View this table: [in this window] [in a new window] [as a PowerPoint slide]   Table. Year 1 Residency Positions (PY-1) and Median Specialty Salary Data

Results
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.

View larger version (26K): [in this window] [in a new window] [as a PowerPoint slide]   Figure. Percentage change in number of year 1 residency positions (PY-1) offered from 1998 to 2008 vs 2007 income by specialty. Percentages in parentheses are percentage growth in specialty income adjusted for inflation between 1998 and 2007.

Comment
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.

AUTHOR INFORMATION
Correspondence: Dr Phillips, The Robert Graham Center, 1350 Connecticut Ave NW, Ste 201, Washington, DC 20036 (bphillips{at}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.