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Characteristics and Distribution of Graduate Medical Education Training Sites: Are We Missing Opportunities to Meet U.S. Health Workforce Needs?

Blanchard, Janice MD, PhD; Petterson, Stephen PhD; Bazemore, Andrew MD, MPH; Watkins, Kayla MPH; Mullan, Fitzhugh MD

Author Information
doi: 10.1097/ACM.0000000000001184
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Abstract

In 1961, Kerr White and colleagues’1 examination1 of the ecology of medical care demonstrated that, while most medical care takes place in the community, almost all medical training occurs within the walls of hospitals and academic medical centers. A 2001 update to White’s work reaffirmed these findings.2 Research in the intervening 50 years has demonstrated that health systems built on primary care produce better patient outcomes at lower costs.3–6

Policy makers have responded by expanding efforts to strengthen primary care and public health systems, most recently by passing the Patient Protection and Affordable Care Act (ACA) in 2010. The ACA contained a number of provisions that focused on these goals, including increasing Medicare and Medicaid payments for primary care providers and creating the Prevention and Public Health Fund. However the ACA’s only new direct investment in graduate medical education (GME) was in the creation of the Teaching Health Centers (THC) program, which funds new and expanding primary care residency programs specifically sponsored by community-based ambulatory health centers.7,8

Introduction

As the number of newly insured grows with the implementation of the ACA, providers who practice in community-based settings are needed, in particular generalist physicians who can treat patients with a broad spectrum of conditions. The Health Resources and Services Administration (HRSA) predicted a shortage of physicians in the generalist specialties of family medicine, internal medicine, and general surgery.9 Despite the need for such providers, the number of trainees in U.S. residency programs who are pursuing these fields will not meet this demand.10 Four of every five general surgeons complete subspecialty fellowships after residency.11 Similarly, a self-reported survey of third-year internal medicine residents showed that only 22% planned to practice general internal medicine.12 This shortage is most salient in medically underserved areas, such as rural settings and low-income urban community health centers.13–16

Training in these outpatient settings prepares residents to provide long-term care for patients with chronic illnesses.17–19 In particular, outpatient training in community-based settings exposes residents to the social deter minants of health, health advocacy, and cultural competency.20–23 In addition, training in federally qualified health centers and rural health centers is associated with a greater likelihood of practicing in these settings after residency.24–30

Yet, reports of the amount of GME training that occurs in different settings, particularly in community-based health clinics, are limited, and existing studies are either dated or based on one-time voluntary surveys.31–33 For example, a 1989–1990 study of internal medicine residency program directors found that the amount of time residents were assigned to ambulatory care settings ranged from only 19% for first-year residents to 31% for third-year residents.31 A 1998 study of internal medicine residency program directors suggested an increase in the amount of time spent in ambulatory care settings; however, the majority of internal medicine residents were trained in academic-medical-center-sponsored programs, so most of this time was spent in a hospital-based clinic or in the emergency department.32 According to a 2010 study, although 23% of family medicine residencies offered their trainees some type of community-based health clinic experience, only 9% (32 programs) reported that their main residency continuity clinic was located in such a setting.33

The objective of this study was to examine the distribution of residency training sites in different settings for three high-need specialties—family medicine, internal medicine, and general surgery—using data from the Accreditation Council for Graduate Medical Education (ACGME) and the Centers for Medicare and Medicaid Services (CMS). We also sought to under stand the amount of training that occurs in high-need, low-access areas, such as community-based health clinics and rural settings.

Method

We pulled our data from the ACGME Accreditation Data System and the CMS hospital cost report. The ACGME maintains a comprehensive repository of information about each of the residency programs it accredits. Programs are required to report and update their information annually; this process includes providing data about all training sites with required rotations of one month or longer. Thus, in this analysis, we were unable to examine rotations of less than one month (including longitudinal rotations that add up to less than one month).34 We analyzed data both at the residency program level and at the training site level, including the number of months residents spent in each rotation at each training site.

The CMS hospital cost report is publicly available through the Healthcare Cost Report Information System.35 Hospitals may make adjustments to the data for up to three years; therefore, the most recent year for which data are available varies by facility.35–38 The hospital cost report contains data from institutional providers only, including associated institution-based outpatient facilities. It does not include data from individual practitioners, noninstitutional providers, or federal hospitals that do not receive Medicare payments, such as Department of Veterans Affairs (VA) hospitals. The report also excludes some children’s and emergency hospitals.35–38 The data collected include hospital name, address, size, and financial information, as well as hospital characteristics, such as control status, number of beds, number of primary care residents, and number of residents funded by direct GME payments.35–38

We merged 2012 Accreditation Data System data for family medicine, internal medicine, and general surgery residency programs with 2010 CMS hospital cost report data to match training sites with descriptive data about those locations.

Using our merged ACGME and CMS dataset, we described the distribution and characteristics of training sites at both CMS-funded hospitals and non-CMS-funded hospitals. CMS hospital training site characteristics included control type (private for-profit, private not-for-profit, government), number of hospital beds (0–99, 100–399, 400 or more), number of residency slots across all specialties funded by direct GME payments to the site (0, 1–24, 25–99, 100–199, 200 or more), and percentage of residents training in the primary care specialties of internal medicine and family medicine at the site (0–24, 25–49, 50–74, 75–100).

Non-CMS hospital training sites were grouped into three categories—VA hospitals, community-based health clinics, and other sites (private physician offices, noninstitutional ambulatory/outpatient settings, ambulatory surgery centers, and other non-CMS hospitals). We identified community-based health clinic sites using name and address to match our data to those in the HRSA Uniform Data System of health care delivery sites funded by Section 330 of the Public Health Service Act. This system includes data regarding federally qualified health centers and their lookalikes, migrant health, health care for the homeless, public housing primary care, Indian Health Service, and rural health clinics.39 We counted all clinical sites (both CMS and non-CMS) by program; thus, a site was included more than once if residents from multiple programs trained there.

Next, we calculated the average number of months per year that residents spent training at each site. Because the total length of training varies across specialties, to make our calculations comparable, we computed the mean number of months per year that residents spent at each site for each specialty across all postgraduate years. In some cases, programs reported rotation lengths that did not sum to 12 months (e.g., 13 was the most common deviation, likely due to rounding or calculations based on four-week rotations). In these cases, we calculated an adjusted months of training value which was equal to the number of training months at each site divided by the total number of training months for each year of the residency program. To get a sense of residents’ exposure to different training settings, we calculated “resident-months,” a value derived from the mean number of months spent at each site per year multiplied by the number of residents in the program.

Finally, we calculated the percentage of training months that residents spent in urban versus rural locations. To determine this percentage, we used the 2013 rural–urban commuting area codes to classify the ZIP code of each training site as urban (codes: 1.*–3.*, 4.1, 5.1, 7.1, 8.1, 10.1) or rural (codes: 4.*–10.*, except 4.1, 5.1, 7.1, 8.1, 10.1).40

We performed our descriptive analysis using STATA Version 13.1 (StataCorp, College Station, Texas). We used chi-square tests to examine differences between specialties. We report the number of training sites and resident-months by specialty and site characteristic. P values indicate comparisons across training sites. Because resident-months is a derived value calculated from the training site distribution values, we do not report separate P values for these calculations.

The George Washington University institutional review board approved our study.

Results

We found 460 family medicine, 385 internal medicine, and 250 general surgery ACGME-accredited residency programs in 2012. Across the three specialties, we identified 41,247 residents (10,060 in family medicine, 23,597 in internal medicine, and 7,590 in general surgery) and 3,373 training sites (1,390 in family medicine, 936 in internal medicine, and 1,047 in general surgery) (see Table 1). Almost 40% of internal medicine programs were large, composed of 60 or more trainees, compared with less than 6% of all general surgery programs and less than 1% of all family medicine programs (P < .001). More than one-third of internal medicine programs were located in the northeast region of the country, which was more than the proportion of family medicine and general surgery programs located there (P < .001).

Table 1
Table 1:
Characteristics of ACGME-Accredited Residency Programs in Family Medicine, Internal Medicine, and General Surgery, 2012a

Of the 3,373 training sites in the three specialties, we matched 2,513 with facilities in the 2010 CMS hospital cost report. The 860 remaining sites included VA hospitals and other medical facilities not contained in the hospital cost report (see Method). CMS hospitals accounted for 76% (1,050) of family medicine training sites, 65% (611) of internal medicine training sites, and 81% (852) of general surgery training sites (see Table 2). General surgery and internal medicine residents predominantly trained in large hospitals of 400 or more beds, while most family medicine residents trained in medium-sized hospitals (100–399 beds) (P < .001). Family medicine residents most often trained at CMS hospital-based sites at which a majority of all residents were training in primary care (323 [31%] hospitals reported having 75% or more of their residents training in primary care specialties). At only 92 (15%) internal medicine sites and 82 (10%) general surgery sites did residents train in a similar environment (see Table 2).

Table 2
Table 2:
Characteristics of Family Medicine, Internal Medicine, and General Surgery Residency Training Sites by Specialty, 2012

VA medical facilities, community-based health clinics, and other ambulatory settings were sources of non-CMS hospital-based training sites. Only a small percentage of training occurred in community-based health clinics. Of the 1,390 family medicine training sites, only 48 (4%) were community-based health clinics. Of the 936 internal medicine training sites, only 43 (5%) were community-based health clinics (see Table 2). One hundred thirty (14%) internal medicine training sites were VA medical facilities, compared with 78 (6%) family medicine training sites and 94 (9%) general surgery training sites (P < .001) (see Table 2).

The amount of exposure residents received to different training settings matched the distribution of training sites. When considering both the mean amount of time spent in training by site and the total number of residents, measured as resident-months, more than 80% of all resident training time was spent in CMS hospitals. More than 10% of internal medicine resident training time was spent in a VA hospital setting (29,688 resident-months) compared with 6% of general surgery resident training time (5,525 resident-months) and just over 1% of family medicine resident training time (1,560 resident-months). In contrast, only 3% of internal medicine resident training time (7,872 resident-months) and 3% of family medicine resident training time (3,525 resident-months) were spent in community-based health clinics (see Table 2).

Table 2 also shows the distribution of training by rural versus urban setting. In all three specialties, training occurred largely in urban areas (only 78 [6%] family medicine sites, 8 [1%] internal medicine sites, and 16 [2%] general surgery sites were classified as rural).

Discussion

Our findings shed light on the training experiences of residents in family medicine, internal medicine, and general surgery. We found that internal medicine and general surgery training occurs predominantly in large hospitals at which the majority of GME training is focused on non-primary-care specialties. Relatively little training, even in family medicine and internal medicine, occurs at community-based health clinics, which is consistent with previously reported data.33

To address primary care workforce shortages, the ACA expanded the number of community-based training opportunities by implementing the THC Graduate Medical Education program (THC-GME program), which devoted $230 million over five years to create more primary care providers.7,8,41,42 Now, 60 THC residency programs offer slots for more than 690 residents, who will have provided care for a million patients by the time they complete their residency.42,43 The THC-GME program also provides the additional financial resources needed to overcome administrative and financial barriers to training residents in community-based health clinics. For example, resident practice may be perceived as more expensive and less productive in a community-based health clinic setting that has a mission of serving a large volume of patients.44 Still, the THC-GME program has been successful, with demand for training slots from potential applicants exceeding availability.45 However, opportunity for expansion exists.45

We also found that training in the three specialties mainly occurs in large urban areas. Even among family medicine programs, which offer more training opportunities in rural areas than internal medicine or general surgery, less than 6% of residents’ training time is spent in rural settings, despite these locations being home to nearly 20% of the U.S. population.46 Given evidence that rural training experiences influence physician career choices and that physicians tend to practice near their residency program after graduation, expanding training in rural areas may be an opportunity to address workforce shortages.24,27 Options include shifting GME training slots to rural residency programs, increasing partnerships between rural community hospitals and urban residency programs, and expanding opportunities for rural elective rotations and rural health residency tracks to offer residents greater exposure to such settings during training.47,48 Such opportunities can be supported through increased funding for initiatives that promote medical education and practice in rural and community-based settings, such as Title VII Section 747 of the Public Health Service Act and National Health Service Corps–funded scholarships,49,50 as well as enhanced partnerships with health care organizations that are engaged in both community-based health care and medical education, such as the Area Health Education Centers program.51 However, efforts to expand training in rural areas must take into consideration the Residency Review Committee requirements for optimal exposure to clinical procedures, appropriate faculty supervision, and adequate patient volume, which may be challenging in some cases.52,53

Although we have focused on the paucity of training opportunities at community-based health clinics and in rural settings, our findings also highlight the role that VA facilities play in GME training. The Veterans Access, Choice, and Accountability Act, signed into law in 2014, includes $16.3 billion in funding for up to 1,500 more residency positions to expand primary care access for veterans.54,55 Our findings indicate that the VA has supported more internal medicine than family medicine training opportunities, but more research is needed to understand the optimal distribution of GME funding by specialty to support the VA’s primary care requirements.56

This study has a number of limitations. Because the data we used are from the ACGME, we did not include American Osteopathic Association–accredited residency programs. By excluding these programs, we may have underestimated the number of training sites in rural settings.57,58 In addition, only those rotations reported to the ACGME were included in our analysis. Residents may be training at sites that are not reported to the ACGME because the duration of the rotation is less than one month. Also, as noted above, a number of new THC-GME programs now exist that were not included in our analysis of 2012 data. Next, because we included only those community-based health clinic sites identified in the HRSA Uniform Data System, we may have underestimated residents’ exposure to other outpatient settings that are not formally classified as HRSA community-based health clinics but that still provide care to similarly underserved populations. We do not have any measures of capacity at community-based health clinics and rural training sites; therefore, we cannot discuss whether this is a potential limitation to expanding resident training in these locations. Finally, we were unable to report the distribution of time spent training in ambulatory versus inpatient settings, so we reported all time spent in CMS hospitals in aggregate.

Data available to assess the characteristics of residency training sites are limited in scope. This limitation highlights the need for more robust data sources to allow policy makers to better evaluate the distribution of these training sites. Without such data, we cannot determine whether residency programs are producing an adequate number of physicians who serve in areas of greatest need. Understanding where residents train sheds light on the GME system in a way that can be used to reshape training experiences and policies, particularly today when an aging population and expansion of the ACA will require more physicians with generalist and primary care training.9 Residency training has the potential to impact where residents decide to practice, especially with regard to rural and underserved locations. Therefore, future investments might be made to expand training in low-access areas with the goal of growing physician supply in these locations. Opportunities exist to move training into settings such as rural communities and community-based health clinics that are more likely to achieve these outcomes to meet the health care needs of the country.

Acknowledgments: The authors wish to thank Dr. Candice Chen, director of the Division of Medicine and Dentistry in the Bureau of Health Workforce at the Health Resources and Services Administration, for her contribution to the development of this study and manuscript. They also wish to thank Peter Wingrove and the Robert Graham Center for their support of these data analysis activities and Dr. Timothy Brigham, Dr. Kathleen Holt, and Rebecca Miller of the Accreditation Council for Graduate Medical Education for their assistance in pulling the data used in this study and their helpful comments on the manuscript. Finally, the authors wish to thank Dr. Robert Phillips of the American Board of Family Medicine for his helpful comments on the manuscript.

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