Whitcomb, Michael E. MD
Most readers probably know that the academic medicine community generally believes that our country will soon face a serious shortage of physicians. This is a remarkable turn of events! Less than a decade ago almost everyone believed that an oversupply of physicians was just a few short years away. Richard (“Buz”) Cooper, MD, former dean of the Medical College of Wisconsin, had the distinction of being one of the few dissenting voices. Throughout the 1990s, Buz authored a series of articles challenging the conventional wisdom. When the projected surplus of physicians did not materialize in the latter years of the 20th century, the Council of Deans, Council of Teaching Hospitals, and Council of Academic Societies held a joint session at the Association of American Medical Colleges (AAMC) annual meeting entitled, “What if Buz is Right?”
Dan Fox, president of the Milbank Memorial Fund, was one of three presenters at that session. Dan began his presentation by stating bluntly, “It doesn’t matter whether Buz is right!” He then went on to explain that even if Buz is right, there will be no effective response to the impending shortage until government policymakers focus their attention on the issue and become convinced that it is real. In other words, the views of academicians are of practical significance only if they affect the policymaking process. Since most workforce analysts now believe that Buz was right, it seems appropriate to ask, “Was Dan right?” To answer that question requires some understanding of the actions being taken to increase the supply of physicians in this country.
To begin, the AAMC has recently called on its member medical schools to increase their enrollments, perhaps by as much as 30%. In response, a number of schools have indicated that they plan to do so. For example, Texas A&M has announced that it will increase the size of its entering class from 80 to 200 students over the next six years, and the University of Nevada School of Medicine has plans to double enrollment in coming years. But the majority of schools that have indicated that they will increase enrollments plan to make relatively small increases in the sizes of their entering classes. In addition, there are schools that have indicated that they are unable to increase enrollments. Some schools lack the resources needed to accommodate more students in the preclerkship phase of their curricula, while others are limited by lack of access to the additional patient care settings that would be needed to provide clinical education experiences for more students. Given this, it seems unlikely that it will be possible to meet the goal of increasing enrollments in allopathic medical schools by as much as 30% unless new schools are established around the country.
At present, there are only a handful of new schools on the immediate horizon. Two universities in Florida have received approval from the Florida Board of Governors to establish new medical schools, but they will not be able to enroll students until the Florida legislature allocates funds for the schools’ operating budgets. The Texas Higher Education Coordinating Body has approved the establishment of a new school in El Paso, but the legislature has yet to appropriate the funds required to open the school. Two of the campuses within the University of California system have indicated their desire to open medical schools, but the university has not yet completed its review of the campuses’ plans, and it is not clear when it will seek the necessary funding from the legislature. And in several other states initiatives to explore the possibility of establishing new schools are just getting under way.
It is clear from the experiences cited above that obtaining approval to begin a new medical school from the appropriate authority is a major challenge. But that challenge surely pales in comparison to the challenge of obtaining the funding needed to actually open the school. The reason, of course, is that for state universities, obtaining the necessary funding depends on how state legislators, faced with the need to address many serious problems within their states, view the need to fund a new medical school. And the reality is that until state policymakers view the impending shortage of physicians as a pressing problem within their states, it is unlikely that they will appropriate the funds required to start new schools. This, of course, is the point that Dan Fox was making.
Let us assume for the moment that the number of allopathic medical school graduates does increase substantially in the coming years. If so, what impact will that have on the aggregate supply of physicians for the country? It should not surprise anyone to learn that the impact might be quite small. How can that be? Quite simply because the aggregate supply of physicians is determined by the number of entry-level positions in the country’s graduate medical education (GME) system, not the number of graduates from U.S. allopathic medical schools.
At present, the number of entry-level positions in the GME system exceeds by almost 50% the number of this country’s allopathic medical school graduates (USMGs). It is almost a given that GME programs that now accept graduates of non-U.S. medical schools (IMGs) and/or graduates of osteopathic medical schools (DOs) into those positions will preferentially accept any additional graduates of U.S. allopathic schools. Thus, if the total number of entry level positions in the GME system remains relatively constant while the number of USMGs increases, some IMGs and DOs who might otherwise have been accepted into allopathic GME programs will not be accepted in the future. The end result will be that the number of physicians entering practice will remain relatively constant.
Now some might not see this is a likely scenario. In their minds, teaching hospitals will respond to the impending shortage of physicians by increasing the number of positions they currently fund. Well, maybe, but certainly not to the degree that would be required to provide new positions for all of the additional USMGs. Again, it is important to realize that the current system could accommodate a 30% increase in USMGs simply by limiting the number of IMGs and DOs entering the system. But even if hospitals were inclined to increase the number of entry-level positions they sponsor, I think it is highly unlikely that the number will increase substantially unless the Centers for Medicare and Medicaid Services agrees to provide Medicare funding for those positions by removing the Medicare caps currently imposed on GME sponsors. And even if that were to occur, hospitals would still be faced with providing from their patient care revenues a significant increase in funding to cover the total costs of expanding residency positions. Although nonteaching hospitals that decide to start new GME programs are not affected by predetermined caps, the number of hospitals that are likely to embark on this course is, in my opinion, quite small, and the number of new positions likely to be funded by those that do so will be small. So whatever the increase in enrollments in allopathic medical schools, it is highly unlikely that it will result in a proportionate increase in the aggregate supply of physicians.
Based on what has happened to date, I think we have to conclude that Dan Fox was right. Given that, what can the academic medicine community do to try to increase the aggregate supply of physicians in this country? It seems to me that the leadership of academic medicine should concentrate its advocacy efforts—efforts to affect government policy—on this issue. And I believe that federal policymakers should be the primary target of those efforts. Why? Because if the Medicare caps on GME sponsors are not removed, I don’t believe there is a reasonable chance that the number of entry-level GME positions will be increased to the number needed. Furthermore, I think it will take some kind of federal program to encourage and assist states that might be willing to open new medical schools to do so.
I suspect many will maintain that it is foolish to believe that the federal government will take the lead in addressing the projected physician shortage. I am pretty sure that most will find it inconceivable that the federal government would establish a program designed to catalyze the development of new schools, or the expansion of enrollments in existing schools. Maybe, but it is worth recalling that federal programs designed for those very purposes were largely responsible for doubling the number of students enrolled in allopathic medical schools in this country during the 1960s and 1970s.
Regardless, I think that increasing the aggregate supply of physicians deserves the undivided attention of the academic medicine community for the simple reason that it is the most important health policy issue facing this country. If the projected shortage of physicians materializes to the degree expected, many individuals in this country will find it extremely difficult, if not impossible, to obtain needed medical care. And those who will suffer most will be those who are currently uninsured or underinsured. Think what this will mean for efforts under way to eliminate the health disparities that exist largely along socioeconomic lines in this country. But if the magnitude of the projected shortages is close to being accurate, it will also have an impact on the health of those who are not among the most vulnerable of our citizens.
I acknowledge that efforts to increase federal funding for biomedical research and other mission-related activities conducted in academic medical centers are important. But what meaning will the results of those efforts have if the patients who are to be served by them cannot gain access to the medical care they need? And what does it say about the professional values held by physicians in the academic community if we do not commit ourselves to this effort? I think we need a concerted initiative to impress on policy makers the seriousness of the issue we are facing. And the time to start is now.
Michael E. Whitcomb, MD