Does Graduate Medical Education Also Follow Green?

In his 2008 research letter, Ebell¹ highlights the relationship between residency fill rates and physician specialty salary (r = 0.82). Mullan² referred to this as the “white-follows-green law.” In the same issue, Salsberg et al³ reported that graduate medical education (GME) expansion since funding caps were put in place favored nonprimary care specialties and was associated with a reduction in primary care production. Hospital supply of residency positions is known to play a role in determining the composition of the physician workforce. As noted in the May letter from the Council on Graduate Medical Education (COGME) to Congress,⁴ “financial concerns have affected the majority of teaching hospitals' decisions about selection of training positions.” In the hope of informing these concerns that hospitals may be responding to financial incentives over workforce needs in their allocation of GME positions, we explored the relationship between physician income and 10-year growth in primary care residency positions vs those in a group traditionally noted for their “lifestyle” appeal and higher likelihood of driving hospital revenues.

Median salary for physicians in 4 specialties frequently cited for their high income and “lifestyle” appeal and 3 primary care specialties was obtained from the 1999 and 2008 American Medical Group Management Association surveys. Change in median salary was adjusted for inflation using the US Bureau of Labor Statistics inflation calculator (http://data.bls.gov/cgi-bin/cpicalc.pl). Growth in Accreditation Council for Graduate Medical Education (ACGME)-accredited year 1 positions (PY-1) was calculated using program director projections reported in the 1998 and 2008 JAMA medical education issues.^5,6 General internal medicine PY-1 was modified to account for direct loss to preliminary year graduates and indirect loss to first-year subspecialty positions (Table).

A strong relationship exists between median specialty income and PY-1 growth for primary care and lifestyle specialties (r = 0.87) (Figure). Growth in PY-1 also correlated with the change in median specialty income between 1998 and 2008 (r = 0.84). The relationship between 2007 median specialty income and residency position growth held when considering internal medicine subspecialty positions and emergency medicine positions (r = 0.62) and remained when adding all specialties that Ebell¹ considered in his 2008 study (r = 0.41). While family medicine residency programs lost positions over the past decade (−390 PY-1), emergency medicine residencies added positions (+394 PY-1). Growth in internal medicine subspecialty programs (+1150 PY-1) and internal medicine preliminary positions (+290 PY-1) account for decreased general internal medicine PY-1 targeted toward primary care (−865 PY-1). With low starting salaries and declining median compensation, primary care specialties lost residency positions, while hospitals offered more residency positions to “lifestyle specialties” with high and growing median salaries.

Just as Ebell¹ demonstrated decreased student interest in low-compensation primary care specialties, teaching hospitals have also favored higher revenue-generating specialty training over primary care positions. Expansion of positions in the “R.O.A.D.” disciplines (radiology, ophthalmology, anesthesia, and dermatology) and emergency medicine over the last 10 years parallels losses in family medicine, general pediatrics, and general internal medicine. General internal medicine positions increasingly serve as channels for revenue-generating subspecialty programs, leaving fewer internal medicine positions dedicated to primary care. Policy makers hoping to realize the superior health outcomes and decreased costs associated with greater access to primary care may find this trend alarming.⁷ Our findings support the concern expressed by the COGME that instead of responding to policy aims to correct shortage in the primary care pipeline, hospitals are instead training to meet hospital goals.

Correspondence: Dr Phillips, The Robert Graham Center, 1350 Connecticut Ave NW, Ste 201, Washington, DC 20036 (bphillips@aafp.org).

Author Contributions: Dr Phillips had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Weida, Phillips, and Bazemore. Acquisition of data: Weida, Phillips, and Bazemore. Analysis and interpretation of data: Weida and Phillips. Drafting of the manuscript: Weida, Phillips, and Bazemore. Critical revision of the manuscript for important intellectual content: Weida, Phillips, and Bazemore. Statistical analysis: Weida. Administrative, technical, and material support: Phillips and Bazemore. Study supervision: Phillips.

Financial Disclosure: None reported.

Disclaimer: The information and opinions contained in research from the Robert Graham Center do not necessarily reflect the views or policy of the American Academy of Family Physicians.