"If residency programs do not ramp up the training of these physicians the shortage in primary care, especially in remote areas, will get worse," said lead study author Candice Chen, MD, MPH, an Assistant Research Professor of Health Policy at SPHHS. "The study's findings raise questions about whether federally funded graduate medical education institutions are meeting the nation's need for more primary care physicians."

The graduate medical education system (GME) in the United States relies on public funding including nearly $10 billion in funds from the Medicare program and another $3 billion from Medicaid. Despite the large infusion of cash, experts have said that the federal government does not hold residency programs accountable for producing physicians trained to serve in rural or underserved parts of the country. Even though Medicare and Medicaid represent the largest public investment in the U.S. health workforce, there are still serious shortfalls in the number of primary care physicians in some geographical regions and in other high need specialties like general surgery.

Chen and her colleagues studied the career paths of 8,977 physicians who had graduated from 759 medical residency sites from 2006 to 2008. The researchers analyzed data to find out where these new physicians ended up practicing 3 to 5 years after graduation. They found that overall only 25.2 percent of the physicians in this study worked as primary care docs although this number almost certainly is an overestimate because it includes graduates who practice as hospitalists, Chen said.

In addition, the researchers found that 198 out of 759 institutions produced no rural physicians at all during the study period. And 283 institutions graduated no doctors practicing in Federally Qualified Health Centers, clinics that provide care to low-income patients and others--often in remote or struggling urban areas.

About 66 million people in the United States live in rural areas or urban neighborhoods that have too few primary care physicians or access to primary care in clinics. That's about one in five Americans who lack adequate access to this kind of essential care and might develop more serious health conditions as a result, Chen said.

Currently, the U.S. is producing primary care physicians at rates that are "abysmally low" and unless something changes the nation will have an even greater shortfall of primary care doctors just as the Affordable Care Act (ACA) ramps up demand for these services, she said. Already rural and urban clinics in underserved neighborhoods struggle to find and retain primary care doctors, Chen said.

The new study underscores the growing disconnect between federal funding to pay for residency programs and the nation's shortage of primary care doctors. The study also found that:

• The top twenty primary care producers in this study trained 1,658 primary care doctors out of a total of 4,044 or 41 percent. These sites received just $292 million in GME funding.

• In contrast, the bottom twenty programs produced only 684 primary care graduates out of 10,937 or 6.3 percent. Yet the study notes these sites received a whopping $842 million in GME payments -- an amount that reflects not a dedication to training doctors in primary care but in churning out highly paid specialists who typically practice in big cities or the suburbs.

Chen, Fitzhugh Mullan, MD, the Murdock Head Professor of Medicine and Health Policy at GW and their colleagues note that almost two-thirds of the nearly $10 billion in Medicare funding for GME annually goes to 200 hospitals -- and those sites perform poorly when it comes to producing primary care doctors. Policymakers should take a hard look at the skewed incentives and other factors that have led to the current primary care crisis and develop a more accountable GME system, according to the authors.

"Better balance in medical specialties and more primary care physicians will be essential to building an effective and affordable health system going forward," Mullan said. Other authors of the paper include Andrew Bazemore, MD, MPH, the director of the Robert Graham Center and Robert Phillips, MD, MSPH, the vice president for research and policy at the American Board of Family Medicine.