Introduction

The Health Resources and Services Administration defines primary care health professional shortage areas as regions lacking sufficient primary care physicians (PCPs),¹ with current shortages resulting in only 47% of primary care needs being met.² By 2034, the deficit is projected to reach 86 000 PCPs, disproportionately affecting underserved areas.³ To address this, primary care tracks within internal medicine (IM) residency programs emerged in the 1970s, with 91 programs offering 420 postgraduate year 1 positions in the 2024 Match.⁴ While early programs successfully produced PCPs,^5,6 recent data from the 2019-2021 Internal Medicine In-Training Examination indicate that only 32% of graduates of these tracks pursue general internal medicine, with many shifting toward hospital medicine or subspecialties.⁷

Prior studies found that, though most residents enter primary care tracks intending to become PCPs, many change their plans during training.^8-11 For example, in one program, 93% of residents entered the IM primary care track interested in a primary care career.¹¹ By the end of residency, only 63% maintained similar interest, and after graduation, only 54% worked primarily in primary care.¹¹ This attrition rate is not unique; numerous primary care training programs report that the percentage of graduates who become PCPs fluctuates between 40 and 55%.^8-11 Since students who are genuinely interested in primary care tend to apply for and join these programs, their later decision not to pursue primary care cannot be explained by self-selection; instead, systemic factors and evolving career preferences likely contribute.¹¹ Quantitative and qualitative studies illuminate some of these factors. One multi-institutional survey of IM primary care program graduates found that those who worked as PCPs after graduation were more likely to cite their continuity clinic experience, opportunities for multidisciplinary care, relationships with faculty and peers, and the breadth of conditions seen in primary care as positively influencing their decision to work in the field.¹² Meanwhile, graduates who did not pursue primary care reported that administrative burden and concern for future burnout contributed to their decision.¹² A published qualitative study of primary care track graduates who did not enter primary care reveals similar sentiments.¹³ Physician participants cited mismatch between their expectations of primary care and reality, difficulty navigating complex boundaries between patients’ social and medical needs, and lack of mentorship.¹³

Partially accounting for these factors, newer primary care tracks offer more tailored training experiences and seem to produce better results.^14,15 For example, an innovative primary care track created in 2009 allowed residents to join at the end of postgraduate year 1, offered scheduling autonomy to reduce mismatched expectations, and saw 11 of its first 13 graduates (85%) enter primary care.¹⁴ Similarly, an HIV primary care pathway created in 2011 graduated 75% (6 of 8) of residents into primary care for patients with HIV.¹⁵

With the goal of creating a program dedicated to the specific needs of urban, disadvantaged populations that could serve as a model for residency programs elsewhere, the Johns Hopkins Urban Health (UH) Primary Care Combined Internal Medicine-Pediatrics (MP) residency and UH Internal Medicine Primary Care Track (IM PCT) enrolled their first intern classes in 2010 and 2011, respectively.¹⁶ The programs center a 4-part mission to produce physicians who (1) practice primary care; (2) practice in urban settings; (3) care for underserved populations; and (4) serve in leadership roles.¹⁶ UH leadership attempted to address some of the factors found to discourage primary care careers while maximizing those that incentivize entering primary care.¹⁶ They prioritized creating a focused UH curriculum that prepares residents to address disadvantaged patients’ holistic needs, a robust continuity clinic experience with program leadership as preceptors, and an alumni mentorship community.^16-18

Early data from the first 4 cohorts from each program showed promising results: 56% of UH IM PCT and 79% of UH MP graduates went on to practice primary care.¹⁶ Now, 15 years after the implementation of our UH residency curricula, we surveyed program alumni to determine the percentage of graduates whose current careers align with the programs’ 4-part mission. In doing so, we sought to create a longitudinal dataset, unique in the literature thus far, providing a formal evaluation of our primary care residency outcomes to inform both our program and primary care programs nationwide as they continue to build a primary care workforce responsive to the needs of urban and disadvantaged communities.¹⁶

KEY POINTS

Methods

We surveyed all 63 former residents who graduated from the Johns Hopkins UH IM PCT or UH MP residency between 2014 and 2021. We developed the initial survey in 2022 based on a literature review of residency program evaluation surveys.^8,19-25

Our survey (provided as online supplementary data) included 2 sections. The first asked respondents about their demographics and current careers (eg, specialty). Due to the small number of graduates, we aggregated the results into two 4-year cohorts and limited answer choices for multiple choice questions to decrease the possibility of inadvertently identifying respondents. For instance, the survey asked respondents whether they come from a background underrepresented in medicine rather than asking about specific racial or ethnic identities. The survey’s second section asked graduates if their residency program adequately prepared them in a variety of competencies outlined in the learning objectives of core rotations. All questions from both sections were optional. Responses were collected anonymously and kept confidential. We asked 13 current UH IM PCT/UH MP residents to fill out the survey and provide open-ended feedback. Based on their feedback, we made minor adjustments to optimize length and clarity. We estimated that the final 38-item survey, containing 32 multiple-choice and 6 short-answer questions, took a median time of 10.5 minutes to complete.

Qualtrics generated the survey, and the UH IM PCT and MP program director provided graduate emails and phone numbers. Graduates received individualized emails asking them to participate. The survey remained open for 3 months with up to 7 reminder emails and individualized text messages sent during this period to non-responders. The survey closed in January 2023.

The research coordinator downloaded de-identified survey responses from Qualtrics into an Excel spreadsheet, stratifying counts for demographic and career data by program (UH IM PCT or UH MP) and graduation year (grouped by 2014-2017 and 2018-2021). Using R (4.2.0) in 2023-2024, authors P.B. and A.G.V. performed chi-square tests to compare demographic and career characteristics by program or year and median tests to compare median time spent on clinical activities. They also calculated how many parts of the 4-part mission each respondent reported meeting, using these totals to determine the percent of respondents meeting each part of the mission and all 4 parts. Respondents choosing not to answer one or more questions related to the program’s mission were treated as not fulfilling those components of the mission. They then analyzed odds ratios with Fisher exact tests to determine whether individuals from a given demographic, program, or graduation cohort were more likely to report that their current careers meet all 4 parts of our programs’ mission. One respondent did not specify their graduation year cohort; their data were excluded from year-based comparisons but included in program-based analyses. Assumptions for chi-square (minimum expected counts, independence), Fisher exact (independence, fixed totals, mutually exclusive groups), and median tests (independence, ordinal data, similarly shaped distributions, no extreme outliers) were met. Although our study surveyed the full population of UH graduates rather than a random sample, we felt it was reasonable to assume that non-responders were randomly distributed across cohorts, supporting the validity of these tests.

This study was deemed exempt from full review by the Johns Hopkins Medicine Institutional Review Board.

Results

Fifty-seven of 63 UH graduates completed the survey for an overall 91% response rate (IM, 85% (28/33) response rate; MP, 97% (29/30); Table 1). Among respondents, 60% (34 of 57) are female, 21% (12 of 57) identify as an underrepresented in medicine (URiM), 16% (9 of 57) come from a disadvantaged background, and 23% (13 of 57) were raised in an urban setting (Table 1). We found no significant demographic differences when stratifying by program or graduation cohort (Table 1).

Table 1Demographic Characteristics of Urban Health Graduates

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Seventy-nine percent (45 of 57) of respondents report practicing primary care (Table 2). Eighty-six percent (49 of 57) and 77% (44 of 57) report working primarily in urban settings and serving predominantly underserved patients, respectively (Table 2). Most respondents report working either outpatient only (23 of 57, 40%) or both inpatient and outpatient (29 of 57, 51%; Table 2), while only 4 graduates work exclusively inpatient (4 of 57, 7%). We found no statistically significant differences between programs or graduation cohorts regarding these elements of their clinical practice (Table 2).

Table 2Clinical Practice Characteristics of Urban Health Graduates

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Table 2 shows that the median proportion of time spent in the work week for clinical activities was 70% (IQR 25-85) with no significant differences between programs and graduation cohorts. Several respondents pursued further training via fellowships (22 of 57, 39%) and/or certifications (17 of 57, 30%; Table 3). Of those who pursued fellowships, 73% (16 of 22) completed general fellowships often associated with primary care (eg, geriatric medicine; Table 3). Most participants (38 of 57, 67%) hold a leadership position (Table 4). Additionally, many respondents report using the remainder of their work week for nonclinical activities (eg, research, consulting; Table 4). We observed no significant differences between programs and graduation cohorts (Tables 3 and 4).

Table 3Additional Training Pursued by Urban Health Graduates

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Table 4Leadership and Nonclinical Activities of Urban Health Graduates

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Thirty-five percent (20 of 57) of graduates have careers that fulfill all 4 mission objectives (Figure). When comparing those whose careers fulfill all 4 parts of the mission to those whose careers do not, we did not observe any statistically significant differences in respondent demographics (including gender, URiM status, and urban hometown), program, or graduation cohort (online supplementary data Tables 1 and 2). All respondents reported that their careers meet at least one component of the mission (online supplementary data Table 2).

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Discussion

This study, which included survey responses from 57 of 63 (91%) former residents from our first 8 cohorts of graduates, revealed a 79% retention rate in primary care, which is greater than the 40-55% retention rates reported in prior studies.^8-11 The retention rates of 68% and 90% surpassed our previously reported 56% and 79% in 2017 for our UH IM PCT and UH MP cohorts, respectively.¹⁶ Most of our UH cohort did not pursue fellowships or certifications; those who did largely focused on general fellowships or certifications in areas commonly managed by PCPs, such as addiction and HIV. Only 11% (6 of 57) pursued subspecialty fellowships not typically associated with primary care, a rate lower than in prior studies.^8,10 While many factors may contribute to our improvement, further research is needed to identify them for national replication. We suspect the 3 most important factors are our continuity clinic design, residents’ specific training in addressing medical problems that disproportionately affect underserved urban communities, and an emphasis on the range of career and leadership opportunities within primary care.

Our continuity clinic serves as the foundation of the UH programs and emphasizes using team-based care to address the social determinants of health.^26,27 Designated as a Federally Qualified Health Center since 2020, the clinic includes an interdisciplinary team of social workers, case managers, community health workers, pharmacists, and nutritionists/diabetes educators. This team-based structure enhances resident education, strengthens patient relationships, and allows more time for direct patient care.^26,27 Building on their continuity clinic experiences, residents gain focused exposure in areas directly applicable to their patients through dedicated rotations on topics including women’s health, carceral medicine, addiction, HIV, Hepatitis C, mental health, and care for unhoused individuals. These rotations, along with available public health and policy experiences at local, state, and federal levels, enhance residents’ ability to advocate for systemic change. Altogether, the curriculum equips residents for the challenges they will face in independent practice and enables them to identify areas where they can take on leadership roles to shape the field.

While our mission is specific, our curricular emphasis on diverse career and leadership opportunities within primary care likely contributes to our high retention rate, showcasing pathways in research, medical education, advocacy, and administration that graduates can pursue alongside clinical practice. While prior surveys show an average primary care retention rate of 57%,⁸ newer tailored residency models, including ours, report rates above 75%.^14,15 These programs may achieve higher retention by aligning with students’ specific interests and providing relevant curricular offerings that promote long-term retention in primary care.^14,15 Consistent with this hypothesis, all survey respondents reported engaging in activities beyond direct clinical care and the majority (67%, 38 of 57) hold leadership roles, reflecting the emphasis on leadership development in our programs. Our graduates find their niche in primary care.

Further demonstrating the impact of our programs’ targeted design, outcomes across our 4-part mission did not significantly differ by demographics, program, or graduation cohort.

Our study has limitations. First, definitions of “underserved,” “primary care,” and “leadership,” rely on self-identification. This design allowed participants to interpret these terms based on their professional context and lived experiences, with the goal of capturing diverse and potentially nontraditional—but meaningful—forms of service. Nevertheless, this flexibility introduces subjectivity to our findings.

Second, self-selection likely plays a role in our graduates’ high primary care retention rate. However, as the data reflects that self-selection plays a role for all residents choosing primary care programs, this alone cannot account for the higher primary care retention observed in our program.^8-11 Future research will focus on which elements, including our recruitment process and specific residency experiences, most influence our graduates’ career choices.

Third, our survey captured only respondents’ current careers, though medical careers evolve over time. Nevertheless, given the relatively young age of our programs, many of our graduates may have only had one postgraduation job up until this point. With this early-career baseline established, future surveys may track career progression, providing longitudinal data to identify factors that support long-term primary care retention. Relatedly, to protect respondent anonymity, we chose to dichotomize graduation years as 2014 to 2017 and 2018 to 2021. We recognize that this approach limits detection of gradual changes in career outcomes over time, but anticipate that longitudinal data collected over future iterations of the survey will help further clarify temporal trends. Furthermore, while we had an excellent response rate of 91%, there is likely self-selection bias based on who chose to respond. Including non-responders may have dampened the results. Finally, responses may have been influenced by social desirability bias, with participants potentially overstating behaviors related to the programs’ 4-part mission.

Understanding the factors influencing career outcomes of primary care residency graduates is crucial to solving the national PCP shortage. We aim to continue using this survey with future cohorts to develop a novel, longitudinal database of post-residency outcomes to inform primary care residency program design. Moreover, we also aim to collaborate with newer programs with similar goals and curricula, including those at the University of Miami, Mount Sinai, and MetroHealth, to determine which aspects of our model are both most successful and most generalizable. We hope this will lead more institutions serving disadvantaged populations to build programs of their own based on our model.

Conclusions

Our survey demonstrates that the majority of Johns Hopkins Urban Health residency graduates report careers in primary care, primarily in urban and underserved settings, with high rates of involvement in both clinical and nonclinical activities. Two-thirds hold leadership roles, and over one-third pursued additional training through fellowships or certifications. All respondents reported careers aligning with at least one component of the programs’ mission, with 35% (20/57) fulfilling all 4 components.