Every day in America, 10,000 people celebrate their 65th birthday. Each will slide a new Medicare card into a purse or wallet where it will stay for life, ensuring access to health care. In addition, when the provisions of the new healthcare law are fully implemented, it's estimated that 30 million Americans of all ages previously uninsured or underinsured also will have health benefits.
Some of these people will be new to the healthcare system. All of them will need doctors. And that's where I have some significant concerns, along with a dose of optimism that the health-care system can work its way through this. Will we be able to train a sufficient number of physicians, given budget woes and threats to Medicare funding, to make sure that everyone who needs a doctor can find one?
Some Background
The Association of American Medical Colleges has called for a 30 percent increase in the number of medical students trained in U.S. schools. In response, new medical schools and expanded programs at existing schools have begun training more future MDs.
But medical training is much more than a degree from a medical school. From there, newly minted MDs are still years away from being qualified to practice medicine. They must first go through graduate medical training at one of more than 1,000 teaching hospitals. There, as interns, residents and fellows, they see and treat patients under the close supervision of more senior physicians. Depending on the chosen specialty, these newly minted doctors just out of medical school still face an average of four years, and as many as eight, nine or more years of further training, depending on the specialty or subspecialty that they chose.
The graduate medical education that takes place in the nation's teaching hospitals is at risk in our current budget crunch. Some states contribute to this education through their Medicaid programs, but Medicare contributes the majority of money — $9.5 billion — to teaching hospitals to help cover the additional costs of training new physicians.
Projected Physician Shortages
The Association of American Medical Colleges projects a shortage of 62,900 doctors by 2015, and 91,500 by 2020 if nothing changes. In addition to the aging population and millions of newly insured Americans, their calculations take into account the rising rates of chronic conditions, such as diabetes and obesity, suffered by Americans.
The growth in the number of medical schools has not been matched by a similar expansion in the number of residency slots at teaching hospitals. "Training in medical school does not necessarily allow you to be a doctor," said Mark Noah, MD, medical director of Graduate and Continuing Medical Education at Cedars-Sinai. So while the federal government has supported an increase in the number of medical schools, it has not increased funding for residency training slots at teaching hospitals. In fact, the number of government-supported residencies has been frozen at 1996 levels, and there is growing support in Washington, D.C., to actively decrease graduate medical education for physicians as part of Medicare reform. "It will become more difficult for students to get residency slots," Noah added. So the goal of increasing the number of physicians can be stymied as more medical students come out of schools with fewer places to continue their medical training.
"I have immediate concerns," Noah said. "If some of the proposed cuts go into place, some hospitals will have to close programs or decrease the number of trainees. If graduate medical education isn't supported, it will have an impact on the number and quality of physicians we train." The formerly uninsured and underinsured people who will come into the system may have trouble finding a doctor. Traditionally, residents in training have been a kind of safety net for patients in need. Perhaps the best way to understand the importance of this problem is to ask the simple question: Who will take care of my family and me when we are old?
The Way Forward
It's going to take some time, and a great deal of thought, but I believe we can find a way forward on this question. The issue of how we pay for graduate medical education is entwined with other important issues in our health care delivery system, which I have previously written about: How do we entice more graduating medical students to choose primary care rather than become specialists, despite the facts that they get paid less and work longer hours than most specialists? How do we get primary care providers to practice in the places they are most needed, such as underserved areas? How do we redesign the system to create a team approach with doctors, nurses, pharmacists, nutritionists and other providers working together in a coordinated fashion to deliver personalized care to a population of patients? How do we provide the appropriate, necessary care without overutilizing our precious medical resources?
No matter how the medical delivery system evolves, we need to continue to train top-notch physicians for primary care, and for specialty care. We should consider developing a national physician manpower blueprint that projects how many primary care doctors are needed, and how many specialists and subspecialists are required for efficiently managing the healthcare needs of our country, and only pay for the training slots that conform to those numbers. Figuring out how to pay for medical training for the physicians we will need in the future will involve discussions on such diverse issues as: Who should provide medical care? Are there greater roles for professionals such as nurse practitioners? Should we change our payment system to better reward physicians for their time, and not just for the number of procedures they perform, as a way of encouraging more medical school students to choose primary care?
I share my colleague Mark Noah's optimism for an evolving, improved way forward in graduate medical education. "My hope is that the system will allow doctors to train within a new type of medical system that will allow them to provide care to patients while appropriately distributing professional care according to the needs of the country," Noah said.