Kozakowski SM, Travis A, Bentley A, Jr GF. Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016. Fam Med 2016;48(9):688-695.
Entry of US Medical School Graduates Into Family Medicine Residencies: 2015–2016
Stanley M. Kozakowski, MD; Alexandra Travis; Ashley Bentley, MBA; Gerald Fetter Jr, MSA
Background and Objectives: This is the 35th national study conducted by the American Academy of Family Physicians (AAFP) that reports retrospectively the percentage of graduates from 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. Approximately 8.7% of the 18,929 students graduating from US MD-granting medical schools and 15.5% of the 5,314 students graduating from DO-granting medical schools between July 2014 and June 2015 entered an ACGME family medicine residency in 2015. Together, 10.2% of graduates of MD- and DO-granting schools entered family medicine. Of the 1,640 graduates of the MD-granting medical schools who entered a family medicine residency in 2015, 80% graduated from 70 of the 134 schools (52%). In 2015, DO-granting medical schools graduated 823 into ACGME-accredited family medicine residencies, 80% graduating from 19 of the 32 schools (59%). In aggregate, medical schools west of the Mississippi River represent less than a third of all MD-granting schools but have a rate of students selecting family medicine that is 40% higher than schools located east of the Mississippi. Fifty-one percent (24/47) of states and territories containing medical schools produce 80% of the graduates entering ACGME-accredited family medicine residency programs. A rank order list of MD-granting medical schools was created based on the last 3 years’ average percentage of graduates who became family medicine residents, using the 2015 and prior AAFP census data.
(Fam Med 2016;48(9):688-95.)
This is the 35th national study conducted by the American Academy of Family Physicians (AAFP) that reports retrospectively the percentage of graduates from US Liaison Committee on Medical Education (LCME)-accredited, hereafter called MD-granting medical schools; American Osteopathic Association (AOA)-accredited, hereafter called DO-granting medical schools; and international medical schools who enter Accreditation Council for Graduate Medical Education (ACGME)- accredited family medicine residency programs as first-year residents. The following studies and sources are used to analyze graduates entering family medicine residencies as first-year residents: data from the AAFP’s annual census of these family medicine residency programs, the LCME Annual Medical School Questionnaire Part II, and the American Association of Colleges of Osteopathic Medicine (AACOM) Fast Facts About Osteopathic Medical Education.1,2 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. Primary care has been demonstrated to improve health care outcomes and reduce health disparities while reducing per capita costs.3 Many medical schools and states exhibit positive deviance from their peers in production of family physicians and can enable others to discover strategies to implement solutions to increase student choice of primary care, particularly family medicine.
The AAFP conducts an annual online census to identify all residents in ACGME-accredited family medicine residency programs. Among the data collected is a list of all first-year residents and their medical schools, including the month and year of graduation. This study reports on only the subset of PGY-1 residents who entered ACGME-accredited family medicine residency programs for the 2015–2016 academic year and had graduated from medical school between July 1, 2014, and June 30, 2015. Residency programs that failed to respond to the initial survey were contacted by email or telephone. 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 MD-granting medical school as public or private.1 Aggregate data for both MD- and DO-granting medical schools by state were paired with the state-specific data from the Robert Graham Center population to primary care physician ratio. Primary care physicians were defined as those physicians in direct patient care with a primary specialty of family medicine, general practice, general internal medicine, general pediatrics, or geriatrics.4 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 2015 and prior AAFP census data.
Descriptive analysis and Ordinary Least Squares (OLS) regression were utilized to assess the relationship between the year and each of the types of medical school for graduates in 2015–2016 and in previously published studies in this series since 2005–2006.5-14 Significance was defined at the .05 level, and analyses were conducted using IBM SPSS Statistics 22.0 (IBM, New York, NY).
The residency census was granted an exemption from the AAFP Institutional Review Board.
All but one ACGME-accredited family medicine residency programs completed the annual AAFP online census to achieve a 99.8% response rate.
Type of Medical School
In 2015, 3,594 medical school graduates matriculated into ACGME-accredited family medicine residency programs as first-year residents. US MD-graduates compose 46% of the entering first-year resident class, a percentage that has not changed significantly over the last decade. The percentage of DO graduates and international graduates in the first-year class has changed in a reciprocal fashion over the last decade. DO graduates have increased approximately 1% per year (P=.02) from 16% in 2005 to 23% in 2015, while international graduates have had a reciprocal annual 1% decrease (P=.01) from 38% in 2005 to 29% in 2015 (Figure 1).
Categorically, MD- and DO-granting medical schools had different rates in the production of graduates selecting family medicine (Table 1). There are four times as many MD-granting medical schools as DO-granting medical schools, and they produce only three and a half times as many total graduates compared to the DO-granting schools. The DO-granting medical schools have twice the percentage of graduates entering family medicine.
Among the MD-granting medical schools, 10 schools produced 30 or more graduates entering family medicine in 2015 (see Table A). Fifty-two percent of the schools (70/134) produced 80% of the MD-granting graduates choosing family medicine, while six schools produced none. The greatest number of graduates was from the University of Minnesota Medical School with 42. The Uniformed Services University of the Health Sciences had the highest percentage at 19.8%.
All DO-granting schools with graduates in 2015 had students enter ACGME-accredited family medicine programs (see Table B). Nineteen of the 32 schools with graduates produced 80% of the DO-granting graduates entering family medicine. Nine schools had 30 or more students enter family medicine. Des Moines University College of Osteopathic Medicine had both the greatest number of students (68) and highest percentage of students (32.7%) entering family medicine. Five international medical schools (Ross University School of Medicine, St. George’s University School of Medicine, American University of the Caribbean School of Medicine, American University of Antigua College of Medicine, and Saba University School of Medicine) each produced 40 or more graduates entering family medicine and combined for 73% of the total number of international students entering family medicine residencies. Two of those schools, Ross University School of Medicine and St. George’s University School of Medicine, each graduated more than 100 students who entered family medicine residencies in 2015.
Medical School Location
The number of graduates from MD-granting medical schools and entry rates into family medicine residency programs were calculated by US census region and state in 2015 (see Table C). The West North Central region had the highest percentage of students entering family medicine (12%), while the Puerto Rico region had the lowest percentage (1.5%). The overall average was 8.7%. In aggregate, schools east of the Mississippi River had more than twice the number of total graduates than schools west of the Mississippi and also had 370 more graduates enter family medicine than those schools west of the Mississippi. However, the western medical schools graduated students entering family medicine at a higher rate than schools east of the Mississippi (10.8% versus 7.7%). Overall, the average percentage of MD and DO graduates entering family medicine was 10.2%. It should be noted that not every state or territory has a medical school located within its boundaries. US states and territories ranged in the number of graduates from MD- and DO-granting schools entering family medicine residencies—from 194 (California) to 4 (Puerto Rico)—with a mean of 52, median of 38, and standard deviation of 46. States and territories ranged in the rate of students entering family medicine from 25.2% (Iowa) to 1.5% (Puerto Rico) (see Table D). States were ranked by the production of all medical students entering family medicine residencies from the MD- and DO-granting schools located within the state (Table 2). Only one state, Iowa, had more than 20% of all graduates enter family medicine. Fifty-one percent (24/47) of states and territories containing medical schools produce 80% of the graduates entering into ACGME-accredited family medicine residency programs. Six states produce more than 100 graduates each entering ACGME-accredited family medicine residency programs. Seven states (Alabama, Florida, Georgia, Louisiana, Missouri, North Carolina, and Ohio) were below the national average of population to primary care physician ratio and produced fewer than the national average of MD-granting medical school graduates entering into family medicine.
A majority of residents practice within 100 miles of where they completed their residency training. Excluding Puerto Rico, which had no graduates enter a family medicine residency in that territory, the percent of students graduating from MD-granting US medical schools who remain in-state for residency varies from 3.9% in Maryland to 68.8% in California (see Table E).
Medical School Structure
Sixty-two percent (83/134) of MD-granting medical schools are publicly owned. In aggregate, public schools had a higher percentage of their graduates matriculate into family medicine residency programs in comparison to private schools (10.1% versus 6.1%) (see Table F). Ninety-two percent (123/134) of MD-granting medical schools have departments of family medicine (see Table G). Those schools produce more than six times the number of students entering family medicine in comparison to the nine schools that do not have a department or division. Two schools without family medicine departments have centers of family medicine and have twice as many graduates enter family medicine as those that lack any family medicine structure.
The authors continued the annual tradition of creating a rank order list of the top 20 MD-granting medical schools by using a 3-year rolling average of family medicine graduation rates (Table 3). The top five US MD-granting medical schools were University of Minnesota, University of Kansas, University of North Dakota, East Carolina University, and University of Washington. These same schools were also in the top five in the prior year, although in a different order. Six MD-granting medical schools, Uniformed Services University, Michigan State University, University of Nevada, University of Iowa, University of Hawaii, and East Tennessee State University, entered the ranks of the top 20 schools in 2015 (Note the latter two schools were tied for number 20).
The purpose of this annual report is to serve as a barometer for advocates, policy makers, and other stakeholders who recognize the need for a robust primary care workforce. The information captured in the analysis can be used by these same stakeholders to gauge their own performance in contributing to the primary care workforce, set goals, identify institutions with models from which to learn, and develop strategies for continuous improvement. To achieve the “Triple Aim” of health care—better health, better health care, and reducing per-capita costs of health care—the Council on Graduate Medical Education 20th Report, “Advancing Primary Care,” recommended that policies should be implemented that raise the percentage of primary care physicians in the physician workforce to a minimum of 40%.15,16 The most recent estimates from 2008 indicate that primary care physicians represented 35% of the US physician workforce in direct patient care, a rate that is declining.17 As a specialty, family medicine has 80% of primary care positions in the NRMP Match and has the highest proportion of residents who are likely to practice primary care after graduation.16,18
The percentage of graduates of MD-granting medical schools entering ACGME-accredited family medicine programs has remained statistically unchanged over the last decade, as has the total number of family medicine positions available. Against the backdrop of population growth and aging, as well as growth in the number of insured Americans, a stagnant primary care workforce has exacerbated—and will continue to if nothing changes—the shortage of primary care in the United States.
A disproportionately small number of MD-granting medical schools, as well as states, produce the majority of graduates entering into family medicine despite calls for all medical schools to become socially accountable for the billions of dollars of public funding to support medical education.19 DO-granting medical schools are fewer in number, and despite the higher percentage of graduates entering family medicine, the number of DO graduates entering family medicine is smaller than the MD-granting schools, and the percentage entering primary care has been declining since 1995.20 All US medical schools receive federal support directly or indirectly and most as a primary form of funding. Therefore, all US medical schools should be accountable for contributing significantly to the health workforce needs and priorities of their communities and the country.
Studies have uncovered associations and correlations between production of family physicians and certain medical school policies and practices. At this time, however, it is unclear the exact role of specific strategies related to state policy, mission statements favoring primary care production, admissions and recruiting, funding structure and sources, culture, distributed education models, proportion of in-state family medicine residencies, or other factors that may account for some medical schools’ success in primary care production relative to their peers.21-25 This remains an area ripe for future study.
There are several limitations to this report. The methodology used in this report creates a snapshot of residents who entered into an ACGME-accredited family medicine residency program at the start of the traditional academic year. It does not include, however, residents who entered the program off-cycle or who may have a gap of more than 1 year between medical school graduation and the start of residency. The study does not capture graduates from DO-granting schools that enter residency programs that are solely accredited by the AOA. The authors have been unsuccessful in obtaining comparable data on the AOA-only accredited residency programs. A previous report using 2011 data revealed that 35% of osteopathic family medicine residents were training in family medicine residency programs that were accredited only by the AOA.26 There is no central data source on the structure (public/private or presence of departments of family medicine) of the international medical schools whose graduates enter PGY-1 positions at ACGME-accredited family medicine residency programs.
This report is important as an initial attempt to analyze combined data for US MD-granting and DO-granting medical schools. The move toward a single graduate medical education accreditation system by 2020 presents an opportunity to facilitate the creation of an annual residency census for all US family medicine residency programs.
Understanding family medicine production on a state basis allows policy makers, state organizations, and both MD-granting and DO-granting medical schools within the states to collaborate to improve family medicine production and retention of graduates. For example, states with lower than the national average percentage of graduates remaining in the state for their family medicine residency should increase opportunities for family medicine residency training in that state since a majority of family medicine graduates remain within 100 miles of where they have completed their residency training.27 This combined report of US MD-granting and DO-granting medical schools and their 2015–2016 contribution to the US family medicine workforce will serve as a tool for states and institutions to develop strategies to improve their impact on the nation’s primary care workforce.
Evidence continues to grow showing the impact of primary care and the diversity of the physician workforce on the health outcomes of the population.28,29 This study reaffirms that the current medical school system is failing, collectively, to produce the primary care workforce that is needed to achieve optimal health. It builds upon previous articles in this series by integrating data from both MD- and DO-granting medical schools and organizing information by state. The information captured in this report allows advocates, policy makers, and other stakeholders, particularly at the state level, to identify medical schools and states with similar structures, environments, and challenges as their own, yet exhibit positive deviance in production of family physicians. These states and schools likely have uncommon yet successful strategies from which others should learn to develop their own strategies for continuous improvement in primary care production. Many states and schools have policies and practices that result in success in certain areas, yet all US medical schools need to improve their performance to produce the primary care workforce needed in the United States. Though this study did not capture workforce diversity, future studies should examine representation of all populations currently underrepresented in medicine, including racial, ethnic, and/or rural background attributes of graduates entering family medicine residency programs, as well as practice distribution of those graduates in practice. Building the physician workforce to achieve optimal health for the United States will require having the right numbers of physicians, of a diversity mix representative of the population, practicing in the right geographic locations.
AcknowledgmentS: The authors would like to acknowledge Natalia Loskutova, MD, PhD, and William Venable, MBA, MPA, from the AAFP National Research Network for their assistance with statistical analysis.
Corresponding Author: Address correspondence to Dr Kozakowski, American Academy of Family Physicians, Medical Education Division, 11400 Tomahawk Creek Parkway, 800-274-2237, ext: 6700. Fax: 913-906-6289. firstname.lastname@example.org.
From the Medical Education Division, American Academy of Family Physicians, Leawood, KS
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I should think that primary care doctors include Internal Medicine, Med/Peds, and possibly pediatrics and OB/Gyn.
I think that by specifying only FM residents, you are shorting the percentage of docs in primary care.'
My own son, a graduate of the U. of Minn, chose Med/Peds. He felt that few modern women wanted to be given pelvic exams or have babies delivered by a white male.
I am a family medicine guy who just retired completely at age 74.
Posted on 10/27/2016 1:45:41 PM