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The Nation's Physician Workforce: Options for Balancing Supply and Requirements Summary As the twenty-first century draws near, the size and composition of the physician workforce trouble both health professionals and policymakers, particularly because of the radical, rapid, and unpredictable transformation of the health care delivery system. With the collapse of efforts between 1992 and 1994 to enact comprehensive health care reform, much of this restructuring is taking place through changes in the private sector, with-as yet-unforeseen consequences. An ongoing debate is anticipated about how many and what mix of health care personnel the nation needs and judges affordable. These questions are complex and deserve careful, rigorous, and sustained study. This fact notwithstanding, the Institute of Medicine (IOM) concluded that a brief review of data on aggregate supply and requirements and an examination of options for dealing with the physician workforce would be a valuable—and more timely—contribution in the current policy environment. Given the present lack of a clear locus for informed debate and decisionmaking, the IOM appointed an expert committee to carry out a short but substantive review of existing data about the U.S. physician supply, to identify positive and negative implications of the possible mismatch between supply and requirements in coming years, and to lay out possible options for addressing any perceived problems. During the spring and summer of 1995, the committee reviewed a wide range of materials on these issues; it met once in July 1995 to discuss the issues
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements and come to consensus on conclusions and recommendations. The committee ended its deliberations with three principles. First, the nation should not tie national workforce policy or graduate medical education to the service delivery needs of selected parts of the health care system. Second, long-term physician workforce policy should be driven by aggregate requirements nationally, and meeting those requirements should be cued more to the output of U.S. allopathic and osteopathic schools than it is today. Third, opportunities in the United States for careers in the healing arts, such as medicine, should be reserved first for graduates of U.S. schools. Its draft report, grounded in those principles, underwent external review in accordance with procedures of the National Research Council, and this monograph is the committee's final report. U.S. PHYSICIAN SUPPLY AND REQUIREMENTS Most studies of the adequacy of the physician workforce for the past 15 years have concluded that the United States has an oversupply of physicians, generally characterized as a large surplus of most nonprimary care specialists and either a shortage or relative balance in the supply of primary care physicians. Workforce experts often characterize physician supply in terms of total active physicians. In 1970, the United States had a total of 308,487 active physicians (both allopathic and osteopathic), or a ratio of 151.4 physicians per 100,000 population; in 1992, the respective figures were 627,723 and 245.0, which represented an increase in the physician-to-population ratio of about 62 percent. Another important number involves active physicians in patient care (excluding those in training). In 1970, the figure was 222,657, with a physician-population ratio of 109.2 per 100,000; two decades later, the number was 461,405, giving a ratio of 180.1 physicians per 100,000 population in that year (an increase in the ratio of about 65 percent). These figures should be interpreted in light of a landmark report in 1981 on the adequacy of the U.S. physician workforce from the Graduate Medical Education National Advisory Committee (GMENAC). Its estimating techniques forecast a supply of nearly 536,000 professionally active physicians in 1990 and nearly 643,000 in the year 2000—for physician-to-population ratios of 220 and 247, respectively, per 100,000 persons. GMENAC concluded that the nation could expect to have a surplus of physicians in the future (not a shortage) and that the surplus would grow from 70,000 physicians in 1990 to 145,000 by the year 2000. Looked at another way, for the past two decades the U.S. physician supply grew at one and one-half times the rate of growth of the general population. Clearly, by the mid-1990s, the nation was well on its way to surpassing the GMENAC predictions.
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements Graduate medical education (GME) plays a significant role in U.S. physician supply because doctors in graduate training (interns, residents, and fellows) provide considerable patient care and because GME is the necessary pathway to a medical career. More than 99,000 physicians were in graduate training in 1992. The number increases steadily at about 4 percent per year; more than 108,000 physicians were in GME training in 1993-1994 as compared to fewer than 85,000 in 1988-1989. The rise in these GME figures is explained by three factors: Physicians in residency training are a source of financial support for hospitals through the current incentives and mechanisms of GME payments from the federal government. On average, residents remain in training longer than they once did. In large part, the increasing numbers of residency positions are occupied by growing numbers of international medical graduates (IMGs). The number of U.S. medical graduates (USMGs) in GME training has remained stable since the early 1980s, but between 1988 and 1993, the number of IMGs in residency or fellowship training increased by 80 percent (from 12,433 to 22,706); the number of IMGs in first-year residency positions grew by more than 3,200 between 1988 and 1993, whereas the number of USMGs declined by nearly 230 individuals. The vast majority of IMGs are not born in this country but instead are foreign born (FNIMGs); as many as 75 percent of the FNIMGs who take their residency training in the United States will remain in this country to practice. In short, the issue of the long-term match between the supply of physicians in this country and the expected requirements for physician services cannot be addressed without consideration of the role of GME and the role of IMGs within GME. This committee was not unanimous in labeling the current number of physicians as an absolute oversupply or excess, for two reasons: (1) the need or demand for physicians is better understood as requirements for physician services, and (2) the idea that a surplus exists (or does not) is best settled in the context of explicit assumptions about the goals and characteristics of the health care system now (and in the future) and about different ways in which those goals might be met. Rather, the committee concluded (as discussed in Chapter 2 of the text) that the nation, at present, clearly has an abundant supply of physicians—which some members of the committee were prepared to label a surplus; judgments about the implications of those numbers must be made in the context of the overall U.S. health care system and the components of that
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements system of greatest concern—the quality and costs of health care and access to services; the increase in the numbers of physicians in training and entering practice each year is sufficient to cause concern that supply in the future will be excessive, regardless of the assumptions made about the structure of the health care system; and the steady growth in numbers of physicians coming into practice is attributable primarily to ever increasing numbers of IMGs, about which the committee is very concerned. RELATIONSHIP OF PHYSICIAN SUPPLY TO KEY ELEMENTS OF THE HEALTH CARE SYSTEM Will the current or anticipated numbers of physicians have, on balance, positive or negative consequences for costs, accessibility, and quality of health care in the nation? Will that supply have beneficial or harmful effects on such matters as the efficient use of human resources and the long-term future of the nation's academic health centers? Will these judgments differ depending on where the U.S. health care system ultimately settles on a spectrum from tightly controlled capitated managed care to loosely controlled fee-for-service medicine? As elaborated in Chapter 3 of the text, the committee's review of data and published materials, discussions with physician workforce experts at its July meeting, and further deliberations led it to conclude that an oversupply of physicians in this country poses more problems for than solutions to the nation's health care issues. Taken as a whole, the literature on empirical inquiries into the relationship between the overall supply of physicians (on the one hand) and phenomena such as access to health care, quality of health care, and its costs (on the other) is, unfortunately, quite ambiguous. Among the points to be emphasized are the following: No firm evidence can be marshaled to show a beneficial effect of a physician oversupply on costs, access, or quality. It is difficult to see that an oversupply will have much effect on problems of access to care in this country; an abundance of physicians will not solve the problems of maldistribution by geographic area or specialty. Furthermore, evidence is mixed about the impact of a substantial oversupply on either the quality or the costs of care, in part because the effects of restructuring health care toward much greater penetration of managed care are unpredictable. One cannot demonstrate that a surplus will improve the quality of patient care; in some scenarios, it may dilute quality, and a surplus will contribute to higher aggregate health care costs at least as long as the nation has a significant fee-for-service sector.
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements Having far more physicians than needed to meet the nation's requirements is a waste of the federal resources currently spent on physician graduate education, and it may also be a poor personal investment on the part of prospective medical students. When individuals pursue a medical career in the face of a significant oversupply of physicians, their underemployment or underutilization is a tremendous waste of human resources for them and for the nation. Use of large numbers of IMGs here lowers opportunities for able young persons from the United States to enter the medical profession, and some might argue that it also deprives the citizens of other nations of their own talented youth. Thus, the committee believes that however a better balance is to be achieved, it is in the national interest to avoid a serious oversupply of physicians. If the nation had to choose today between too many physicians and too few, it would prefer an excess to a dearth, but little appears to be gained from a huge imbalance between supply and requirements, especially if circumstances adverse to cost, quality, or access were to result. The committee agrees with this assessment—recognizing that an accurate balance between physician supply and societal requirements is an unachievable goal and generally favoring too many rather than too few physicians. The net effects of very high numbers of physicians over time are difficult to predict. The interactions of the underlying forces that shape the U.S. health care system are complex and evolving; in particular, the influence that the managed care revolution will exert is uncertain (although a physician surplus might speed the move toward better managed care). Furthermore, good data on patterns of production and employment of the entire health care workforce, as they relate to these systemwide changes, are sparse. Nevertheless, the committee believes that, on balance, the large and rising numbers of physicians in this nation can have some negative consequences. Apart from those just noted (and discussed in Chapter 3 of the text of this report), a physician surplus could also demoralize U.S. physicians or complicate the future of academic health centers. Predicaments such as these will be far more difficult to address and resolve in the future than they are today. For this reason, the committee advocates action on several fronts to moderate current growth in the U.S. physician supply and to forestall the potentially deleterious effects of unfettered increases. Some concrete steps need to be taken, and they need to be taken soon.
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements STRATEGIES FOR ADDRESSING PHYSICIAN SUPPLY ISSUES Three categories of strategic choices were discussed by the committee: an extreme laissez-faire approach; a strong regulatory program; and a regulated or planned market strategy. In the end, the committee in toto did not embrace the two extreme positions (all market, all regulatory), although some members voiced strong arguments in favor of a free market orientation and others spoke up for various regulatory tactics. Rather, for pragmatic and philosophical reasons, the committee examined several ''constrained market" steps and reached five policy recommendations that are elaborated in Chapter 4 of this report (see Box). Producing Physicians from U.S. Medical Schools The committee concluded that increasing the number of students at U.S. allopathic and osteopathic medical schools would be unwise public policy; the nation clearly graduates a sufficient number of physicians today. It opted for a steady-state approach to undergraduate medical education. Specifically, the committee recommends that no new schools of allopathic or osteopathic medicine be opened, that class sizes in existing schools not be increased, and that public funds not be made available to open new schools or expand class size. Maintaining, but not increasing, the current number of medical graduates, especially if more minorities are brought into the student bodies, was judged to be the most appealing short-run strategy for undergraduate medical education. Although some downsizing might occur over time, the committee has not advised specific action in this direction, for various reasons. First, in the 1960s and 1970s, public policy and government programs led to an overexpansion of U.S. schools and class sizes, and this contributed to a significant increase in physicians who remain in practice today. However, the number of physicians graduating from U.S. schools has now stabilized at a level that seems consistent with likely requirements and the nation's ability to absorb them. Second, recent increases in the number of residents in training are due almost exclusively to increases in IMG trainees. Because 75 percent or more of IMG residents remain in the United States to practice, these increases will result in continued growth in the nation's physician supply. No persuasive rationale can be put forward for leaving the incentives and openings in place for IMGs to practice in the United States while curtailing the opportunities for the nation's own youth to enter a distinguished profession. Third, closing medical schools or reducing class sizes might well undermine efforts to bring more minorities into the profession. In the main, therefore, the committee could not accept the view that decreasing
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements opportunities for young people of this country, while leaving open those same opportunities for those from abroad, is acceptable social or health care policy. Revamping Graduate Medical Training The present system of Medicare reimbursement for residencies through direct and indirect medical education (DME, IME) payments is a major incentive for teaching institutions to keep their numbers of residency positions high and expanding. One part of the solution to potential oversupply problems in the future is to revamp the ways in which federal programs support GME. In keeping with the principles stated earlier and the committee's concerns about the growing number and proportion of IMGs in the nation's physician supply, the committee recommends that the federal government reform policies relating to the funding of graduate medical education, with the aim of bringing support for the total number of first-year residency slots much closer to the current number of graduates of U.S. medical schools. Specifically, the committee believes that the government ought to limit the number of GME positions that it funds through the Medicare program and that this limited number of residency positions should be available first to physicians who have graduated from U.S. medical schools. These basic ideas are not especially new. In 1995, two groups, the Council on Graduate Medical Education and the Pew Health Professions Commission advanced similar ideas, as did the Prospective Payment Assessment Commission, and very recent proposals set out by the current U.S. Congress also connect GME payments to citizenship. The nation's current mechanisms for underwriting GME costs have some perverse effects because the link between payments for service and GME creates incentives for hospitals to establish more and more residency programs and to fill them with IMGs (once the output of domestic schools has been used up). Because the country's present approach—open-ended GME support to hospitals for their residency positions—offers no easy means of implementing the committee's recommendation to lower the total number of residencies or of controlling the entry of IMGs into practice in this country (see below), the committee concluded that the connection between patient care and residency training through these mechanisms ought to be severed. One way to accomplish this is to tie GME support to medical graduates directly rather than to send it solely to hospitals. A commonly advanced tactic for doing this is through the use of vouchers, at least for the direct medical education portion of GME, conferred specifically on USMGs; additional vouchers might be made available to IMGs who come to the United States solely for training and then return to their countries of origin or otherwise depart the
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements United States. Several knotty questions—for example, the pros and cons of using a voucher system to accomplish these goals—would have to be answered before any program to direct part or all of federal GME support to physicians in training rather than to hospitals (or other settings or institutions) could be implemented. Expanded data collection and research will be needed to provide information on such a significant change in the health care sector. Controlling IMG Numbers through GME The committee had strong concerns about the mismatch of physician supply and requirements and about the negative consequences of open-ended immigration of physicians and physicians-to-be from other countries for both the United States and donor nations. Two issues were of paramount interest: the long-term career opportunities for U.S.-schooled physicians and the use of federal tax revenues to underwrite the costs of training foreign physicians here. Changes in general immigration law did not seem to be the best (or even a reasonably feasible) route by which to address these concerns. Rather, the most practical means of creating and enforcing limits on the use of IMGs and federal funds in their training appeared to be through constraints on graduate medical training, which is the final common pathway to practice and employment for physicians. Training institutions in the United States (and the nation as a whole) have an interest in continuing to provide graduate training experiences for foreign medical graduates. Such training brings individuals of many cultures and backgrounds together in ways that can have major beneficial effects on international understanding, communication, and cooperation (although the committee notes that the residency training that IMGs now receive here can be inappropriate preparation for the kinds of health care challenges they may face upon returning home). The sticking point for the committee was that such foreign graduates, upon completion of their training here, ought not to remain in the United States to practice, for two main reasons: (1) their skills and professional contributions are doubtless more valuable to their own countries than to this nation, and (2) their presence in the practicing community here aggravates the mismatch between domestic physician supply and requirements. Replacement Funding for IMG-Dependent Hospitals For purposes of implementing its second recommendation above, the committee believed that payments for GME should be decoupled from those related to the demand for health care services. The committee was very aware, however, that for a small number of hospitals, severe reductions in IMGs in residency slots may constitute a hardship, because those hospitals depend on such
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements trainees for provision of significant amounts of care to the poor, particularly in the nation's inner cities. The committee believed that policymakers and the professions cannot ignore these service responsibilities. Thus, it urges that new or different replacement funding and care delivery mechanisms be found to provide these services to these populations and that the impact of its other suggestions and recommendations on these hospitals should be phased in over time. Therefore, the committee recommends that the federal and state governments take immediate steps to develop a mechanism for replacement funding for IMG-dependent hospitals that provide substantial amounts of care to the poor and disadvantaged. The committee underscores the concept "replacement funding," believing that short-term "transition funding" (the idea usually put forward in proposals to deal with the IMG-dependent hospitals that provide major amounts of care to the poor) was not a sensible idea. In the near future, those hospitals would not likely be able successfully to implement a transition to a more secure financial base while continuing to deliver such high levels of uncompensated care to the uninsured and disadvantaged, inner-city populations. Therefore, committee members preferred a concept of replacement funding for those parts of GME funding that now go to underwrite service delivery, understanding that such subsidies might be needed for a considerable number of years in the present competitive market environment for health care. The committee did not, however, see this as a permanent solution to the problem of serving the needs of poor and disadvantaged populations that may today turn to such institutions for their care. Several options are available for implementing a replacement funding strategy, although the committee could not explore them in depth. Rather, the committee wished to go on record as favoring limitations in the use of IMGs in graduate training as a means of solving service-delivery problems and, at the same time, as urging policymakers and health professionals to take responsible steps to ensure that poor and other populations now served chiefly by IMG-dependent hospitals are not harmed. In regard to this later point, the committee acknowledged the broader issues of access to health care for all and took note of the view of an earlier IOM committee, which had identified making basic health care coverage universal as a fundamental goal of health care reform. Data Collection and Information Dissemination The kinds of steps recommended up to this point could have unanticipated consequences for solving the physician supply problem; moreover, the U.S. physician supply is a moving target, and additional steps may be needed. Rather than simply standing aside and assuming that the problems will be solved, the
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements committee judged that a less hands-off approach was appropriate—namely, one that would call for the government or the professions, or both, to monitor the situation actively and closely. It also recognized that information gathering and reporting, essentially in a vacuum, would not accomplish the changes and reforms necessary to correct, or prevent, problems of an oversupply of physicians in this country. To reflect these positions, the committee offered a pair of recommendations on data collection and research. The importance of getting accurate market information to prospective and current medical students was heavily underscored in committee deliberations, especially because of the rising numbers of applications to medical school at a time when a surplus of physicians either exists or at least can be expected in the near future. Young adults ought to be able to plan careers on the basis of reasonably accurate data about employment prospects. Moreover, an efficient, well-functioning market must have good information available to all. The equivocal findings on whether an oversupply of physicians has positive, negative, or neutral effects on costs, quality, access, use of human resources, and academic health centers is evidence enough of the dearth of reliable and valid information on these matters. Hence: The committee recommends that the Department of Health and Human Services, chiefly through the Health Resources and Services Administration, regularly make information on physician supply and requirements and the status of career opportunities in medicine available to policymakers, educators, professional associations, and the public. The committee further recommends that the American Medical Association, the American Association of American Medical Colleges, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and other professional associations cooperate with the federal government in widely disseminating such information to students indicating an interest in careers in medicine. Needed are data on: the current size and composition of the physician workforce and future projections of supply and requirements; specialty and practice location choices; other parts of the workforce, particularly training and employment of personnel that are likely to be substituted for physicians in managed care organizations or hospitals; and the complex interactions of physician supply with health care costs, access, and quality. The committee recognized that the Department of Health and Human Services, chiefly through its Bureau of Health Professions in the Health Resources and Services Administration, already acquires substantial amounts of
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements such information. In addition, the Council on Graduate Medical Education (COGME) can and does generate topics for data collection, propose workforce policies, and further publicize information generated by the data collection and analysis efforts of federal agencies. So, too, do the major physician associations and specialty societies, including the American Medical Association and the American Osteopathic Association. The committee encourages all these entities to work together in designing or carrying out surveys and other steps in the data collection and analysis enterprise. The committee calls explicitly for such information to be made widely public in a timely manner—to the professions, to health education institutions, to health care delivery systems and facilities, to university and possibly even high school students (particularly first-year college students), and to the public at large. It fully supports the current efforts of these agencies and organizations and wishes to state its sense that they should continue to be pursued and provided with adequate financial backing, recognizing that different audiences will need different types of reports and information. These activities lie more in the area of routine, regular data collection, analysis, and reporting. More than that is needed to provide policymakers and the public with an adequate picture of health workforce issues, especially those involving as sensitive and complex a matter as the supply of physicians in the country. Therefore: The committee recommends that the Department of Health and Human Services provide the resources for research on physician supply and requirements; it specifically recommends that relationships between supply and health care expenditures, access to care, quality of care, specialty and geographic maldistribution, inclusion of women and people of color, and other key elements of the health care system be studied in detail. Responsibility for these kinds of complex studies would fall within the purview of at least three different federal agencies: the Health Resources and Services Administration (and COGME); the Agency for Health Care Policy and Research, the main source of funding for health service research in this nation; and the Health Care Financing Administration, which oversees the Medicare program (and its GME funding activities) and the federal aspect of the Medicaid program. The nation's major health foundations also can support the types of physician workforce research envisioned above, particularly those with long interest in issues related to the health professions, for example, the Pew Charitable Trusts, the Robert Wood Johnson Foundation, and the Josiah Macy, Jr., Foundation.
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements CONCLUDING STATEMENT At the very least, the United States has an abundance of physicians, and many observers have concluded that it either now has or soon will have a surplus. The size of that surplus will depend on several unpredictable factors: the extent to which managed care dominates fee-for-service arrangements as the basic organizing and financing structure for the U.S. health care system; technological breakthroughs and the shifting balance between halfway technologies and the definitive interventions that will prevent or cure disease; the changes that may occur in the production of U.S. medical graduates; changes in the financing for graduate medical education; shifts in the rate of immigration and entry into practice of foreign medical graduates; and developments in the use of nonphysician health personnel. The committee concluded that the probability of an appreciable surplus of physicians was high enough that some steps need to be taken now to ensure that the nation produces the best physicians it can in appropriate, but not excessive, numbers. The committee's strategies reflected an orientation toward a "constrained" market, and focused on five areas: production of U.S. medical graduates; changes in the financing of graduate training to target it to U.S. medical graduates and to break the link between service and education reimbursements; limitations on the training and entry into practice of international medical graduates; replacement funding for IMG-dependent hospitals to permit them to continue to discharge their service responsibilities to poor and disadvantaged populations; and collection and broad dissemination of information related to physician supply and requirements, market forces, and relationships to costs, quality, access, and similar concerns. These issues are extremely complex—more so because of the rapid and unpredictable transformation of the health care system that the nation is now experiencing. Moreover, the practical steps outlined in this report may have some unforeseen consequences, and further elaboration, discussion, and analysis over time are warranted. Nevertheless, the committee believes that its report reflects a prudent examination of strategies for dealing with major elements of physician supply issues and will permit readers to pursue a knowledgeable debate about these serious policy questions. Although not all audiences may find all the committee's conclusions and recommendations compelling, constructive critique of the report might well be healthy if it prompts a deeper examination and fuller understanding of the problems and likely consequences of proposed solutions.
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The Nation's Physician Workforce: Options for Balancing Supply and Requirements In the meantime, the report points the way to decisive actions that all interested parties in both the public and private sectors can usefully take now to forestall even more significant difficulties in the future. Recommendations The Institute of Medicine committee recommends that no new schools of allopathic or osteopathic medicine be opened, that class sizes in existing schools not be increased, and that public funds not be made available to open new schools or expand class size; the federal government reform policies relating to the funding of graduate medical education, with the aim of bringing support for the total number of first-year residency slots much closer to the current number of graduates of U.S. medical schools; the federal and state governments take immediate steps to develop a mechanism for replacement funding for IMG-dependent hospitals that provide substantial amounts of care to the poor and disadvantaged; the Department of Health and Human Services, chiefly through the Health Resources and Services Administration, regularly make information on physician supply and requirements and the status of career opportunities in medicine available to policymakers, educators, professional associations, and the public; the committee further recommends that the American Medical Association, the Association of American Medical Colleges, the American Osteopathic Association, the American Association of Colleges of Osteopathic Medicine, and other professional associations cooperate with the federal government in widely disseminating such information to students indicating an interest in careers in medicine; and the Department of Health and Human Services provide the resources for research on physician supply and requirements and specifically that relationships between supply and health care expenditures, access to care, quality of care, specialty and geographic maldistribution, inclusion of women and people of color, and other key elements of the health care system be studied in detail.
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Representative terms from entire chapter: