Jordan J. Cohen MD said:
Challenge number 5 is to enlarge the capacity of LCME-accredited medical schools. As Yogi Berra is famously credited with saying, 'prediction is a risky business, especially about the future.' Nowhere is that adage more apt than in trying to predict our country's future need for physicians.
As I'm sure you all remember, the AAMC, along with most other national organizations, announced with great fanfare less than a decade ago that the U.S. was heading for a huge surplus of physicians.
The assumptions underlying that prediction seemed altogether reasonable at the time-namely, that closed panel HMOs would soon become the dominant mode of healthcare delivery. Since that model uses far fewer physicians than the open-ended, fee-for-service model, we and many others surmised that the U.S. would soon be awash in an abundance of doctors. How quickly things change!
The consensus now is that present trends will soon culminate in a significant shortage of physicians. Workforce gurus now point to the fact that our population is increasing substantially, is growing older, and is using more healthcare services. In the meantime, the overall supply of physicians is barely increasing at all.
Moreover, physicians as a group are growing older even faster than the U.S. population, while younger physicians are choosing to work shorter hours. Convinced that these trends are unstoppable, the AAMC this past February called for an expansion of medical school and GME capacity by some 15 percent over the next 10 years.
Will this be enough? Is 15 percent the right number? Who knows? What we do know is that a 15 percent increase in our graduates will add only about 2500 new MDs to the workforce each year, and only after many years in the pipeline, at that.
Close monitoring of the physician supply and demand will be essential to recalibrate our target, if needed. Should current trends continue, even more doctors may be called for. Alternatively, should the healthcare delivery system be refashioned along more rational lines, fewer may be needed.
Fortunately, the AAMC's new Center for Workforce Studies, which is already making significant contributions to our understanding of this complex issue, is positioned to play a key role in helping us keep tabs on future trends.
But there is much more at stake for us in this arena than just getting the overall number right. We need, as a community, to have a serious discussion about the nature of the educational pipeline that produces our nation's doctors.
Let me ask you a question:
What fraction of the physicians emerging from ACGME-accredited training programs and joining the practitioner workforce each year do you think are graduates of LCME-accredited medical schools?
The answer may surprise you. It certainly surprised me. The answer is 64 percent-less than two thirds.
As Lynn Eckhert noted a few moments ago, of the some 24,000 individuals who funnel through the GME pathway toward independent practice each year, more than one third-over 8,500 individuals-have received their undergraduate medical education from somewhere other than an LCME-accredited school.
To be specific, about 2,700 are graduates of osteopathic medical schools, some 1,300 are U.S. citizen graduates of foreign medical schools, largely in the Caribbean, and well over 4,500 are non-U.S. citizens who attended a wide variety of schools abroad.
As you may know, all the other suppliers of U.S. physicians-the osteopathic schools, the for-profit offshore schools, and many other foreign schools-also see a U.S. doctor shortage on the horizon, and they are rapidly expanding their capacity even as we speak. Five new osteopathic schools have opened in the past 10 years and several more are on the drawing board.
Even more arresting, no fewer than 15 off-shore schools have opened their doors over the same 10-year period and those already in existence are increasing their capacity dramatically. India, and perhaps other foreign countries, see a lucrative export market for physicians and are cranking up their already sizable medical education apparatus.
Hence, if current projections prove accurate-that our health care system will demand and be able to assimilate many more doctors over the next few decades-we could be facing an unwelcomed reality. When considered against the far more dramatic expansion occurring in the non-LCME world, our modest expansion plans could result in our corner of the medical profession becoming a minority presence.
Is this a cause for concern? I certainly think it is. To think otherwise would imply that ACGME training provides graduates of non-LCME schools with all the benefits our students obtain as undergraduates-that by the time residents finish their training, any differences that existed on entry to GME are no longer evident. I just don't believe that.
I think our model of undergraduate medical education offers the public something of special value-that it equips our students with a set of critically important, foundational capabilities and attitudes that the current format of GME does not and cannot provide.
Even if you think otherwise, consider the ethical questions raised by our reliance on foreign schools to educate so many of our country's doctors. Can we, in good conscience, continue to recruit so many highly educated professionals from developing countries who clearly need them much more than we do?
A recent United Nations report captured this issue in its headline: 'Health care brain drain threatens to overwhelm developing world.'
Last week's New England Journal of Medicine echoed that threat and documented its magnitude.
And there is yet another ethical question raised by our current reliance on foreign schools. What is our obligation to qualified American citizens who aspire to become doctors? Rather than consign so many of them to schools in the Caribbean, don't we have a civic responsibility to open our doors to more students who can meet our standards?
Given the need to ensure that the preponderance of tomorrow's doctors are educated in LCME-accredited medical schools, and the need to face up to the ethical implications of a global medical brain drain, I've come to the conclusion that we should begin thinking seriously about expanding our capacity, not by 15 percent, but by something more like 30 percent, or 5,000 additional MDs each year.
Considering the large gap between the number of students we now graduate each year and the much larger number of GME slots that exist, an expansion of this magnitude would still leave room for over 1,000 graduates of foreign schools each year, even if an expanded physician workforce turned out to be unneeded and GME capacity were not increased at all--which seems highly unlikely.
Increasing U.S. medical school capacity by 5,000 students per class is a tall order, to be sure, but not impossible. Consider this scenario: an average increase of 30 students per class for each of our current 125 schools would get us three-quarters of the way to this goal.
Just eight new schools with an average class size of 150 would take us the rest of the way. Our analysis shows that there are plenty of qualified applicants already available. Using MCAT scores as a rough indicator, we could accept 30 percent more students from the current pool and still have an entering class with an average total MCAT score above 26.
