DOs: Primary Care Numbers Not Increasing With School Expansion

Diana Swift

June 15, 2015

In the context of the worsening shortfall in primary care physicians, the Graham Center has published a policy paper on osteopathic medical graduates. It states that the expansion of osteopathic medical schools, fueled in part by the expectation of benefit to areas underserved by family physicians, has not translated to a commensurate increase in the number of graduating physicians of osteopathic medicine (DOs) entering primary care.

Since 2000, the number of US osteopathic medical schools has increased from 19 to 34, offering about 1900 new training positions, write family medicine resident Kathleen Barnes, MD, MPH, from the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, Washington, DC, and colleagues in an article published in the June 1 issue of the American Family Physician. However, when the researchers calculated the percentages of DO graduates entering primary care for the years 1985 to 2008 (the most recent with available data), they found that the numbers of osteopathic physicians in primary care did not increase at a rate proportional to the growth in osteopathic students.

In fact, using data from the American Medical Association Physician Masterfile and the American Association of Colleges of Osteopathic Medicine, the authors saw a decline in primary care physician production as a percentage of DO graduates, going from a peak of 56% of 1741 graduates in 1995 to 42% of 2726 graduates in 2005. In 2008, 42% of 3302 graduates entered primary care.

The American Osteopathic Association (AOA), however, disputes these findings and says they are based on outdated figures. "While the numbers shift a bit with each year's match, our data show consistent levels of new graduates choosing primary care, with 64% of all active DOs practicing in primary care specialties," AOA Senior Vice President and General Counsel Joshua Prober told Medscape Medical News.

It should be noted, however, that the AOA defines primary care broadly and considers DOs specializing in family and internal medicine, pediatrics, and obstetrics/gynecology to be primary care physicians.

Nevertheless, more DOs may be choosing specialties, said Prober, "because of the punishing combination of increasing student loan debt burdens and lack of incentive from the government and payers to shift the trend toward primary care."

The challenges in graduate medical education compound the issue, he added. "We need policies that address training capacity and how those opportunities are distributed and financed."

According to Tanveer Mir, MD, a New York City palliative care physician and chair of the American College of Physicians board of regents, incentives to attract physicians into primary care need to be not only financial, such as loan mitigation and better remuneration, but also inspirational. "There needs to be more emphasis on the challenges and complexities of primary care as part of internal medicine in medical training," she told Medscape Medical News. And students need to encounter more primary care role models in senior positions. "They need to see more deans of medicine and hospital chiefs of staff who come from primary care."

Whether new osteopathic schools will reverse the decline in the proportion of graduates working in primary care is unclear, write Dr Barnes and colleagues. "However, these findings parallel national trends of declining primary care production from allopathic, physician assistant, and nurse practitioner training programs, and suggest that osteopathic graduates are not immune to powerful market forces pulling graduates into specialty fields."

The authors conclude that maintaining osteopathic leadership in primary care production will require attention to admissions, tuition, and curricular exposures, as well as payment policies that reduce disparities in specialty vs primary care compensation.

The authors have disclosed no relevant financial relationships.

Am Fam Physician. 2015;91:756. Full text

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