How should we fund GME and increase the physician workforce?

In the March 2006 issue of the GME E-letter, we wrote, "If recent trends continue, there should be over 25,000 applicants in this month's match. About 15,000 applicants are current seniors in US medical schools (soon to be US MDs). Most of the rest are IMGs (both US citizens and noncitizens) and a growing number of osteopathic school graduates (DOs).

"Whatever the starting point, all paths leading to US physician licensure must pass through GME. When it's all tallied, about 26 percent of residents/fellows will be IMGs, and almost 6 percent will be DOs.

"Perceiving a looming shortage of physicians, US allopathic medical schools have started ramping up enrollments. But unless an expansion in GME is planned for now and funded soon, in just a few years the growing numbers of US MDs will only compete with IMGs and DOs for the same number of
residency slots.

"The AMA believes the current caps on federally funded residency slots should be removed and all payers (not just Medicare and Medicaid) should contribute to the costs of GME--but for now, that message hasn't resonated in Congress.

"We welcome your thoughts on how to raise broader public awareness of these issues."

Below are the responses we received, with identifying information removed.

The funding process of GME is difficult to understand even for those of us who work with GME in our institutions. I don't think it would be an effective use of time and money to attempt to educate the public on GME funding. The focus of the public education should be the cap on the number of residents allowed and how this is not allowing the GME education locations to respond to the shortage of physicians. The main point must be to lift the caps, and the second point must be to improve the funding mechanism.

I'd suggest mass marketing to residency and fellowship program directors, GME administrators, clinic and hospital physician administrators, and finally finance administrators who have to support increasing program size.

Because they are already concerned with 80-hour work week issues, adding this NOW might help get a push from the institutions to increase program size.

The other suggestion is for broader "public" awareness, bringing this to the national media's attention. Besides CBS and NBC, programs like DateLine love this stuff.

If the AMA is behind it, the ACGME should be too.

I agree with you re: the funding issue. Seems as if Congress has never been interested because they see physicians as already doing quite well--though you would think they would wish to control physicians' Medicare expenditures. So I wonder if we need to work through the insurance companies, via pressure through organizations such as the AMA.

I agree with Congress. We have too many MDs as it is; increasing residency slots would only increase the influx of poorly qualified IMGs.

Since I was helped through medical school by the federal government under the Physician Shortage Program and promised to return to my hometown area to practice primary care, I have some thoughts on this issue. Unlike many others in the program, I did return to the smalltown area, where I practiced internal medicine for 9 years (barely eking out a living...$1,000 take home every 2 weeks for my first 5 years in practice, since overhead was so high, even though I had 80 hour-plus work weeks and felt abandoned from academics). I left that practice to retrain in pathology and am currently academically based and a pathology residency director

• I believe both the federal government, as well as ALL 3rd party payors, should contribute in a balanced method toward GME, however with some mandatory conditions that will assist with coverage of underserved patient populations.
• I do not believe that removing current federal caps on GME will improve patient care, nor will the underserved or underpopulated specialties be served. I strongly believe that it should be left primarily to the ACGME (along with the specialties themselves through an improved survey system of job availability and population area statistics) to advise the Federal government. Increasing numbers through the pipeline is unlikely to improve quality. Thus I believe the ACGME should continue to be the main spokesperson for number of residency spots in the varied specialties, with input from government, AAMC, etc.
• All medical organizations, plus the federal government, should take a serious look at trying to assist/retain the physicians who are out in the underserved areas, often with little support or respect from their academic centers.

I think if we concentrate on these three items and work together to get a handle on what the problems are, there will be improved patient care within our finite resources.

As a DIO, GME chair, and program director, I am very aware of such problems. South Florida, for example, has almost no ACGME programs in Broward or Palm Beach counties, an area of about four million people.

As with most institutions, our number of GME slots are capped. In 2001, we moved to a new hospital and were told by CMS that we had 3 years to establish a new cap allowing us expand training programs. We then embarked on an agressive application process, ultimately obtaining approval for five new programs as well as expanding internal medicine by four slots and colorectal surgery by two. We started residents in June 2004, only to be denied funding by CMS for the new positions, thereby placing a difficult financial burden on the institution. Despite legal appeals to CMS and an application for the one-time redistribution of positions, we were denied both. Currently we are funding these positions internally but have had to cut back the program sizes to be fiscally sound, to the detriment of the community and our committment to training.

We would agree that something needs to be done. State funding, funds from private insurers, taxes, and/or CMS expansion of the cap is required, especially in areas with either growing populations or growing programs that ultimately will improve health care in the US.

As a practicing MD, I disagree with the AMA's position on removing current caps relating to cost of GME. Physician pay and workforce are held to basic economic theories of supply and demand. Limit our supply of physicians and the increased demand will increase our pay. If there is a limited physician provider pool such that medical care becomes a true shortage, physician extenders (NPs, PAs) should be utilized. More clinical authority should be allowed for physician extenders.

One obvious solution is to lobby senators from rural states (especially the Midwest, Mountain West, Alaska, maybe even the South) as well as congressman from rural districts in the same (and even more populous) states, as well as representatives of economically disadvantaged inner city populations. These are likely to represent the people hit hardest in terms of quantity and quality of physician care.

Perhaps this is a hard sell now when so much money is going to military campaigns, defense, and disaster relief, with no appetite to raise taxes, but we have to start somewhere.

The problem is that the American public does not have a clue as to how GME is funded or how hard trainees work (despite the 80-hour work week) to become practitioners. I have long believed that the answer to many of the questions we pose both in the inpatient and outpatient arena is not the thoughtless increase in the pool of PAs and NPs but an increase in the number of physicians in the pipeline as well. This is hard to do, as physicians who are going to be practicing medicine in the mid-21st century need to be well schooled in the basic sciences or else they will end up being no better informed than PAs and NPs and there will be no need to pay them any more. If our profession ignores the basic sciences, the very foundation on which the practice of medicine rests, it does so at its own peril and that of its patients.

The public therefore also must understand the need to fund research in residency/fellowship and to support young physicians in training in a more comprehensive way. They need to know that future developments in cancer treatment and the better management of diabetes, heart disease, and HIV-related disease will not come out of a vacuum, but from dedicated research workers, be it bench or clinical research.

I would strongly suggest that the AMA, together with the ACP and subspecialty societies, use every possible method to inform the public so they can place pressure on their trial lawyer representatives in Congress at the national and state levels. Newspaper advertising, television and radio talk shows, and even town hall meetings need to be held. However, these need to be properly scripted so that a uniform theme emerges. These should not be the expression of random thoughts by well-intentioned physicians speaking different languages.

Furthermore, one cannot talk of GME in an isolated fashion. The issues of malpractice insurance reform need to be addressed as well. The profession seriously needs to consider obligating service either during or after residency training in order to pay back the debt incurred during undergraduate and medical school training. The service obligation ought to be mandatory, the only choice being between choosing a civil or a military option.

I have continued to try to educate people on a local level about this shortage. The numbers I have used are the same that you have used. There are 15,000-16,000 US medical graduates, with 22,000 accredited residency slots within the US. That means that programs to fill their residencies must look to international candidates or DOs to fill all of their positions. As a result, we have been in competition with the computer industry for J-1 visas, which are limited to only so many per year. If this continues, then many physicians in the US will be foreign born and educated. We want to restrict the number of medical students who are American citizens but allow others easy access to work and operate within our medical system.

Is this what the American public had in mind? That their children would be restricted from becoming doctors so that, with a shortage, their families would be treated by physicians only educated for residency in this country? The number of medical school positions should match the number of residency slots within the country, or we should cut back the number of residencies.

As the Chair of a non-medical school family medicine department that recruits about 35 residents/fellows annually, I am feeling the pain you so well described. The recent JAMA article by Rosenblatt et al regarding the workforce crisis in the community health center system lends further support to our concerns. In a state with a huge underserved population, and more than 20 counties without a single physician, we are sensitive to the needs to develop a pipeline from premedical education through medical fellowships.

Our state currently loses up to 43 percent of its medical school grads to out-of-state GME because of a lack of residency slots. A recent survey we completed reveals that seven of the eight medical schools (including osteopathic) have indeed increased their class sizes by 10 percent to 20 percent, but we have not increased slots for GME as you suggest. Nonetheless, the interest in frontline primary care continues to wane, and our current family medicine slots will be filled by 50 percent IMGs in the State as they are in the country. The editorial response to the Rosenblatt article suggests that at least in the generalist specialties there should be a coordinated effort, including advanced practice nurses, to develop the pipeline for greater workforce reliability.

We believe you are correct that GME is the end of that process which the public recognizes as creating the reliable health providers. The Future of Family Medicine Project has indeed corroborated that. If this is indeed true, I believe it is time for the current physician workforce cohort to "get into the game” and take ownership of our own futures. We need to have input at the beginning of the pipeline. If we are not to be replaced by health technicians, paraprofessionals, and alternative providers in niche areas, I believe that we will need to take several measures now:

• Develop a dedicated PAC (inside the AMA) to leverage the legislative process to require all employers of residents and all payors, including patients, to fund part of GME of up to 50 percent of the cost. Require each specialty to provide funding (perhaps up to 25 percent) for the GME slots in their specialty--from dues or pulled from government-funded patient revenues; they could receive credits for providing training in the practice site.
• Cobble together a consortium of pharma, lab, technology health firms, etc, to cover the rest of the cost (as with the dermatology model?). Develop and use validated assessment tools for premedical trainees in professionalism, patient care, communication skills, practice-based learning and tracking of outcomes, and systems-based teamwork experience, and not just knowledge base (MCAT). We need medical students who have these aptitudes before medical school. After all, the GME system must demonstrate that the students are proficient at the end, why are we the only ones doing the heavy lifting. (In our state, medical schools receive a subsidy up to $50,000 per student per year, while residents get $15,000 per year.). We need to be able to demand and support an evidence-based modification of the premedical and preclinical educational model to fit the needs of the students and public. GME cannot provide all of the debt management and retraining currently required of graduating med students.
• Provide templated short programs for physicians to deliver to small businesses (most physicians are small businesses) regarding the value of the physician(s) to their own community and their effect on the overall health indicators of the community and revenue to the community. (Will be different in each specialty. Compare evidence-based medicine to current alternative medical solutions which compete with them) Get the public behind GME.
• Develop motivational and other programs for young and talented students to choose medicine for the right reasons to begin with, so that we have fewer disenfranchised practicing physicians from lower incomes--the public knows that they still are better off than 99.9 percent of the population.
• Continue strong efforts to maintain life-long learning, promote self-reflection, modify our own practice patterns for quality and safety, and place patient interests ahead of our own at all times and in all places.

Some of these measures are being implemented in some specialties, but the house of medicine needs to unite if we are going to truly affect GME overall. It is otherwise reasonable to expect that wealthier specialties will fund their own GME (if they don’t just train technicians) at the expense of others and that the goal of a cohesive supply of well-trained professionals to improve the nation's health will never be reached. This expanding vacuum will be filled by a loose association of paraprofessionals and technicians as it is currently in many underserved locations.

I and my faculty do not believe that it is too late, yet.