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78 Making General Practice Attractive: Encouraging GP attraction and Retention <strong>KCE</strong> Reports 90<br />
US federal and state policies<br />
In <strong>the</strong> 1990s, US federal and especially state policies were designed to mandate medical<br />
schools to "produce" more PCPs, which resulted in proportions of PCPs graduates<br />
reaching 25 to 35% in 1995, short of <strong>the</strong> 50% target however <strong>150</strong> . The particularity of<br />
<strong>the</strong>se state policies is that <strong>the</strong>y were not intrusive, <strong>the</strong>y were unfunded mandates and<br />
mostly signals to hold medical schools accountable for producing more PCPs <strong>150</strong> .<br />
Generalist Physician Initiative<br />
Private initiatives were also launched, e.g. <strong>the</strong> Robert Wood Foundation, which<br />
provided financial support to <strong>the</strong> Generalist Physician Initiative (GPI) in 13 universities<br />
(1991-2001), targeting <strong>the</strong> supply of family practitioners, general internists, and general<br />
pediatricians 26 , 48 , 151 . Several aspects of <strong>the</strong> GPI are close to what was observed in<br />
Belgium with <strong>the</strong> development of Academic Centers of General Medicine. The<br />
Generalist Physician Initiative helped catalyze educational reform in medical schools that<br />
had had little educational change in two to three decades. Those changes included:<br />
• elevating generalist faculty into major leadership roles,<br />
• instituting new administrative structures to coordinate generalist<br />
activities,<br />
• increasing <strong>the</strong> number of generalist faculty.<br />
Some changes <strong>the</strong> schools carried out to promote general practice were for example:<br />
• changing <strong>the</strong> admissions process to target more students with GP<br />
potential, along with increasing <strong>the</strong> number of GPs on admissions<br />
committees,<br />
• developing high school and college undergraduate recruitment<br />
programs,<br />
• redesigning undergraduate medical education to include <strong>the</strong> primarycare<br />
community experiences, GP-oriented clinical medicine courses<br />
and GP clerkships.<br />
The Generalist Physician Initiative increased output of GPs by approximately 39% during<br />
<strong>the</strong> course of <strong>the</strong> program, from a baseline of 26.4 % of graduates in 19881991 to<br />
36.7% of graduates in 1999. By 2000, <strong>the</strong>re had been a decline in GP graduates to 32.8<br />
percent of all graduates, so <strong>the</strong> final increase was 24 percent. Note that this trend in<br />
increased production of GPs may not be attributed solely to <strong>the</strong> GPI and that it is not<br />
ei<strong>the</strong>r stable: national data show that after <strong>the</strong> mid-1990s peak, <strong>the</strong> number of PCPs is<br />
leveling off in <strong>the</strong> mid-2000s 152 . The causal effect of <strong>the</strong> GPI is <strong>the</strong>n questionable, and<br />
o<strong>the</strong>r incentives and determinants of career choice by physicians should be considered.<br />
Specific US initiatives for rural and deprived areas<br />
Since <strong>the</strong>re is little evidence to support <strong>the</strong> idea that distributional issues would resolve<br />
by <strong>the</strong>mselves, several education programs were developed in parallel by US medical<br />
schools to attract and train future GPs, with an accent on rural practice and<br />
underserved communities for some initiatives. Programs were initiated in <strong>the</strong> 1970s and<br />
<strong>the</strong> 1980s and are still operating (see Geyman et al 2000 153 and McDonald et al 2002<br />
154 50 , 56 , 57 , 87 , 89<br />
). Some of <strong>the</strong>se programs were evaluated. See <strong>the</strong> following references :<br />
, 94 , 119 , 122 , 123 , 148 , 155 , 156 , 157 .<br />
All <strong>the</strong>se programs concern small numbers of physicians (about 30 to 100/year).<br />
Common features of <strong>the</strong>se programs include:<br />
• selection of students with rural background, with service orientation<br />
and interests in family medicine,<br />
• education in community medicine,