AAMC Reporter: April 2005

A Word from the President: "Filling the Workforce Gap"

As you probably know, growing concern about an impending physician shortage has prompted the AAMC to call for a 15 percent expansion of medical school capacity over the next 10 years and for a corresponding increase in residency positions.

Now that we've answered the question (for now!) about the need for more physicians, it's time that we begin in earnest to consider the educational backgrounds of those who will be filling the gap. Specifically, should all future U.S. physicians be graduates of schools that have met educational standards as rigorous as those of the Liaison Committee on Medical Education (LCME)?

Before addressing this question, let's review where individuals currently entering the U.S. physician workforce have been educated. Eleven percent are osteopathic graduates; five percent are U.S.-born international medical graduates (IMGs); and 20 percent are foreign-born IMGs. That means less than two-thirds (64 percent, to be precise) of today's new entrants into practice are graduates of LCME schools. Putting aside any parochial concerns raised by our schools' falling "market share" of would-be physicians, let's consider some of the policy considerations raised by our country's dependence on each of the three other sources of future doctors.

Osteopathic medical schools: After more than a century of often bitterly contentious relationships between the osteopathic and allopathic medical professions, we now find ourselves living at a time when osteopathic and allopathic graduates are both sought after by many of the same residency programs; are in most instances both licensed by the same licensing boards; are both privileged by many of the same hospitals; and are found in appreciable numbers on the faculties of each other's medical schools.

One clear difference is that, while the number of LCME graduates has remained virtually constant over the past 25 years, the number of osteopathic graduates has more than doubled (from about 1,150 to about 2,600) and is expected to increase to 3,300 by the year 2010 and to perhaps 4,000 by 2015.

Many believe, as I do, that the educational model championed by our community and upheld by the LCME's rigorous processes offers the best preparation for future physicians, all of whom will be challenged to keep abreast of unpredictable scientific developments. But many also believe, as I do, that our country's two medical professions ought to reconcile what differences remain between them and begin working more closely together to advance the public's interest. All of which raises at least two important questions: (1) Do those of us steeped in the allopathic tradition have an obligation to substantiate the advantages of adhering to the LCME standards undergirding our educational model? (2) Do we have an obligation to assist our osteopathic colleagues in ensuring that all U.S. medical school graduates, irrespective of differences in practice philosophy, meet the same exacting educational standards?

U.S.-born IMGs: LCME-accredited medical schools receive many more qualified applicants than they can accommodate. Many unsuccessful applicants, as well as many Americans who don't even try for a spot in a U.S. school, choose to study medicine abroad, mostly in the Caribbean. We know precious little about these schools but believe that they are, at best, highly variable and, at worst, wholly inadequate. Nevertheless, many students emerge from their "off-shore" experience in good enough shape to obtain ECFMG (Educational Commission for Foreign Medical Graduates) certification and to compete successfully for a place in an accredited residency.

These facts raise several additional questions: (1) What obligation do we have to toughen the ECFMG certification process to bolster confidence that those passing muster have overcome the presumed deficiencies in their undergraduate education? (2) What obligation do we have to go even further and try to improve the quality of the education obtained by U.S.-born IMGs? (3) What obligation do we have to enlarge the capacity of U.S. medical schools, not only to meet the need for more physicians, but also to accommodate more qualified students who would otherwise have no choice but to study medicine in a non-LCME accredited school?

Foreign-born IMGs: The contributions made by physicians born and educated abroad cannot be overestimated. In addition to shoring up the U.S. physician supply generally, foreign-born IMGs have contributed disproportionately to the ranks of primary care physicians and to those practicing in underserved areas, to say nothing of their contributions to medical school faculties and to medical science. Currently, approximately 5,000 foreign-born IMGs enter accredited residency programs annually, the majority of whom remain permanently in this country to practice.

Given our country's tradition of welcoming immigrants seeking a better life and given our dependency on immigrant physicians to meet our workforce needs, we must continue to support the integration of foreign-born IMGs into the U.S. medical profession. However, the current high rate at which such physicians are now entering the system raises two final questions: (1) Should our country, with its abundant resources, continue to depend on other countries to bear the expense of educating so many doctors for us? (2) Can we, in good conscience, continue to drain so many highly educated professionals from countries that need them even more than we do?

Ensuring an appropriate supply of future physicians raises far more complicated matters than merely coming to agreement that we need to educate a larger number. Addressing those complicated matters seemed less urgent when we thought we were heading for a huge surplus of doctors. Now that a shortage appears to be looming, we can no longer dodge the difficult questions raised by the variable educational backgrounds of those who are currently on track to fill the gap. We dare not allow our obligation to meet future physician workforce needs to compromise our obligation to promote the highest possible educational standards for all U.S. physicians.

Jordan J. Cohen, M.D.
AAMC President

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