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Wanted: Health Care Providers

By Kathy Whitney
July 2009

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A perfect storm is forming. The United States population is growing rapidly, increasing by about 25 million people per decade. The nation, including its doctors, is aging. One third of active physicians are over age 55, which means in the next 10 to 15 years 250,000 of them will retire. Thanks to medical advances, people are living longer with more chronic illness.

Ed Salsberg, M.P.A., director of the Association of American Medical Colleges (AAMC) Center for Workforce Studies, has his eyes on the gathering storm clouds and doesn’t like what he sees.

The AAMC issued a report in November 2008 authored by Salsberg and colleague Michael Dill that projects future supply and demand for physicians and concludes that a national shortage is likely. The demand for doctors will outstrip the supply through at least 2025, the report says.

If physician supply and use patterns stay the same, the United States will experience a shortage of 124,000 full-time physicians by 2025, according to the AAMC. Other projections based on continued increase in utilization rates, changes in work schedules with older physicians continuing to work more hours and younger physicians working fewer, a moderate expansion of the graduate medical education (GME) capacity and productivity improvements puts the shortage at 159,000, the authors write in their report.

John Zic, M.D., associate dean of Admissions, left, and the AAMC’s Ed Salsberg, M.P.A., believe medical schools need to examine a number of ways to increase the physician pipeline. Photo (left) by Susan Urmy, Photo (righ) courtesy AAMC

John Zic, M.D., associate dean of Admissions, left, and the AAMC’s Ed Salsberg, M.P.A., believe medical schools need to examine a number of ways to increase the physician pipeline. Photo (left) by Susan Urmy, Photo (righ) courtesy AAMC

“Projections are complex, but the simple drivers are pretty clear. The growing population and aging population will be driving demand up,” Salsberg said. “In addition, most of the medical advances over the last 30-40 years have had the impact of keeping people alive longer and surviving illness. In the end, this actually drives up demand.”

To help offset the shortage, the AAMC recommends a 30 percent national increase in U.S. medical school enrollment between 2002 and 2015.

According to a May 2008 AAMC survey, more than 86 percent of existing schools have already expanded the number of first-year students or plan to do so within the next five years. In addition, nine new medical schools are under development or discussion.

Beginning in fall 2009, Vanderbilt University School of Medicine will increase its enrollment by 6 percent, from 104 to 110 first-year students.

“Based on my discussions with deans and instructors, we should be able to comfortably accommodate 110 students each year. If we wanted to go beyond that, there would have to be some serious planning,” said John Zic, M.D., Vanderbilt’s associate dean of Admissions.

Much of Vanderbilt’s first- and second-year curriculum is based on small group instruction, and adding just six more students means adding another group and another instructor to the mix.

“Even when we increase it by just 6 percent we need to let the Liaison Committee on Medical Education know we’re doing that. They want to stay on top of the number of medical students who are matriculating each year and make sure we justify why we’re doing this and we have the resources to do it well,” Zic said. “We would never want to have a school increase its enrollment to the point that it jeopardizes its educational mission.”

Medical school administrators need to look at their school’s circumstances, resources, communities, and state demographics before deciding how many additional first-year slots to offer, Salsberg said.

“We expect that states that have grown more rapidly over the last 25 years – a period with no growth in medical education – would be the states more likely to expand, such as southern and western states that have far fewer medical school slots per capita.”

In 2007 VUSM received 5,032 applications, the highest number in a decade. In 2008, it received 4,890 applications – for 104 spots. After five consecutive years of growth, the national pool of applications decreased slightly from around 42,315 to 42,231 in 2008.

But Salsberg and Zic agree that given the current economic recession, medical school applications are likely to be on the rise.

“What we often see when there is an economic downturn, consideration of job stability starts to rise high on the list of reasons people decide to pursue one career over another. Medicine starts to be more interesting to young people. It wouldn’t surprise me if over the next three years we see an increase in the number of applicants to medical school,” Zic said.

Medical school isn’t the only part of the physician pipeline under scrutiny. Graduate medical education (GME) programs should consider expanding their residency slots in order to continue to train foreign-educated physicians, Salsberg said.

About 25 percent of all physicians entering training in the United States are graduates of foreign medical schools. Since U.S. medical schools will be graduating more physicians, residency programs will need to expand and train more physicians, otherwise U.S. M.D.s (and graduates from osteopathic schools) may squeeze out physicians in training who attended medical schools outside of the United States, and there will be no increase in the supply of physicians.

“We’ve recommended an increase in residency training positions to accommodate the growth in U.S. M.D. graduates. The issues around GME are complex. Each teaching hospital makes its decisions about what programs to offer. There has been some growth over the last few years. We don’t know if residency positions are going to continue to increase or not,” Salsberg said.

Physicians who have been educated in other countries cannot practice medicine in the United States without completing a residency. In order for graduates of foreign medical schools to get into U.S. residencies, they have to pass an additional exam.

“An accomplished surgeon who has been practicing in another country – who could certainly help and impact the health care of Americans – can’t practice medicine here without going through an entire residency again. That’s an enormous burden. Some think it’s worth it depending on conditions in their home country,” Zic said.

The search for future physicians is now turning to America’s best and brightest students – while they are still in elementary and middle school.

“The pipeline for increasing our physician pool goes all the way back to grade school,” Zic said. “We need to expose young people to the joys and challenges of the health care field – getting young people turned on to science – letting these young people think that becoming a physician is a real possibility for them.”

The AAMC recognizes this and is in a position to encourage medical schools to increase pipeline programs, particularly for underrepresented minority groups. Vanderbilt already offers the School for Science and Math for high school students and is looking at offering additional programs. “We are looking at ways to establish more well-organized connections with colleges that educate underrepresented students. Currently, high school students can come to Vanderbilt during the summer to make them more competitive medical school applicants. We are having discussions now to see how we can expand those programs,” Zic said.

The AAMC realizes that increasing the pipeline alone will not be sufficient to meet future patient needs and demand.

Jeff Balser, M.D., Ph.D., vice chancellor for Health Affairs and dean of VUSM, agrees.

“There is no way we could possibly educate enough physicians to manage the growth of the population and its need for health care,” Balser said. “Vanderbilt could double the size of its medical class, every medical school in the country could do the same, and we’d still fall short of the number of providers needed to meet the nation’s needs in our existing health care model.”

According to Balser, increasing the supply of physicians will not be sufficient. Complex changes such as improving efficiency through technology, re-engineering the health care team, and improving prevention efforts will also be necessary.

“We must come to terms with how we will deploy physicians more efficiently and effectively, and work in teams with other health care providers.”

Can the United States make major strides in overhauling the health care delivery system in time to offset the impending physician shortage? Or is adding capacity the answer? There are strong feelings on both sides of the debate, but most agree the answer lies somewhere in between.

“I think the case for increasing undergraduate medical education is very strong,” Salsberg said. “If America did things differently, we think we could reduce the need for physicians. We’re certainly hopeful the nation will find ways to improve efficiency and effectiveness, but it takes us 10 years to produce a physician. What we’re doing today in 2009 is making decisions about how many doctors we produce in 2019.”




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