Whitcomb, Michael E. MD
Dr. Whitcomb is professorial lecturer in health policy, School of Public Health and Health Services, George Washington University, Washington, DC.
Correspondence should be addressed to Dr. Whitcomb, 526 Sixth St., Annapolis, MD 21403; telephone: (410) 280-0947; e-mail: firstname.lastname@example.org.
Recent studies indicate that the number of first-year residency positions must increase to meet the United States' projected need for physicians, but these studies rarely consider whether it will be possible to increase the country's graduate medical education system to meet the need. State-level studies suggest that most existing programs have already reached their approved capacity, and nonteaching hospitals are unlikely to create new programs because of the financial impact and their lack of faculty and staff who would meet accreditation standards as program directors and institutional officials. A perfect storm is therefore brewing: The effects of the Patient Protection and Affordable Care Act of 2010, the obesity epidemic, the rise in chronic disease, and the aging and continuing growth of the population will combine to create a much greater demand for medical services at the same time as the relative size of the physician workforce will begin to decline. Given the urgency of the situation, the author calls for medical professionals (with significant representation from the academic medicine community) to enter into meaningful partnerships with state and federal officials to develop strategies for addressing this challenge. They must work together to increase the number of entry-level positions to the level needed to produce the doctors required to meet the growing demand for medical care. Otherwise, the perfect storm will soon disrupt the U.S. health care system.
During the past decade, professional organizations, government agencies, and individual analysts have projected that the United States is facing a major shortage of physicians.1 For the supply of physicians to keep pace with the growing demand for medical care, the number of entry-level (postgraduate year one [PGY-1]) positions in the U.S. graduate medical education (GME) system must be substantially increased.2 Given the magnitude of this challenge, it is disconcerting to note that almost no attention has been paid to a critically important issue: whether the nation's teaching hospitals have the capacity to increase the number of PGY-1 positions to the level required.
Estimates of the number of new PGY-1 positions that may be necessary vary depending on the projected number of additional physicians who will be needed by a particular date.3 In 2005, the Council on Graduate Medical Education recommended that an additional 3,000 positions be created by 2015, but acknowledged that this increase would probably not be adequate to maintain a sufficient supply of physicians over time.4 In fact, a more detailed analysis indicates that, based on the current rate of population growth, approximately 10,000 new PGY-1 positions will be needed by 2020 simply to preserve the relative size (number of MDs/100,000 persons) of the current physician workforce.5
In a recent study, Charles and colleagues6 determined that existing U.S. general surgery programs do not have the capacity to add the PGY-1 positions needed to meet the projected demand for general surgeons. Their findings emphasize the importance of recognizing that, on a national basis, residency programs may be limited in their ability to add enough PGY-1 positions to meet future workforce needs in a given specialty.
A recent study conducted in New York examined the potential to increase residency positions in core specialties at a state level.7 In keeping with the results of Charles and colleagues' analysis, the New York investigators found there to be little capacity to do so. The inability to create an adequate number of new PGY-1 positions in the state's teaching hospitals is likely because program sizes are currently close or equal to the sizes approved by the Accreditation Council for Graduate Medical Education, the body that accredits residency programs. Further, the study results indicate that many of New York's nonteaching hospitals are unlikely to establish new training programs; those that may do so are likely to establish only a few, relatively small programs in selected specialties (e.g., primary care). Preliminary results from an ongoing study I am conducting of GME in Florida are identical to the New York team's findings.
The aforementioned studies provide insight into the reasons why nonteaching hospitals are not likely to develop much-needed new GME programs. For hospital executives and governing board members, the degree to which the funding required to start and maintain GME programs would affect the overall financial status of their institutions is an important consideration. In addition, most nonteaching hospitals do not have administrative staff members who possess the knowledge and experience to establish new GME programs and to serve as designated institutional officials for accreditation purposes. Similarly, nonteaching hospitals are not likely to have staff physicians who would be able to meet the accreditation requirements for program directors. Thus, to create new GME programs, institutions would have to hire individuals who could serve in those roles and allow them to spend several years developing the programs before the programs could actually begin. Furthermore, many members of the medical staffs of nonteaching hospitals decided intentionally to pursue a career path that allows them to be engaged in the practice of medicine on a full-time basis and have little or no interest in training residents.
The results of the studies conducted to date therefore suggest that it is highly unlikely that it will be possible to add the number of PGY-1 positions required simply to maintain the relative size of the current physician workforce. The results are not surprising, considering that only about 1,500 new PGY-1 positions were created during the past decade.8 The inability to increase substantially the number of GME positions in core specialties exists at a time when there are forces at play that will produce a growing demand for medical services.9 The impact of the Patient Protection and Affordable Care Act of 2010, the obesity epidemic, the rise in chronic disease, and the aging and continuing growth of the population will combine to create a much greater demand for medical services during the period when the relative size of the physician workforce will begin to decline. It seems clear, therefore, that a perfect storm is brewing—and it will have a major adverse impact on the U.S. health care delivery system.
Given the seriousness of the situation, it is urgent that medical professionals (with significant representation from the academic medicine community) enter into meaningful partnerships with state and federal officials to develop strategies for addressing the challenge at hand. They must work together to increase the number of PGY-1 positions to the level needed to produce the number of doctors who will be required to meet the growing demand for medical care. Absent solutions, the perfect storm that is now brewing will, in the not-too-distant future, disrupt the U.S. health care system to a degree not previously experienced.
3 Center for Workforce Studies. The Complexities of Physician Supply and Demand: Projections Through 2025. Washington, DC: Association of American Medical Colleges; 2008.
4 Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the United States, 2000–2020. Rockville, Md: U.S. Department of Health and Human Services, Health Resources and Services Administration; 2005.
5 Cooper RA. It's time to address the problem of physician shortages. Graduate medical education is the key. Ann Surg. 2007;246:527–534.
7 Edelman N, Goldsteen K, Goldsteen R. The looming physician shortage and graduate medical education capacity in teaching hospitals. Paper presented at: Physician Workforce Conference, Association of American Medical Colleges; May 6, 2010; Alexandria, Va.
8 Erikson C, Jolly P, Garrison G. Trends in Graduate Medical Education in Ensuring an Effective Physician Workforce for America. New York, NY: The Josiah Macy, Jr. Foundation; 2011.
9 Iglehart JK. Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med. 2008;358:1741–1749.