Medical Education Surveys Reveal Need for Further Scrutiny

Roxanne Nelson, BSN, RN

September 12, 2018

Every year the American Medical Association (AMA), Liaison Committee on Medical Education (LCME), and the Association of American Medical Colleges (AAMC) publish updates on undergraduate and graduate medical education in the United States.

The results from these two surveys, however, raise several questions that are critical in planning for the US system of medical education, says S. Claiborne Johnston, MD, PhD, dean of Dell Medical School, University of Texas at Austin, in an accompanying editorial.  

All three articles were published September 11 in JAMA.

The AMA/AAMC provides information on the number and demographic characteristics of residents and fellows, including the number of trainees in each specialty and subspecialty, their sex, and type of medical school attended (American, osteopathic, international, or Canadian).  A total of 10,909 active programs were surveyed, and there were an estimated 130,545 active residents in Accreditation Council for Graduate Medical Education (ACGME) accredited programs during the 2017-2018 academic year.

The LCME survey looks at medical school programs and reports on the number and sex of students, curriculum, clerkships, and interprofessional educational opportunities. The questionnaire was sent to the 147 LCME-accredited medical schools with students enrolled in at least 1 year of the curriculum. The response rate was 100%.

During the past decade, the number of students enrolled in medical school grew by 23%, from 70,349 (2007-2008) to 86,420. This has been largely a result of an increase in the number of new medical schools that opened during that time, from 126 to 147. This growth has remained steady despite a 2.6% decline in the number of applicants to medical school from 2016. Even though this is the largest decrease in 15 years, previous declines were reported in 2002 and 2008.

The number of women enrolled in medical school has also steadily increased during the past 20 years, from 28,447 in 1997-1998 to 41,359 in 2017-2018. For the first time, the number of women enrolling in US medical schools has topped the number of men, with women making up 50.7% of the 21,338 new enrollees in 2017 as compared with 49.8% in 2016.  

The number of graduate medical education (GME) programs increased from 10,343 in 2016-2017 to 10,909 in 2017-2018, along with an increase in the number of resident physicians: 124,096 and 130,545, respectively. The breakdown by sex is uneven, however, with women predominating in certain specialties and men predominating in others. For example, female residents make up 64% of dermatology residents, 54% for family medicine, 65% for hospice/palliative care, and 72% for pediatrics; conversely, women fill only 28% of plastic surgery residency slots, 34% for anesthesiology, 34% for medical oncology, and 35% for emergency medicine.

When broken down by race, the majority of resident physicians were white (n = 72,881), followed by Asian (n = 34,611), Hispanic (n = 10,180), and black (n = 7217). The remaining residents belonged to other groups, were multiracial, or were of unknown ethnic origin.

Key Issues

In his editorial, Johnston focuses on a few key questions gleaned from the survey information, one being the looming physician shortage. The AAMC estimates a shortfall by 2030 of 42,600 to 121,300 physicians in the United States. Although the numbers entering residency programs has increased by 15% during the last 5 years, it still will not be sufficient. "Should the numbers of positions in medical schools, residency programs, or both be increased?" he asks.

Another pressing issue is the shortage of primary care physicians, and as needs increase, this shortfall is also likely to increase. The number of first-year family medicine residents has grown by 12% during the past few years, as has the number of first-year internal medicine residents (14%) and first-year pediatrics residents (6%), but there is still a shortfall. "Although studies have examined barriers to physicians choosing careers in primary care, insights have not produced the changes required and more study is needed," writes Johnston.

In 2016-2017, 3482 physicians completed a GME program in family medicine, and for the coming academic year, there are 12,585 residents in family medicine programs, with 4195 entering the first year.

To fill the gaps in primary care, are osteopathic physicians and graduates of international schools the answer? There are almost 16,000 osteopathic physicians currently in residency programs, and 50% are training in these primary care areas. Additionally, almost a quarter of family medicine residency positions were recently filled by osteopathic physicians. Thus, graduates of osteopathic schools are disproportionately helping to fill the gap in primary care.

However, international medical school graduates tend to subspecialize more frequently and account for more than 50% of fellows in critical care medicine, interventional cardiology, endocrinology, nephrology, and geriatrics and more than 40% of those in cardiovascular medicine, hematology-oncology, and infectious disease. Thus, they "may not be the solution to the primary care shortage but may fill other important roles," says Johnston.

Another question he poses is how an increasingly female workforce might change the profession. For the first time, more women than men entered US medical schools in 2017-2018 (52%), up from 43% 20 years ago. Women, however, are more likely to choose primary care specialties, with 47% of all female residents in family medicine, internal medicine, pediatrics, or obstetrics-gynecology. Although they may be helping to fill gaps in primary care, Johnston notes that "their distribution in medical specialties may have other consequences."

Little Scrutiny

Johnston points out that educating future physicians is "a huge investment with returns measured over decades."

Training a medical student costs an estimated $112,000 a year, whereas the estimated cost for a resident is $158,000. Therefore, the price tag for a typical 4-year medical school and 3-year residency runs about $1 million.

Despite this high investment, Johnston writes that it is "remarkable" how little scrutiny medical education receives. In other countries, for example, the number of students/residents and the distribution of specialty positions are dictated. Conversely, the United States tends to rely on market forces and, for residency and fellowship positions, also relies on specialties to expand or restrict growth.

Markets cannot function well, however, in the absence of accurate data and careful analysis, he notes. "Even if government control over the number of medical students and distribution of residency and fellowship slots was excluded as an option, a clear understanding of the current status and possible future status of physician workforce and training programs could allow for a more rational system of physician training," he writes.

Experts Weigh In

Robert Centor, MD, professor of medicine at the University of Alabama, Birmingham, explained that training more medical students alone won't solve the looming physician shortage unless the number of residencies is also expanded.

Selecting the optimal composition of residencies is also a challenge. "It's true that in other countries there is more of a central body deciding that, and they may offer a limited number of specialty slots," he said. "But we have that here as well. If you want to be a cardiologist, for instance, there are also a limited number of slots and it's very competitive. We just don't have a central body making those decisions, and I'm not sure we really need that — in fact, I would be somewhat worried about having a central body making residency decisions."

There has been a lot of concern in particular about the shortage of physicians in primary care, but Centor thinks a more multifaceted approach is needed, rather than just increasing the allocated number of slots. "If we think that family care and primary care are important, then we need to change the way we train our medical students," he told Medscape Medical News. "In most medical schools, the majority of the faculty are not primary care physicians, and in many cases, students get a rotation with a family practice doctor who is separate from the campus."

Students need exposure to great physicians in family practice and good role models. "It has to be intentional to expose them to the field," he explained. "You have to show them and attract them rather than try to force them into it."

Other specialties, such as psychiatry, also have shortages, and they often have to do with the design of the medical school experience. As with family practice, medical students do not get to experience psychiatry, and a connection to these specialties is lacking.

"Basically, you can't get doctors into these specialties with laws, and that is the wrong way to solve the problem," Centor said. "You want to make it attractive, make it financially feasible with some incentives, give them a balanced view, and many will find that it can be a great career for them."

Molly Cooke, MD, professor of medicine at the University of California, San Francisco, told Medscape Medical News that medical education faces many complex, interlocking issues.

"Most but not all comparable countries manage the composition of their physician workforce much more actively than does the US," she said, adding that the problem is "both economic and administrative." 

The primary specialties — general internal medicine, general pediatrics, and family medicine — are at the low end of the annual earnings range for physicians, Cooke explained.  "Because both public and private payers do not pay much for a primary care visit, even a very complex one, physicians are forced to attempt to cover their practice costs and their own salaries, seeing patients every 7 to 10 minutes."

This situation is further exacerbated by the increasing volume of non–face-to-face work, and many primary care doctors spend at least as much time, and sometimes considerably more, dealing with patient inquiries, questions, and requests through the electronic health record. "This vast amount of this work is uncompensated and can and should be done by nonphysicians," Cooke said. "However, as long as primary care physicians need high volumes to keep their practices afloat, they/we will look for 'easy cases.'"   

As for filling gaps with graduates of osteopathic and international medical schools, she pointed out that although osteopathic education has traditionally emphasized primary care training, graduates are susceptible to the same economic and sociologic forces facing all doctors.  The same is true for graduates of international medical schools, Cooke explained. At the residency level, both groups have tended to fill in spots that graduates of US allopathic schools are less than enthusiastic about, such as rural residency programs and "those in gritty, hard-core inner-city locations."

"However, as the class size of US allopathic schools increases while graduate medical education funding remains stable, the gap between the number of residency slots and the number of US medical school graduates has closed," Cooke said. "This leaves less 'room,' particularly for international medical graduates, but in any event, once past the residency phase, the same pressures apply." 

The American Medical Association funded both surveys. None of the authors have disclosed any relevant financial relationships.

JAMA. 2018;320:1042-1050, 1051-1070, 982-983. Medical school report, Graduate medical education report, Editorial

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