Kirch, Darrell G. MD; Salsberg, Edward MPA
With 30 million Americans now living in federally designated Health Professional Shortage Areas and increasingly frequent reports regarding shortages in selected medical specialties (eg, geriatrics, primary care, oncology) and within certain states, the United States already faces a physician shortage.1 Given the growing number of Americans over age 65 (who use twice as many physician services compared with younger patients2) and medical advances that have made it possible for more Americans to live longer with chronic disease, this shortage is likely to become even more acute.
In response to these facts and numerous other concerns about a US physician shortage, the Association of American Medical Colleges (AAMC) in 2006 called for a 30% increase in student enrollment at Liaison Committee on Medical Education (LCME)-accredited schools by 2015.3 Concomitant with this recommendation was a call to substantially increase the number of federally supported residency training positions at the nation’s teaching hospitals.
The US medical education community has been responding in several ways to the anticipated shortage and need to increase capacity. Individual medical schools have expanded, or are planning to expand enrollment, the AAMC has been closely monitoring key trends and physician practice patterns, and efforts have been initiated to gain a better understanding of related dynamics, such as the rapidly growing number of physicians with degrees in osteopathic medicine (DOs) and international medical graduates (IMGs).
Using data from several recent surveys and reports by the AAMC Center for Workforce Studies (CWS), this article discusses the medical education community’s response to the physician shortage along 3 key dimensions: physician entry, physician exit, and changes in the expectations held by the newest generation of doctors. The article then discusses why strategies in addition to medical school expansion also must be considered, and how the broader reexamination of medical education now underway holds the potential for providing some of the flexibility needed in education and training to help address the shortage. Finally, some of the implications specific to surgical specialties will be noted.
Although many factors influence entry to the physician “pipeline,” including the aspirations of a growing number of universities to create new schools, the focus here is on 3 approaches being used by existing LCME-accredited medical schools to expand enrollment and some of the barriers faced in implementing these plans. Additionally, key factors, such as the burgeoning numbers of DOs and IMGs and the need to increase the number of federally funded residency training positions, are discussed.
A Trend Toward Rising Enrollment
In assessing whether and how to expand enrollment, LCME-accredited medical schools have undertaken a wide array of activities and studies such as analyzing the financial aspects of expansion, assessing the depth and quality of their applicant pool, constructing new teaching space, and/or developing new teaching or curriculum methods. All of these activities are ongoing.4
To learn about these activities and studies in depth, the AAMC conducted its third annual survey in 2006 regarding the expansion plans of US medical schools. The survey was designed to assess the likelihood of medical schools expanding enrollment during the next 5 years and to track enrollment and expansion trends over time. Of the 125 LCME-accredited medical schools in the United States, 121 participated in the survey. Together, these schools represent a mix of institutions that already have undertaken plans to expand future capacity or recently have expanded, as well as medical schools that have indicated such expansion is “probable,” or “possible.”
The survey findings show that the US medical school community is making significant progress in responding to the AAMC recommendation for a 30% increase. On the basis of the survey responses, the AAMC forecasts first-year enrollment in LCME-accredited schools to rise to 19,296 in 2012, a 17% increase from 16,488 in 2002 (Fig. 1). In fact, one-third of this projected increase has already occurred, with the number of first-year medical students increasing from 16,488 in 2002 to 17,370 in 2006.4
Although schools across the country are expanding, the greatest expansion is in the southern and western parts of the United States (the so-called Sun Belt) where medical schools are planning to grow more significantly (18% and 31%, respectively) compared with schools in the northeastern and central sections of the nation (10% and 13%, respectively).4 Notably, it is in these areas of population growth (which also have fewer MDs per capita) where public pressure on state governments to address the shortage has been greatest. Correlating with this increased demand for government action, the survey found the greatest growth to be in public medical schools (19%) as opposed to in private medical schools (11%).4
Expanding Medical School Capacity and Enrollment: Three Approaches
The survey results show that a total of 93 schools have expanded or will do so between 2002 and 2012.4 The largest increase projected among these schools is 165%.4 Of those schools planning to increase capacity between now and 2011–2012, the median planned expansion is 16%.4
In general, existing medical schools are using one or more of the following approaches to expand enrollment: (1) expanding in place, (2) developing a regional, or branch campus, and (3) establishing new affiliations.
Expanding in Place
This first approach involves maximizing marginal capacity, ie, undertaking only minimal, if any, new construction or renovations of key facilities such as lecture halls, small group teaching rooms, gross anatomy laboratories, and similar facilities. According to the AAMC survey, 50% of medical schools have used or are planning to use this approach,4 indicating that at least some unused capacity has existed within the current physical infrastructure of our nation’s medical schools.
Developing a Regional or Branch Campus
The second approach, and one that might appear to have certain inherent efficiencies, is “borrowing” from a medical school’s existing infrastructure to develop a regional campus (also known as a branch campus or, when the focus is on third- and fourth-year students, a clinical campus). Following a “boom” in the early 1970s, when the majority of today’s clinical branch campuses were founded, relatively little new activity occurred until the 1990s when an additional 9 regional medical campuses were founded.5 Today, regional campuses are again a viable option for many schools to expand class size. According to the CWS survey, approximately 22% of schools with plans to increase enrollment report they will use this approach.4
There are several benefits to this approach. The first and obvious benefit is that it enables schools that have reached the limits of clinical capacity to teach medical students in their academic centers to expand in locales that have the clinical resources to support a robust medical education program. Second, it allows an existing medical school to serve areas within the state that are rapidly growing and/or chronically underserved.
Further, there is the potential that in time, the clinical campus will evolve into a full 4-year MD program. Texas Tech University Health Sciences School of Medicine’s El Paso campus, the University of Arizona’s Phoenix campus, and Mercer University School of Medicine’s Savannah campus all began as regional sites for third- and fourth-year students, but now plan to offer a full 4-year MD program to complement the efforts of each home campus.
Recognizing the growing interest in this strategy, and the wide range of issues inherent in providing quality medical programs on branch campuses, the AAMC in 2002 established the Group on Regional Medical Campuses (GRMC). In addition to providing a forum for ongoing discussion, the GRMC mission is to foster professional growth and development among the executives leading regional campuses.
Establishing New Clinical Affiliations
A third expansion strategy—one that the majority of schools surveyed (68%) have used or plan to use—is developing new affiliations, especially for the provision of clinical teaching.4 Often these affiliations are established with community-based, or nonuniversity-based hospitals. Although the physical capacity to teach the basic sciences is also an issue, finding clinical placements is generally perceived to be a larger obstacle in expanding medical school capacity. Accommodating more students for teaching clerkships and electives is especially challenging to faculty and their residents who operate under increasing pressure to maximize clinical productivity.
Additional Barriers to Expansion
Depending on the approach being considered, medical schools face a number of other barriers to expansion. The availability of scholarship funds was regarded by almost half of schools responding as a significant barrier (49%), followed by the availability of ambulatory preceptors (44%), classroom space (44%), general costs (41%), and ambulatory training sites (39%).4
Significantly, only 3.5% responded that the quality of the available applicant pool poses a barrier.4 Further, it is important to consider whether this issue is primarily a function of the high expectations currently placed on applicants’ premedical credentials. These credentials, especially the required premedical courses that place a heavy emphasis upon math and the physical sciences, represent the area of medical education that has changed the least in recent years. It will be important to consider whether the longstanding expectations of premedical qualifications are consonant with future practice. It is quite possible that significant changes in premedical expectations could have a major positive effect on the size of the qualified applicant pool. In addition, a recent AAMC analysis indicated that a number of factors make it likely that the applicant pool will be sufficient into the foreseeable future.6
Other Important Workforce Entry Considerations
Although medical schools are undertaking expansion, the numbers of DO graduates and IMGs continue to grow rapidly. Together, these 2 physician groups currently account for one-third of the US physician pipeline (at 12% and 26%, respectively), with US MD graduates comprising the remaining two-thirds (about 62%).7,8 The medical education community, through the AAMC, has initiated several activities to better assess the implications of this rapid growth for the quality of medical education and delivery of care.
For years, US medicine has been characterized by 2 parallel medical school tracks—allopathic and osteopathic. For reasons of history, geography, and professional political forces, these 2 tracks educationally remained independent of each other with minimal interaction.
With first-year enrollment in DO programs projected to increase 53% from 3079 in 2002 to 4724 in 2012,7 the growing presence of DOs in the US physician workforce should not be overlooked. Further, many DO-granting schools are pursuing an expansive strategy keyed on building capacity in areas of high population growth. As a result, long-established DO schools in Pennsylvania and Missouri are developing new campuses in Florida, Georgia, and Arizona.
In an effort to determine whether greater common ground exists between these 2 tracks of medicine than previously acknowledged, the AAMC and its Council of Deans have initiated a process to assess the relationship between MD-granting and DO-granting institutions. Earlier this year, members of an internal AAMC task force met to identify key issues for consideration.
International Medical Schools and Their Graduates
With 1 in 4 US practicing physicians having received their undergraduate education from a foreign medical school,9 IMGs constitute a significant presence in the physician workforce. The contributions by IMGs to US health care are numerous, with many choosing to take up specialties found less attractive by US MD graduates and committing to work in medically underserved areas.10 However, the growing number of physicians in US residencies who received undergraduate degrees from Caribbean schools (including US citizens) raises important issues about the quality of education received and the foundation these graduates bring to specialty training.
One need only consider that 3 of the top 5 countries sending medical school graduates to the United States for residency were Dominica, Grenada, and Netherland Antilles. The 2 schools in Dominica and Grenada each place more graduates into Accreditation Council for Graduate Medical Education (ACGME) residency programs than any US medical school.8 This last statistic underscores a point made earlier about the quality of the applicant pool. There is the interesting irony for US medical education that a US citizen can be assessed as unqualified for admission into a US medical school, but 4 years later, be readily admitted into 1 of the country’s residency training programs after graduating from a foreign school. Given the lack of consistent, well-known accreditation standards and processes and the resultant likely variation in the quality of education provided by these institutions, the medical community (including representatives of the AAMC) is working with a group in the Caribbean to better understand the all-important issue of accreditation of “offshore” schools in that region.
Residency Training Positions
A critically important variable in the capacity of the US physician pipeline is the number of residency training positions. Although the Balanced Budget Act of 1997 imposed caps that significantly limited the number of federally funded residency positions available, the overall number of resident positions actually increased over the last decade, from 98,000 in 1995–1996 to 103,106 in 2005–2006.11,12 Health system leaders, despite the absence of additional direct and indirect federal support for residency training, have added residency positions using clinical funds to increase the numbers of physicians trained in critical specialties. Because, ultimately, physician entry is defined by graduate medical education capacity, the AAMC recommendation to expand medical school enrollment is coupled with a strong recommendation to increase support for federally funded residency positions.
Physician exit is an important workforce dynamic that is only beginning to be measured and assessed. To gain a better understanding of physician attitudes at the career stage approaching retirement, the AAMC CWS, in collaboration with the American Medical Association (AMA) and 8 specialty associations, conducted a survey in 2006 of physicians over age 50 (AAMC-AMA 2006 Survey of Physicians Over 50, unpublished report). All of the data in this section refer to findings from this survey.
Overall, the survey revealed high levels of satisfaction (“somewhat” or “very satisfied”) along several dimensions among the majority of physicians over 50. Approximately 82% of respondents reported they were satisfied with medicine as a career, 85% said they were satisfied with their specialty, and 80% answered they were satisfied with their position. However, when these same physicians were asked to compare their status to 3 years ago, the survey showed an increase in dissatisfaction. Nearly 40% replied they were “somewhat” or “much less” satisfied (Fig. 2).
A surprising finding resulting from preliminary analysis of survey data was whether active physicians over 50 would retire today if income were not a factor. The answer was more than 1 in 3 (37%) would retire, a finding that, if realized, would have a drastic impact on the physician workforce and American health care. The percentage of those who would retire if financially able to do so decreases with age, with 42% of those aged 55 to 59 reporting they would exit if income were not a factor compared with 27% of those aged 65 to 69.
Additional reasons physicians would consider exiting the workforce earlier than planned, with some variation between the genders, were stress of practice (women 50%, men 41%), insufficient reimbursement (women 45%, men 44%), increased regulation of medicine (women 46%, men 47%), and decreasing clinical autonomy (women 43%, men 41%). Other factors measured by the survey were on call responsibility (women 41%, men 36%), rising malpractice costs (women 41%, men 42%), lack of professional satisfaction (women 39%, men 31%), interest in pursuits not related to medicine (women 33%, men 24%), personal health issues (women 29%, men 22%), effort to keep clinically current (women 31%, men 19%), increased family responsibilities (women 24%, men 11%), and recertification requirements (women 21%, men 14%).
Taking into consideration the data emerging from the initial analysis of survey results, it appears that previous forecasts may have significantly underestimated physician retirement. For example, the model used in the past by the Health Resources and Services Administration would estimate 760,000 physicians in active practice 23 years from now (in 2030) (Fig. 3). According to the AAMC CWS, however, data based on the actual and expected plans of physicians over age 70 would place that figure closer to 740,000. If the actual and expected plans of doctors over age 50 are considered, the total number would be closer to 712,500, or nearly 50,000 fewer doctors in practice.
Having identified some of the factors that might cause physicians over 50 to retire earlier, the survey posed the inverse question: What factors would entice them to practice longer? The most persuasive factor, at 51% of older physicians surveyed, was the availability of part-time work and/or more flexible scheduling. More than one-fifth of these physicians already were working part time, and another 46% were either considering or wanted the option to work part time. (It is important to note that although such flexibility might keep some doctors working longer, others might reduce their hours, but still retire at the same age. Therefore, the implications of these findings are unclear.) Other factors that might convince these physicians to stay in the workforce longer were the elimination of paperwork/reducing bureaucracy (33%) and the ease of changing specialties (9%).
EXPECTATIONS OF A NEW GENERATION
A third important factor in the workforce equation pertains to the expectations held by a new generation of physicians entering the workforce. To better understand these expectations, the CWS joined with the AMA to conduct another survey in 2006, this one focusing on physicians under age 50 (2006 AAMC-AMC Survey of Physicians Under 50, unpublished report). All of the data in this section refer to findings from this survey.
Preliminary analysis of these data indicates that, when asked to rate factors “very important” to a desirable position, 71% of younger physicians pointed to work-life balance. Additional factors rated as important were support staff and services (43%), income potential (42%), practice income (39%), flexible scheduling (37%), health insurance coverage (35%), no or very limited on-call responsibilities (31%), adequate patient volume (30%), and the opportunity to advance professionally (28%). It is interesting to note that some of the factors younger physicians consider very important in accepting new positions are the same ones older doctors said might keep them in the workforce longer.
Interestingly, some of these expectations vary by gender. With female students accounting for nearly half of all medical students (48.8% as of 2005–2006),13 this gender shift very well may have significant workforce implications in coming years. The greatest difference between young male and female doctors is their view of full-time versus part-time work. According to the survey, 28% of female physicians now work part time and 22% are considering it for later, compared with 4% of male physicians who work part time and 10% who are thinking about it for the future (Fig. 4).
Overall, younger doctors appear less inclined to trade time off for increased income. Over two-thirds (66%) of respondents said they would not be willing to work longer hours for more pay, and most (80%) replied that they would reduce their hours now, if income were not a factor.
WORKFORCE STRATEGIES GOING FORWARD
The AAMC recommendations to expand medical school enrollment and achieve a concomitant increase in the number of federally supported residency training positions are critical first steps toward meeting future workforce needs, but will close less than half the projected gap between supply and demand in 2020. In addition to undertaking enrollment expansion plans, LCME-accredited medical schools and teaching hospitals are beginning to reexamine longstanding views about medical education and explore innovative approaches to clinical care.
A New Emerging View of Medical Education
Efforts by the medical education community to address the workforce shortages are occurring at a time when medical education itself is undergoing intense reexamination. Historically, the community has generally viewed medical education as largely independent compartments, with separation between premedical, medical school, residency, and continuing medical education. Recent national meetings indicate that leaders in medical education and in surgical and other specialty associations, and regulatory bodies, are beginning to view medical education more as a single, integrated continuum, and are beginning to design interventions accordingly.
The potential for redesigning aspects of this continuum, ranging from premedical requirements to the manner and assessment of skills enhancement in practice, is under active discussion on multiple fronts. In particular, the emphasis on knowledge-based examinations is being rethought, with a new focus on assessment of competencies specific to individual career path and practice.
A competence-based “individualization” would result in a medical education community in a much better position to respond to physicians with nonlinear career pathways. For example, given the shifting expectations of younger physicians, it would be important to respond more readily to those who—for any reason—wish to retrain or to change specialties.
Innovative Clinical Solutions to Immediate Workforce Shortages
Like medical schools, teaching hospitals and clinics are pursuing innovative strategies to rethink longstanding issues, and are developing innovative approaches to addressing immediate, specific shortages. The redesign of clinical care delivery models can make the existing physician workforce more effective, while also reducing unwanted practice variation and improving quality.
One workforce dynamic that bears special mention is the potential for more creative interdisciplinary configurations of the care delivery team. The experience of academic surgical practices in making use of various types of “physician extenders” to manage the constraints of new duty hours is a case in point. The fundamental question is not how many physicians exist in each specialty and subspecialty, but rather, how do we bring health professional teams together to meet the primary and specialty care needs of the population?
IMPLICATIONS FOR SURGERY AS A SPECIALTY
The overall workforce landscape raises some interesting and challenging questions with which surgery as a specialty must grapple. One set of questions stems from the AAMC–AMA surveys. For example, given the changing demography of our population and our best projections regarding the epidemiology of surgical problems, what should be the specific response of surgery regarding residency expansion? With the desire expressed by so many older physicians to engage in part-time practice and have more flexible schedules, how would issues such as surgical continuity of care and liability insurance be resolved? And, with so many younger physicians of both genders expressing very different work-life balance expectations, would surgical training and practice require major redesign? Also, how can nonphysician providers be most effectively integrated into surgical care?
Another set of questions pertains to education and training. In the face of looming shortages, is the combined time length of premedical, medical school, and surgical training no longer tenable, and are creative strategies needed to achieve shortening?
Finally, and perhaps most importantly, how can the vexing issue of physician maldistribution and underserved areas be most effectively countered? Clearly, the national leadership of surgery as a specialty must be prepared to engage actively with all these complex questions.
In the face of major demographic changes, the mounting evidence of physician shortages in the United States creates a compelling need for medicine as a profession—and for individual specialties—to take action. The medical school community already is in the process of a significant expansion of medical education capacity. The key workforce pipeline question remaining largely unresolved is how the critical factor of increasing support for residency training will be addressed. In addition, it is clear that isolated workforce planning by individual specialties or by medicine independent of the response of other health professions will not adequately respond to the overall health needs of the population. In a world marked by team models of care, health care workforce planning must be interdisciplinary.
Every crisis also represents an opportunity. The looming physician workforce crisis indeed will be an opportunity for the medical education community to think about redesigning the continuum of education. The positive result could be a more time-efficient process, one that selects learners well suited to the practice of the future and that measures lifelong development of competencies specific to their individual practice. This opportunity is one that American medicine should not ignore.
The authors thank Louise Arnheim, MPA, Clese Erikson, MPAff, Susan Monseur, BS, Rajeev Sabharwal, MPH, and Marian Taliaferro, MSLS, for their help in the preparation of this manuscript.
© 2007 Lippincott Williams & Wilkins, Inc.