Among other things, title VII programs support the education and training of primary care providers, such as primary care physicians, physician assistants, general dentists, pediatric dentists, and allied health practitioners. HRSA includes in its definition of primary care services, health services related to family medicine, internal medicine, preventative medicine, osteopathic general practice, and general pediatrics that are furnished by physicians or other types of health professionals. Also, HRSA recognizes diagnostic services, preventive services (including immunizations and preventive dental care), and emergency medical services as primary care. Thus, in some cases, nonprimary care practitioners provide primary care services to populations that they serve. Title VII programs support a wide variety of activities related to this broad topic. For example, they provide grants to institutions that train health professionals; offer direct assistance to students in the form of scholarships, loans, or repayment of educational loans; and provide funding for health workforce analyses, such as estimates of supply and demand. In recent years, title VII programs have focused on three specific areas of need—improving the distribution of health professionals in underserved areas such as rural and inner-city communities, increasing representation of minorities and individuals from disadvantaged backgrounds in health professions, and increasing the number of primary care providers. For example, the Scholarships for Disadvantaged Students Program awards grants to health professions schools to provide scholarships to full-time, financially needy students from disadvantaged backgrounds, many of whom are minorities. After completing medical school, medical students enter a multiyear training program called residency, during which they complete their formal education as a physician. Because medical students must select their area of practice specialty as part of the process of being matched into a residency program, the number of physician residents participating in primary care residency programs is used as an indication of the likely future supply of primary care physicians. Physician residents receive most of their training in teaching hospitals, which are hospitals that operate one or more graduate medical education programs. Completion of a physician residency program can take from 3 to 7 years after graduation from medical school, depending on the specialty or subspecialty chosen by the physician. Most primary care specialties require a 3-year residency program. In some cases, primary care physicians may choose to pursue additional residency training and become a subspecialist—such as a pediatrician who specializes in cardiology. In this case, the physician would no longer be considered a primary care physician, but rather, a cardiologist. According to the AAPA, most physician assistant programs require applicants to have some college education. The average physician assistant program takes about 26 months, with classroom education followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, and geriatric medicine. Physician assistants practice in primary care medicine, including family medicine, internal medicine, pediatrics, and obstetrics and gynecology, as well in surgical specialties. After completion of a bachelor’s degree in nursing, a nurse may become a nurse practitioner after completing a master’s degree in nursing. According to the AACN, full-time master’s programs are generally 18 to 24 months in duration and include both classroom and clinical work. Nurse practitioner programs generally include areas of specialization such as acute care, adult health, child health, emergency care, geriatric care, neonatal health, occupational health, and oncology. Dentists typically complete 3 to 4 years of undergraduate university education, followed by 4 years of professional education in dental school. The 4 years of dental school are organized into 2 years of basic science and pre-clinical instruction followed by 2 years of clinical instruction. Unlike training programs for physicians, there is no universal requirement for dental residency training. However, a substantial proportion of dentists—about 65 percent of dental school graduates—enroll in dental specialty or general dentistry residency programs. In recent years, the supply of primary care professionals increased, with the supply of nonphysicians increasing faster than physicians. The numbers of primary care professionals in training programs also increased. Little information was available on trends during this period regarding minorities in training or actively practicing in primary care specialties. In recent years, the number of primary care professionals nationwide grew faster than the population, resulting in an increased supply of primary care professionals on a per capita basis (expressed per 100,000 people). Table 1 shows that over roughly the last decade, per capita supply of primary care physicians—internists, pediatricians, general practice physicians, and family practitioners—rose an average of about 1 percent per year, while the per capita supply of nonphysician primary care professionals— physician assistants and nurse practitioners—rose faster, at an average of about 4 percent and 9 percent per year, respectively. Nurse practitioners accounted for most of the increase in nonphysician primary care professionals. The per capita supply of primary care dentists—general dentists and pediatric dentists—remained relatively unchanged. Growth in the per capita supply of primary care physicians outpaced growth in the per capita supply of physician specialists by 7 percentage points in the 1995-2005 period. (See table 2.) By definition, aggregate supply figures do not show the distribution of primary care professionals across geographic areas. Compared with metropolitan areas, nonmetropolitan areas, which are more rural and less populated, have substantially fewer primary care physicians per 100,000 people. In 2005, there were 93 primary care physicians per 100,000 people in metropolitan areas, compared with 55 primary care physicians per 100,000 people in nonmetropolitan areas. Data were not available on the distribution of physician assistants, nurse practitioners, or dentists providing primary care in metropolitan and nonmetropolitan areas. For two groups of primary care professionals—physicians and nurse practitioners—the number in primary care training has increased in recent years. Over the same period, the number of primary care training programs for physicians declined, while programs for nurse practitioners increased. Comparable information for physician assistants and dentists was not available. From 1995 to 2006, the number of physician residents in primary care training programs increased 6 percent, as shown in table 3. Over this same period, primary care residency programs declined, from 1,184 programs to 1,145 programs. The composition of primary care physician residents changed from 1995 to 2006. A decline in the number of allopathic U.S. medical school graduates (known as USMD) selecting primary care residencies was more than offset by increases in the numbers of international medical graduates (IMG) and doctor of osteopathy (DO) graduates entering primary care residencies. Specifically, from 1995 to 2006, USMD graduates in primary care residencies dropped by 1,655 physicians, while the number of IMGs and DOs in primary care residencies rose by 2,540 and 1,415 physicians respectively. (See table 4.) From 1994 to 2005, the number of primary care training programs for nurse practitioners and the number of graduates from these programs grew substantially. During this period, the number of nurse practitioner training programs increased 61 percent, from 213 to 342 programs. The number of primary care graduates from these programs increased 157 percent from 1,944 to 5,000. Little information was available regarding participation of minority health professionals in primary care training programs or with active practices in primary care. Physicians were the only type of primary care professional for whom we found information on minority representation. We found information not specific to primary care for physician assistants, nurse practitioners, and dentists identified as minorities, which may be a reasonable substitute for information on proportions of minorities in primary care. For physicians, we used the proportion of minority primary care residents as a proxy measure for minorities in the active primary care physician workforce. From 1995 to 2006, the proportion of primary care residents who were African-American increased from 5.1 percent to 6.3 percent; the proportion of primary care residents who were Hispanic increased from 5.8 percent to 7.6 percent. Data on American Indian/Alaska Natives were not collected in 1995, so this group could not be compared over time; in 2006, 0.2 percent of primary care residents were identified as American Indian/Alaska Natives. Minority representation among each of the other health professional types—overall, not by specialty—increased slightly. AAPA data show that from 1995 to 2007, minority representation among physician assistants increased from 7.8 percent to 8.4 percent. AANP data show that from 2003 to 2005, minority representation among nurse practitioners increased from 8.8 percent to 10.0 percent. ADEA data show that from 2000 to 2005, the proportion of African-Americans among graduating dental students rose slightly from 4.2 percent to 4.4 percent, while the proportion of Hispanics among graduating dental students increased from 4.9 percent to 5.9 percent. The proportion of Native American/Alaska Native among graduating dental students grew from 0.6 percent to 0.9 percent. Other demographic characteristics of the primary care workforce have also changed in recent years. In two of the professions that were traditionally dominated by men in previous years—physicians and dentists—the proportion of women has grown or is growing. Between 1995 and 2006, the proportion of primary care residents who were women rose from 41 percent to 51 percent. Growth of women in dentistry is more recent. In 2005, 19 percent of professionally active dentists were women, compared with almost 45 percent of graduating dental school students who were women. Accurately projecting the future supply of primary care health professionals is difficult, particularly over long time horizons, as illustrated by substantial swings in physician workforce projections during the past several decades. Few projections have focused on the likely supply of primary care physician or nonphysician primary care professionals. Over a 50-year period, government and industry groups’ projections of physician shortfalls gave way to projections of surpluses, and now the pendulum has swung back to projections of shortfalls again.