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The Ultimate Challenge

Whitcomb, Michael E. MD

doi: 10.1097/ACM.0b013e318159cc7a
From the Editor

During the six years that I have had the privilege of serving as the journal's editor, I have focused a number of my editorials on major challenges facing academic medicine. Given that, I decided to devote this editorial—my last—to what I view as the most important challenge that the academic medicine community must confront: producing a physician workforce that is truly capable of meeting the public's needs for high-quality medical care.

I am sure that there are members of our community who do not see this as the most important challenge. Instead, some of them will choose the conduct of biomedical research, while others will focus on the role that academic medical centers play in providing highly specialized patient care services. While there is no doubt that there are significant challenges associated with each of those missions and others, I do not believe they are as important as the one I have identified. Why? Because in the absence of an adequate, well-qualified physician workforce, many individuals in this country will be unable to obtain the kind of medical care they have a right to expect. The academic medicine community must take steps to ensure that this does not occur. And I believe that one of the most essential of those steps is to increase the supply of physicians.

Having said that, I am well aware that there are those who discount the importance of studies that project an impending shortage of physicians.1 They believe that the size of the physician workforce is more than adequate to meet the public's future needs for physicians' services.2,3 They take the position that what is needed to ensure that the public's needs are met is not more physicians but a health care delivery system that utilizes physicians more efficiently. Indeed, there are some data that support this view.4 But even a casual review of the history of attempts to reform the delivery system makes clear that a more efficient one isn't going to materialize in the foreseeable future. Accordingly, the need for more physicians remains urgent. So if the profession is going to be able to meet its core responsibility to society even in the near term, the academic medicine community must begin to take steps to increase physician supply.

In that regard, five of the articles that appear this month describe efforts under way to increase the number of students graduating from allopathic medical schools in this country. Four (by Cosgrove, Joiner, Manetta, Boyd, and colleagues) describe approaches that the deans and faculties of certain schools (the University of New Mexico School of Medicine, the University of Arizona College of Medicine, the University of California–Irvine School of Medicine, and the Oregon Health & Sciences University School of Medicine) have adopted to augment the size of their student bodies. An additional article by Nation and colleagues describes the overarching strategy adopted by the University of California system to increase enrollments in each of its five medical schools. And, in his Commentary, Bill Mallon provides an overview of efforts undertaken by medical schools across the country to produce more graduates of allopathic medical schools. Taken as a whole, the collection of papers makes clear that the leaders of the country's medical schools take seriously their responsibility to contribute to the effort to produce a physician workforce of adequate size.

Unfortunately, those efforts will not in and of themselves lead to the development of a sufficient physician workforce. As I have noted previously,5 an increase in medical school enrollments will not result in an increase in physician supply unless there is a corresponding increase in the number of entry-level positions (PGY-1s) in the country's graduate medical education (GME) system. At the present time, there is no evidence that that is going to occur. There are also other important issues that must be addressed to produce an adequate workforce. For example, how will the public's needs be met if, as is now the case, fewer than a quarter of those training in internal medicine choose to practice as general internists and an even smaller percentage of those training in surgery choose to practice as general surgeons? Also, what will the lack of diversity within the physician workforce mean for the ability of some in our society to gain access to the care they need? And, finally, are the residency programs that prepare physicians for practice designed properly to ensure that they are producing graduates who are capable of providing high-quality care to the public?

Three articles that appear this month (by Clayton, Pugno, Sachdeva, and colleagues) describe efforts under way by the leadership of three major specialties (internal medicine, family medicine, and surgery) to address that particular issue. The residency redesign initiatives described in the articles are clearly intended to ensure that future program graduates will be capable of providing high-quality specialty care to the patients who seek their help. The articles make it clear that the leaders of the involved specialties take seriously their responsibility to create a workforce of physicians who can meet the challenges of modern medicine. The articles also explain how difficult it is to make changes in residents' education because of the complex nature of the funding of GME programs and, particularly important, by restrictions imposed on the design and conduct of the programs by regulatory bodies (the accrediting agency and specialty boards).

Absent a concerted effort to address the issues at hand, the future portends a time when the average citizen will find it difficult, if not impossible, to obtain needed health care services because of an inadequate number of properly trained physicians to meet the demand. So, who will see to it that this does not occur? At present, there is no effort under way by any of the profession's major organizations to address the challenge in a comprehensive manner. Nor has the federal government or any state government shown any interest in becoming involved, even though government has a critical role to play in crafting approaches for addressing the issues. I believe that the leadership of the profession and key government officials must jointly commit to a process, much like the one recently completed in Canada,6 that will lead to a shared understanding of how the issues involved should be addressed and to the development of concrete strategies for doing so. So, I agree with those who have recently called for the creation of a medical–societal alliance to address the many impediments that stand in the way of the profession's ability to serve the needs of the public.7

But once again, the critical question is, who will lead?

Michael E. Whitcomb, MD

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1 Cooper RA. Weighing the evidence for expanding physician supply. Ann Intern Med. 2004;141:705–714.
2 Weiner JP. Expanding the US medical workforce: global perspectives and parallels. BMJ. 2007;335:236–238.
3 Goodman DC. Expanding the medical workforce is unlikely to be cost effective or produce better outcomes for patients. BMJ. 2007;335:218–219.
4 Weiner JP. Prepaid group practice staffing and U.S. physician supply: lessons for workforce policy. Health Aff (Millwood). 2005;W4:59. Available at: ( Accessed August 24, 2007.
5 Whitcomb ME. Increasing the aggregate supply of physicians. Acad Med. 2006;81:593–594.
6 Task Force Two: A Physician Human Resource Strategy for Canada Web site. Available at: ( Accessed August 24, 2007.
7 Cohen JJ, Cruess S, Davidson C. Alliance between society and medicine. The public's stake in medical professionalism. JAMA. 2007;298:670–673.
© 2007 Association of American Medical Colleges