Is GME Snubbing Rural America?

Theories abound as to why young physicians won't practice in rural areas. But the key reason why young medical doctors don't fill these much-needed roles readily is a lack of accountability in publicly funded Graduate Medical Education programs, researchers suggest.

A new round of metrics doesn't bode well for rural healthcare.

The U.S. Census for 2010 says that one in five people —19.3% of the population, about 59.4 million people—live in rural America. Unfortunately, a new report this month from George Washington University School of Public Health and Health Services says that only 4.8% of new physicians plan to establish a practice in rural areas, despite the critical need.  

Clearly there is a disconnect between supply and demand. This is hardly news to most rural healthcare professionals, researchers on the topic, or physician recruiters serving rural areas. It's a topic that's been predicted and discussed for decades. That's what makes this persistent shortage all the more vexing. We know what the problem is but we can't fix it.

"I can't say we were terribly surprised but it does definitely confirm what a lot of us suspected. When you see the actual numbers it is hard not to be a little shocked and disturbed," says Candice Chen, MD, MPH, an assistant research professor of health policy at SPHHS, and a lead author of the study, which appeared this month in Academic Medicine.

Theories abound as to why young physicians won't practice in rural areas: less money, horribly long or erratic working hours, massive medical school debts to repay, a lack of cultural diversity and other social chasms with the populations they serve, practicing in isolation, a lack of professional support, and generally poorer schools for their children and fewer career options for spouses, to name a few.

The failures continue despite the efforts and financial incentives by the federal and state governments to encourage medical students and residents to practice in underserved areas both rural and urban. The key reason why young physicians don't take up these obvious and dire needs is a lack of accountability in publicly funded Graduate Medical Education programs, researchers suggest.

Chen and her colleagues studied the career paths of 8,977 physicians who had graduated from 759 medical residency sites from 2006 to 2008. The researchers analyzed data to find out where these new physicians ended up practicing three to five years after graduation. They found that overall only 25.2% of the physicians in this study worked as primary care physicians.  

Chen says this number likely too high because it includes hospitalists. The researchers found that 198 of 759 institutions produced no rural physicians during the study period. And 283 institutions graduated no doctors practicing in the Federally Qualified Health Centers that serve low-income or destitute patients in underserved urban and rural areas.

The study's findings are blunt: GME operates on public money—nearly $10 billion in funds from the Medicare program and another $3 billion from Medicaid—but apparently the nation's teaching hospitals can't address physician shortages that were identified and anticipated decades ago.  

The problem is not just in rural and underserved areas. Chen says GME institutions produce primary care physicians at an "abysmally low" rate. This failure by a taxpayer funded program to address a dire public need is occurring despite the full knowledge that the need for primary care physicians will dramatically increase in the coming years as more Americans gain health insurance coverage under the Patient Protection and Affordable Care Act.  

"If residency programs do not ramp up the training of these physicians, the shortage in primary care, especially in remote areas, will get worse," Chen says. "The study's findings raise questions about whether federally funded GME institutions are meeting the nation's need for more primary care physicians."  

"Right now with the Medicare money that goes for GME there is very little requirement around that money other than that you train and report that you train 'X' number of residents," Chen says.  

"There is nothing that says we need more primary care doctors or other kinds of doctors. General surgery is another area where a lot of communities are struggling. There is nothing in the payment that says you need to produce these kinds of doctors or produce doctors who are going into certain areas to serve the need that America has."  

Consider these findings from Chen and her colleagues:

• The top 20 primary care producers in this study trained 1,658 primary care doctors out of a total of 4,044 or 41%. These sites received just $292 million in GME funding.
• The bottom 20 programs produced only 684 primary care graduates out of 10,937 or 6.3%. These sites received $842 million in GME payments—an amount that reflects not a dedication to training doctors in primary care but in churning out highly paid specialists who typically practice in big cities or the suburbs.
• Almost two-thirds of the nearly $10 billion in Medicare funding for GME annually goes to 200 hospitals—and those sites perform poorly when it comes to producing primary care doctors.

Chen and her colleagues say policymakers should examine the skewed incentives that have led to the ongoing primary care crisis and the lack of physicians in underserved areas, and develop a more accountable GME system. Of course there are other nagging issues out there that disincentivize primary care, especially the huge compensation gap between primary care physicians and their specialist colleagues.  

"GME reform alone will not be the thing that magically fixes the system," Chen says. "But there is a definitely a sense and there is research evidence out there that shows that GME residency training programs can do things that would increase the likelihood of people going into primary care and underserved areas. Where we locate our residency programs and the exposure to different kinds of mentors in GME and the exposure to positive experiences in rural and underserved areas, those do make a difference to trainees."

Chen believes the failure of GME to respond to glaring shortage of primary care physicians will prompt that review.

"The fact remains that there is no accountability in the system currently," she says. "Even with the system the way it is, [could you] layer in an accountability system could that make the difference? It could depending upon what it looks like. There are definitely things going on now. People are looking at GME and they're interested in how you can start to align it with producing the physicians that we ultimately need."

Simply building more accountability into GME and ignoring other issues such as compensation won't remove all the hurdles that keep physicians away from rural America. But it's a good start and it's long overdue.