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Entry of US Medical School Graduates Into Family Medicine Residencies: 2014–2015

Stanley M. Kozakowski, MD; Gerald Fetter Jr, MSA; Ashley Bentley, MBA

Background and Objectives: This is the 34th national study conducted by the American Academy of Family Physicians (AAFP) that reports retrospectively the percentage of graduates from US MD-granting and DO-granting medical schools who entered Accreditation Council for Graduate Medical Education (ACGME)-accredited family medicine residency programs as first-year residents in 2014. Approximately 8.5% of the 18,241 students graduating from US MD-granting medical schools between July 2013 and June 2014 entered a family medicine residency. Of the 1,458 graduates of the US MD-granting medical schools who entered a family medicine residency in 2014, 80% graduated from 69 of the 131 schools. Eleven schools lacking departments or divisions of family medicine produced only a total of 26 students entering family medicine. In aggregate, medical schools west of the Mississippi River represent less than a third of all US MD-granting schools but have an aggregate rate of students selecting family medicine that is two-thirds higher than schools to the east of the Mississippi. A rank order list of US MD-granting medical schools was created based on the last 3 years’ average percentage of graduates who became family medicine residents, using the 2014 and prior AAFP census data. US MD schools continue to fail to produce a primary care workforce, a key measure of social responsibility as measured by their production of graduates entering into family medicine. DO-granting and international medical school graduates filled the majority of ACGME-accredited family medicine first-year resident positions in 2014.

(Fam Med 2015;47(9):712-6.)

This is the 34th national study conducted by the American Academy of Family Physicians (AAFP) that reports retrospectively the percentage of graduates from Liaison Committee on Medical Education (LCME)-accredited, hereafter called US MD-granting, and of American Osteopathic Association (AOA)-accredited, hereafter called DO-granting medical schools, who enter Accreditation Council for Graduate Medical Education (ACGME)-accredited family medicine residency programs as first-year residents. Data from the AAFP’s annual census of these family medicine residency programs and the LCME Annual Medical School Questionnaire Part II are used to analyze the US medical school origin of each student entering into a family medicine residency as a first-year resident.1 This annual report is one measure of the effectiveness of medical schools to produce a primary care workforce, a key measure of social responsibility as measured by their production of graduates entering into family medicine. Medical schools that have higher entrance rates into family medicine residencies exhibit “positive deviance” from their peers and can enable others to discover uncommon strategies to implement solutions to increase student choice of primary care, particularly family medicine.

 

Methods

 
 

The AAFP conducts an annual online census of all residents in ACGME-accredited family medicine residency programs. This study reports on the data from the 2014 survey. Among the data collected is a list all first-year residents and their medical school, including the month and year of graduation. Residency programs that failed to respond to the initial survey were contacted by email or telephone to ensure a 100% response rate to the online survey. All graduates of US MD-granting medical schools who graduated between July 1, 2013, and June 30, 2014, were verified by using the American Medical Association (AMA) Physician Masterfile. Those who did not graduate between July 1, 2013, and June 30, 2014, were not independently verified. The American Association of Colleges of Osteopathic Medicine (AACOM) Fast Facts About Osteopathic Medical Education was referenced for the graduate totals for each DO-granting medical school.2 The LCME Annual Medical School Questionnaire Part II data were used to classify each US MD-granting medical school as public or private.1 The authors created a rank order list of US MD-granting medical schools based on the last 3 years’ average percentage of graduates who became family medicine residents, using the 2014 and prior AAFP census data. The residency census was granted an exemption from the AAFP Institutional Review Board.

 

Results

 
 

Type of Medical School

In 2014, 3,595 students matriculated into ACGME-accredited family medicine residency programs as first-year residents. Almost half were from US MD-granting medical schools. Of the remainder, there were twice as many graduates of international schools as there were of graduates of DO-granting schools (Figure 1).

Figure1

Medical School Structure

Medical schools vary in both the absolute numbers and percentages of graduates entering family medicine residencies. Sixty-two percent of the 131 US MD-granting medical schools graduating students in 2014 were public, and they produced almost double the percentage of graduates entering family medicine residencies than those that were private. (Table A)  

tablea

US MD-granting medical schools without a department or division of family medicine have a lower percentage of graduates entering family medicine residencies than those with departments of divisions of family medicine (Table 1).

Table1

Sixty-nine of the 131 US LCME-accredited medical schools (53%) produced 80% of the graduates entering ACGME-accredited family medicine residency programs. Among all US MD-granting schools, only 21 (16%) produced 20 or more graduates selecting family medicine, while 58 (44) produce fewer than 10 each. Six schools graduated no students into family medicine (See Table B).

Eight of the 28 DO-granting medical schools program, while only one US MD-granting medical school, graduated more than 20% of its class into family medicine. Fourteen of the DO-granting schools produced 20 or more graduates selecting family medicine in an ACGME-accredited residency program. (See Table C).

Three-Year Averages

The authors continued the annual tradition of creating a rank order list of the top 20 medical schools by using 3-year rolling average to determine which US MD-granting schools graduate a higher percentage of students into family medicine (Table 2). The University of North Dakota, University of Kansas, University of Minnesota, East Carolina University, and University of Washington top the list of US MD-granting schools. Five schools, University of California-Irvine, University of Oklahoma, Texas Tech University, University of Arkansas, and the University of Colorado entered the ranks of the top 20 schools in 2014.

Table2

Geographic Variation

There were variations in the number of US LCME graduates and entry rates into family medicine residency programs by state and AAFP census regions in 2014. (See Table D). Rates were highest in the Pacific, West North Central, Mountain, and West South Central census regions. The 97 US MD-granting medical schools located in states east of the Mississippi River produced 69% of the graduates, and the average rate of entry into family medicine was 7.3%. In contrast, the 43 US MD-granting medical schools in states west of the Mississippi had an aggregate entry rate of 11.1%.

 

Conclusions

 
 

The number of students from US MD-granting medical schools choosing family medicine as a career continues to be intractably flat. There are wide variations in the percentages of students entering ACGME-accredited family medicine residency programs by type of medical school, presence or absence of a department or division of family medicine at the school, region, state, and even within states, reflecting that none of these factors alone directly predicts production of graduates who choose family medicine. As in the past, the number of students from publicly supported US MD-granting medical schools is higher than from US MD-granting private schools. There are some notable exceptions such as Thomas Jefferson University, a private school that has the highest rate in Pennsylvania. It is important to note, however, the higher rate of students entering into ACGME-accredited family medicine residency programs from DO-granting medical schools than US MD-granting medical schools, despite the fact that all but six of the 31 DO-granting schools are privately funded.3 Perhaps a more important determinant is the social mission of the medical school as expressed through its mission statement.4 There is wide variation in production of graduates entering into family medicine among schools that have departments or divisions of family medicine. However, schools without departments or divisions of family medicine consistently produce few students entering family medicine. In aggregate, medical schools west of the Mississippi River represent less than a third of all US MD-granting schools but have an aggregate rate of students selecting family medicine that is two-thirds higher than schools to the east of the Mississippi. Rates can vary significantly within some states, such as Florida, in which the rates range between 0% and 14.8% among public schools.

It is clear that in aggregate, US MD-granting medical schools are failing to produce an adequate number of students who are choosing specialties that will lead to a career in primary care. DO-granting schools have had a consistent trend of producing a higher proportion of their graduates entering primary care. Caution should be noted regarding the future production of family physicians through DO-granting schools. In 2014, the proportion of graduates from DO-granting schools in the entering class was 18% in comparison to 27% in 2013.5 While this change could be common cause variation, the change may be initial evidence of some material change particularly in the context of reports that the rate of osteopathic students planning a career in primary care is declining and that the rate of osteopathic graduates matriculating into primary care specialties is also declining, despite the increase in the number of DO-granting medical schools as well as class size.6,7 There has been a decline in US LCME medical school graduates in training in primary care residency programs from 2000–2014 with a commensurate increase in the percent of graduates from international medical schools, meanwhile earlier increases in graduates of DO-granting schools has leveled off. The increase in the number of international medical school graduates may contribute to a “brain drain” on their countries of origin. The increase is also a reflection of the inability of the US medical schools to be accountable to produce a sustainable workforce that meets the needs of the population given the considerable public financing that they receive.8,9

There are several limitations with this study. This annual report has been focused on ACGME-accredited programs. These programs represent the largest but not the only avenue for graduate medical education in the United States. In the past, it has been difficult to obtain data to determine the total family medicine residency pipeline because a significant number of DO graduates train in programs accredited by both the AOA and the ACGME and potential double-counting. The first comprehensive accounting of the numbers of individuals in medical residency training in the United States, including those in both AOA- and ACGME-accredited residencies has been published.10 That study identified that in 2011, 942 (35%) of osteopathic family medicine residents were training in family medicine residency programs that were accredited only by the American Osteopathic Association. In 2020, the projected implementation year for a single accreditation system for all graduate medical education, the challenges of counting family physicians in training will be minimized. The AAFP annual census relies on the residency programs to self-report the medical school origin of their residents and may be subject to error. Only the subset of the graduates who trained in US MD-granting medical schools was verified through the AMA Masterfile for the purposes of determining the 3-year averages. The study does not discern whether students trained at Regional Medical Campuses (RMC) of their medical school. Prior studies have demonstrated that students who receive their medical school training at an RMC site are twice as likely to match into family medicine as those who did not train at an RMC.11

Primary care has been demonstrated to improve health care outcomes and reduce health disparities while reducing per capita costs.12 Despite the need to produce more primary care physicians in this country, there has been a notable decline that limits the potential to deliver the promise of primary care, which is to create better health, better health care, and reducing per-capita costs of health care—the Triple Aim of health care.13 Based on the current composition of the primary care physician production, it is estimated that there will need to be an additional 973 family medicine and 727 non-family physician primary care graduates per year until 2035 in order to eliminate projected shortages.14 The decline in physicians entering careers in primary care is occurring at the same time that a growing percentage of nurse practitioners and physicians assistants are choosing to practice outside of primary care.15 The unique position of the US medical schools as the gateway to the physician workforce, and considerable public financing, demands that schools be held accountable to the needs of the population. Creating a primary care workforce to address those needs must be an important part of their compact with society.

This annual report highlights the failure of the US MD-granting schools to deliver on a key measure of social responsibility that is to deliver a primary care workforce that meets the needs of the population. The variability of family medicine production between the medical schools suggests that there are local differences at the medical school level that play crucial roles in students choosing a career in family medicine. In order to change the status quo, medical school leaders will need to study the interventions at their school that may impact student choice of a career in family medicine. The outcomes of these interventions must be measured and shared with others. Together medical school leaders from both the allopathic and osteopathic schools, family physicians, medical students, and patients can form a vibrant learning community to engage and learn from each other to better understand those common and uncommon programs, policies, curriculum, activities, and tools used to achieve and measure up to the promise to our people and our social responsibility.

Acknowledgments: The authors would like to acknowledge Sam Carlson, AAFP Student Interest Project Specialist, for his assistance in the preparation and review of the data.

Corresponding Author: Address correspondence to Dr Kozakowski, American Academy of Family Physicians, Medical Education Division, 11400 Tomahawk Creek Parkway, Leawood, KS 66211. 800-274-2237, ext: 6700. Fax: 913-906-6289. kozakowski@aafp.org.

 

References

 
 

 

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From the Medical Education Division, American Academy of Family Physicians, Leawood, KS.


Copyright 2017 by Society of Teachers of Family Medicine