Current Projects
Learn more about our active projects here:
Year 12 (2024-2025) Projects
Project 1. DocFlows 2.0: Exploring the Interstate Migration of Residents-in-Training and Practicing Physicians
Investigators: Erin Fraher, PhD, MPP, Evan Galloway, MPS, Brianna Lombardi, PhD, MSW
Shifts in the migration patterns of the population, recent increases in immigration, and new state and federal sources of GME funding have likely spurred changes in where physicians train and practice. This study will update DocFlows version 1 (https://docflows.unc.edu) to track the moves that newly trained physicians and actively practicing physicians made between 2015-2023.
Project 2. Visualizing Trends in Foreign-Born and Foreign-Trained Physicians Working in the United States
Investigators: Brianna Lombardi, PhD, MSW, Evan Galloway, MPS, Brooke Lombardi, PhD, MSW, Erin Fraher, PhD, MPP
As the United States faces worsening workforce shortages and a persistent maldistribution of health care workers, foreign-born and foreign-trained health professionals may comprise an increasingly important labor source. We will develop a data visualization that allows users to explore the demographic, practice, and geographic characteristics of this workforce, as well as their origin-countries and their destinations in the United States.
Project 3. Understanding States’ Use of Alternative Pathways for Foreign-Trained Physicians
Investigators: Erin Fraher, PhD, MPP Colleen Tapen, MPH, MBA, Haley Simons, Emily Hawes, PharmD, BCPS, CPP
An increasing number of US states are allowing international medical graduates (IMGs) to pursue alternative pathways to residency, licensure, and practice, in some cases bypassing the requirement to complete a US residency. In this study, we will interview experts from states pursuing alternative pathways for IMGs to understand the types of alternative pathways being developed, states’ motivations in pursuing these pathways, their design and implementation, and the degree to which they are measuring the outcomes of these changes.
Project 4. Understanding Trends in Nurse Practitioner Turnover by Setting
Investigators: Esita Patel, PhD, Erin Fraher, PhD, MPP
It is unclear how the COVID-19 pandemic affected turnover of Nurse Practitioners (NP) and how NP turnover varies by setting. This study will compare NP workforce behaviors (e.g., turnover rates, intention to leave, and reasons for leaving or staying) during the pre-pandemic (2018) and mid-pandemic (2022) periods in hospital and outpatient settings.
Ongoing Projects
Colocation of Primary Care, Dental, and Pharmacy Residencies: An Analysis of Interprofessional Post-Graduate Training
Principal Investigator: Emily M. Hawes, PharmD, BCPS, CPP
An integrated, interprofessional team-based model of practice is an essential element of delivering high- quality primary care. Integrating dentists and primary care physicians enhances access and coordination of care. Despite support for interprofessional education across national health organizations and accrediting bodies, little is known about the prevalence and composition of interprofessional post- graduate training on a national level. This project will produce a much-needed body of evidence on the prevalence, location and factors predicting co-location of dental, pharmacy and primary care residencies in the United States.
The aims of this study are:
- Identify the proportion of pharmacy and primary care physician post-graduate training programs that are collocated.
- Identify the proportion of pharmacy, dental, and primary care physician post-graduate training programs that are collocated.
- Examine predictors of pharmacy and primary care post-graduate training program colocation as well as pharmacy, dental, and primary care post-graduate training program colocation [such as program sponsor, residency specialty/size, training setting (e.g., FQHC, hospital.), state, and measures of underservice (e.g., Area Deprivation Indices, metro/non-metro)].
Investing in New Nurse Faculty Retention: Understanding Transitions, Onboarding and Integration into the Academic Environment
Principal Investigator: Cheryl Jones PhD, RN
Emerging discussions in nursing academia recognize the need to provide intentional onboarding to recruit, grow, develop, and retain new nursing faculty in response to nursing faculty shortages which are often described as a major bottleneck in preparing new nurses to enter nursing practice. This project will examine the prevalence and characteristics of faculty onboarding programs and the value of programs in achieving key program outcomes. The work will proceed in two phases: (1) a systematic review of the literature on nursing faculty onboarding programs and (2) a cross-sectional survey of U.S Schools of Nursing to describe the characteristics of existing faculty onboarding programs and examine leaders’ perceptions of these programs.
Intersecting Identities: The Influence of Race/Ethnicity, Sex and Undergraduate Historically Black College and University (HBCU) Education on Black Student’s Application, Acceptance and Graduation from Medical School
Principal Investigator: Jasmine Weiss, MD, MHS
As a follow-up to a Year 10 study that highlighted the contributions of HBCU undergraduate institutions on the acceptance, matriculation, and graduation of Black physicians from 1980-2020, this project will explore differences in these trends by sex to characterize how intersectionality between race and gender may contribute to the production of Black physicians who complete their undergraduate studies at HBCUs. Findings from this study could serve as evidence of the changing dynamics of gender and race of those applying and matriculating into medicine from HBCUs vs. non-HBCUs. Understanding these dynamics is important to educational accrediting bodies, hospital systems, medical schools, and for federal and state policy makers to shape investments in undergraduate institutions that increase representation in the physician workforce.
Using Latent Transition Analysis as A Tool to Understand How Physician Careers Evolve over the Life Course
Principal Investigator: Erin P. Fraher, PhD, MPP
In a Year 10 study, we used latent class analysis (LCA) to describe the career typologies of primary care physicians (PCPs) in North Carolina which found that PCPs were sorted into four types of careers in 2009 and 2019 with high class separation and classification certainty in both years (entropy = 0.98, mean posterior probabilities > 0.9). Key attributes that predicted career type were whether the PCP practiced in a rural vs urban area, hospital vs. ambulatory care settings, and whether they provided prenatal and obstetric care. We found statistically significant differences in PCPs’ demographic characteristics (gender, age, race/ethnicity), medical school location (IMG vs not) and years in practice between classes. Findings from our Year 10 study suggest that primary care physician career typologies were stable over the decade as a whole, but we could not observe whether individual physicians transitioned to different career typologies during the decade.
In this project, we will leverage the unique panel nature of the North Carolina licensure data to conduct a latent transition analysis (LTA) of the 4,617 PCPs who were present in the data in both 2009 and 2019. LTA will allow us to examine if PCPs display career transitions between different typologies during the 10-year period and identify the factors associated with these transitions. Such an understanding could help policy makers identify if there are specific points in time, and physician characteristics, that are associated with an increased probability of transitioning from one career typology to another.
The Changing Hospital Workforce
Principal Investigator: Erin Fraher, PhD, MPP
This project will examine staffing data from the American Hospital Association’s Annual Survey to understand whether, and how, hospital staffing composition has changed between 2005 and 2021. There is speculation that the number and skill mix of the hospital workforce has, and will continue, to change in response to the pandemic; this project provides the historical data needed to evaluate whether changes occur and, if they do, what hospital characteristics are associated with these changes.
The Workforce Providing Social Risk Screenings in Community Health Centers
Principal Investigator: Brianna Lombardi, PhD, MSW
Community Health Centers (CHCs) are mandated to address the physical, behavioral, and social needs of the vulnerable communities they serve and the composition of staff in CHCs likely is associated with their ability to conduct social risk screenings. Using the Uniform Data System (UDS) for HRSA-supported CHCs, this study will examine if employment of social workers or enabling providers (i.e., community health workers, case managers, health educators) is associated with an increased documentation of social risk screening at CHCs.
Understanding the Contributions of Undergraduate Historically Black Colleges and Universities to Increasing the Diversity of the Physician Workforce: Supplement Funded
Principal Investigator: Jasmine Weiss, MD, MHS
Increasing the diversity of the physician workforce is critical to addressing health disparities in the United States, particularly for Black Americans. This study will examine the role of undergraduate Historically Black Colleges and Universities (HBCUs) in increasing the representation of Black physicians in medical schools and ultimately the physician workforce.
Toward a Better Understanding of the Career Trajectories of Physicians from Underrepresented Groups in Medicine.
Principal Investigator: Erin Fraher, PhD, MPP
The purpose of this study is to use life course theory as a conceptual and methodological framework to investigate how race/ethnicity, age, and gender influence the practice patterns of North Carolina’s primary care physician workforce in different time periods, including whether the physician provides prenatal care, if s/he performs obstetric deliveries, the number of hours worked per week, the type of employment setting in which s/he practices (hospital, group clinic, solo practitioner, medical school etc.) and whether s/he practices in an underserved community. Using data collected on physicians between 2005 and 2019, we will test the following hypotheses:
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- Between cohort effects: Primary care physicians from URM groups who graduated medical school in different periods will exhibit different practice patterns than their white colleagues.
- Intracohort gender effects: Different practice patterns will be observed for male and female primary care physicians of different race/ethnicities within the same medical school cohort.
- Age effects: Male and female primary care physicians from URM groups will exhibit different practice patterns at the same age, depending on when they graduated medical school.
Structural Factors Driving Burnout in Medicine: A Study of Pediatric Surgeons
Principal Investigator: Tania Jenkins, PhD
While research on wellbeing and satisfaction in medicine has increased exponentially over the last ten years, much of this research has emphasized individual-level causes and interventions. Yet, individual-level approaches do little to address the broader structural factors that may be shaping physician satisfaction and wellbeing. A 2019 National Academies of Science, Engineering, and Medicine (NASEM) consensus study called for more research taking a more systemic approach to clinician burnout, but to date, no available study has comprehensively considered how these factors shape physicians’ everyday experience.
This study compared two specialties (pediatrics and pediatric surgery) to investigate:
- How do societal- and institutional-level factors (factors external to the profession) work together to shape physicians’ professional satisfaction and wellbeing?
- How do factors internal to the profession, such as training structures and specialty cultures, interact with external societal and institutional pressures to shape physicians’ satisfaction and wellbeing?
- And how do societal, institutional, and professional factors affect physicians’ satisfaction and wellbeing across the career span?
How Institutional, Professional and Societal/System Factors Shape Career Satisfaction and Wellbeing among Physicians and Trainees
Principal Investigator: Tania Jenkins, PhD
This mixed-methods study is a novel analysis of existing quantitative burnout and job satisfaction data and qualitative interviews (n=~125) and observational data (n=~500 hours) collected during previously funded work (2020-2022) to investigate new research questions including: 1) what ‘feeling valued’ means to physicians and trainees, 2) how workflow and work organization—often designed to optimize economic value—might exact a toll on workers, and 3) what workplace changes can be made to improve physician health. Findings from this study will generate evidence on the factors influencing physician and trainee well-being that can inform future rounds of HRSA funding to support health workforce resiliency and educators as well as guide employers seeking information about ways to address health care worker burnout.
Toward a Better Understanding of Primary Care Physician Career Typologies (LCA)
Principal Investigator: Erin Fraher, PhD, MPP
The purpose of this study is to use life course theory as a conceptual and methodological framework to investigate how race/ethnicity, age, and gender influence the practice patterns of North Carolina’s primary care physician workforce in different time periods, including whether the physician provides prenatal care, if they perform obstetric deliveries, the number of hours worked per week, the type of employment setting in which they practice (hospital, group clinic, solo practitioner, medical school etc.) and whether they practice in an underserved community. Using data collected on physicians between 2005 and 2019, we will test the following hypotheses:
- Between cohort effects: Primary care physicians from URM groups who graduated medical school in different periods will exhibit different practice patterns than their white colleagues.
- Intracohort gender effects: Different practice patterns will be observed for male and female primary care physicians of different race/ethnicities within the same medical school cohort.
- Age effects: Male and female primary care physicians from URM groups will exhibit different practice patterns at the same age, depending on when they graduated medical school.
Rural-urban differences within primary care scope of practice
Investigators: Ryan Kandrack, PhD, Erin Fraher, PhD, Mark Holmes, PhD
There is some evidence that primary care physicians in rural areas respond to the limited local supply of specialists by offering a broader array of clinical services than their urban colleagues. These studies suggest that there is “plasticity” in the scope of services provided by physicians. Plasticity describes the dynamic and real world nature of scope of practice; physicians within the same specialty may provide different types of services depending on their demographic characteristics and training, the density of other physicians who provide overlapping services in their local area, the needs of their local patient population, and their personal preferences. Previous studies have described primary care physicians’ plasticity between rural and urban locations but little work has been done investigating the factors that affect plasticity within primary care specialties. The goal of this project is to investigate how the breadth and volume of primary care services varies within family medicine and general internal medicine between rural and urban areas.
This project is/was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under Cooperative Agreement for a Regional Center for Health Workforce Studies #U81HP26495. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.
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