This column was originally published in AMA eVoice on March 20, 2008. Dr. Davis is president of the American Medical Association.
Numerous reports during the past several years have forecast a looming shortage of physicians in the United States. A 2005 report by the Council on Graduate Medical Education (COGME) predicted that this work force shortage will reach 85,000 by 2020, and some experts have projected a shortfall as high as 200,000 by then.
Factors contributing to the shortage are the nation’s growing population, the increasing number of elderly Americans, an aging physician work force, and a rising demand for health care services. Physicians are facing Medicare payment cuts that threaten their ability to maintain their practices. And medical liability insurance premiums in some states cause some doctors to move their practices—or leave medicine altogether.
If this shortage materializes as predicted, the existing lack of access for the 20 percent of Americans who live in government-designated health professional shortage areas likely will worsen substantially. And access in other areas could decrease as well.
Primary care already is feeling the pinch. For example, according to a 2006 study published in the Journal of the American Medical Association, recent physician work force trends may be adversely affecting recruitment of family physicians at community health centers, which serve a growing number of people from vulnerable populations, including migrant workers, the uninsured, and the homeless.
To address these physician shortages, the Association of American Medical Colleges (AAMC) has called for a 30 percent increase in the number of medical school graduates by 2015. In response, existing medical schools have expanded their classes and at least 10 new schools are being planned. However, we will not achieve growth in the U.S. physician work force without a commensurate increase in the number of residency positions.
How do we generate that increase? A logical way is for all payers for health care—including the federal government, states, and private payers—to fund their fair share of both the direct and indirect costs of graduate medical education. The AMA has long-standing policy to advocate for this solution, as explained in AMA Council on Medical Education Report 7 (A-05) (PDF, 291KB) .
A specific strategy would lift the current cap on the number of Medicare-supported residency positions, especially in physician shortage/underserved areas and in undersupplied specialties. Doing so would help teaching hospitals increase the number of resident physicians. Unless this cap is rescinded, an increase in U.S. medical school graduates would likely displace international medical graduates and result in a static supply of future practicing physicians.
The AMA also supports continued funding of Section 747 of Title VII of the Public Health Service Act, a federal program that helps pay for primary health care training and education. Section 747 is vital to increasing the number of primary care physicians working in medically underserved communities.
The growing debt burden for medical school graduates, now averaging nearly $140,000, may discourage some people from applying to medical school and probably steers many medical students away from lower-income primary care specialties. Thus the AMA supports loan deferment programs and income tax exemptions for medical student scholarships.
One loan deferment program, the 20/220 pathway (PDF, 179KB), allows residents to qualify for economic hardship and postpone payment on federal loans for three years without accruing interest on the subsidized portion of the loans. The U.S. Department of Education nearly discontinued the 20/220 pathway last year, but after significant AMA advocacy, the agency reinstated it temporarily through at least this fall. Permanently restoring this program will be a major focus of the AMA Resident and Fellow/Medical Student Lobby Day at the end of this month in Washington, D.C.
Increasing funding for the National Health Service Corps (NHSC) and similar programs is a key step as well. The NHSC is a valuable program that recruits primary care physicians to underserved areas through loan forgiveness programs and scholarships. Incentives such as scholarship and loan repayment support help ensure that medical students and resident physicians are not deterred from practicing in medically underserved areas, starting a career in medical education or research, entering public health service, or practicing primary care.
The Initiative to Transform Medical Education (ITME), launched by the AMA in 2005, aims to strengthen the medical education and training system to better equip young physicians with the knowledge, skills, attitudes, and values necessary to provide high-quality medical care. One ITME recommendation is particularly relevant to the physician work force challenge: “Consider creating alternatives to the current sequence of the medical education continuum, including introducing options so that physicians can re-enter or modify their practice … such as through focused mini-residencies.” Obviously these alternatives are preferable to the permanent loss of physicians from medical practice.
Enhancing diversity in the physician work force can help ensure care to underserved populations. We saw some good news on that front last year when the AMA successfully advocated for the federal J-1 visa waiver program, also known as the Conrad 30 program. It’s a major means of placing international medical graduates in rural and low-income urban areas that have had difficulty attracting physicians to meet their health care needs.
In my travels and correspondence, I’ve been hearing about aggressive efforts to address state and local shortages in the physician work force. On Monday I met with Jeffrey Gold, MD, dean of the University of Toledo College of Medicine, who has produced a document showing the serious dearth of physicians and residents in northwest Ohio (PDF, 328KB). To reverse this trend, Dr. Gold proposes a large expansion in graduate medical education positions in the school and region through 2012.
Several state medical societies have produced reports that illustrate how the work force shortage could impact their states. In 2005, the Michigan State Medical Society (MSMS) developed a physician supply study that predicted a potential difference of as many as 6,000 physicians between what the state’s population is likely to require and the number of doctors available to meet those demands by 2020. In its 2006 report on “The Future of Medicine” in Michigan, MSMS offered several recommendations to assure that the state has an adequate number of physicians in the years to come.
In the 2007 edition of “The State of Medicine in Pennsylvania,” the Pennsylvania Medical Society revealed that the state’s physician work force is comprised of increasing numbers of part-time and older physicians, and fewer and fewer young physicians. According to the study, half of Pennsylvania physicians are 50 years of age or older, but only 6 (excludes residents) to 8 (includes residents) percent are younger than 35.
In January, MedChi (the Maryland State Medical Society) and the Maryland Hospital Association released a work force study that found the state to be 16 percent below the national average for number of physicians available for clinical practice. The problem is especially acute in the state’s three rural regions.
Many other states have done similar work, and the AAMC has produced a list of recent studies and reports on physician shortages (PDF, 57KB) that provides sobering data about particular states and specialties.
Ensuring that the nation has a sufficient number of physicians and an appropriate geographic and specialty distribution to care for a growing number of patients is one of our most pressing needs in heath care today. All stakeholders in health care must work together to expand efforts to accomplish that goal.
Please send comments, questions, and replies to amaprez@ama-assn.org.
Content provided by: Dr. Robert M. Davis, MD