I spoke at the Student National Medical Association’s (SNMA) Annual Medical Education Conference in Louisville, KY this past weekend. Accompanying me was former SNMA President Bryant Cameron Webb, MD, JD. We spoke on three main topics: medical education, the practice of medicine, and the underserved.
Many people believe that there is, or soon will be, a physician shortage. There are nearly 1 million physicians scattered across America representing a ratio of 319 doctors per 100,000 Americans. According to estimates, the AAMC (the organization representing medical schools) states that there are 13,700 too few physicians for our communities. In contrast to that, the GAO implies that adequate access exists for 97% of Medicare patients. So is there a physician shortage? I suppose that depends on who you ask.
What we could likely agree upon is that there exists problems with the geographic and specialty distribution of physicians across the country. While our physician workforce appears to be about one-third primary care and two-thirds specialists, many experts would recommend a ratio closer to one primary care physician for every specialist. The presence of primary care physicians improves the quality of health care. Thus rebalancing this maldistribution of generalists and specialists constitutes a legitimate policy goal.
Even if we had more generalists, it is critical that physicians (especially specialists) become distributed geographically in a manner that best serves the needs of our communities. A study from 2011 in the journal Health Affairs showed that the distribution of cardiologists was skewed away from low-income areas, rural areas, and the Midwest. The maldistribution of physicians, not necessarily the absolute number of physicians, is a more significant threat to the health of the nation.
So where do medical students go when they graduate? And why don’t they hang their shingles in the areas of the country with most need for medical expertise? Part of this answer rests on the fact that new physicians receive their training in academic medical centers, many of which are located in urban areas, the Northeast, or the West Coast. Upon completion of their training, many physicians remain close to these academic medical centers. While we need teaching hospitals to educate the newest generations of physicians, it subtly influences the production of medical oases and medical deserts across the country.
The other pertinent question to this policy dilemma is: why are many graduating medical students choosing to go into specialty care as opposed to primary care. Some of it may have to do with debt – the median debt for a graduating medical student is $170,000. But it also has something to do with the incentives surrounding graduate medical education (GME) which each new physician must do in order to hone his or her craft and receive a license to practice independently.
GME funding – provided by the Medicare program to the tune of almost $10 billion dollars or $100,000 per resident – has capped the number of residency slots available to graduating medical students since 1997. The Affordable Care Act does not work to lift this cap but it does work to redistribute 65% of unused residency slots to programs focusing on primary care. Some groups have argued for lifting the cap on GME so that more physicians could be trained. Others, however, note that there are already more available residency slots than there are new graduates from U.S. medical schools. For example, over 16,000 U.S. medical graduates matched into the over 25,000 first-year residency slots open in the most recent National Resident Matching Program (“the Match”).
There were over 7,000 foreign nationals who obtained residency positions via the Match this spring. Opponents of lifting the cap on residency slots point to these numbers and to the idea of international “brain drain” as a reason to keep the cap in place. Instead, medical schools could continue to increase their enrollment without serious risk to U.S. medical graduates being unable to find advanced training.
Dr. Atul Grover of the AAMC states that ”since 2002 we have almost expanded enrollment by 30%.” Yet, without lifting the cap on residency slots the total number of independently practicing physicians would still only grow at its current rate. There are some other alternatives to physicians, however, in the delivery of health care.
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