Primary Care Workforce Shortages Research Articles

Primary Care Physicians' Experiences With and Adaptations to Time Constraints.

The primary care workforce shortage is significant and persistent, with organizational and policy leaders urgently seeking interventions to enhance retention and recruitment. Time constraints are a valuable focus for action; however, designing effective interventions requires deeper understanding of how time constraints shape employees' experiences and outcomes of work. To examine how time constraints affect primary care physicians' work experiences and careers. Between May 1, 2021, and September 31, 2022, US-based primary care physicians who trained in family or internal medicine were interviewed. Using qualitative analysis of in-depth interviews, this study examined how participants experience and adapt to time constraints during a typical clinic day, taking account of their professional and personal responsibilities. It also incorporates physicians' reflections on implications for their careers. Thematic analysis of in-depth interviews and a measure of well-being (American Medical Association Mini-Z survey). Interviews with 25 primary care physicians (14 [56%] female and 11 [44%] male; median [range] age, 43 [34-63] years) practicing in 11 US states were analyzed. Two physicians owned their own practice, whereas the rest worked as employees. The participants represented a wide range of years in practice (range, 1 to ≥21), with 11 participants (44%) in their first 5 years. Physicians described that the structure of their work hours did not match the work that was expected of them. This structural mismatch between time allocation and work expectations created a constant experience of time scarcity. Physicians described having to make tradeoffs between maintaining high-quality patient care and having their work overflow into their personal lives. These experiences led to feelings of guilt, disillusionment, and dissatisfaction. To attempt to sustain long-term careers in primary care, many sought ways to see fewer patients. These findings suggest that organizational leaders must align schedules with work expectations for primary care physicians to mitigate physicians' withdrawal from work as a coping mechanism. Specific strategies are needed to achieve this realignment, including incorporating more slack into schedules and establishing realistic work expectations for physicians.

Higher Rates Of Emergency Surgery, Serious Complications, And Readmissions In Primary Care Shortage Areas, 2015-19.

Primary care physicians are often the first to screen and identify patients with access-sensitive surgical conditions that should be treated electively. These conditions require surgery that is preferably planned (elective), but, when access is limited, treatment may be delayed and worsening symptoms lead to emergency surgery (for example, colectomy for cancer, abdominal aortic aneurysm repair, and incisional hernia repair). We evaluated the rates of elective versus emergency surgery for patients with three access-sensitive surgical conditions living in primary care Health Professional Shortage Areas during 2015-19. Medicare beneficiaries in more severe primary care shortage areas had higher rates of emergency surgery compared with rates in the least severe shortage areas (37.8percent versus 29.9percent). They were also more likely to have serious complications (14.9percent versus 11.7percent) and readmissions (15.7percent versus 13.5percent). When we accounted for areas with a shortage of surgeons, the findings were similar. Taken together, these findings suggest that residents of areas with greater primary care workforce shortages may also face challenges in accessing elective surgical care. As policy makers consider investing in Health Professional Shortage Areas, our findings underscore the importance of primary care access to a broader range of services.

Legislators Must Act to Address Primary Care Workforce Shortages

Legislators Must Act to Address Primary Care Workforce Shortages

Dual-eligible beneficiaries and inadequate access to primary care.

To determine whether enough primary care providers are in close proximity to where dual-eligible beneficiaries live to provide the capacity needed for integrated care models. Secondary data analysis using dual-eligible enrollment data and health care workforce data. We determined the density of dual-eligible beneficiaries per 1000 population in 2017 for each of 3142 US counties. County-level supply of primary care physicians (PCPs), primary care nurse practitioners, and physician assistants was determined. One-third of the 791 counties with the highest density of dual-eligible beneficiaries had PCP shortages. Counties with the highest density of dual-eligible beneficiaries and the fewest primary care clinicians of any type were concentrated in Southeastern states. These areas also had some of the highest coronavirus disease 2019 outbreaks within their states. States in the Southeastern region of the United States with some of the most restrictive scope-of-practice laws have an inadequate supply of primary care providers to serve a high concentration of dual-eligible beneficiaries. The fragmented care of the dually eligible population leads to extremely high costs, prompting policy makers to consider integrated delivery models that emphasize primary care. However, primary care workforce shortages will be an enduring challenge without scope-of-practice reforms.

Geneva medical students increasingly identify primary care physicians as role models after introduction of a compulsory clerkship

Background Role modelling is recognised as an important element in career choice. In strongly hospital-based medical education settings, students identify few primary care physicians as positive role models, which might impact their career plans and potentially contribute to primary care workforce shortage. At Geneva Faculty of Medicine (Switzerland), a compulsory final-year clerkship in primary care practices was introduced to strengthen primary care teaching in the curriculum. Objectives To assess the proportion of graduating students identifying a primary care physician as positive role model, before and after the introduction of the clerkship. Methods Cross-sectional survey in four consecutive classes of graduating medical students one year before and three years after the introduction of the clerkship. The main outcome measure was the proportion of students in each class citing a primary care physician role model. Comparisons were analysed using Pearson’s Chi-square test and one-way ANOVA. Results The total sample included 505 students. The proportion of students recalling a primary care physician role model increased steadily from 8% (before introduction of the clerkship) to 13, 16, and 21%, respectively, at 1, 2 and 3 years after the introduction of the clerkship (p = 0.03). Conclusion Our exploratory study suggests that introducing a compulsory primary care clerkship may have contributed to increasing the visibility of primary care physicians as role models. Future research should explore primary care physicians’ awareness of role modelling and its contribution to career choices.

Addressing the Community-Based Geriatric Healthcare Workforce Shortage by Leveraging the Potential of Interprofessional Teams.

As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community-based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end-of-life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400-S408, 2019.

Distributional Differences between Family Physicians and General Internists.

While differences in practice style and costs between family medicine and internal medicine are relatively well known, the differences in geographic distribution between the two remain underexplored. This study aims to examine differences in distribution of family physicians and general internists by geographic and demographic characteristics. Data sources are the 2016 American Medical Association Physician Master File and 2015 American Community Survey. Results show that internists are more dominant in urban areas, especially in the Northeast; they are also more likely to practice in the West and South. Family physicians are more likely to practice in rural areas and primary care Health Professional Shortage Areas than internists; their distribution also varies significantly with respect to areas whose residents are members of racial/ethnic minority groups, live in poverty, and are uninsured. Such differences should be a consideration for planning to address regional and national primary care workforce shortages.

Perspectives: Using Results from HRSA's Health Workforce Simulation Model to Examine the Geography of Primary Care.

Inform health planning and policy discussions by describing Health Resources and Services Administration's (HRSA's) Health Workforce Simulation Model (HWSM) and examining the HWSM's 2025 supply and demand projections for primary care physicians, nurse practitioners (NPs), and physician assistants (PAs). HRSA's recently published projections for primary care providers derive from an integrated microsimulation model that estimates health workforce supply and demand at national, regional, and state levels. Thirty-seven states are projected to have shortages of primary care physicians in 2025, and nine states are projected to have shortages of both primary care physicians and PAs. While no state is projected to have a 2025 shortage of primary care NPs, many states are expected to have only a small surplus. Primary care physician shortages are projected for all parts of the United States, while primary care PA shortages are generally confined to Midwestern and Southern states. No state is projected to have shortages of all three provider types. Projected shortages must be considered in the context of baseline assumptions regarding current supply, demand, provider-service ratios, and other factors. Still, these findings suggest geographies with possible primary care workforce shortages in 2025 and offer opportunities for targeting efforts to enhance workforce flexibility.

Scarcity of primary care positions may divert physician assistants into specialty practice

Background: Physician assistants (PAs) are often suggested as a partial solution to predicted primary care workforce shortages, but a declining proportion of PAs are entering primary care practice. Policy efforts have focused on increasing primary care PA supply, but low labor market demand might be constricting the primary care PA pipeline. Method: In this descriptive, cross-sectional study, we compare primary care and specialty job postings to each other and to occupied PA positions. Job posting data for 2014 are from a leading labor analytics firm. Results: Only 18% of job postings were in primary care, compared with 27% of occupied PA positions. The proportion of postings that were for primary care varied widely by state (9% to 40%) and were highest in the West. Discussion: Job availability is a potential barrier to PAs practicing in primary care, especially in some locations. Other job factors are examined and policy solutions are suggested.

Scarcity of Primary Care Positions May Divert Physician Assistants Into Specialty Practice.

Physician assistants (PAs) are often suggested as a partial solution to predicted primary care workforce shortages, but a declining proportion of PAs are entering primary care practice. Policy efforts have focused on increasing primary care PA supply, but low labor market demand might be constricting the primary care PA pipeline. In this descriptive, cross-sectional study, we compare primary care and specialty job postings to each other and to occupied PA positions. Job posting data for 2014 are from a leading labor analytics firm. Only 18% of job postings were in primary care, compared with 27% of occupied PA positions. The proportion of postings that were for primary care varied widely by state (9% to 40%) and were highest in the West. Job availability is a potential barrier to PAs practicing in primary care, especially in some locations. Other job factors are examined and policy solutions are suggested.

Over Half of Graduating Family Medicine Residents Report More Than $150,000 in Educational Debt.

Primary care workforce shortages are thought to result not only from lower remuneration than other specialties but also from increasing amounts of debt at graduation. A census of 3083 graduating family medicine residents found that 58% reported having >$150,000 in educational debt and 26% reported having >$250,000-levels that may deter students' interest in primary care and constrain the practice location choices of those who do choose primary care.

Recruiting Quarterbacks: Strategies for Revitalizing Training in Primary Care Internal Medicine.

Current U.S. primary care workforce shortages and trainees' declining interest in primary care residency training, especially regarding primary care internal medicine, have many parallels with circumstances in the early 1970s, when modern adult primary care first emerged. Rediscovery of the lessons learned and the solutions developed at that time and applying them to the current situation have the potential to help engage a new generation of young physicians in the primary care mission.The author compares the internal medicine residency primary care track at the University of New Mexico, described by Brislen and colleagues in this issue, with the nation's first three-year primary care internal medicine residency track introduced at Massachusetts General Hospital in 1973. Strategies for addressing the challenges of primary care practice and improving learner attitudes toward the field are discussed. The author suggests that primary care physicians should be likened to "quarterbacks" rather than "gatekeepers" or "providers" to underscore the intensity of training, level of responsibility, degree of professionalism, and amount of compensation required for this profession. The advent of multidisciplinary team practice, modern health information technology, and fundamental payment reform promises to dramatically alter the picture of primary care, restoring its standing as one of the best job descriptions in medicine.

Primary care workforce shortages and career recommendations from practicing clinicians.

The success of efforts to bolster the primary care workforce rests in part on how these clinicians view their professions and their willingness to recommend their careers to others. The authors sought to examine career and job satisfaction, perceptions of workforce shortages, and willingness to make career recommendations among primary care physicians (PCPs) and primary care nurse practitioners (PCNPs). In 2012, the authors mailed a national survey concerning the issues above to 1,914 randomly chosen clinicians found on national databases: 957 PCPs and 957 PCNPs. A total of 972 eligible clinicians (505 PCPs, 467 PCNPs) returned the survey. Using standard opinion research procedures, the authors estimated there were approximately 1,589 eligible clinicians in their sample (response rate, 61.2%). PCNPs and PCPs were more likely to recommend a career as a PCNP than as a PCP, despite the perception among all clinicians of a serious shortage of PCPs nationally and in their own communities. This finding held among PCNPs who reported low workplace autonomy and among PCPs reporting that they were satisfied with their own careers. Efforts to solve the primary care workforce shortage that ignore the significant dissatisfaction of PCPs with their own careers are unlikely to be successful. Simply adding training slots and increasing reimbursement rates will do little to solve the problem if PCPs continue to view their own careers as ones they cannot recommend to others.

Profiles of rural longitudinal integrated clerkship students: A descriptive study of six consecutive student cohorts

Background: Medical schools worldwide are challenged to address the rural primary care workforce shortage by creating community-engaged curricula to nurture student interest in rural practice.Aim: To examine the personal characteristics of six consecutive rural longitudinal integrated clerkship student cohorts to understand whom the programs attract and select and thus inform the development of such programs.Method: A cross-sectional cohort design was used. Six cohorts (2007–2012) completed a survey on demographics and factors that influenced their choice of rural primary care. The Temperament and Character Inventory was used to measure personality. Analysis was mainly descriptive. Where appropriate univariate analysis compared variables between groups.Results: Sample size was 205 with the majority female (61%), between 25 and 29 years (64%), single (60%) and lived longest in rural communities with populations less than 20,000 (60%).Rural lifestyle, background and desire to work in underserved areas were noted to impact rural medicine interest. Professional satisfaction, personal and professional goals and family needs had the highest impact on career decisions, and financial concerns lowest.Conclusion: The stability of students’ personal characteristics across cohorts and the workforce outcomes of this program suggest the recruitment process successfully nurtures students who will fit well into future rural practice.

Pharmacists and the Primary Care Workforce

The primary care workforce shortage will be magnified by the growing elderly population and expanded coverage as a result of health care reform initiatives. The pharmacist workforce consists of community-based health care professionals who are well trained and highly accessible, yet underutilized. Some health care professionals have advocated that primary care teams should include pharmacists with complementary skills to those of the physician to achieve quality improvement goals and enhance primary care practice efficiencies. New primary care delivery models such as medical homes, health neighborhoods, and accountable care organizations provide opportunities for pharmacists to become integral members of primary care interdisciplinary teams.

Training Residents in Outpatient HIV Care

To the Editor:—The recent JGIM article entitled, Training Internal Medicine Residents in Outpatient HIV Care: A Survey of Program Directors by Adams et al. found that fewer than half of the program directors surveyed agreed that it was important to train residents to be PCPs for patients with HIV and provide residents with an outpatient-based HIV curricula 1. One of the most common reasons cited was the belief by program directors that most graduates will not provide HIV ambulatory care as a generalist. The authors go on to say that it is not known if surveying residents would yield the same result. In fact, these findings are in stark contrast to internal medicine residents’ perceptions of training, competence, and performance in outpatient HIV care as reported in our recent multicenter study 2. In our study managing HIV patients was rated an excellent educational opportunity by 89% of residents and 77% planned to care for HIV patients in the future. Adams et al. also found that very few program directors believed their graduates had the skills to care for HIV outpatients, which is consistent with our findings with residents, 39% of whom stated that they did not feel competent to provide HIV outpatient care. Furthermore, we found that higher rates of residents reported deficiency in outpatient HIV training compared to outpatient non-HIV training (p < 0.05) or inpatient HIV training (p < 0.05). Residents reported substandard HIV risk assessment, testing, counseling, and initial management performance. Self-reported proficiency correlated with the number of HIV outpatients cared for and perceived training adequacy. The combined findings of these two studies suggest several things that may be important for medical education. First, residents and program directors may have different points of view when it comes to resident training needs, deficits, and future plans. Second, current residency training in HIV care remains largely inpatient-based and residents frequently rate HIV outpatient training as inadequate despite a desire to care for HIV outpatients in the future. Finally, as both articles point out, in the face of the Centers for Disease Control and Prevention (CDC) recommendation to provide routine HIV screening and a primary care workforce shortage, it is imperative that the care of the HIV outpatient be integrated into internal medicine residency curricula and that when developing training programs both the point of view of the residents and the program directors should be incorporated. Karran A. Phillips, MD, MSc;National Institute on Drug Abuse, Intramural Research Program, National Institutes of Health, 251 Bayview Blvd., BRC 01B-616, Baltimore, MD 21224, USA (e-mail: phillipsk@nida.nih.gov).

Primary Care Specialty Choices of United States Medical Graduates, 1997–2006

To describe trends in specialty choice and to identify predictors of primary care specialty choices among graduates of U.S. MD-granting medical schools. A longitudinal study evaluated 1997-2006 medical school graduates who completed the Association of American Medical Colleges' Matriculating Student Questionnaire and Graduation Questionnaire. Multivariate logistic regression identified significant predictors of graduates' choice of primary care specialty (general internal medicine, general pediatrics, internal medicine subspecialties, pediatrics subspecialties, family medicine, and obstetrics-gynecology) or "no-board-certification specialty," compared with all other specialties (reference). The sample included 102,673 graduates (64.9% of all 1997-2006 graduates). General internal medicine, family medicine, general pediatrics, and obstetrics-gynecology choice decreased, whereas internal medicine subspecialties, pediatrics subspecialties, and no-board-certification specialty choice increased over time (each: P < .001). Female graduates and those who planned to practice in underserved communities, espoused more-altruistic beliefs about health care, and ascribed greater importance to social responsibility in their choice of medicine at matriculation were more likely to choose general internal medicine, general pediatrics, family medicine, or obstetrics-gynecology, whereas graduates who had a physician parent and who planned full-time academic medicine careers were less likely to do so (each: P < .01). Graduates with higher debt were less likely to choose internal medicine and pediatrics specialties (each: P < .001) and more likely to choose obstetrics-gynecology (P = .001). Generalist-primary care specialty choices declined since 1997, whereas primary care subspecialty and no-board-certification specialty choices increased. Associations between primary care specialty choices and demographic, attitudinal, and career intention variables can inform the design of interventions to address expected primary care workforce shortages.