Abstract: This chapter serves as background for this report's assessment of graduate medical education (GME) financing and governance. It reviews trends in the characteristics of GME trainees and considers whether the GME system is producing the type of physicians that the nation requires. The focus is on specialty distribution, geographic location, the ability to care for diverse patient populations, and physicians' overall readiness to practice medicine in settings where most Americans receive their health care. The committee finds that the recent expansion in physician education has occurred with little strategic direction. Several areas need the attention of policy makers to ensure the strategic investment of public funding for GME programs. These include learning how to motivate young physicians to train in specialties and locate in areas where they are most needed; identifying ways to improve the diversity of the physician trainees to better mirror the overall population; increasing GME training in community settings; and ensuring that newly trained physicians possess the skills essential for everyday practice.

PHYSICIAN SUPPLY

The sufficiency of the physician supply—and the public's future role in financing the production of a larger physician supply—are among today's most contentious health workforce issues (Iglehart, 2013a; Nicholson, 2009). Determining future workforce requirements is an inherently imprecise activity (Bipartisan Policy Center, 2011). As Figure 2-1 illustrates, understanding the dynamics of physician supply involves many variables and uncertainties. Health care reimbursement and the organization of health care services, for example, are far more important than GME in determining the makeup and productivity of the physician supply (Salsberg, 2009). Nevertheless, the capacity of the GME system is a limiting factor because states require at least 1 year of residency training in the United States before a physician can obtain an unrestricted license to practice medicine (FSMB, 2013).

FIGURE 2-1

Physician supply: The complex reality. NOTE: DO = doctor of osteopathy; EMR = electronic medical record; GME = graduate medical education; HIT = health information technology; IMG = international medical graduate; MD = medical doctor; NP = nurse practitioner; (more...)

Although the committee was not charged with projecting the future demand for physicians, it reviewed recent projections and analyses of the capacity of the physician workforce to meet the nation's health needs (AAMC Center for Workforce Studies; 2012; Altschuler et al., 2012; Colwill et al., 2008; Green et al., 2013; Hofer et al., 2011; Ku et al., 2011; Petterson et al., 2012; Ricketts, 2011). Forecasts of the future physician supply are variable and contradictory in part because it is difficult to anticipate future directions in the health care system (Blumenthal, 2004; Iglehart, 2013b). In the 1970s, for example, concern about imminent shortages led to a significant push for expansion in the number of medical schools and students (Cooper, 2003). Title VII of the Public Health Service Act provided significant funding for the expansion of medical schools (Phillips and Turner, 2012). From 1970 to 1984, the number of medical students increased by 66 percent and the number of residents by 25 percent. A decade later, the conventional wisdom was that the nation faced a significant oversupply of physicians because of the looming impact of managed care on demand for health care services (Fink et al., 2003; Pew Health Professions Commission, 1995).

More recently, projections of the physician supply suggest impending shortages that could prevent many people from getting needed health services. These analyses raise concerns that the rapid aging of the population and the expansion in health coverage in the Patient Protection and Affordable Care Act (ACA)² will fuel demand for physician services far beyond current capacity (AAMC, 2012a; Grover and Niecko-Najjum, 2013; Kirch et al., 2012; Sheldon, 2010). However, the underlying methodologies and assumptions about the future in these studies are problematic. They often assume historic provider-patient ratios with limited relevance to either contemporary health care delivery or the pressing need for a more coordinated, affordable, and patient-centered health care system (Bipartisan Policy Center, 2011; Dower and O'Neill, 2011). Other analyses that consider the potential impact of changes in health care delivery draw opposite conclusions. These studies suggest that an expanded primary care role for physician assistants (PAs) and advanced practice registered nurses (APRNs), redesign of care delivery and other innovations in health care delivery, such as telehealth and electronic communication, may ultimately lessen the demand for physicians despite the aging of the population or coverage expansions (Auerbach et al., 2013a,b; Bodenheimer and Smith, 2013; Bodenheimer et al., 2009; Ghorob and Bodenheimer, 2012; Green et al., 2013; Reinhardt, 2013; Weiner et al., 2013).

In response to the forecasts of shortages, some stakeholders and policy makers are pushing for significant increases in Medicare GME funding. They argue that Medicare should raise the current cap on the number of Medicare-funded residency positions in order to ensure the production of more physicians (Grover and Niecko-Najjum, 2013; Jolly et al., 2013; Kirch et al., 2012). Yet, the available evidence suggests that increasing the production of physicians is not dependent on additional federal funding. A recent analysis of 20 years of residency data documents that, despite the implementation of Medicare caps on funded training slots in 1997, the number of first-year residency positions has grown steadily since 2003—at a rate of increase similar to the period before the caps (Chandra et al., 2014).

Some proponents of increased Medicare GME funding also claim that the number of medical school graduates will soon exceed the available GME training slots (Jolly et al., 2013). Recent evidence does not support this concern. According to the National Residency Matching Program (NRMP),³ about 3,500 new first-year Accreditation Council for Graduate Medical Education (ACGME)-accredited training slots have been created since 2010 (NRMP, 2014a,b). In the 2014 match, there were 7,000 more first-year residency slots than U.S. applicants: 22,300 U.S. allopathic and osteopathic medical school seniors applied for 1 of 29,666 first-year positions (Salsberg, 2014).

Simply increasing the numbers of physicians is unlikely to resolve workforce shortages in the regions of the country where shortages are most acute and is also unlikely to ensure a sufficient number of providers in all specialties and care settings. The evidence instead suggests that, although the capacity of the GME system has grown in recent years, it is not producing an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural or other underserved areas (Rabinowitz et al., 2012; Rosenblatt, 2010; Shipman et al., 2013; West and Dupras, 2012). Also, although the numbers of underrepresented minorities have increased, their proportion in medical school and physician populations does not reflect the increasing racial and ethnic diversity of the American population (AAMC, 2010, 2012a,b,c; Sullivan, 2010; Sullivan and Suez Mittman, 2010).

THE GME PIPELINE—MEDICAL SCHOOL ENROLLMENT

In the past decade, there has been a marked increase in the number of medical colleges (both allopathic and osteopathic) and the size of medical school classes. No one factor explains the expansion. Numerous studies in the 1990s predicting serious physician shortages probably had a role. It appears that much of the growth was spurred by local concerns—both public and private—about physician supply. For example, several states—including Arizona, Florida, Michigan, Pennsylvania, and Texas—invested in medical school expansion with the expectation that many graduates would remain to practice locally (Whitcomb, 2009, 2013).

In 2005, the Council on Graduate Medical Education (COGME) released an influential report predicting rapid increases in the demand for physician services with the aging of the baby boomer population, growing U.S. population, and expansions in health insurance coverage (COGME, 2005a). The following year, the Association of American Medical Colleges issued a call for a 30 percent increase in the physician supply (AAMC, 2006; Adler et al., 2013). Since then, the number of medical schools and school enrollments has grown substantially. As Table 2-1 indicates, in the decade ending in 2012, overall enrollment in U.S. undergraduate medical colleges rose by nearly 28 percent, increasing from 80,180 to 102,498 students (AAMC, 2013a). Both allopathic and osteopathic medicine have expanded class sizes at many schools and also built new medical schools. Fourteen allopathic medical schools increased class sizes by more than 10 percent in 2013 (AAMC, 2013b). The growth in osteopathic medical colleges has been even more dramatic. Enrollment in institutions that granted the Doctor of Osteopathy (D.O.) nearly doubled during the decade, increasing from 11,432 students to nearly 22,000 students.

TABLE 2-1

Change in the Number of Medical Schools, Medical School Enrollment, and Applicants to GME Programs, 2002 to 2012.

In 2013 alone, four new allopathic and three osteopathic medical schools opened their doors (AAMC, 2013b). Additional growth is under way: As this report was prepared, five new allopathic medical schools have initiated applications for accreditation (LCME, 2013).

GME TRAINING CAPACITY

Workforce planning involves gauging not only the numbers of needed personnel but also whether those with the right training are available “to deliver the right services to the right people at the right time” (Birch et al., 2009, p. S-56). Thus, to assess the output of the GME system, one should consider the capacity of the system to produce the types of physicians that will meet the health needs of a growing, aging, and diversifying population (Ricketts, 2011). This section provides a brief review of trends in the number and type of GME programs and the available evidence on key characteristics of the physician trainee population and recent GME graduates—by specialty and subspecialty, readiness to practice medicine in settings where most people seek health care, racial and ethnic diversity, and geographic location.

Numbers of GME Programs and Trainees

As noted earlier, the capacity of the GME system to train additional physicians has been growing. Both ACGME-accredited residency programs and residents have steadily increased in number over the last decade (see Table 2-2). Between academic years 2003-2004 and 2012-2013, the number of ACGME programs increased by 16.3 percent (from 7,968 to 9,265) and the number of residents by 17.5 percent (from 100,176 to 117,717). There were an additional 7,498 osteopathic physicians in 1,068 American Osteopathic Association (AOA)-accredited residencies in 2012-2013.⁴

TABLE 2-2

Growth in ACGME-Accredited Programs and Residents, Academic Years 2003–2004 to 2012–2013.

Primary Care Training and Increasing Subspecialization in GME

The makeup of specialties and subspecialties⁵ in the American physician workforce has changed dramatically since the advent of Medicare and Medicaid GME funding. In the early 1960s, primary care doctors made up an estimated half of the physician workforce (COGME, 2010). In 2010, the percentage was roughly 33 percent (AHRQ, 2011).

In less than a generation—from 1999 to 2013—the number of specialty certificates issued by the American Board of Medical Specialties increased from 84 to 145 (see Table 2-3) (ABMS, 2013). Although some of the increase was due to the creation of new pipeline specialties (e.g., family medicine, emergency medicine), the greatest growth has been in subspecialty programs. As Table 2-2 indicates, the number of ACGME-accredited subspecialty programs rose by more than 30 percent from academic years 2003-2004 to 2012-2013. The number of fellows in subspecialty training grew by 40 percent.

TABLE 2-3

Initial Residency Period and Subspecialty Certificates Issued by the American Board of Medical Specialties, Selected Years.

The trend toward a highly specialized physician workforce is especially apparent in internal medicine (IM) (Cassel and Reuben, 2011). The proportion of IM residents interested in a primary care career has dropped precipitously. In 1998, 54 percent of third-year IM residents planned careers in general IM. By academic years 2009-2011, the percentage was only 21.5 percent (West and Dupras, 2012). After completing an IM residency, physicians can now pursue further training and certification in 22 subspecialties—5 of which are devoted just to heart disease (adult congenital heart disease, advanced heart failure and transplant cardiology, cardiovascular disease, clinical cardiology electrophysiology, and interventional cardiology) (see Table 2-4). The other IM subspecialties are adolescent medicine, critical care medicine, diabetes and metabolism, endocrinology, gastroenterology, geriatric medicine, hematology, hospice and palliative medicine, infectious disease, medical oncology, nephrology, pulmonary disease, rheumatology, sleep medicine, sports medicine, and transplant hepatology.

TABLE 2-4

Selected Pipeline Specialties (Initial Residency Period) with Five or More Subspecialties.

A similar trend has occurred in surgery as surgical residents increasingly eschew general surgery for subspecialty practice in vascular surgery, pediatric surgery, surgical critical care, surgery of the hand, hospice and palliative medicine, complex general surgical oncology, or thoracic surgery. From 2001 to 2010, the number of new general surgery residents who expected to enter practice without specialized training declined by 33.3 percent (Jolly et al., 2013).

See Table 2-4 for a list of selected pipeline specialties with numerous pathways to subspecialization.

Influences on Specialty Career Choice

There is a considerable literature—based largely on surveys, questionnaires, and other personal reports—describing factors that influence physicians' decision specialty choice. The evidence suggests that a complex interplay of many variables, including expected future income (and physician payment rules that favor certain specialties and subspecialties), the prestige of the specialty (or lack of it for primary care), medical educators' bias against primary care, design and location of residency programs, the personal desire for clearly defined responsibilities, lifestyle considerations, medical school debt, demographic factors, and practice location (Chen et al., 2013; Cordasco et al, 2009; Diehl et al., 2006; Dowdy, 2011; Garibaldi et al., 2005; Greysen et al., 2011; Hauer et al., 2008; Jeffe et al., 2010; Kussmaul, 2013; Phillips et al., 2009; Schwartz et al., 2011; Warm and Goetz, 2013; West et al., 2009).

The income differentials between various specialties and/or subspecialties are substantial (Bodenheimer et al., 2007; COGME, 2010; Vaughn et al., 2010) and a particularly strong influence on career choice (Ebell, 2008; Weida et al., 2010). For example, an analysis comparing the present value of career wealth (up to age 65) between a primary care physician and a cardiologist estimated a differential of more than $2.7 million (Vaughn et al., 2010). Other studies have documented annual income differentials ranging from about $100,000 to several hundred thousand depending on the subspecialty (Bodenheimer et al., 2007; COGME, 2010; Ebell, 2008).

Regardless, it is clear is that the GME system's production of specialists and subspecialists has evolved without strategic direction in relation to the nation's health needs. The overriding influences are the personal career choices of individual trainees and the decisions of teaching hospitals regarding what type of residencies to sponsor. As the next chapter will describe, Medicare GME funding is not linked in any way with local, regional, or national health care workforce priorities.

Primary Care Physicians

Many experts are concerned that the rapid transition to a highly specialized physician workforce has undermined the nation's capacity to progress to a higher-quality and less costly health care system. The corresponding evidence, however, is inconclusive (Baicker and Chandra, 2004; Chang et al., 2011; Detsky et al., 2012). Regardless, the crucial issue is not necessarily the declining numbers of primary care physicians but effective organization, deployment of health personnel, and integration of primary care with other health care services. A growing body of literature demonstrates that the Patient-Centered Medical Home (PCMH) and other well-integrated delivery models provide higher-quality and more cost-effective care than the less coordinated systems of care typical of U.S. health care delivery (Gilfillan et al., 2010; IOM, 2012a; Liss et al., 2013; Maeng et al., 2012; Reid and Larson, 2012). There is also compelling evidence that integrating mental health and substance use services into primary care improves outcomes, particularly for older adults with depression or at-risk drinking (IOM, 2012b).

Physicians make up approximately 74 percent of the primary care workforce; nurse practitioners, 19 percent; and PAs, 7 percent (Dower and O'Neill, 2011). No one ideal staffing mix for delivering effective primary care services has been determined. A variety of workforce models suggests that innovative mixes of primary care personnel—including greater use of APRNs, PAs, and team-based task delegation—may reduce the demand for primary care physicians in the future (Altschuler et al., 2012; Auerbach et al., 2013a,b; Bodenheimer and Pham, 2010; Bodenheimer and Smith, 2013; Bodenheimer et al., 2009; Ghorob and Bodenheimer, 2012). The PCMH model, for example, uses interprofessional teams of physicians, advanced practice nurses, physician assistants, pharmacists, nutritionists, social workers, health educators, and care coordinators to provide primary care. In nurse-managed health centers, nurse practitioners provide primary care services (Auerbach et al., 2013a). The role of the physician may vary from being central to a more consultative role (Patel et al., 2013).

Diversity of the Physician Trainee Pool

Producing a physician workforce that reflects the diversity of the American population has been a goal of medical schools, teaching hospitals, policy makers, and the health care professions for many years (AAMC and ASPH, 2012; COGME, 1998, 2005b; Grumbach and Mendoza, 2008; IOM, 2003a, 2004; Nivet and Berlin, 2013; Saha, 2014; Saha and Shipman, 2008). The importance of these efforts is underscored by strong evidence that racial, ethnic, and linguistic diversity among health care providers is correlated with better access to and quality of care for underserved populations (Grumbach and Mendoza, 2008). In addition, nearly two decades of research have documented that non-white physicians disproportionately care for underserved groups and racial and ethnic minority populations (IOM, 2003b; Komaromy et al., 1996; Marrast et al., 2013; Moy and Bartman, 1995). Recent studies also suggest that a more diverse student and faculty presence can enhance the learning environment of all students by providing formative multicultural experiences (Saha et al., 2008; Shaw, 2005).

The challenge in ensuring a diverse physician workforce is daunting. Real progress has been made; the numbers of underrepresented minorities in U.S. medical schools have increased. However, with the growing diversity of the overall U.S. population, the racial and ethnic differences between medical school graduates and the overall population is actually widening (as illustrated in Figure 2-2). In 2012, there were 5,630 African American and 7,225 Hispanic students in U.S. medical schools, representing 6.9 percent and 8.8 percent of total enrollment, respectively (AAMC, 2012c). The Census Bureau projects that, by 2015, 38 percent of the U.S. population will be persons who identify as a racial minority or of Hispanic background, and this proportion will rise to 51 percent by 2045 (U.S. Census Bureau, 2012). In some states and geographic regions, the contrast between the racial and ethnic makeup of the physician and overall population is especially striking. In California, for example, 36 percent of the population is Hispanic, compared with only 5 percent of the state's physicians (UCLA International Medical Graduate Program, 2013).

FIGURE 2-2

Trends in the proportion of underrepresented racial minorities (URMs) among medical school graduates and the U.S. general population. SOURCE: Sullivan, 2010 (AAMC).

Achieving greater income diversity in the GME pipeline is also a concern. More than 75 percent of medical students come from the two highest quintiles of family incomes, and only 5.5 percent have come from families in the lowest quintile of income ($19,178 or less in 2006) (AAMC, 2013b; Jolly, 2008).

There is promising evidence that GME programs can modify recruitment practices to attract competitive underrepresented minorities (Auseon et al., 2013). However, the GME system has limited leverage because the trainee population depends on the pipeline that begins with premedical education. Therefore, most diversity initiatives focus on interventions early in the physician education continuum—during application to medical school, college, or even earlier (Nivet and Berlin, 2013).

The lack of research on the effectiveness of diversity interventions is a major barrier to progress. Despite the decades of efforts to address the problem, little is actually known about what works.

CONCLUSIONS

The United States has a robust GME system, emulated by many other nations, with significant capacity to produce the nation's physician workforce. GME programs are increasingly producing a highly specialized workforce. It is notable that growth in the number of specialties and subspecialties is occurring without any coordinated planning. This chapter's examination of the makeup and output of the GME pipeline indicates that the trend toward greater specialization has occurred with little strategic direction—at least with respect to local, regional, and national needs for a balance of primary care practitioners and subspecialists. The number of physician trainees is increasing, but there is little evidence to suggest that the expansion in training capacity is in areas—either geographically or by specialty—where they are most needed.

The proportions of internal medicine residents pursuing careers in general internal medicine and of surgery residents pursuing careers in general surgery have markedly declined. Less than 3 percent of medical students expect to practice in a rural or small-town environment, where physician shortages are most acute.

The United States is rapidly becoming one of the most racially and ethnically diverse nations in the world, but the gap between the diversity among physician trainees compared with the overall population is actually widening. In addition, residents report that they feel ill-prepared to provide culturally competent care to diverse populations.

Much attention of late has focused on the possibility of future shortages in primary care and other specialties nationwide. But this concern is based on studies with unreliable methodologies that do not adequately relate the demand for physicians to the features of a high-performing system of care and that also ignore the regional variations in workforce supply. In contrast, too little focus has been given to how best to organize and deploy physicians through innovative approaches to care delivery. Much remains to be learned. But no interventions have been tested to identify what works to resolve persistent problems such as how to motivate young physicians to train in specialties and locate in areas where they are most needed or ways to reverse the widening gap between the diversity of the physician trainee population compared with the overall population.

Finally, and particularly concerning, is the evidence that recent GME graduates do not have some of the essential skills for office-based practice, where most of them will spend their careers. This is likely due, in part, to the overwhelming emphasis of current GME programs on training physicians in hospitals rather than in community settings.

In summary, there is a clear and compelling imperative for the nation to leverage its investment in GME toward producing a physician workforce ready to provide high-quality, patient-centered, and affordable health care in all regions of the nation.

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Footnotes

1

Allopathic medical schools confer the Doctor of Medicine (M.D.) degree and are accredited by the Liaison Committee of Medical Education. Osteopathic medical schools confer the Doctor of Osteopathy (D.O.) degrees and are accredited by the American Osteopathic Association.

2

Public Law 111-148.

3

The National Residency Matching Program (NRMP) is a private, non-profit corporation that matches applicants for ACGME-accredited training slots with ACGME-accredited training programs (NRMP, 2013). NRMP uses a computerized mathematical algorithm to match applicants' preferences with the preferences of residency program directors at U.S. teaching hospitals.

4

Osteopathic data were provided by personal communications from Konrad Miskowitz-Retz, Secretary, AOA, COCA, and Jim Swartwout, Executive Director, AOA, on March 17, 2014, and March 19, 2013, respectively.

5

Specialty terminology can be confusing. All physicians who successfully complete a residency program are considered specialists even if the specialty is a primary care specialty.

6

See Chapter 4 for a discussion of GME governance including accreditation.

7

Chapter 3 provides more details on the funding of the THC program.

8

The U.S. Census Bureau defines rural as any population, housing, or territory outside urban areas.

9

Chen et al. (2010) mapped zip codes to Rural-Urban Community Area codes to determine rural residence.

10

Chapter 3 describes Medicare payment rules that affect the geographic location of trainees.