Where, oh where have all the family doctors gone? In recent years, the number of US seniors choosing to train in primary care fields has declined. A major driver of this drop is the increased numbers of internal medicine and pediatric senior residents selecting to pursue fellowship training after residency. The enticement of higher income and prestige that accompanies subspecialization is a strong motivator in many cases.
Where does that leave family medicine? Are we the only generalist left standing? As a matter of fact, family medicine has its own fellowship programs including obstetrics, geriatrics, sports medicine, and academic development. More recently, our graduates have gained access to palliative care and sleep medicine training after residency.
Currently, of the 451 accredited family medicine programs in the United States, 232 programs with 282 ACGME accredited fellowship programs are listed on the American Academy of Family Physicians Web site. Others are in areas sponsored by family medicine (FM) programs or departments but lack formal recognition by the ACGME. Still, other programs offer advanced degrees (MBA, MPH, MS) as part of the residency and/or fellowship.
Sports medicine seems to be the most popular offering with 106 programs. Match and fill rates for FM residency graduates going into fellowships are only available for primary care sports medicine programs (PCSM) that participate in the National Resident Matching Program (NRMP). The most recent data indicate an average 94.3% fill rate for these programs from 2005 to 2009.
The impact of fellowship training is unclear. One recent study noted that residencies having a PCSM fellowship failed to show a higher fill rate in the NRMP.1 They did match a higher proportion of US graduates. Another study showed that residency research productivity was positively associated with having a fellowship program.2 In regards to compensation, a 2008 Medical Group Management Association survey indicated that fellowship trained family medicine physicians would command higher compensation for obstetrics and sports medicine but not geriatrics, whether in academic or private practice settings.3 Interestingly, the same survey reported that FM urgent care positions were compensated higher than most FM fellowship trained positions.
This raises many questions about how advanced training in certain aspects of our family medicine specialty is incorporated and promoted in the volatile world of medical student recruiting and the economic realities of specialty compensation and prestige.
Would fewer students consider family medicine training if no post-residency fellowship options existed? Do residency programs with fellowships experience better recruitment than non-fellowship programs? Does a fellowship trained family medicine physician earn more money than the average family medicine doctor? Is there more prestige afforded to those fellowship trained family medicine physicians? What is the advantage of an advanced degree for a primary care doctor? How many of our fellowship graduates practice only that aspect of their job? Are we training too many of one fellowship area (enhanced interest like sports medicine) vs another fellowship area (increased need like geriatrics)?4
In a time when we are promoting the patient-centered medical home, health care reform, and a national refocus on the need for more primary care providers, we need to have discussions about the role of “specialization” in family medicine. What will be its impact on the viability and expansion of our specialty? How will specialization shape our training programs in the future? How much more “special’” does family medicine really need to be?
- © 2010 Annals of Family Medicine, Inc.
