Too many steps, Too many separations, Too many leaks in the pipeline, Too little yield across the segments, Too many accreditations, Too many funding sources, Too many determining training curricula, and very few focused on basic health access

The last rural workforce meeting of AAMC in 1990 broke up when a Dean from SD  Robert Taylor    suggested primary care coordination such as combining primary care. Much of his presentation and work failed to notice the talk about unifying accreditation and funding and responsibility, but as is typical when turf is discussed, the meeting went south. Immediately the talk focused on the various primary care types instead of rural workforce focus. At this meeting those at the previous meeting 17 years before noted that nothing had been done and those at the previous meeting 17 years before noted the same. Of note is that it has been 20 years now and counting, not that meeting did much anyway.

http://www.ruralmedicaleducation.org/images/Retention4.GIF         These four graphics indicate that  we have added lots of PC grads, but get decreased PC delivery per grad

We keep adding steps, lengthening the time in academic centers, and then claim more primary care when we have less. also note that the substantial reforms of the 1990s, barely made a dent in primary care delivery increases to stop the steady declines of past decades.

As a chemistry major I was not very good when there were multiple steps in the synthesis. With each new reaction my product yield got smaller and smaller. I was a much better teacher than I was a chemist.

The teaching pathways to primary care workforce are a real problem for primary care workforce.

Market forces training has totally failed with perhaps 10 - 20% of MD, DO, NP, and PA graduates entering primary care.

With some public assistance and some responsibility for the yield, the "quality" goes up as measured by 20 - 30% remaining in primary care.

But the problem is that the yield is far too low.

Historical standards - the Class of 1960 AMA Longitudinal study tracked graduates of primary care training and the survival curve indicated 50% remaining in primary care at retirement. The overall primary care was 71% for an entire career. Also the volume of primary care delivered was likely to be higher for a number of reasons. Activity in practice was also higher (male, more hours).

What do we have now - FM at about 75 - 80% for a career, PD beginning at less than 50%, PA beginning at 28% in primary care, NP - hard to tell as entry data is poor but about 33% would be a starting point for the first decade with lower in the last 17 years. Also all sources have increasing administrative positions with even higher levels in NP.

The problem is that there are too many stages in the pathway from entry into higher education until entry into practice.

And we have added the need for retention at every year after graduation for IM, NP, and PA - the most flexible primary care forms.

What would work?

• Age 18 entry into basic health access primary care training
• 2 years of premed specific to health access preparation while working in a health access location
• 6 years of specific health access training similar to medical school and a primary care residency, although more specific to basic health access
• 10 years of an instate obligation for primary care delivery with 5 years in a most needed location determined by the state's primary care leadership and a second 5 years somewhere other than where primary care is sufficient

Fewer Steps

• One entry point
• One opt out point in the first two years for those not matching up (their call or ours)
• One exit point at age 36 after providing more most needed health access than any current graduate of any source and school, and after providing the same primary care as a PD graduate or an FM non-citizen IMG, twice the primary care of an average US origin IM graduate, three to four times a current NP or PA graduate, and 5 times the non-citizen IM IMG graduate

And after the ten year obligation is over there are 28 - 30 years remaining in their career also likely to be health access after 18 years of selection, training, and dedication to such a career.

• Longer years in a career
• Primary care and most needed workforce during training
• Nearly twice the primary care of an average US primary care graduate (only 6 and decreasing to 4 SPC years) during the obligation and all instate
• Then much more remaining

But of course there are barriers as we separate preparation, admission, initial training, graduate training, short term obligation (if any), and subsequent voluntary choice to remain in primary care at all (each year) or to remain in most needed health access (each year) and the tendency over a career is to move steadily away from primary care and most needed health access.

And these steps and the accreditation process, and the funding for training, and the funding for primary care support - are all determined by panels that are 70% or greater hospital and specialty and academic.

Even those who do call for responsibility, accountability, and illustrate health access models make no headway as Butler found out  (by permission of Academic Medicine) at http://www.ruralmedicaleducation.org/season_of_accountability.htm

Also the most productive years are dedicated to primary care delivery and health access as compared to primary care forms that enter age 38 and later.

Bob Bowman  www.basichealthaccess.org

AACOM had a nice review by Eskew regarding the barriers to what we need http://www.aacom.org/events/annualmtg/past/2010/Documents/Eskew_Finding-a-Faster-Route.pdf

The info on Accelerated FM programs is not accurate  My site has data representative of the national output, and discussions of the termination of this model that involve failure of primary care innovation support    http://www.ruralmedicaleducation.org/short_and_sweet_accelerated.htm    150 grads were tracked by me from eleven programs, 3 years med school and 3 years FM residency,   40% rural (FM is 24%, US docs 10%), 19% high poverty (FM 15%, US docs 7%) - over 50% in various underserved areas at any given time     54% were four or more years older at graduation - maturation, previous life and health experience      all committed to FM one year early indicating the impact of early focus on FM      the Nebraska track continued at 4 to 5 per year and had 70% remaining instate in rural locations, the same as the Nebraska RTT programs, other Nebraska FM grads have about 40 - 50% rural but not the same instate rate.

The WHO Report on Rural and Remote Health also mistakenly noted that controls for origins, training, and career choices were lacking in workforce studies

Here is what various origins plus FM types of training accomplish in outcomes for the 1997 - 2003 FM grads