Projections indicate that the health workforce shortage of primary care physicians will increase significantly in the coming years1–5 and will continue to affect access to care disproportionately in underserved areas.4,6–10 One solution to these problems is the development of community health center–family medicine residency (CHC-FMR) training partnerships.9,11–14 Studies have shown that such partnerships increase physician recruitment and retention in underserved areas and provide high-quality training environments with high levels of trainee satisfaction.11,15–22 Recent health care reform legislation embraced the concept of CHC training and included new GME funding for “teaching health centers” to increase primary care residency training opportunities in CHC settings.23
Although family medicine residents have trained in CHCs for more than 20 years, no comprehensive evaluation of the scope and extent of CHC-FMR affiliations exists. One 1992 study estimated that 25 FMRs (6.3% of U.S. FMRs at that time) provided continuity training experiences in which the main residency clinic was a CHC.16 No other national estimates are available to the best of our knowledge, although a number of case reports in the literature have documented the length, quality, and cost of residency programs in CHCs.19,24–29
Since the 1980s, a variety of CHC-FMR training partnership models have been developed.16 They exist in a variety of settings: underserved rural and urban clinics, and university- and community-based locations. They also vary in the amount of CHC-based training provided and the type of affiliation. Whereas some residents may spend only one or two days of their entire residency in a CHC (brief elective experience), others may spend all three years of their ambulatory clinic training providing care to a panel of CHC patients (continuity training). In the most concentrated relationship, the main residency clinic—where residents and residency faculty have their continuity practice—is located in a CHC. Alternatively, FMRs may use “satellite” CHC sites to provide continuity clinic training to a subset of their residents. In the least concentrated relationship, FMRs partner with CHCs to arrange noncontinuity training experiences for residents, including one- to two-month required or elective block rotations.
This study, which we undertook to inform health workforce planning for care of underserved populations, is the first national evaluation of CHC-FMR training partnerships. We present here our findings from a national survey of FMR directors regarding the number, type, location, satisfaction, and length of CHC-FMR partnerships for the training of family physicians in the United States.
In 2007, the University of Washington WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) Rural Health Research Center surveyed 439 FMR program directors in the United States. We obtained a mailing list of all FMRs and their directors from the American Academy of Family Physicians (AAFP). Before sending the surveys, we excluded from the study 21 other programs. These were closed programs that no longer provided training, military programs, and programs located in Puerto Rico. The University of Washington human subjects board approved this study with a certification of exemption (no. 07-6760-X/A).
We developed a 21-item questionnaire to identify residency characteristics, evaluate the type and amount of training occurring within CHCs, and assess qualitative information regarding barriers and benefits to affiliation with CHCs (see Supplemental Digital Content 1, http://links.lww.com/ACADMED/A25). This survey was a follow-up to a 14-item survey we conducted in 2000 on residency training activities in rural areas.30 For the 2007 survey, we added seven questions regarding CHC affiliation. We pilot-tested the CHC survey questions with FMR directors within the WWAMI FMR network; we used their feedback to modify the questions before distributing the survey nationally.
In February 2007, we mailed each FMR director an introductory letter, the three-page questionnaire, and a postage-paid return envelope. Our subsequent attempts to contact nonresponders included two mailed reminders with questionnaires and a telephone call. During the call, one of the investigators (H.A.) offered the program director the opportunity to complete the questionnaire over the telephone or to request that another questionnaire be mailed, e-mailed, or faxed. Follow-up attempts occurred throughout the summer of 2007; as many as four attempts were made to reach each program. We did not offer any financial incentive for completing the survey.
We asked program directors to provide data regarding program and respondent identity, training type (full-time, block rotation, other), type of CHC-FMR affiliation (the main residency continuity clinic in a CHC, a satellite continuity clinic in a CHC, other), number of residents training in a CHC, and length of CHC training affiliation. We also asked respondents to rate their “satisfaction with the training experiences in CHCs” on a five-point scale (from 1 = very dissatisfied to 5 = very satisfied). We used the AAFP residency database31 to obtain information about each respondent program's location (zip code) and type (university based, community based, total number of residents per program including both CHC and non-CHC trainees) and combined this information with the director's responses on the study questionnaire.
We used AAFP classifications to identify FMRs as university based (located in or administered by a medical school) or community based (located in the community, with or without a medical school affiliation). We used zip codes to make rural and urban designations on the basis of the FMR's rural urban commuting area code, a measure that classifies tracts by population density, urbanization, and daily commuting. We considered training to be full-time when it occurred at a continuity clinic where residents provided care to a panel of patients during at least the second and third years of their residency. We defined training as a block rotation when it was noncontinuous and occurred in one- to two-month rotations. Other types of training included occasional, intermittent exposure, and elective opportunities in the CHC. CHC affiliation was defined as a training relationship between an FMR and a CHC.
We tabulated and categorized program survey responses by the criteria above. We compared satisfaction with the affiliation among the different affiliation models, using ANOVA. We used Stata statistical software to analyze the data (Stata Statistical Software: Release 10, College Station, Texas: StataCorp, 2007).
We received completed questionnaires from 354 of 439 FMRs (80%) that trained 7,530 residents annually. Respondents did not differ from nonrespondents by type of medical school affiliation.
Characteristics of all respondent FMRs
Table 1 describes the 354 FMRs by location, residency type, and number reporting any CHC affiliation. The overwhelming majority of FMRs were located in urban areas (323; 91.2%), and most programs were community based (239; 67.5%). Nearly one-quarter (83; 23.4%) reported some type of training affiliation with CHCs. Fewer programs (51; 14.4%) reported that full-time continuity training occurred in a CHC, representing 10.5% (788/7,530) of family medicine residents.
Characteristics of CHC-affiliated training programs
CHC training affiliation and type.
The most common FMR-CHC affiliation (32/80; 40.0%) was one in which the main residency continuity clinic was located in a CHC (Table 2). The 32 residencies with this type of affiliation represent 9% of FMRs (32/354). The most common category of residency training provided in CHCs was full-time (51/97 program training types [52.6%]; 788/1,199 residents [65.7%]), followed by block rotation, and other. (Other types of training reported included occasional intermittent exposure and elective opportunities in the CHC.) The mean length of affiliation varied by affiliation type: The longest was full-time (15.5 years), followed by other (9.1 years) and block rotation (8.9 years); however, this difference was not statistically significant.
Residency location and type.
The overwhelming majority of CHC-based training occurred in urban locations (77/83; 92.7%) and in community-based settings (51/83; 61.4%) (Table 2). The mean length of CHC-FMR affiliation was 10.2 years. University-based residencies had the highest mean length of affiliation (12.7 years), followed by those in urban settings (10.6 years). The differences in length of affiliation across location and residency type were not significant, however, as there was wide variation within each type of program.
CHC affiliation satisfaction
FMR program directors ranked their satisfaction with their CHC training affiliations as high overall (mean = 4.3 on a scale of 1–5), and this did not differ by location, type of affiliation, or type of training (Table 3).
CHC-FMR affiliations may be a rich resource for training the health workforce needed to care for underserved populations. In this first national survey on CHC-FMR affiliations, nearly one-quarter of FMRs reported some type of training partnership with CHCs. The majority of CHC-based training was full-time continuity training, and the majority of affiliations were with community-based FMRs. Residency program directors found that training in CHCs created satisfying experiences for residents, as evidenced by their very high satisfaction scores. The mean length of CHC-FMR affiliation was more than 10 years. Importantly, full-time continuity training, the type of CHC-FMR affiliation most associated with providing longitudinal immersion in care of underserved populations—and subsequent recruitment to practice in underserved areas following graduation11—had a mean affiliation length of more than 15 years.
CHC-based training is consistent with the goals of community-based health professions education, and it is concordant with recent workforce recommendations.32–38 Although certain states are rich with CHC-FMR affiliations (e.g., in Massachusetts, 69% of family medicine residents are trained in CHCs30), the proportion of continuity training affiliations in which the main residency continuity clinic is located in a CHC has grown only slightly during the past 15 years. It was estimated that approximately 6.3% of FMRs (25/397) were affiliated in this manner in 1992.16 In 2007, we found an increase to 9% (32/354 FMRs). During the past decade, the health workforce needs of CHCs have expanded significantly, and it appears that training affiliations have not kept pace with demand for primary care physicians.8–10,39–41
The National Association of Community Health Centers estimates that CHCs currently need 1,843 more primary care providers.9 According to our survey, at least 788 family medicine residents receive full-time continuity training in CHCs annually. Assuming one-third of the 788 graduate each year, seven years' worth of these graduates would need to choose to work in CHCs to meet the current CHC primary care workforce shortage. Alternatively, the current CHC primary care workforce could be met by 18.3% of all residents currently training in FMR programs.42 CHC physician shortages are estimated to increase significantly in the next decade, however. By 2015, CHCs may need an additional 15,585 primary care providers.9 Policy changes that offer incentives to form CHC-FMR affiliations could potentially address the primary care workforce crisis in underserved areas.4,26,43
Although this is the largest study of its kind to date, it has limitations. The 80% response rate provides confidence in the results, but it may be faulty to extrapolate CHC-training affiliation results to the nonrespondents. CHC-affiliated training programs may have been more likely to respond, which would overestimate the percentage of CHC-FMR affiliations (it could possibly be as low as 18.9% of FMRs). Survey data also generate the potential for recall bias, especially regarding the rating of satisfaction with relationships. The multiple-choice format of the survey questions regarding affiliation and training type may not have allowed for accurate representation of the training in CHCs. Finally, this study does not address non-family-practice primary care training (pediatrics, internal medicine, nursing, and physician assistant). The scope and extent of pediatric and internal medicine residency training in CHCs are poorly quantified, although such relationships do exist.
Training primary care physicians in underserved community-based settings—particularly via CHC-FMR training partnerships—is essential to meet the current and future health workforce needs of underserved populations in the United States.36,43 CHC-FMR training affiliations are an integral part of family medicine residents' education, have a long-standing and satisfying history, and offer a significant opportunity to expand the training of residents for care of the underserved. Further work is needed to characterize similar partnerships in primary care internal medicine and pediatrics. With changes in the financing, governance, and administration of CHC-FMR partnerships, including legislative support for teaching health centers,23 there is potential to expand the number and scope of such partnerships.9,41,44 Fostering expansion of the training relationships between community-based safety net providers and primary care residencies will help address the primary care health workforce crisis for underserved areas.
This study was supported by a grant from the Office of Rural Health Policy Health Resources and Services Administration, Department of Health and Human Services.
The University of Washington human subjects board approved this study with a certification of exemption (#07-6760-X/A).
The opinions expressed in this report are those of the authors alone.
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