Adler, Benjamin; Biggs, Wendy S. MD; Bazemore, Andrew W. MD, MPH
At a time of strained federal and state budgets and amid calls for cost containment and accountability in both health care and physician training, it is important to develop strategies to align the use of scarce resources with population needs.1,2 Subsequent to the 1980 Graduate Medical Education National Advisory Committee report that projected an oversupply of physicians by 2000,3 medical schools had two decades of limited growth. In 2005, the Council on Graduate Medical Education (COGME) predicted that demand for physicians would grow rapidly after 2015 because of projected U.S. population growth, population aging, and increased need for services because of expanded access to health insurance.4 The Association of American Medical Colleges (AAMC) responded by recommending a 30% increase over 2002 enrollment in MD-granting medical schools by the year 2016, indicating that “increases in enrollment are particularly appropriate in areas of the country where the population has grown rapidly over the past 25 years and areas where the population is projected to grow rapidly in future years.” The AAMC noted that expansion “may also be appropriate” in “states with low medical school enrollment per capita.”5
Between 2005 and 2012, enrollment increased dramatically at both U.S. MD-granting and DO-granting medical schools (hereafter, MD schools and DO schools).6,7 The United States lacks the type of national coordinating structure present in other Western nations. Allowing uncoordinated expansion rather than acting on a national level may result in the misalignment of new and existing resources compared with population needs, and it risks “serious consequences in the years ahead.”8
If, as Cooke et al9 suggest, medical education is a public good, we agree with Boelen and Hack10 that medical schools should be accountable for the society’s health, especially if they receive funding from public sources. State stakeholders fund institutions with the “potential to increase the supply of physicians inclined to practice in the community, region, or state.”11 Although their applicants come from a national cohort instead of a local or regional one, private medical schools receiving local and/or regional investment also need to be accountable to those stakeholders. One measure of medical schools’ social accountability is their outcomes10—that is, how well their graduates meet local and regional health care needs, such as providing an adequate primary care workforce. Despite evidence tying access to primary care physicians to improved community health outcomes and decreased costs,12–14 medical student interest in primary care and, thus, medical school output of primary care physicians, has been declining.15
In this Perspective, we explore four key measures—population growth, primary care physicians per capita, medical students per capita, and medical school retention rate (i.e., percentage of medical school graduates who return to practice medicine in the state of their medical school)—and their relationship to medical school expansion at a state level. Our intent is to inform the current medical school enrollment expansion process and to speak to the need for coordination and evaluation around the much debated, but likely inevitable, expansion of graduate medical education (GME).16,17
Data Collection and Analysis
To explore our four measures and their relationship to medical school expansion, we studied data on provider supply and medical school enrollment using the established national health workforce and training site datasets described below. We then examined state-level associations between total medical school enrollment and population change, medical school retention rate, and supply of primary care physicians.
For these analyses, we obtained from the AAMC 2011 State Physician Workforce Data Book18 counts of MD and DO students enrolled in 2000 and 2010 (for most states), residents and fellows in Accreditation Council for Graduate Medical Education–accredited programs in 2000 and 2010, and the number of active patient care primary care physicians in 2010. Primary care was defined as adolescent medicine, family medicine, general practice, geriatric medicine, internal medicine, internal medicine/pediatrics, or pediatrics; active patient care physicians were those predominantly providing clinical care and excluded residents, fellows, and physicians who were classified as retired, semiretired, temporarily not in practice, or inactive for other reasons. The American Association of Colleges of Osteopathic Medicine provided numbers of DO schools.19
The University of Washington School of Medicine (UWSOM) contracts with the states of Wyoming, Alaska, Montana, and Idaho, which do not have medical schools of their own, to provide state-subsidized positions in its medical classes to citizens of those states through the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) regional medical education program. Because of this unique arrangement, we obtained medical student admission data directly from the UWSOM, which we used to determine enrollment for those states in 2000 and 2010.
We gathered state population data from the 2000 and 2010 U.S. Census.20 We obtained states’ medical student retention rates from the Med School Mapper,21 which uses practice address and school of graduation information for all physicians in the 2009 American Medical Association (AMA) Physician Masterfile. For each state, all physicians labeled as “in direct patient care” who graduated from a medical school in the state were identified to determine the proportion with an in-state practice address. The WWAMI program provided state retention rates derived from UWSOM data and the 2009 AMA Masterfile.
Observations of Variations in State Patterns of Expansion
From 2000 to 2010, the total U.S. population grew by 10%. Nevada (+35%), Arizona (+25%), Utah (+24%), Idaho (+21%), and Texas (+21%) experienced the greatest growth (Figure 1), whereas the population did not increase in Michigan. Over the same 10 years, total enrollment at MD schools and DO schools increased in Washington, DC, and every state except Utah and Montana. Nine states increased total enrollment by more than 50% from 2000 to 2010: Nevada (+274%), Arizona (+117%), Colorado (+109%), Alaska (+97%), Florida (+87%), West Virginia (+80%), Virginia (+58%), Wyoming (+57%), and Washington (+57%). Increases in enrollment of 5% or less occurred in Connecticut, Kansas, and Iowa. Overall, between 2000 and 2010, MD school enrollment increased by 13.9%.15 (For state-level population change and medical school enrollment data, see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A163.)
The number of medical schools has also increased. By 2013, the Liaison Committee on Medical Education listed 15 new medical schools established since 2005 with applicant (3), preliminary (7), or provisional (5) status.22 The number of DO schools expanded from 20 in 2003 to 37 in 2013, including branch campuses and satellites,19 and their first-year enrollment approximately doubled (2,968 to 5,778).6 The proportion of MD and DO students enrolled in public medical schools in 2010 is provided in Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A163.
From 2000 to 2010, median state population growth was 7.4%, while median enrollment growth was 14.7%, with a wide variation in concordance and discordance between these measures across the states. Concordant expanders like Nevada and Arizona experienced large population growth (35% and 25%, respectively) alongside large expansion in medical student enrollment (274% and 117%, respectively). Concordant maintainers like Kansas, Nebraska, Iowa, and Maine had little population growth and little enrollment expansion. Discordant expanders like West Virginia and Michigan increased total medical school enrollment (80% and 37%, respectively) but had little if any population growth (2.5% and −0.6%, respectively). Discordant maintainers decreased enrollment despite population growth; Utah, for example, had a 2.9% decrease in enrollment, but its population grew by 23.8%.
As of 2009, states’ cumulative medical school retention rates (the percentage of graduates of medical schools in a state who return to practice in that state) ranged from 10% in New Hampshire to 67% in Wyoming (see Figure 2 and see Supplemental Digital Appendix 1 at http://links.lww.com/ACADMED/A163). Wide variation in concordance and discordance existed between retention rate and enrollment growth. States like Alaska, Mississippi, and Georgia showed significant enrollment expansion and relatively high retention rates. The much smaller enrollment increases in Nebraska, Iowa, and Missouri were concordant with those states’ lower retention rates. In contrast, the substantial enrollment increases in New Hampshire, Vermont, West Virginia, and Nevada were discordant with these states’ low retention rates. Utah, Alabama, and Arkansas showed discordance with high retention values but little to no enrollment growth.
Figure 3 compares states’ primary care physician supply with their medical school enrollment in 2010, informing states on their ratio between number of medical students and their current primary care physician supply and allowing comparisons between states. For example, Michigan and New York have higher numbers of MD/DO students per 10,000 people in their state and a higher than median number of active primary care physicians. States like Missouri and Nebraska are also above the national median in MD/DO students per capita but are below the median for primary care physicians per capita. Other states with fewer active primary care physicians and a lower number of MD/DO students per 10,000, such as Florida and Utah, may face a substantial shortage of primary care physicians in their state in the future. If GME positions do not increase proportionately to medical school enrollment, however, more graduates will leave their medical school states for GME training and may not return to practice there. Supplemental Digital Appendix 1, http://links.lww.com/ACADMED/A163, displays the changes in GME positions by state alongside the changes in medical school enrollment over the same 10-year period, 2000 to 2010.
A recent AAMC report highlighted current or projected physician shortages in 33 states, especially in rural areas.23 These shortages will be exacerbated by an aging populace and an aging physician workforce.22 Most states and their medical schools have responded to forecasted shortages by increasing enrollment, a process that is ongoing. Our analysis of the free-market expansion of medical schools and enrollment, however, illustrates variations in correlations between expansion and measures of population need and physician workforce capacity. The AAMC projects that first-year medical school enrollment in 2018 will be 30% above the 2002 enrollment, which meets the enrollment increase it recommended in 2006.24 More than three-fourths of the increase (76%) is expected to be due to increased enrollment in existing schools.24 Current projections suggest that existing public schools will increase their enrollment more than private schools (23.2% versus 12.8%).24 Future osteopathic enrollment is projected to triple from 2002 levels to reach 7,253 by 2016.7 By 2017, combined first-year MD and DO student enrollment will have increased 37% over 2002–2003 enrollment.25
States funding new medical schools or the expansion of existing ones hope that they will train physicians who will eventually practice in the state, particularly in shortage disciplines such as primary care.23 Figure 3 may help inform medical schools and states on policy changes or financial incentives for primary care. States with fewer primary care physicians per 10,000 people and with a high medical student enrollment rate may consider enacting policy or legislation to encourage medical student selection of primary care. Medical schools in states with a lower ratio of primary care physicians to the state population may advocate for state financial support for curricular changes or loan repayment programs designed to encourage medical student primary care specialty selection. Absent sufficient and well-targeted GME training positions, however, the main effect of medical school expansion may be to squeeze international medical students out of GME positions rather than increasing the pipeline of students who remain in state and practice in primary care and other specialties in which providers are needed.26 Seifer and colleagues27 found that resident physicians who attended medical school in the same state as their GME training institution were more likely to remain in the state after they completed their residencies. Although the number of federally funded GME positions was capped at 1996 levels due to the Balanced Budget Act of 1997,28 some hospitals have added unfunded residency slots. Most of these new positions are not in primary care, however.29,30
Sixty-three percent of medical students enter a school in their state of residence, but only 39% of MD and DO students return to practice in the state where they went to medical school.18 The medical school retention rate is higher (47%) among students who attend public medical schools.18 Increasing medical school enrollment in states without sufficient GME positions and with medical student retention rates below the national median may not be a prudent investment.26 States with low retention rates and state-funded medical education may want to consider enacting policy or passing legislation directed at increasing retention of medical students and supporting need-based GME expansion.
Several limitations to the datasets used in this analysis exist. The AMA Physician Masterfile has been known to be slow to remove retired physicians, and listed practice type is self-reported. Direct patient care physicians may not translate into full-time equivalents. The addresses used to determine retention rates may be flawed for some physicians (e.g., out of date, different from the physician’s practice location). The retention rates used are historical and may not reflect more recent trends. Medical school expansion that appears uncoordinated or discordant to population growth or current ratio of primary care physicians to population may reflect efforts to combat an earlier deficit of physicians in the state. Similarly, low medical student retention rates may be counterbalanced by higher resident retention rates.
Recommendations and Conclusions
These maps and data may assist states and academic health centers in developing state or regional solutions to medical school enrollment and physician shortages. By providing enrollment data for both MD schools and DO schools, this analysis provides a more complete picture of each state’s total medical school enrollment. Although the 22.9% increase in total U.S. medical school enrollment18 from 2000 to 2010 will increase supply of physicians, as the COGME suggested, an increase in supply “will not in and of itself address issues of maldistribution of physicians.”4
We offer the following recommendations to help states and academic health centers develop strategies for expansion of physician training to accomplish the goal of improving access to care. First, local and regional health care needs, such as population growth, access to care, and the geographic distribution of physicians, should inform medical school expansion efforts. Second, coordinated efforts among neighboring states, such as the WWAMI model at UWSOM, should be pursued where appropriate given the high costs of medical education.
Third, policies encouraging careers in primary care are needed at the preadmission, admission, and curriculum levels. In terms of increasing the primary care workforce, prioritizing the admission of students with known intentions and characteristics conducive to choosing primary care is crucial.31 Medical schools that increase enrollment by creating or expanding branch campuses may graduate more physicians who will practice in primary care, because medical students educated on branch campuses are more likely to enter primary care.32 Fourth, new medical schools’ intentions to increase the supply of physicians in primary care should be assessed by measuring graduates’ practice five years after graduation.33
Finally, the manner in which medical school expansion occurred after warnings of provider shortages may foretell the course of future GME expansion. Thus, when GME training slots are increased and the “‘key bottleneck’ … in fulfilling the call to increase medical supply”34 is loosened, we recommend that state and federal stakeholders find ways to coordinate expansion to meet societal needs for more equitable distribution of physicians according to specialty and geographic location.
Acknowledgments: The authors thank the Robert Graham Center staff. They also thank Mr. Sean Finnegan for his mapping expertise, Dr. Jennifer Rankin for her insightful feedback, Dr. Suzanne Allen for her explanation of and data from the University of Washington School of Medicine’s WWAMI program, and Dr. Leonard Morse for his wisdom and support.
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