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Primary Care Workforce:

Primary Care Workforce:. Cathleen Morrow MD Department of Community and Family Medicine Dartmouth Medical School. Goals and Objectives. To review some background about workforce data nationally and in NE. To attempt to create some context and perspective on workforce issues.

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Primary Care Workforce:

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  1. Primary Care Workforce: Cathleen Morrow MD Department of Community and Family Medicine Dartmouth Medical School

  2. Goals and Objectives • To review some background about workforce data nationally and in NE. • To attempt to create some context and perspective on workforce issues. • To make the case for the centrality of education to workforce dilemmas and solutions. • To attempt to convince you that the expansion of your health centers’ interface with education is in your long term interests.

  3. Background • Board of Access to Medical Education Comm of FAME (Finance Authority of ME) • Legislative Commission on Primary Care Workforce Development - State of NH

  4. Primary Care Workforce • 97,752 family physicians • 1 for every 3, 081 persons • 92,257 general internists • 1 per 2,443 adults • 48,930 general pediatricians • 1 for 1,548 children and adolescents • 238,939 primary care physicians • 1 for every 1,260 persons

  5. Primary Care Shortage? • Currently a problem of distribution • 239,000 primary care physicians (2007) • 1 for every 1,260 people in the US • Still concentrated in desirable areas • Relative shortage in underserved areas • True for physicians, NPs and Pas • 20% of the population living in rural areas; 9% of the doctors.

  6. Primary Care Shortage • Real shortage and greater distribution problem possible • Substantial decline in US student interest • Increased reliance on international students • Increased interest in specialization and alternative careers • Contraction of training programs • Majority of PA’s now sub specialize; NPs? • Current physician expansion effort not promoting primary care - AAMC

  7. Status check: Family Medicine Family Medicine Positions March, 2008 Filled by US Graduates

  8. Reliance on International Medical Graduates Change in Number of IMGs in Training 2002-2006 Source: JAMA Medical Education Issues, Ed Salsberg, AAMC

  9. Student Interest • General Internal Medicine 2.0% • Med/Peds 2.7% • Family Medicine 4.9% • General Pediatrics 11.7% • Total: 21.3% K. E. Hauer et al. Choices Regarding Internal Medicine Factors Associated With Medical Students' CareerJAMA. 2008;300(10):1154-1164

  10. M. H. Ebell. Future Salary and US Residency Fill Rate RevisitedJAMA. 2008;300

  11. Primary care losing ground GME • Between 2002 and 2007 • Residency positions grew 7.9% • Subspecialty positions grew 24.7% • Primary care positions grew 2.3% • However…the estimated number of graduates going on to practice primary care fell 15% (from 28.1% to 23.8%) E. Salsberg et al. US Residency Training Before and After the 1997 Balanced Budget Act. JAMA. 2008;300(10):1174-1180.

  12. Summary • We may have enough primary care physicians (all physicians too) • Need to improve distribution and access • Pipeline in trouble for future • Need to fix income gap • Schools need to choose and train wisely • GME priorities, payments, and places need updating

  13. Primary Care Vacancies • NH – 17 Family physicians 13 Internists 12 NP/PA’s 5 Dentists • VT - 20 Family physicians 9 Internists 7 NP/PA’s 4 Pediatricians 1 Dentist

  14. Primary Care Vacancies • Maine - 50 Family physicians 2 Pediatricians 27 Internists 9 NP/PA’s

  15. NH Dartmouth Residency • 2004 - 62% • 2005 - 50% • 2006 - 70% • 2007 - 50% NH; 25% Ma. • 2008 - 83% • 2009 - 70% NH; 30% Ma. • 2010 – 100% say they are staying.

  16. More from NH Dartmouth • “The graduates have actually mostly gone south - Manchester, Derry, Londonderry, Nashua, Hudson, a few in Concord area. One of our 2002 graduates went to Littleton because her family is there. During the resident practice management series in the fall of 3rd year, we have the Bi State Primary Care Association folks come and talk with them. They outline loan repayment options, talk about using their recruitment center, and talk about the north country practices”

  17. MMC FM Residency - Portland • Over the past five years: • 75 % have stayed in Maine • 81 % have stayed in New England (including those who stayed in Maine) • Of those who stayed in Maine, 16% have gone to more rural (north or west) and 84% have stayed in Greater Portland, Lewiston, or southern Maine.

  18. EMMC FM Residency - Bangor • Graduation year Maine Total • 2004 5 8 • 2005 5 6 • 2006 5 8 • 2007 2 8 • 2008 4 7 • 2009 10 10 • TOTAL 31 47 • 66% “My recollection is that we are around 50% for the entire life of the Residency”

  19. CMMC – Lewiston ME • 2005 – 50% ME; 50% NE (Ma, VT, RI) • 2006 – 28% ME • 2007 – 65% ME • 2008 – 50% ME and NH • 2009 – 85% ME and NH • Graduated 1st ‘rural track’ resident in 2008; fill 2 positions/yr in Rumford, ME.

  20. Maine Dartmouth FM Residency • 57 % of graduates remain in practice in Maine • Overall total since the beginning of the program (1973)

  21. Jessie Reynolds story • Grew up in Indiana, small town pop 500 • Went to Middlebury College • Did a Jan. term in Wells River VT with Steve Genereaux MD • Taught 7th grade science; went to Indiana University Medical School • Matched in CMMC Rural Track Residency Program in Rumford, ME • Now in Wells River, VT practicing at a FQHC; offered positions at 2 x salary.

  22. Macy Foundation StudyApril 2009 • Born in a rural area: 2.5x more likely to practice in rural area 2x more likely to go into FM. • Attend a public medical school: 2x more likely to go into FM 2x practice in rural area

  23. Macy Foundation • NHCS recipient: 4x more likely to work in a FQHC If you express interest in serving underserved pop 3 x more likely to be in a FQHC and 4x more likely to practice in a rural area. Conclusion: Rotations in these environments matter! Growing your own matters!

  24. Workforce: Future and Present Practice Culture Trainees: Students and Residents Patient Needs Productivity EHR Regulatory Demands

  25. Training Obstacles • Largest: Lack of practicum placements: no reimbursement, administrative costs of placement, slowing down already overbooked providers; Medicare regulations regarding documentation. • Faculty shortages • EMR’s- lack of standardization/ challenges for learners • Certification obstacles – e.g. VA, background checks

  26. Macy Foundation Report • New entities, to be called “teaching community health centers” should be established. These centers would serve as sites for the training of healthcare professionals and would work with primary care practices to raise standards of care. These teaching CHC’s will require strong collaborative ties with teaching hospitals continuing the theme that collaboration is essential for better patient care and for preventing disease.

  27. Educational Home • Create an educational environment such that students and learners of all kinds feel welcomed and embraced • Workforce that feels always responsible for teaching/learning • Teaching/learning is intrinsic to patient care – patients enjoy it; engage in a sense of ownership “I’m helping this student to learn, I am providing value here as well as obtaining medical care.

  28. Educational Home • Education is so intrinsic to the environment that the process of ‘permission’ asking is not such an ordeal. • Buy in from staff is critical. • Clear permissions to not engage is also critical.

  29. Ideals of Learners • Making a difference • Making a difference • Making a difference • My work matters; what I do is important; I am contributing to the outcome of this patient, this practice, this institution, this community.

  30. Positioning Your Institution Pipeline development – grow your own Loan repayment 3rd and 4th year medical student electives Rural Scholars programs Creating an educational home within your institution

  31. Educational Home and Recruitment • Physician burnout/compassion fatigue is real. • Majority of people entering primary care want to teach. • The opportunity to teach offers you a recruiting advantage. • Time to teach must be a component of a realistic offer.

  32. Macy Foundation Report • AHECs should be designated and well supported to coordinate the educational experiences of health professions students and primary care residents in teaching CHC’s and in other primary care community based clinical settings.

  33. Macy Foundation Report • Title VII of the US Public Health Service Act must be expanded to direct more financial support to education in the primary care professions.

  34. Macy Foundation Report • Private and federal insurance program payment policies must be changed to reduce income disparities between primary care providers and other specialists.

  35. Macy Foundation Report • The NHSC, with substantially increased funding, should become a focus of efforts to alleviate the burden of debt that discourages medical students from selecting primary care as a specialty and to increase the numbers and diversity of primary care professionals who practice and teach in underserved communities.

  36. Macy Foundation Report • Criteria for admission to medical school should be changed to attract a larger and more diverse mix of students who are likely to choose primary care and to care for patients in inner cities, small towns, and rural areas.

  37. Macy Foundation Report • The graduate medical education system needs to be better aligned to meet the physician workforce needs of the country.

  38. Taking Care of One Another • Burn-out and compassion fatigue are real and contributing significantly to our challenges in recruitment and retention. • An angry, resentful provider is the worst recruiter to primary care imaginable (and patients and co-workers suffer too!) • Our work in primary care is important, hard, and good work – we must also take care of each other.

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