Sponsoring Institutions with Five or Fewer Residency Programs Produce a Larger Proportion of General Internists and Family Physicians

• Family Practice
• Health Policy
• Primary Health Care

The Balanced Budget Act of 1997 restricted Centers for Medicare and Medicaid–funded positions for existing SIs, known as “the cap.”¹ Despite federal cost containment, the number of positions has expanded,² favoring subspecialty expansion at a significantly higher rate than primary care.³

Since smaller SIs provide limited exposure to specialty medicine and a potentially wider scope of practice during residency training, we hypothesized that they might also produce more primary care physicians. Practicing general internists and family physicians were matched with the size of the SI where they trained, and the SIs were grouped by the number of residencies they sponsor.⁴ Physicians were identified through the American Medical Association Masterfile and its GME historic supplement. We included those who completed a residency between 2006 and 2008 and determined whether they practiced primary care in 2014, intentionally allowing time for graduates who pursued fellowships to complete subspecialty training.

SIs with ≤5 residencies produce nearly 40% the national primary care workforce. While small SIs vastly outnumber larger institutions, only 14% of all residents graduated from small SIs. Thus the key finding is that a significantly higher percentage of internal medicine (IM) graduates will remain working in primary care if they trained at a small SI. Over 56% of IM graduates from small SIs (1–5 residencies) pursue generalist careers compared with graduates from large SIs (with ≥41 residencies), where only 28% practice primary care (P < .01). Figure 1.

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Figure 1.

Residents eventually practicing in primary care by number of training specialties within a sponsoring institution.

This simple association reminds us that the majority of our primary care workforce comes not from the more traditional behemoths of GME, but smaller, often community-based hospital training sites, and that these sites produce disproportionate numbers of general internists, whose numbers are steeply declining nationally. It is understood that residents who plan to subspecialize often intentionally attend large SIs where they will benefit from exposure to the fellowship of their choice. These same large institutions often provide primary care training tracks. Despite this, small SIs continue to produce a larger percentage of IM graduates who practice primary care. The majority of GME funding goes to large SIs, yet they yield the smallest numbers of family physicians and an even smaller number of general internists. It is crucial to understand the influences that may encourage undecided IM residents to remain in primary care. Secure and sufficient funding for small SIs is a key opportunity to increase the national primary care workforce.

• Received for publication March 27, 2015.
• Revision received February 29, 2016.
• Accepted for publication March 8, 2016.