Recently, there has been movement towards substantial growth in the number of medical schools and in the number of medical students training in the US. About 15-18 new schools may be added to the 131 current schools. Also, medical schools have been encouraged to increase their enrollment. Eventually, there may be up to a 30% increase in the number of medical students training in US medical schools or an increase of about 5,000 more graduating medical students per year. This growth should lead to more US doctors, especially primary care doctors, and improved access to health care ...right? Not necessarily.
After medical students finish medical school, they enter into residency training where they focus on a specific area of medicine. For example, a graduating medical student may elect to do a three-year residency in family medicine or a four-year psychiatry residency. There are more residency training slots than there are US medical school graduates. Therefore, about 25% of the physicians entering into US residency training programs come from medical schools outside of the US. These doctors are referred to as international medical graduates (IMGs). In order to train in a US residency program, IMGs' medical training must satisfy strict requirements, and they must pass the same standardized US medical licensing examinations (USMLEs) that US students take during medical school. Many IMGs who complete residency training in the US stay here and practice medicine.
So, what will an increased number of US medical school graduates mean in terms of the number and composition of physicians attending US residency programs? It is likely that many of the US graduates will take positions that would have been filled by IMGs. Therefore, the total number of residents will remain about the same, but the percentage that are US graduates will increase and the percentage that are international graduates will decrease. Thus, increasing the number of US medical students will not significantly increase the overall number of residents.
Will a change in the proportion of US trained to foreign trained residents improve quality of care even if it doesn't increase the number of doctors? A recent study indicated that the quality of care provided by IMGs is at least as good as that provided by doctors who went to medical school in this country. Therefore, quality of care will not necessarily improve.
The way to increase the total number of doctors practicing in the US is to increase the number of residency training positions and the number of US medical students simultaneously. This would allow us to maintain the number of excellent IMGs training in US residency programs while increasing the total number of residents.
So, what's the problem? Why don't we just increase the number of residents? As usual, the problem is money. Medicare supports the bulk of residency training. For the most part, hospitals cannot afford to pay the hundred thousand dollars or more per year it costs to train each resident, given that residents cannot practice independently and require supervision by certified specialists. Unless a way is discovered to fund more residency slots, there will not be a major increase in the number of practicing doctors.
Even if we train more doctors, we still need to attract a larger percentage into primary care fields. Once again, money can help address this problem. Increasing the salaries of primary care doctors and providing student loan repayment assistance for those choosing fields such as family medicine, pediatrics, and ob-gyn would attract more doctors into these primary care fields. A large number of residents have student loans in excess of $150,000. Salaries of family medicine doctors are much lower than salaries of most other fields of medicine. Physicians who become orthopedic surgeons, for example, earn much larger salaries than general practitioners, pediatricians, geriatricians or psychiatrists. Of course, finding the money to compensate primary care doctors will be problematic. Could some funds come from cutting the salaries of those in very high paying specialties? Perhaps a bit, but the amount generated would not come close to the amount needed and would likely have a negative impact on the medical specialties that are adversely impacted. For example, many areas of the country already have a shortage of orthopedic surgeons and neurosurgeons, particularly when it comes to trauma care; reducing their compensation would likely increase this shortage.
In addition to producing more physicians to address the physician shortage, more extensive use of non-MD health care professionals such as nurse practitioners and physician assistants can be beneficial in extending the delivery of health care. These are well trained professionals who, for the most part, work closely with physicians. Such professionals can also play an important role by enhancing communication between primary care teams and specialists. For instance, to address the shortage of psychiatrists, there could be enhanced coordination and communication between primary care teams and mental health care teams.
Much work is needed to address the issues involved in providing universal high quality health care in the US. The initial plan to increase the number of medical schools and the number of US medical students is a necessary first step, but it must be coupled with many other components, like increasing the number of residency positions, increasing the proportion of primary care doctors, increasing the coordination between primary care providers and specialists, and increasing compensation for primary care practitioners. Only then will there be a reasonable chance to correct the physician shortage in this country.
This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.
