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Published on Wednesday, August 19, 2015

How will U.S. meet physician training needs?

The debate over how to ensure an adequate future supply and distribution of healthcare providers is heating up as new medical schools open around the country, veterans' hospitals are expanding their medical residency training programs under a new law, and Congress is stepping up its oversight over the use of graduate medical education funds.

Experts sharply disagree about whether there will be a physician shortage or whether healthcare delivery system changes will reduce the demand for doctors. Some cite last year's controversial Institute of Medicine report on GME, which said physician shortages are caused by poor geographic distribution of physicians and lopsided ratios of primary-care and specialty physicians and that some of the problems could be eased by new technology and innovations in healthcare delivery.

Last May, three new medical schools graduated their first classes: the Charles E. Schmidt College of Medicine at Florida Atlantic University had an inaugural class of 53; Oakland University William Beaumont School of Medicine, Rochester, Mich., had 47 graduates; and Hofstra North Shore-LIJ School of Medicine, Hempstead, N.Y., had 30 students. The Medical School of Temple University/St. Luke's University Health Network in Bethlehem, Pa., is considered a new Temple campus; it added 28 new doctors with its inaugural class this past spring.

Three more medical schools recently have been accredited: California Northstate University College of Medicine, Elk Grove, Calif.; City University of New York School of Medicine, at City College of New York in Harlem; and University of Texas at Austin Dell Medical School.

It's projected that total U.S. medical school enrollment will be 30% higher in 2018 than it was in 2006.

That's a change from the period of the mid-1970s to 1999, when no new medical schools opened, said Dr. Joel Rosenfeld, chief academic officer and associate dean at the Temple/St. Luke's campus. “There was a belief that by controlling the amount of doctors, you can control healthcare costs. But they didn't take in account the growing, and graying, population.”

Dr. David Goodman, professor of pediatrics and health policy at the Dartmouth Institute for Health Policy and Clinical Practice, said states opted to build medical schools rather than fund residency programs. “States seek home-grown doctors, but they haven't faced up to the other side of the equation—resident training,” he said.

For the 2014-2015 academic year, there 85,260 students enrolled in allopathic medical schools and 24,600 at osteopathic programs. There were 27,293 available first-year and 2,698 second-year residency positions openthis past March. 

For the 2013-2014 academic year, there were 120,108 residents training in 9,527 programs at 4,591 institutions, according to the Accreditation Council for Graduate Medical Education annual report (PDF).

The Veterans Access, Choice and Accountability Act of 2014 called for creating 1,500 new residency positions within VA facilities over the next five years. The VA reform effort is underway and 204 new positions opened last month at 61 VA facilities in 36 states. Plans call for 325 new positions to open in July 2016. (Interested programs had until Aug. 15 to send in a proposal.)

But Matthew Shick, senior legislative analyst with the Association of American Medical Colleges, said that most VA residency programs are operated in affiliation with a local academic medical center and that residents usually spend only three to four months a year training at VA facilities. He said most AMCs can absorb these new positions, but only in the short term or in small numbers and that more Medicare funding will eventually be needed.

“The AMCs see this as an important mission and have increased positions at their own expense,” he said. “But we're not quite sure at this point where it's impossible to raise one without the other. Even if the VA got all 1,500 positions off the ground, they would not be sustainable long term without a corresponding Medicare increase.”

The AAMC and its teaching hospital members long have warned of an impending doctor shortage and have advocated for expanding Medicare funding for GME as the solution. 

But an Institute of Medicine report last year advocated reforming GME. The report by an IOM committee, co-chaired by former Medicare chiefs Gail Wilensky and Dr. Donald Berwick, recommended establishing an HHS policy council for graduate medical education that would develop policy for geographic distribution and specialty configuration of the physician workforce. It also recommended moving more programs out of academic medical centers and into community clinic settings. 

Members of Congress have expressed concern that there is little accountability over where and how that money is spent. Members of the House Ways and Means and Energy and Commerce committees have requested that the Government Accountability Office conduct an evaluation of the GME system and provide recommendations for improvements.

“Despite the web of funding allocated to train physicians, very little is known about how our tax dollars are being spent,” the representatives wrote in their letter to the GAO (PDF). “Our concern is that, like most federal programs, duplication, overlap or waste is preventing our dollars from being spent efficiently and effectively.”

The number of Medicare-supported GME positions has stayed roughly the same since 1997. But Medicare is still the largest source of GME funding. In 2012, Medicare spent $9.7 billion on GME, Medicaid contributed $3.9 billion, the Veterans Affairs Department spent $1.4 billion, and the federal Health Resources and Services Administration provided about $500 million. 

While Medicare support has remained flat, the number of residency positions supported by other sources has grown. The 2013-2014 count of 120,108 residency positions represents a 7.8% increase over the 111,386 spots in 2009-2010. Despite these increases, physician shortages in rural and inner-city location have persisted—as have shortages in primary-care specialties.

Rosenfeld said the GAO scrutiny is welcome. “It's good that there will be accountability,” he said. He added that the GAO should also look at “outdated methods of training" that favor inpatient hospital settings over training in ambulatory settings and what can be done to lower the debt load medical students face on graduation—which some cite as a reason for choosing more financially rewarding specialties over primary care.

Still, he expressed confidence that more positions are needed, citing 18 studies that have said so. If these positions are not created, the nation faces a projected shortage of 90,000 doctors by 2020 and 140,000 by 2024. “It's more than a maldistribution,” he said.

Goodman disagreed. “At any given time, there are always spot shortages both by location and specialty,” he said. “But the claim of an impending doctor shortage is 15 years old. The predicted shortages of 15 years ago, 10 years ago and five years ago haven't manifested. We know from past experience, when residency positions increase, they don't go into high-priority specialties or high-priority areas. There's no reason to think (adding more GME positions) would be any more successful in the future.”

While this debate goes on, the AAMC and the Artemis Medical Society, a Fort Worth, Texas-based group advocating for minority women in medicine, have launched an initiative aimed at getting grade-school children interested in medical careers. 

The AAMC hopes its concerns with GME funding will be addressed by the time some of those students start their residency training. But if current trends continue, the AAMC is worried that those students may need to leave the country to receive their GME. “Even those students who enroll now are starting to meet if not exceed the number of first-year residency program positions,” Shick said.
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