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Entry of US Medical School Graduates Into Family Medicine Residencies: 2012–2013

Wendy S. Biggs, MD; Philip W. Crosley, MBA; Stanley M. Kozakowski, MD

Background: Analyzing the US medical school origin of family medicine residents highlights schools, states, or regions that have higher entrance rates into family medicine.

Methods: The American Academy of Family Physicians (AAFP) 2013 Residency Census has a 100% response rate and lists information for family medicine residents who entered training July 2012. MD graduates are verified through medical school registrars or the American Medical Association’s Physicians Masterfile data. The American Association of Colleges of Osteopathic Medicine provides data on DO graduates. Three-year rolling averages of graduates entering family medicine are calculated for Liaison Committee of Medical Education (LCME)-accredited medical schools.

Results: In July 2012, 3,523 first-year residents entered Accreditation Council for Graduation Medical Education (ACGME)-accredited family medicine residencies. Medical students from LCME-accredited schools account for less than half of the family medicine residents (46%). Public MD-granting medical schools graduate almost threefold more students into family medicine residencies than do private schools (1,101 versus 380). The Mountain, West North Central, and Pacific regions of the United States have the highest percentage of MD graduates (13.5%, 12.3%, and 11.4%, respectively) entering family medicine. Forty-five percent of MD medical students enter a family medicine residency in the state in which they attended medical school.

Conclusions: LCME-accredited medical schools with lower percentages of graduates entering family medicine should examine the economic, environmental, and academic factors that may be causing low numbers of their students graduating and entering family medicine residencies.

(Fam Med 2013;45(9):642-6.)

This is the 32nd national study conducted by the American Academy of Family Physicians (AAFP) that reports retrospectively the percentage of graduates from allopathic and osteopathic medical schools who enter Accreditation Council for Graduate Medical Education (ACGME)-accredited family medicine residency programs. The Council on Graduate Medical Education (COGME) 20th report, “Advancing Primary Care,” states that at least 40% of the physician workforce should be primary care to provide optimal health care and health system efficiency.1 Analyzing the US medical school origin of family medicine residents highlights the schools, states, or regions that have higher entrance rates into family medicine residencies and may suggest factors that will help improve the number of graduates entering family medicine from other medical schools.

 

Methods

 
 

The AAFP performed an online Residency Census of all residents in family medicine residency programs. The Institutional Review Board of the AAFP deemed this analysis to be exempt. AAFP staff contacted initial nonrespondents by telephone to ensure a 100% response rate. Program directors listed all first-year residents and their medical schools, including the month and year of graduation. The US allopathic (MD) graduates reported are verified by contacting the medical school registrars or by the American Medical Association (AMA) Physician Masterfile data for MD graduates with a graduation date between July 1, 2011 to June 30, 2012.2 Residents reported in the Residency Census who graduated outside July 1, 2011 to June 30, 2012, are not independently verified. The American Association of Colleges of Osteopathic Medicine provided the number of graduates from each college of osteopathic medicine.3 Data reported in the AAFP Residency Census determines the number of osteopathic (DO) family medicine residents in ACGME-accredited residencies. The percentages reported for graduates from Liaison Committee on Medical Education (LCME)-accredited medical schools who become family medicine residents are 3-year rolling averages.2 The AMA data listed medical schools as public or private.2

 

Results

 
 

Type of Medical School

In 2012, there were 3,523 first-year residents entering ACGME-accredited family medicine residencies. LCME-accredited medical school graduates outnumber the number of international graduates and osteopathic graduates, respectively (1,589 versus 1,163 and 711). When added together, however, international and osteopathic graduates comprised more than half of the incoming family medicine residents in 2012 (54%) (Table 1).

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Medical School Structure

Public LCME-accredited medical schools graduate 34% more graduates than private LCME-accredited medical schools (10,511 versus 6,935); however, almost three times as many graduates from public schools entered family medicine residencies in 2012 as did graduates from private schools (1,101 versus 380). Eight LCME-accredited medical schools do not have a department or division of family medicine, and a total of only 26 students who graduated from these eight schools entered family medicine, approximately the same number as in 2011 (n=27) (Table 2). One medical school has a center for family medicine, and in 2012, it graduated four students, whereas in 2011 it graduated nine students who entered family medicine. The number of students entering family medicine from 59 of 126 LCME accredited medical schools (includes their regional medical campuses) was in the single digits, with the remaining schools’ graduates numbering in the teens and 20s (see “Number and Percentage of Medical School Graduates Who Were Family Medicine Residents, by US Medical School, 2012 at www.stfm.org/fammed_match.cfm). The University of Kansas, University of Minnesota, and University of Washington were the only MD-granting medical schools to graduate more than 35 students into family medicine (39, 38, and 39, respectively). DO-granting medical schools are predominately private schools, yet only three schools graduated students entering ACGME-accredited family medicine residencies in the single digits, with nine schools graduating more than 30 students entering family medicine (see “Number and Percentage of Graduates of Colleges of Osteopathic Medicine Who Were Residents in ACGME-accedited Family Medicine Residencies, by US Osteopathic Medical College, 2012 at www.stfm.org/fammed_match.cfm).

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Three-Year Averages

A 3-year rolling average is used to determine which medical schools graduate a higher percentage of students into family medicine annually. The list of the top medical schools remains fairly consistent over the years (Table 3). This year, however, three schools not in the top 10 last year appear: Wright State, University of California, Davis, and University of Missouri-Columbia. Wright State has more than 20 graduates (n=22), whereas UC-Davis and Missouri have 18 graduates each. Some schools moved from the top 10 to the second decade: Uniformed Services dropped from fourth to 13th, and the University of Iowa from seventh to 16th. Medical school class size does affect percentages (see “Number and Percentage of Medical School Graduates Who Were Family Medicine Residents, by US Medical School, 2012 at www.stfm.org/fammed_match.cfm). For example, East Carolina has more than 20% of its graduating class enter family medicine, but since it has only 68–74 students per class, approximately 15 graduates enter family medicine from East Carolina annually.

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Geographic Variation

The US census regions of the country show different graduation rates for family medicine bound students (see “Number and Percentage of Medical School Graduates Who Were Family Medicine Residents, by US Census Region and State of Medical School, 2012 at www.stfm.org/fammed_match.cfm). The Mountain, West North Central, and Pacific regions have the highest percentages of graduates (14.7%. 13.3%, and 11.4%, respectively). When looking at numbers of students, the East North Central, South Atlantic, and Middle Atlantic regions graduate approximately the same number of students (3,216, 3,199, and 3,217, respectively). The first two regions have similar percentages of their graduates entering family medicine (8.8% and 8.4%, respectively), whereas only 4.7% of the graduates in the Middle Atlantic enter family medicine.

States also differ in how many of their graduates enter residencies in the same state (see “Percent of 2011–2012 Medical School Graduates by State or Territory Who Entered a Family Medicine Residency Program in the Same State in 2012” at www.stfm.org/fammed_match.cfm). Two large states, California and Texas, have high percentages (76% and 72.1%, respectively); however, two smaller states do also: Indiana (75.9%) and West Virginia (68.4%). Overall, more than four out of 10 medical students enter a family medicine residency within the state in which they attend medical school (45.1%).

 

Conclusions

 
 

The AAFP annual report of the entry of US students into family medicine residencies continues to highlight the sub-optimal number of MD medical students entering family medicine. The regional variations are striking. Medical schools west of the Mississippi graduate a higher percentage of their medical school classes into family medicine than eastern medical schools. The total number of western schools, however, is less than the number of schools in the eastern United States. Students in a rural MD-granting medical school program who had pre-medical experiences observing or shadowing in an urban hospital were 67% less likely to enter family medicine residencies (OR=0.33 [95% CI=0.11–0.97]).4 Clinical rotations in the eastern US academic health centers located in very large urban areas could have similar dissuading effects on medical students. The schools with lower percentages should examine the economic, environmental, and academic factors that may be leading to this geographic discrepancy.

This data only examines osteopathic graduates who enter ACGME-
accredited family medicine residencies and does not include graduates entering residencies accredited only by the American Osteopathic Association (AOA). The AOA accredits 241 family medicine residencies; however, 114 of these family medicine residencies are also ACGME accredited. Since the data here accounts for less than half of the osteopathic family medicine residencies, the total number of osteopathic graduates entering family medicine is more than 711 as reported here.

Some have speculated that the higher tuition cost of private medical schools equates to higher debt and, thus, discourages graduates from entering family medicine. This hypothesis, however, does not appear to hold for osteopathic education. The tuition for most osteopathic medical schools is comparable to private MD-granting institutions.5 However, DO-granting medical schools graduate a higher percentage of their students into family medicine. More DO students report debt upon medical school graduation than MD students (91% versus 86%), with higher average debt ($205,674 versus $161,300).6,7 In contrast to MD-granting medical schools that tend to be within an undergraduate and graduate university, research institute or health care system, osteopathic medical schools do not generally contain research or clinical enterprises that the allopathic academic health centers encompass.8 MD-granting medical schools also tend to assign their students to the hospitals that sponsor the graduate medical education programs whereas DO medical education is distributed to more community-based settings.8 More graduates of MD-granting medical school regional campuses enter family medicine than non-
regional campus graduates (14.2% versus 7.9%).9 Factors such as admissions processes or curriculum also may differ between the two medical education systems. Future educational research should be directed to investigate all these factors further.

Although this survey has a 100% response rate, the medical school from which each resident graduated is self-reported. Several medical schools have had long-standing regional medical campuses; however, over the last 5 years, more medical schools have established different models of regional medical campuses. The data is unclear to determine if programs reported residents graduating from the regional medical campuses or the main campuses. The medical school 3-year rolling percentages now aggregate the number of graduates from all the campuses of a medical school. Regional and branch campuses have been shown to have an increased percentage of medical students entering family medicine.9 The AAFP will inquire if the resident attended a branch campus to attempt to capture this national data in future surveys.

Since only 7.8% of MD medical students graduating in 2013 entered family medicine, medical schools must consider COGME’s 20th Report recommendation of the importance of “strategically focusing and changing the processes of medical student and resident selection and altering the design of educational environments to foster a physician workforce of at least 40% primary care physicians and a health system that meets societal needs.”1 Many factors influence medical student specialty choice. The AAFP Student Influencer Portfolio describes the complex interaction between people, policy, payment, programs, perception, and personal characteristics influencing students’ choice of family medicine.10 The MD-granting medical schools must prioritize initiatives influencing family medicine specialty choice. Only 35% of 46 MD-granting medical schools that stated in 2010 they planned to enact primary care initiatives did so in the subsequent 2 years.11 The progressive implementation of the Patient Protection and Accountable Care Act will cause ripple effects through these factors that influence student specialty choice. For the sake of the health of the US population, we hope to see an increase in US medical student entrance into family medicine residencies in the future.

 

Corresponding Author: Address correspondence to Dr Biggs, University of Kansas Medical Center, Department of Family Medicine, 3901 Rainbow Blvd, Mail Stop 4010, Kansas City, KS 66160. 913-588-0199. Fax: 913-588-1951. wbiggs@kumc.edu.

 

References

 
 
  1. Council on Graduate Medical Education. Twentieth report: advancing primary care. 2010. www.hrsa.gov/advisorycommittees/bhpradvisory/cogme/Reports/twentiethreport.pdf. Accessed June 29, 2013.
  2. Barzansky B, Etzel SI. Medical schools in the United States, 2011-12. JAMA 2012;308(21):2257-63.
  3. American Association of Colleges of Osteopathic Medicine. Applications, enrollment and graduates by osteopathic medical colleges. www.aacom.org/data/studentenrollment/pages/default.aspx. Accessed June 29, 2013.
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  6. Avery DM, Wheat JR, Leeper JD, et al. Admission factors predicting family medicine specialty choice: a literature review and exploratory study among students in the Rural Medical Scholars Program. J Rural Health 2012;28:128-36.
  7. American Association of Colleges of Osteopathic Medicine. Osteopathic Medical College Information Book. Chevy Chase, MD: American Association of Colleges of Osteopathic Medicine, 2013.
  8. American Association of Colleges of Osteopathic Medicine. AACOM 2011-12 academic year survey of graduating seniors summary report. www.aacom.org/data/classsurveys/pages/default.aspx. Accessed June 29, 2013.
  9. Association of American Medical Colleges. Analysis in brief: trends in cost and debt at US medical schools using a new measure of medical school cost of attendance. July 2012;12(2). www.aamc.org/data/aib/archive. Accessed June 29, 2013.
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  12. Whitcomb, ME. New and developing medical schools: motivating factors, major challenges, planning strategies. Josiah Macy, Jr. Foundation. October 2009. www.macyfoundation.org/publications. Accessed June 29, 2013.
  13. Liaw W, Cheifetz C, Luangkbot S, Sheridan M, Bazemore A, Phillips RL. Match rates into family medicine among regional medical campus graduates, 2007–2009. J Am Board Fam Med 2012;25(6):894-907.
  14. American Academy of Family Physicians. Student Interest Portfolio. www.aafp.org/siportfolio. Accessed June 29, 2013.
  15. Association of American Medical Colleges. Analysis in brief: US medical schools’ ongoing efforts to meet physician workforce needs. June 2013;13(4). www.aamc.org/data/aib. Accessed June 29, 2013.

From the Department of Family Medicine, University of Kansas Medical Center, Kansas City, KS (Dr Biggs); and Medical Education Division, American Academy of Family Physicians, Leawood, KS (Mr Crosley and Dr Kozakowski).


Copyright 2017 by Society of Teachers of Family Medicine