The Future of Our Physician Workforce
Journal of Minority Medical Students. Published Summer 2005.
By Leana S. Wen, 2005-2006 National President, American Medical Student Association
Greetings from the American Medical Student Association! I am honored and excited to serve as the 2005-2006 AMSA National President and to continue contributing to the JMMS. Throughout our 55-year history, AMSA has advocated for the rights of all students and provided a home for minority and underrepresented students. Our four strategic priorities are fighting for universal healthcare, eliminating health disparities, advocating for diversity in medicine, and transforming the culture of medical education; and our projects on the national, regional, and local levels reflect our commitment to our priorities. AMSA also works closely with partner organizations in medicine and the community to increase diversity and strengthen our shared commitment to minority medical students-together we will shape the future of medicine in this country and around the world!
With its focus on "Careers", this issue brings up many topics of concern to us as advocates for minority students, such as the continued underrepresentation of minority students in medical schools (11% vs. 25% of the population), increased debt load (now at $115,000 for graduating seniors), maldistribution of practicing physicians, lack of physicians in primary care, and the role of international medical graduates (IMGs). The common link of issues is physician workforce composition: how many doctors do we need? Are we training enough doctors, both at the undergraduate level (in the US medical school) and at the graduate level (during residency, through both IMGs and US graduates)? What kind of distribution of physicians do we require, in different geographic areas and in specialty versus primary care areas? And how can we increase diversity in the physician workforce and ensure that the diverse physician workforce translates to equitable distribution to underserved geographic areas?
Are we training enough doctors?
In the last 30 years, there has been a general consensus that a surplus of physicians was looming. While several new osteopathic medical schools were started and others expanded, the number of graduates from allopathic medical school schools has remained steady since the 1980s. The limit on allopathic undergraduate medical education did not extend to graduate medical education (GME), however; the number of first-year residency spots open are 30% higher than the number of graduates from U.S. allopathic schools, and every year graduates of international medical schools account for 25% of residents, and now 25% of the physician workforce in the US are composed of IMGs.
Over the last few years, studies have shown that a physician shortage rather than an oversupply will likely develop, with middle-range estimates of a shortage around 90,000 by 2020. Reasons for the projected shortage include population growth particularly of the elderly, growing demand for medical care, retirement of practicing physicians, and younger doctors working fewer hours. The Council on Graduate Medical Education (COGME), a national advisory body that makes policy recommendations regarding the adequacy of the supply and distribution of physicians, predicts that if the current trends continue, demand for physicians will far outstrip supply. The AAMC also reversed its longstanding position soon after the COGME report to call for increased training of physicians.
How to train more physicians?
The cap on undergraduate medical education without a concurrent one on GME has already created a system where the US is dependent on IMGs to fill 25% of residency positions. We are far from self-sufficient in training the number of medical students needed to fill residency positions and meet our practice needs, despite the sufficient number of qualified students applying to enter medical school and the wealth and capability of our nation to develop more schools. Not only does reliance on IMGs take opportunities away from US students, it creates an unfair burden on countries around the world. Sixty-six percent of IMGs in the US come from the developing world, mostly countries that are in dire need of health professionals. IMGs have contributed tremendously to the US medical profession and continue to provide skill and talent-I myself am a first-generation immigrant, and many of my friends and my parents' friends are IMGs. No one is questioning the competency of IMGs. The question is whether it's fair to further tax other countries by drawing away their best and the brightest to fill our workforce needs when we have many bright students capable and willing to be physicians?
Solutions to our workforce needs
Expanding physician workforce by expanding US medical schools is the most ethical and just way to address the needs of our population. COGME recommends for medical schools to expand graduates by 3,000 per year, and the AAMC recommends an expansion of 15% by 2015. Dr. Fitzhugh Mullan and others have proposed that such expansion of medical education should be made based on societal priorities, such as:
- Recruitment and retention of underrepresented minority groups into medicine.
- Recruitment and development of primary care physicians to meet the needs of the population.
- Distribution of physicians to work in underserved rural and urban communities.
Strategies to address these priorities are easier said than done. Recruitment programs for minorities are in place, but more can be done to widen the pipeline, especially if enrollment is increased overall across the country. Studies have shown that the rising student debt prevents many students from choosing primary care fields and working in underserved communities. Student debt is frequently cited as a major reason why many minorities do not apply for medical school, and AMSA and others are working to reduce debt by advocating for expansions in current loan repayment and service programs and for national educational subsidies. Finally, ensuring that the increased number of medical students translates to increased numbers practicing in underserved areas will take a transformation of the entire culture of medical education. AMSA supports medical schools selecting for and fostering qualities in their students who will be ethical healers, leaders, and advocates; who will be culturally competent, civic-minded, with a sense of community and service; and who will be socially conscious physicians worthy of the inherent public trust. It is towards this goal that we strive, and I look forward to joining you to address workforce, diversity, and many other issues throughout the year!
Leana S. Wen is the National President of the American Medical Student Association and a 4th Year medical Student at Washington University School of Medicine.