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Who Will Lead?

Whitcomb, Michael E. MD

doi: 10.1097/ACM.0b013e31802e4156
From the Editor

When this year’s fourth-year students graduate from medical school and begin their practices, they will face a number of major challenges. I’d like to discuss two of those challenges, which are ones that will intensify over the course of the graduates’ careers. First, these new physicians will increasingly be expected to provide high-quality care to patients with chronic diseases. Second, their patients—whatever their medical needs—will become more racially and ethnically diverse as the years go by. A few facts will place the magnitude of those two challenges in perspective.

There are at present approximately 120 million Americans afflicted with one or more chronic diseases, and there will be more with each passing year. Although 85% of current Medicare beneficiaries have chronic diseases, these diseases are increasingly affecting persons in all age groups, including, importantly, children and adolescents. And the impact of this trend on health care will be staggering. Already, 75% of all health care spending is for patients with chronic disease. While it is true that these patients receive most of their care from family physicians and internists, the reality is that all practicing physicians, regardless of their specialties, will find themselves increasingly involved in chronic care.

And it is equally clear that the racial and ethnic diversity of the population of the country will continue to increase. The Census Bureau projects that over the next 35 years, the U.S. population will grow by one fourth to about 400 million persons. At that time, white, non-Latino Americans will probably account for less than one half of the population (almost one fourth of whom will be over 65 years old). Latinos will probably be almost one fourth of the population, non-Latino blacks will be 15%, Asians will be 8%, and a growing number of individuals will identify themselves as being multiracial.

By viewing these two major trends together, the challenge that today’s graduates and the medical profession will face in the years ahead is apparent. Across all specialties, doctors will be trying to provide high-quality health care to a growing population of patients who have chronic diseases—a population that is at the same time becoming both racially and ethnically diverse. But as I pointed out in a previous editorial,1 if current trends continue, the medical profession will increasingly be composed of non-Latino white physicians from families with incomes ranked in the top quintile of all U.S. families’ incomes. Unless this trend is reversed, U.S. physicians will become even less representative of the several populations they must serve.

What is to be done about this? Or, more specifically, what can the medical education community, which selects and trains physicians, do?

Naturally, I have some proposals. First, the education of medical students and residents must be changed to better prepare them to provide high-quality care to patients with chronic illnesses. Second, their education must be changed to better prepare them to provide care to a more racially and ethnically diverse population. And third, steps must be taken so that young men and women from less well-off families, especially from black and Latino families, can view a career as a physician as an achievable goal. If these three steps are not taken in time, Americans will be less well served by the medical profession.

This month’s journal includes three articles (by Arora, Greene, and Sherman and their colleagues) that offer insights into how doctors can be better educated to provide high-quality care to patients with chronic illnesses. These authors’ messages complement what was said in the August issue in the report by Feifer and colleagues2 and the Commentary by Stevens and Wagner.3 As all these authors indicate, medical educators are taking seriously the challenge of educating doctors to provide high-quality care to patients with chronic illness, and are beginning to develop educational programs toward that goal. Needless to say, more needs to be done, including changing in very fundamental ways the clinical settings where future doctors are trained.

This month’s issue of the journal also contains four articles (by Manetta, Freeman, Winkleby, and Odom and their colleagues) that address issues related to the need to increase the diversity of the physician workforce. These authors give examples of the kinds of programs being implemented by medical schools across the country, and also provide insights into the kinds of challenges that must be addressed to produce a workforce that is both more diverse and better prepared to provide culturally sensitive care to patients from diverse backgrounds. Readers should also refer to the June 2006 supplement entitled Lessons Learned from the Health Professions Partnership Initiative (HPPI), 1996–2005.4 The articles in that supplement describe programs developed across the country to increase the interest of grade-school and high-school students in medicine, and recount the challenges that were faced in implementing and managing those programs.

But as promising as these efforts are, they do not fully address what I see as the most critical questions facing the profession: What can be done to increase the diversity of the physician workforce? How can the dream of a career as a physician become a reality for young men and women who come from less well-off families? I am reasonably confident that the medical education community will continue to modify existing programs to improve the ability of students and residents to provide more culturally sensitive care once they enter practice. But I am not convinced that the leaders of academic medicine are ready to take the steps necessary to increase the diversity of the workforce itself. To accomplish this critical objective, the community will have to revise admission strategies (see ideas about approaches to race-neutral admission in the article by Steinecke and colleagues in this issue), realign course and other admission requirements, change the focus of the MCAT to lessen its emphasis on recall of facts, provide financial support to allow less privileged students to apply to medical school, and make it possible for students to complete the medical school curriculum in less than four years.1

But who will lead the effort to bring about these changes? I hope that the leaders of U.S. medicine will act on their responsibility to serve the public by imploring the medical education community to address these challenges, and will help them do so. To that end, could some major professional organization step up and organize a summit of thought leaders within the profession to discuss and debate how the physician workforce can become more diverse? I hope so, for if this challenge is not addressed, the profession will become progressively less representative of the population that it is to serve. For the sake of tomorrow’s patients, we must not let this happen.

Michael E. Whitcomb, MD

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1 Whitcomb ME. Who will study medicine in the future? Acad Med. 2006;81:205–206.
2 Feifer C, Mora A, White B, Barnett BP. Challenges to improving chronic disease care and training in residencies. Acad Med. 2006;81:696–701.
3 Stevens DP, Wagner EH. Transform residency training in chronic illness care—now. Acad Med. 2006;81:685–687.
4 Cleveland EF, Steinecke A, eds. Lessons Learned from the Health Professions Partnership Initiative (HPPI), 1996–2005. Acad Med. 2006;81:S1–S61.
© 2007 Association of American Medical Colleges