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A Word from the President: The Coming Collision Between U.S. Graduates and GME Slots

AAMC Reporter: May 2011

AAMC President and CEO, Darrell G. Kirch, M.D. Over the course of two days earlier this month, the AAMC's Center for Workforce Studies hosted its seventh annual Physician Workforce Research Conference. The papers presented at this meeting of the nation’s foremost scholars on physician workforce issues confirmed the reality the AAMC has been studying since 2005—that the nation is headed toward an aggregate shortage of physicians. Despite this need, soon there will be more medical school graduates than residency slots in which to train them, limiting our ability to close the gap. To steer clear of this impending collision between the supply and demand curves and to address the nation’s physician workforce needs, the freeze on federally funded residency slots must be lifted and training capacity must be increased.

Federal support for physician training has remained static since 1997 when, as part of the Balanced Budget Act, Congress limited the number of training slots it would support through Medicare, which is the largest source of funding for graduate medical education (GME). While U.S. medical school enrollment is on track to expand by 30 percent over 2002 levels to address the expected shortage, no overall increase in the number of U.S.-trained physicians can occur unless Congress lifts the cap on residency training. Given this situation, the AAMC supports a 15 percent increase in federally supported residency positions implemented gradually over the next decade to accommodate Americans’ increased need for medical care.

According to AAMC estimates, the United States will have 91,500 too few physicians by 2020 based on expected need—and this number will grow to over 130,000 by 2025. The increased demand for physician services over the next 15 years can be attributed to three main factors. First, the U.S. population is growing, and second, it is aging. The U.S. Census Bureau projects that the U.S. population will increase by approximately 60 million in 2030—a year in which nearly one in five Americans is expected to be aged 65 or older. Due to advances in medical care, Americans are living longer with such conditions as cancer and end-stage renal disease. As these patients age, they use up to twice the amount of health care services as younger adults. Additionally, an aging population means that the number of Americans eligible for Medicare will increase as older physicians begin to retire. The third major factor driving demand for health care services is health care reform. Barring any judicial or legislative action to repeal parts of the law, the Affordable Care Act (ACA) will cover an additional 32 million Americans, and it has been shown that health care utilization is higher for those with insurance coverage.

Though many of us hear reports of how the physician shortage will be most palpable in primary care, AAMC data show that the shortage will be felt across other specialties as well. Of the 91,500 physician shortage projected for 2020, approximately half will be primary care physicians. The high degree of public attention on the primary care workforce is certainly well founded. After all, a coordinated care delivery system cannot exist without the right numbers of dedicated family medicine, internal medicine, and pediatric physicians. However, we must not lose focus on other specialties. According to the AAMC Center for Workforce Studies, shortages are projected in all specialties—not just primary care—including medical and surgical specialties. Those specialties that care for the elderly, such as geriatrics and oncology (cancer is far more prevalent in older adults) will see increasing demand as my generation—the baby boomers—ages.

Parts of the country already experiencing shortages of health professionals will be most severely affected by the exacerbation of the physician shortage. According to current estimates, approximately 20 percent of Americans live in federally designated health professional shortage areas (HPSAs) that lack the adequate numbers of primary care, dental, or mental health professionals. The most recent Health Resources and Services Administration figures show that primary care HPSAs are the most prevalent with 65 million people lacking access to adequate primary care services. (More than 16,600 practitioners would be required to address the current primary care shortage.) Further shortages will therefore most adversely affect these vulnerable and underserved populations.

The AAMC has made the GME residency cap issue a key advocacy priority and continues to work with federal, state, and community leaders to increase awareness of the urgent need to expand the number of residency training positions. I am especially proud of our efforts during the 2009 health care reform debate, in which we were able to weave into discussions about reform the urgent need to increase the number of federally supported residency slots. We came close to seeing the cap lifted when the Resident Physician Shortage Reduction Act of 2009 (S.973/H.R.2251) was amended to the ACA. Though the amendment was ultimately dropped due to cost considerations, our efforts put this issue on the congressional radar screen.

We continue to hold discussions with various stakeholders in the physician and hospital community as well as with House and Senate leaders to reintroduce a version of the Resident Physician Shortage Reduction Act. Though recognition of the GME cap issue is growing on the Hill and throughout the nation—and many are sympathetic to our cause—the climate of fiscal austerity in which we find ourselves presents a significant challenge. While addressing the national deficit is important and necessary to the nation’s welfare, so too is ensuring that Americans have access to a physician when they need one. Because it takes seven to 14 years to train a physician for practice, addressing the workforce challenge is something that cannot wait. We will continue to work with Congress to impress upon them the urgency of this situation.

Darrell G. Kirch, M.D.
AAMC President and CEO