Whitcomb, Michael E. MD
Those in the academic medicine community who are particularly concerned about the projected shortage of physicians in this country take comfort from the fact that many allopathic medical schools are increasing their enrollments and several new schools are being established. Despite these favorable developments, it appears that the target for increasing enrollments (a 30% increase) will not be realized in the foreseeable future. Even more important, however, is that the increase in medical school enrollments that will occur is unlikely to result in an increase in aggregate physician supply.
As I pointed out in a previous editorial,1 if the number of entry-level positions (PGY-1s) in the country’s graduate medical education (GME) system remains constant, an increase in allopathic medical school graduates will almost certainly mean that fewer graduates of osteopathic medical schools and non-U.S. schools will be accepted into residency training programs. Thus, when all is said and done, the aggregate supply of physicians will remain unchanged. If the academic medicine community truly believes that the aggregate supply of physicians must be increased to serve the needs of the American public, then the leadership of the community must begin to develop a comprehensive strategy for increasing the total number of PGY-1 positions in the system.
A little over a year ago, I argued that the community needed to make a concerted effort to convince public policy makers of the importance of addressing this issue.1 At that time, I viewed efforts to convince the Centers for Medicare and Medicaid Services to remove the caps imposed on the number of GME positions eligible for Medicare funding in teaching hospitals as a necessary step for increasing physician supply. On second thought, I believe I was being far too simplistic in assuming that this action alone would have the desired effect. In fact, I now doubt that removal of the caps will have much of an affect on physician supply. Allow me to explain.
To begin, it is critically important to understand that while removal of the caps may result in an increase in the total number of positions available in the system, it will not necessarily result in an increase in PGY-1 positions. Since the caps were imposed in 1997, a number of teaching hospitals have been willing to fund positions in excess of their cap. However, virtually all of the positions that were added increased the number of subspecialty fellowship positions in the system. Thus, if the removal of the caps simply allows teaching hospitals to continue recent practices, it will have no meaningful affect on the number of PGY-1 positions. Accordingly, it will have no impact on the aggregate supply of physicians in the long term. Thus, any policy that evolves at the federal level to increase physician supply must link the removal of the caps to an increase in PGY-1 positions. But even if that occurs, it is unlikely for several reasons that the number of PGY-1 positions in the system will increase to any significant degree.
First, I doubt that many teaching hospitals will be willing to increase their GME budgets to the degree that would be required to achieve the desired goal. Remember that hospitals that agree to increase PGY-1 positions must be willing to provide out of existing patient-care revenues the funds required to cover the increased cost not provided by additional Medicare funds (i.e., Direct GME payments). For example, a hospital in which Medicare patients account for roughly 40% of its total patient-days would have to cover from existing patient-care revenues approximately 60% of the increase in its GME budget. In projecting the total cost to the institutions, one must remember that an increase in PGY-1 positions will require a corresponding increase in positions in subsequent postgraduate training years (e.g., two additional years in internal medicine and pediatrics, four additional years in surgery, etc.). Thus, if one assumes that the total number of GME positions will increase to accommodate the increase in allopathic medical school graduates, the total increase in the GME budgets of existing teaching hospitals will be extremely large. Second, and perhaps even more important, many of the institutions currently sponsoring residency programs probably do not have the capacity to expand the size of their core residency programs (those that relate to the clinical clerkships required in the medical school curriculum) because of a lack of an adequate patient volume.
If my assumptions are correct, the only remaining way to significantly increase training positions in core specialties is to significantly expand the size of programs in institutions whose existing programs are small relative to the patient base of the hospital (generally community hospitals) and to develop new programs in hospitals that currently do not sponsor GME. Based on personal experience, it is clear to me that accomplishing either of these objectives will be extremely challenging. At present, plans are under way for the development of new regional clinical campuses and new medical schools in locations where none of the hospitals in the community currently serve as major sponsors of GME. To date, little progress has been made at any of those sites in formulating a coherent plan for the development of the full complement of GME programs that generally exist in hospitals that serve as a major clinical affiliate for a medical school. I think it is fair to say that few of those involved in the planning appreciated the challenges that would have to be met in order to establish new residency programs.
First, because of the methods employed for funding residency programs, the establishment of new programs has serious financial implications for the hospitals that might be involved. And since the lead time involved in establishing new programs is significant, the institution will incur a significant financial obligation in hiring individuals to serve as institutional officials and program directors long before any residents are enrolled in the new programs.
Second, proposing to establish new residency programs engenders anxiety within the medical staffs of the involved hospitals. Members of the medical staffs will be very concerned about how the establishment of new programs will affect the care of their patients. This is a critical issue, since the medical staff alone have the authority to determine whether residents may be involved in patient care. The medical staff will also be very concerned about whether they will be required to participate in the training of residents, and if so, whether they will be compensated for the time involved.
Finally, institutions will face a major challenge in recruiting the initial classes of residents for the new programs. I believe that most graduates of U.S. medical schools will not find the new programs very attractive. To begin, the programs will have no history regarding the career pathways of recent graduates, such as their success in obtaining subspecialty training in highly respected fellowship programs. And perhaps even more important, applicants cannot be assured that the programs will have a full complement of residents across each of the training years. Thus, potential applicants will not be able to be confident about the nature of the training they will receive.
Given the complexity of all of the issues involved, the leadership of the academic medicine community has to become much more active in developing a comprehensive strategy for increasing physician supply. The time has come for a major professional body to organize a national summit for the purpose of developing a set of action steps for how the challenges involved might be addressed. In preparing for that event, it would be extremely useful if the leadership of one of the institutions that is currently involved in trying to develop new GME programs would engage in a series of strategic planning sessions that could bring clarity to the specific issues involved at a local level. I think such a “case study” could serve as a guide for others who are contemplating starting programs and could contribute a great deal to the national discussion.
Once again, the community faces a fundamental question in trying to address this issue: who will lead?
Michael E. Whitcomb, MD