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AAMC Reporter: July 2007
A Word from the President:
The Physician Workforce: Avoiding the Tyranny of the 'Either–Or'
As I travel the country talking about the AAMC physician
workforce policy (particularly the recommendation
to increase enrollment at LCME-accredited medical
schools 30 percent by 2015), I hear a number of interesting,
and sometimes conflicting statements. Some
believe we must first make the health care system more
efficient and effective before increasing physician supply.
Some think we should continue relying on international
medical graduates (IMGs) to meet gaps in medical specialties
and geographic areas, while others feel we must
reduce such dependency. And still others say to improve
America's overall health, it is better to invest more in
public health and prevention than in expanding medical
education and training.
The more I hear these thoughtful concerns, the more I
am reminded of Jim Collins' advice at last year's AAMC
annual meeting. The author of Good to Great, Collins
observed that many decisions should not be caught in
the "tyranny of the either—or." Rather, most are about
finding the appropriate balance among choices and
alternatives, or what Collins called finding "the beauty
in 'and'." Applied to the physician workforce, the question
becomes how do we find the balance needed to
ensure quality care for all Americans?
Improve the System First or Increase Education
and Training Now?—The longstanding goal of fixing
America's broken health care system by reducing waste
and improving access has been elusive in the face of
current payment mechanisms. While we must continue
striving for this goal, planning future supply on the
assumption that we will reach optimal efficiency and
effectiveness in the next decade is far too risky. If we do
not have enough doctors, quality of care is likely to suffer
and those already underserved will have even less
access. Additionally, pursuing this strategy in isolation
leaves no opportunity to "course correct." If we find
ourselves without enough doctors later on, we will not
be able to "produce" them overnight!
The fact is we already face a shortage of physicians.
Thirty million Americans now live in federally designated
Health Professional Shortage Areas (HPSAs), and
every year we learn of new shortages in medical specialties
(e.g., primary care, geriatrics, oncology) and within
certain states. And given the growing number of Americans
over age 65 and medical advances that make it
possible for more people with chronic disease to live
longer, shortages are likely to become even more acute.
Our recommendation to expand medical school enrollment,
coupled with a concomitant increase in the number
of federally supported residency training positions,
are critical first steps toward meeting future needs, but
will close less than half the expected gap between supply
and demand in 2020. Therefore, what we need is balance:
boosting physician supply, while simultaneously
working toward more efficient and coordinated use
of resources.
Continue to Rely on IMGS or Reduce Our Dependency?—Not only do IMGs represent more than 25 percent of
the U.S. physician workforce, many enter specialties
found less attractive by U.S. M.D. graduates and also
work in underserved areas. But if we encourage IMGs
to practice in the U.S., aren't we contributing to the
"brain drain" in underdeveloped nations? And, like
other global dependencies, are we putting ourselves
at risk if we rely too much on non-U.S. physicians
in meeting our own needs?
As a general policy, we must take steps to meet our
nation's health care needs with more U.S. M.D.s. The
National Health Service Corps, which provides scholarships
and loan repayments for physicians who serve in
HPSAs, is a model effort for which the AAMC advocates
increased funding and expansion. The balance here, I
believe, is in recognizing the important role that IMGs
play in our health care system, while also increasing
efforts to encourage U.S. medical school graduates to
practice in underserved areas and to select specialties
(including primary care) where gaps now exist. Additionally,
we must continue studying strategies that
improve distribution, such as the work now being
conducted by our Center for Workforce Studies.
Invest in Prevention or in Increased Capacity?—In my
travels, I also heard some say that if we only did a better
job preventing sickness and disease, we would not need
more doctors. While evidence abounds that good habits
and lifestyle have a major impact on health, the regrettable
reality is that too many Americans continue to
smoke, overeat, and get too little exercise. Further, nearly
half of all American adults—according to a 2004 Institute
of Medicine report (Health Literacy: A Prescription
to End Confusion)—do not have access to, or cannot
understand basic health information.
While we absolutely must invest more in prevention,
we must also recognize that unhealthy lifestyles will
contribute to increased demand and that we have a long
way to go to change behavior. And even those who have
adhered to a lifetime of proper diet and regular exercise
will eventually succumb to the diseases of aging and
require physician care.
However, simply boosting the number of doctors per se
is not sufficient. We must ensure they are thoroughly
knowledgeable about public health and prevention, can
work collaboratively with allied health professionals, and
can convey health information in a way patients, regardless
of culture or lifestyle, will understand and be motivated
to change behavior.
Given all that must be weighed about physician workforce
issues, Jim Collins is wise to counsel that we find
the beauty in "and." We should focus on system improvements
and on having enough doctors. We should recognize
the important role that IMGs play and work to
encourage more U.S. medical school graduates to meet
gaps in geographic areas and medical specialties. We
need to invest both in prevention and in expanding
medical education and training. Nothing less than the
future health of America lies in the balance.
Darrell G. Kirch, M.D.,
AAMC President
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