in office based primary care. In medicine pediatrics 3100 matched into medicine pediatrics for 1987 - 1999 and nearly half have vanished. Less than 20% are found with medicine pediatrics as their primary specialty for the 1987 - 1990 or earliest class years of this group compared to those still in medicine pediatrics. For those graduating from a US allopathic medical school in 1987, only 14 remain in the Masterfile compared to 151 who matched into medicine pediatrics as US Seniors from NRMP data.

Disappearing primary care is a huge problem in PAs and NPs and is also related to subspecialty and hospital changes. PA and NP changes are reflected in changes in their physician employers. About 40% of PAs worked for FPGP docs in the 1996 PA census  surveys and this is down to 28.5%. Rural locations dipped from 25% to 17% during this time period. PAs leaving primary care make more money, also a reflection of US health policy http://www.aapa.org/research/ 

Health policy, health policy, health policy drives location, location, location.

PAs and NPs have become hospital and subspecialty providers shaped by the same US health policies. Primary Care Retention More physicians did not solve maldistribution and neither will more physicians in the current expansion or more PAs and NPs as shaped by current health policy. More family physicians is a different matter, however.

Predictions of primary care workforce that do not include these considerations are likely to be in error.

This study involved 24,119 or all FP Graduates of all types from 1997 - 2003 as reviewed in the AMA Masterfile and in Robert Graham Center databases. These graduation years are family medicine residency graduation years that reflect 1994 - 2000 medical school graduates in most cases. The recent graduates have had time to indicate a continuation in another fellowship. More distant graduates have been out in practice and have had time to think and reconsider, but appear to be remaining in specialty choices.

The review included a search of primary specialty and secondary specialty choices as listed in the 2004 Masterfile. Those who remained with family medicine as their primary specialty were considered to be retained in family medicine.
    537 Did not have a Primary Specialty as FP or 2.23% of 24,199

        259 or about 1% in Fellowships
            130 FP Sports Med   
            8 Other Sports Med
            68 FP Geriatrics  - note 91% of all FP geriatrics doctors were found in urban areas
            51 IM Geriatrics  - note 89% of all graduating from IM Geriatrics programs were found in urban areas

        278 or about 1% who have chosen other disciplines
            62 Internal Medicine
            48 Emergency Medicine
            35 Other types
            31 Ob -Gyn
            21 General Preventive Medicine
            17 General Surgery
            14 General Practice
            13 Anesthesia
            12 Pediatrics
            11 Psychiatry
            8 Child Psychiatry
            6 Dermatology
         76 Unspecified or Unknown

Also about 1.16% of family physicians graduating from medical school in 1987 are inactive. This is a representative middle group of active practitioners. This is better than any other primary care specialty (1.4% IM, 1.5 Peds, 1.56% for Ob-Gyn) and much improved compared to 10% of PAs or nearly half of NPs who are inactive.

In the 1987 match there were 151 US Seniors who chose medicine pediatrics and 167 total who matched. In the 2005 Masterfile there were only 14 remaining with medicine pediatrics as their primary specialty choice who graduated from a US allopathic medical school and 1 graduated from New York Osteopathic. For the 1987 graduating class only 18 total were listed in office based medicine pediatrics and only 26 had medicine pediatrics listed as their primary specialty choice.

Although some decrease in FPs would be expected over time there are also gains post match. About 10 - 12% of family physicians are added after the match. About 10 - 12% of family physicians enter military, teaching, administration, research, or hospital careers. The match in family medicine is an accurate reflection of sustained primary care. Matches in other specialties are not a reflection of primary care with less than half lost over short periods of time. Health policy changes promise even more losses for all who can choose away from primary care and all who can return to major medical center careers that are favored by health policy.

The numbers of FPs will decrease slightly over time, but retention is 98% in the early phase, even for those who were "forced" to choose FP by health policy related to managed care which impacted this group. The medical school graduates of 1995, 1996, and 1997 or 1998 - 2001 FP grads in this group with impact on 1997 and 2002 also were impacted the most. Virtually this entire group.

Managed Care Comparison Table      Managed Care and Choice of FP

86% of this group is in office based practice and more likely 92% when the not classified and non-responders are adjusted. This compares to adjustments of non-classified that increase office based general pediatrics to 76% and office based general internal medicine to 50%. The not classified groups also tend to include more osteopathic, Caribbean, Black, and Mexican American physicians who also have greater choice of family medicine and higher levels of office based care.

Sports medicine remains the major FP loss. Interestingly sports medicine is a major second specialty chosen by rural interested senior students who chose family medicine at 68% levels in the 1995 AAMC GQ. Rural Interested Senior Medical Students 1995

Email for Questions

Robert C. Bowman, M.D.
rbowman@unmc.edu

Sources of the Current US Physician Workforce - Essential specialty estimates and sources, geriatrics

Physician Workforce Studies

www.ruralmedicaleducation.org

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