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Graduate Medical Education That Meets the Nation's Health Needs (2014)

Chapter: 2 Background on the Pipeline to the Physician Workforce

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Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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2

Background on the Pipeline to the Physician Workforce

Abstract: This chapter serves as background for this report’s assessment of graduate medical education (GME) financing and governance. It reviews trends in the characteristics of GME trainees and considers whether the GME system is producing the type of physicians that the nation requires. The focus is on specialty distribution, geographic location, the ability to care for diverse patient populations, and physicians’ overall readiness to practice medicine in settings where most Americans receive their health care. The committee finds that the recent expansion in physician education has occurred with little strategic direction. Several areas need the attention of policy makers to ensure the strategic investment of public funding for GME programs. These include learning how to motivate young physicians to train in specialties and locate in areas where they are most needed; identifying ways to improve the diversity of the physician trainees to better mirror the overall population; increasing GME training in community settings; and ensuring that newly trained physicians possess the skills essential for everyday practice.

Physician education has made significant progress since Flexner revealed the poor quality of medical schools in the early 20th century (Flexner, 1910). The nation has a robust and productive GME system with significant capacity to produce the nation’s physician workforce. Yet, there are also widespread concerns—and differences of opinion—about the size, competencies, and makeup of the physician workforce (Cassel and Reuben,

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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2011; COGME, 2013; Cronenwett and Dzau, 2010; Crosson et al., 2011; Detsky et al., 2012; Saha, 2014; Saha et al., 2008; Weiss et al., 2013).

The objective of this chapter is twofold: first, to briefly describe trends in the pipeline to graduate medical education (GME) programs (allopathic, osteopathic, and international medical school graduates)1 and second, to review what is known about the “output” of today’s GME system (newly trained physicians entering practice). The overarching question in this chapter is to what extent the GME system is producing an appropriately balanced physician workforce ready to provide high-quality, patient-centered, and affordable health care. The subsequent chapters examine the central focus of this study—the impact of GME financing and governance of GME on this question.

PHYSICIAN SUPPLY

The sufficiency of the physician supply—and the public’s future role in financing the production of a larger physician supply—are among today’s most contentious health workforce issues (Iglehart, 2013a; Nicholson, 2009). Determining future workforce requirements is an inherently imprecise activity (Bipartisan Policy Center, 2011). As Figure 2-1 illustrates, understanding the dynamics of physician supply involves many variables and uncertainties. Health care reimbursement and the organization of health care services, for example, are far more important than GME in determining the makeup and productivity of the physician supply (Salsberg, 2009). Nevertheless, the capacity of the GME system is a limiting factor because states require at least 1 year of residency training in the United States before a physician can obtain an unrestricted license to practice medicine (FSMB, 2013).

Although the committee was not charged with projecting the future demand for physicians, it reviewed recent projections and analyses of the capacity of the physician workforce to meet the nation’s health needs (AAMC Center for Workforce Studies; 2012; Altschuler et al., 2012; Colwill et al., 2008; Green et al., 2013; Hofer et al., 2011; Ku et al., 2011; Petterson et al., 2012; Ricketts, 2011). Forecasts of the future physician supply are variable and contradictory in part because it is difficult to anticipate future directions in the health care system (Blumenthal, 2004; Iglehart, 2013b). In the 1970s, for example, concern about imminent shortages led to a significant push for expansion in the number of medical schools and students (Cooper, 2003). Title VII of the Public Health Service Act

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1 Allopathic medical schools confer the Doctor of Medicine (M.D.) degree and are accredited by the Liaison Committee of Medical Education. Osteopathic medical schools confer the Doctor of Osteopathy (D.O.) degrees and are accredited by the American Osteopathic Association.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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image

FIGURE 2-1 Physician supply: The complex reality.

NOTE: DO = doctor of osteopathy; EMR = electronic medical record; GME = graduate medical education; HIT = health information technology; IMG = international medical graduate; MD = medical doctor; NP = nurse practitioner; PA = physician assistant.

SOURCE: Salsberg, 2009 (AAMC State of the Physician Workforce Address).

provided significant funding for the expansion of medical schools (Phillips and Turner, 2012). From 1970 to 1984, the number of medical students increased by 66 percent and the number of residents by 25 percent. A decade later, the conventional wisdom was that the nation faced a significant oversupply of physicians because of the looming impact of managed care on demand for health care services (Fink et al., 2003; Pew Health Professions Commission, 1995).

More recently, projections of the physician supply suggest impending shortages that could prevent many people from getting needed health services. These analyses raise concerns that the rapid aging of the population and the expansion in health coverage in the Patient Protection and Affordable Care Act (ACA)2 will fuel demand for physician services far beyond current capacity (AAMC, 2012a; Grover and Niecko-Najjum, 2013; Kirch et al., 2012; Sheldon, 2010). However, the underlying methodologies and assumptions about the future in these studies are problematic. They often assume historic provider-patient ratios with limited relevance to either contemporary health care delivery or the pressing need for a more coordinated, affordable, and patient-centered health care system (Bipartisan Policy Center, 2011; Dower and O’Neill, 2011). Other analyses that con-

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2 Public Law 111-148.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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sider the potential impact of changes in health care delivery draw opposite conclusions. These studies suggest that an expanded primary care role for physician assistants (PAs) and advanced practice registered nurses (APRNs), redesign of care delivery and other innovations in health care delivery, such as telehealth and electronic communication, may ultimately lessen the demand for physicians despite the aging of the population or coverage expansions (Auerbach et al., 2013a,b; Bodenheimer and Smith, 2013; Bodenheimer et al., 2009; Ghorob and Bodenheimer, 2012; Green et al., 2013; Reinhardt, 2013; Weiner et al., 2013).

In response to the forecasts of shortages, some stakeholders and policy makers are pushing for significant increases in Medicare GME funding. They argue that Medicare should raise the current cap on the number of Medicare-funded residency positions in order to ensure the production of more physicians (Grover and Niecko-Najjum, 2013; Jolly et al., 2013; Kirch et al., 2012). Yet, the available evidence suggests that increasing the production of physicians is not dependent on additional federal funding. A recent analysis of 20 years of residency data documents that, despite the implementation of Medicare caps on funded training slots in 1997, the number of first-year residency positions has grown steadily since 2003—at a rate of increase similar to the period before the caps (Chandra et al., 2014).

Some proponents of increased Medicare GME funding also claim that the number of medical school graduates will soon exceed the available GME training slots (Jolly et al., 2013). Recent evidence does not support this concern. According to the National Residency Matching Program (NRMP),3 about 3,500 new first-year Accreditation Council for Graduate Medical Education (ACGME)-accredited training slots have been created since 2010 (NRMP, 2014a,b). In the 2014 match, there were 7,000 more first-year residency slots than U.S. applicants: 22,300 U.S. allopathic and osteopathic medical school seniors applied for 1 of 29,666 first-year positions (Salsberg, 2014).

Simply increasing the numbers of physicians is unlikely to resolve workforce shortages in the regions of the country where shortages are most acute and is also unlikely to ensure a sufficient number of providers in all specialties and care settings. The evidence instead suggests that, although the capacity of the GME system has grown in recent years, it is not producing an increasing proportion of physicians who choose to practice primary care, to provide care to underserved populations, or to locate in rural

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3 The National Residency Matching Program (NRMP) is a private, non-profit corporation that matches applicants for ACGME-accredited training slots with ACGME-accredited training programs (NRMP, 2013). NRMP uses a computerized mathematical algorithm to match applicants’ preferences with the preferences of residency program directors at U.S. teaching hospitals.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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or other underserved areas (Rabinowitz et al., 2012; Rosenblatt, 2010; Shipman et al., 2013; West and Dupras, 2012). Also, although the numbers of underrepresented minorities have increased, their proportion in medical school and physician populations does not reflect the increasing racial and ethnic diversity of the American population (AAMC, 2010, 2012a,b,c; Sullivan, 2010; Sullivan and Suez Mittman, 2010).

THE GME PIPELINE—MEDICAL SCHOOL ENROLLMENT

In the past decade, there has been a marked increase in the number of medical colleges (both allopathic and osteopathic) and the size of medical school classes. No one factor explains the expansion. Numerous studies in the 1990s predicting serious physician shortages probably had a role. It appears that much of the growth was spurred by local concerns—both public and private—about physician supply. For example, several states—including Arizona, Florida, Michigan, Pennsylvania, and Texas—invested in medical school expansion with the expectation that many graduates would remain to practice locally (Whitcomb, 2009, 2013).

In 2005, the Council on Graduate Medical Education (COGME) released an influential report predicting rapid increases in the demand for physician services with the aging of the baby boomer population, growing U.S. population, and expansions in health insurance coverage (COGME, 2005a). The following year, the Association of American Medical Colleges issued a call for a 30 percent increase in the physician supply (AAMC, 2006; Adler et al., 2013). Since then, the number of medical schools and school enrollments has grown substantially. As Table 2-1 indicates, in the decade ending in 2012, overall enrollment in U.S. undergraduate medical colleges rose by nearly 28 percent, increasing from 80,180 to 102,498 students (AAMC, 2013a). Both allopathic and osteopathic medicine have expanded class sizes at many schools and also built new medical schools. Fourteen allopathic medical schools increased class sizes by more than 10 percent in 2013 (AAMC, 2013b). The growth in osteopathic medical colleges has been even more dramatic. Enrollment in institutions that granted the Doctor of Osteopathy (D.O.) nearly doubled during the decade, increasing from 11,432 students to nearly 22,000 students.

In 2013 alone, four new allopathic and three osteopathic medical schools opened their doors (AAMC, 2013b). Additional growth is under way: As this report was prepared, five new allopathic medical schools have initiated applications for accreditation (LCME, 2013).

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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TABLE 2-1 Change in the Number of Medical Schools, Medical School Enrollment, and Applicants to GME Programs, 2002 to 2012

2002 2012 10-Year Change
Number Percent
Number of medical colleges 145 175 30 20.7
Allopathic 125 141 16 12.8
Osteopathic 20a 34 14 70.0
Students enrolled in U.S. medical colleges 80,180 102,498 22,318 27.8
Allopathic 68,748 80,757 12,009 17.5
Osteopathic 11,432 21,741 10,309 90.2
U.S. medical school graduate applicants to graduate medical education (GME) programs 16,874b 20,248c 3,374 20.0
International medical graduate (IMG) applicants to GME programs 6,585 11,107 4,522 68.7
U.S. citizen IMGs 2,029 4,279 2,250 110.9
Non–U.S. citizen IMG applicants 4,556 6,828 2,272 49.9
Total potential applicant pool for GME positions (U.S. plus IMGs) 23,459 31,335 7,896 33.7
Total potential applicant pool for GME positions (U.S. plus IMGs) 23,459 31,335 7,896 33.7

aData from 2003-2004.

bClass of 2002-2003.

cIncludes seniors and previous graduates of U.S. allopathic medical schools, graduates of osteopathic medical schools, students and graduates of Canadian medical schools, and students and graduates of Fifth Pathway programs.

SOURCE: AACOM, 2012, 2013; AAMC, 2009, 2012b, 2013a; AOA, 2012; NRMP, 2002, 2012.

International Medical Graduates

In addition to the graduates of U.S. medical colleges, the GME pipeline also includes substantial numbers of graduates of international medical schools (referred to as IMGs), both U.S. citizens and foreign nationals. The IMG proportion of the GME applicant pool has been steadily increasing, as has the share of IMGs who are U.S. citizens. In 2012, fewer than two thirds of the GME applicant pool were graduates of U.S. medical schools (20,248, or 64.6 percent) (see Table 2-1) (NRMP, 2013). The remainder included

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
×

4,279 U.S. citizen graduates of international medical schools (13.6 percent), and 6,828 other international graduates (21.8 percent) (NRMP, 2013).

It is important to recognize the significant role of IMGs in U.S. health care; they make up a significant proportion of residents (27.0 percent) and practicing physicians (24.1 percent) (AAMC, 2013a). IMGs play a critical role in the health care of vulnerable populations because they are more likely to practice primary care and to locate in underserved regions of the country (Traverso and McMahon, 2012).

A concern, however, is that U.S. GME programs are contributing to a “brain drain” of physicians from low-income countries, as many of them do not return to their home country after residency training (Hagopian et al., 2004; Mullan, 2005).

GME TRAINING CAPACITY

Workforce planning involves gauging not only the numbers of needed personnel but also whether those with the right training are available “to deliver the right services to the right people at the right time” (Birch et al., 2009, p. S-56). Thus, to assess the output of the GME system, one should consider the capacity of the system to produce the types of physicians that will meet the health needs of a growing, aging, and diversifying population (Ricketts, 2011). This section provides a brief review of trends in the number and type of GME programs and the available evidence on key characteristics of the physician trainee population and recent GME graduates—by specialty and subspecialty, readiness to practice medicine in settings where most people seek health care, racial and ethnic diversity, and geographic location.

Numbers of GME Programs and Trainees

As noted earlier, the capacity of the GME system to train additional physicians has been growing. Both ACGME-accredited residency programs and residents have steadily increased in number over the last decade (see Table 2-2). Between academic years 2003-2004 and 2012-2013, the number of ACGME programs increased by 16.3 percent (from 7,968 to 9,265) and the number of residents by 17.5 percent (from 100,176 to 117,717). There were an additional 7,498 osteopathic physicians in 1,068 American Osteopathic Association (AOA)-accredited residencies in 2012-2013.4

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4 Osteopathic data were provided by personal communications from Konrad Miskowitz-Retz, Secretary, AOA, COCA, and Jim Swartwout, Executive Director, AOA, on March 17, 2014, and March 19, 2013, respectively.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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TABLE 2-2 Growth in ACGME-Accredited Programs and Residents, Academic Years 2003–2004 to 2012–2013

Academic Year Increase
2003–04 2012–13 Number Percent
Number of ACGME-accredited programs 7,968 9,265 1,297 16.3
Initial residency period 4,015 4,084 69 1.7
Subspecialty programs 3,953 5,181 1,228 31.1
Number of residents in ACGME-accredited programs 100,176 117,717 17,541 17.5
Initial residency period 85,513 97,155 11,642 13.6
Subspecialty programs 14,663 20,562 5,899 40.2

NOTE: ACGME = Accreditation Council for Graduate Medical Education.

SOURCE: Data drawn from ACGME, 2013.

Primary Care Training and Increasing Subspecialization in GME

The makeup of specialties and subspecialties5 in the American physician workforce has changed dramatically since the advent of Medicare and Medicaid GME funding. In the early 1960s, primary care doctors made up an estimated half of the physician workforce (COGME, 2010). In 2010, the percentage was roughly 33 percent (AHRQ, 2011).

In less than a generation—from 1999 to 2013—the number of specialty certificates issued by the American Board of Medical Specialties increased from 84 to 145 (see Table 2-3) (ABMS, 2013). Although some of the increase was due to the creation of new pipeline specialties (e.g., family medicine, emergency medicine), the greatest growth has been in subspecialty programs. As Table 2-2 indicates, the number of ACGME-accredited subspecialty programs rose by more than 30 percent from academic years 2003-2004 to 2012-2013. The number of fellows in subspecialty training grew by 40 percent.

The trend toward a highly specialized physician workforce is especially apparent in internal medicine (IM) (Cassel and Reuben, 2011). The proportion of IM residents interested in a primary care career has dropped precipitously. In 1998, 54 percent of third-year IM residents planned careers in general IM. By academic years 2009-2011, the percentage was only 21.5 percent (West and Dupras, 2012). After completing an IM

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5 Specialty terminology can be confusing. All physicians who successfully complete a residency program are considered specialists even if the specialty is a primary care specialty.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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TABLE 2-3 Initial Residency Period and Subspecialty Certificates Issued by the American Board of Medical Specialties, Selected Years

Year Number of Certificates
1969 10
1979 20
1992 66
1996 74
1999 84
2013 145

SOURCE: ABMS, 2013.

residency, physicians can now pursue further training and certification in 22 subspecialties—5 of which are devoted just to heart disease (adult congenital heart disease, advanced heart failure and transplant cardiology, cardiovascular disease, clinical cardiology electrophysiology, and interventional cardiology) (see Table 2-4). The other IM subspecialties are adolescent medicine, critical care medicine, diabetes and metabolism, endocrinology, gastroenterology, geriatric medicine, hematology, hospice and palliative medicine, infectious disease, medical oncology, nephrology, pulmonary disease, rheumatology, sleep medicine, sports medicine, and transplant hepatology.

A similar trend has occurred in surgery as surgical residents increasingly eschew general surgery for subspecialty practice in vascular surgery, pediatric surgery, surgical critical care, surgery of the hand, hospice and palliative medicine, complex general surgical oncology, or thoracic surgery. From 2001 to 2010, the number of new general surgery residents who expected to enter practice without specialized training declined by 33.3 percent (Jolly et al., 2013).

See Table 2-4 for a list of selected pipeline specialties with numerous pathways to subspecialization.

Influences on Specialty Career Choice

There is a considerable literature—based largely on surveys, questionnaires, and other personal reports—describing factors that influence physicians’ decision specialty choice. The evidence suggests that a complex interplay of many variables, including expected future income (and

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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TABLE 2-4 Selected Pipeline Specialties (Initial Residency Period) with Five or More Subspecialties

Pipeline Specialty Number of Subspecialties Subspecialties
Anesthesiology 5 Critical Care Medicine, Hospice and Palliative Medicine, Pain Medicine, Pediatric Anesthesiology, Sleep Medicine
Emergency Medicine 8 Anesthesiology Critical Care, Emergency Medical Services, Hospice and Palliative Medicine, Internal Medicine-Critical Care Medicine, Medical Toxicology, Pediatric Emergency Medicine, Sports Medicine, Undersea and Hyperbaric Medicine
Internal Medicine 22 Adolescent Medicine, Adult Congenital Heart Disease, Advanced Heart Failure and Transplant Cardiology, Cardiovascular Disease, Clinical Cardiac Electrophysiology, Critical Care Medicine, Diabetes and Metabolism, Endocrinology, Gastroenterology, Geriatric Medicine, Hematology, Hospice and Palliative Medicine, Infectious Disease, Interventional Cardiology, Medical Oncology, Nephrology, Pulmonary Disease, Rheumatology, Sleep Medicine, Sports Medicine, Transplant Hepatology
Neurology 9 Brain Injury Medicine, Clinical Neurophysiology, Epilepsy, Hospice and Palliative Medicine, Neurodevelopmental Disabilities, Neuromuscular Medicine, Pain Medicine, Sleep Medicine, Vascular Neurology
Pediatrics 14 Adolescent Medicine, Cardiology, Child Abuse Pediatrics, Critical Care Medicine, Developmental-Behavioral Pediatrics, Emergency Medicine, Endocrinology, Gastroenterology, Hematology-Oncology, Infectious Diseases, Neonatal-Perinatal Medicine, Nephrology, Pulmonology, Rheumatology
Psychiatry 10 Addiction Psychiatry, Brain Injury Medicine, Child and Adolescent Psychiatry, Clinical Neurophysiology, Forensic Psychiatry, Geriatric Psychiatry, Hospice and Palliative Medicine, Pain Medicine, Psychosomatic Medicine, Sleep Medicine
Surgery 8 General Surgery, Vascular Surgery, Pediatric Surgery, Surgical Critical Care, Surgery of the Hand, Hospice and Palliative Medicine, Complex General Surgical Oncology, Thoracic and General Surgery Joint Pathway

NOTE: Neurology and Psychiatry are both governed by the American Board of Psychiatry and Neurology.

SOURCES: ABIM, 2014; ABR, 2014; American Board of Anesthesiology, 2013; American Board of Emergency Medicine, 2014; American Board of Pediatrics, 2014; American Board of Psychiatry and Neurology, 2013; American Board of Surgery, 2014.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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physician payment rules that favor certain specialties and subspecialties), the prestige of the specialty (or lack of it for primary care), medical educators’ bias against primary care, design and location of residency programs, the personal desire for clearly defined responsibilities, lifestyle considerations, medical school debt, demographic factors, and practice location (Chen et al., 2013; Cordasco et al, 2009; Diehl et al., 2006; Dowdy, 2011; Garibaldi et al., 2005; Greysen et al., 2011; Hauer et al., 2008; Jeffe et al., 2010; Kussmaul, 2013; Phillips et al., 2009; Schwartz et al., 2011; Warm and Goetz, 2013; West et al., 2009).

The income differentials between various specialties and/or subspecialties are substantial (Bodenheimer et al., 2007; COGME, 2010; Vaughn et al., 2010) and a particularly strong influence on career choice (Ebell, 2008; Weida et al., 2010). For example, an analysis comparing the present value of career wealth (up to age 65) between a primary care physician and a cardiologist estimated a differential of more than $2.7 million (Vaughn et al., 2010). Other studies have documented annual income differentials ranging from about $100,000 to several hundred thousand depending on the subspecialty (Bodenheimer et al., 2007; COGME, 2010; Ebell, 2008).

Regardless, it is clear is that the GME system’s production of specialists and subspecialists has evolved without strategic direction in relation to the nation’s health needs. The overriding influences are the personal career choices of individual trainees and the decisions of teaching hospitals regarding what type of residencies to sponsor. As the next chapter will describe, Medicare GME funding is not linked in any way with local, regional, or national health care workforce priorities.

Primary Care Physicians

Many experts are concerned that the rapid transition to a highly specialized physician workforce has undermined the nation’s capacity to progress to a higher-quality and less costly health care system. The corresponding evidence, however, is inconclusive (Baicker and Chandra, 2004; Chang et al., 2011; Detsky et al., 2012). Regardless, the crucial issue is not necessarily the declining numbers of primary care physicians but effective organization, deployment of health personnel, and integration of primary care with other health care services. A growing body of literature demonstrates that the Patient-Centered Medical Home (PCMH) and other well-integrated delivery models provide higher-quality and more cost-effective care than the less coordinated systems of care typical of U.S. health care delivery (Gilfillan et al., 2010; IOM, 2012a; Liss et al., 2013; Maeng et al., 2012; Reid and Larson, 2012). There is also compelling evidence that integrating mental health and substance use services into primary care

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
×

improves outcomes, particularly for older adults with depression or at-risk drinking (IOM, 2012b).

Physicians make up approximately 74 percent of the primary care workforce; nurse practitioners, 19 percent; and PAs, 7 percent (Dower and O’Neill, 2011). No one ideal staffing mix for delivering effective primary care services has been determined. A variety of workforce models suggests that innovative mixes of primary care personnel—including greater use of APRNs, PAs, and team-based task delegation—may reduce the demand for primary care physicians in the future (Altschuler et al., 2012; Auerbach et al., 2013a,b; Bodenheimer and Pham, 2010; Bodenheimer and Smith, 2013; Bodenheimer et al., 2009; Ghorob and Bodenheimer, 2012). The PCMH model, for example, uses interprofessional teams of physicians, advanced practice nurses, physician assistants, pharmacists, nutritionists, social workers, health educators, and care coordinators to provide primary care. In nurse-managed health centers, nurse practitioners provide primary care services (Auerbach et al., 2013a). The role of the physician may vary from being central to a more consultative role (Patel et al., 2013).

Readiness to Practice

Many experts have observed that new physicians often lack sufficient training and experience in care coordination, team-based care, costs of care, cultural competence, and quality improvement (Center for Total Health, 2011). Various surveys indicate that recently trained physicians lack essential skills for office-based practice (Cordasco et al., 2009; Crosson et al., 2011a; MedPAC, 2009, 2010). A survey of the clinical department chiefs in IM, pediatrics, general surgery, and obstetrics/gynecology in Kaiser Permanente’s Northern California region, for example, found that new physicians had difficulties in managing routine conditions (e.g., care of minor depression and anxiety, minor chronic pain, certain acute musculoskeletal problems, basic dermatological conditions, and headaches) and performing simple procedures provided in outpatient settings (Crosson et al., 2011a).

In addition, although cultural competence is increasingly recognized as a core competency for all health providers (National Quality Forum, 2009; Wilson-Stronks et al., 2008), surveys of residents suggest that trainees feel ill prepared to provide culturally competent care to diverse populations (Betancourt et al., 2007; Weissman et al., 2005).

Other surveys have found little awareness of the costs of diagnostic procedures among residents and faculty (Patel et al., 2014; Sehgal and Gorman, 2011).

Both allopathic and osteopathic medicine have undertaken ambitious initiatives to remodel the system for accrediting residency training

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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programs,6 in part, to better prepare physicians for practice in real world settings (Buser and Hahn, 2013; Nasca et al., 2010). The ACGME is currently implementing its “Next Accreditation System” (NAS) for all specialties. The new system was specifically developed to enhance the ability of the accreditation process to promote the training of physicians for practice in the 21st century. Assessments of educational outcomes and the clinical learning environment are key components of the NAS and are based on six core competencies—patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (Nasca et al., 2010, 2014a,b).

In 2013, the AOA issued a “New Pathway of Medical Education,” a blueprint for training osteopathic primary care physicians ready to practice in contemporary health care settings (Buser and Hahn, 2013; Shannon et al., 2013). The Pathway builds on five core principles: (1) team-based, patient-centered care; (2) competency-based curriculum; (3) continuous, longitudinal education; (4) clinical experiences in a variety of settings; and (5) a focus on health care delivery science.

Training Site

Some of the problems related to readiness to practice may stem from the nature of the sites where physicians are trained. There is a striking contrast between the sites where residents train compared with the sites where they are likely to spend most of their careers (Sisson and Dalal, 2011). Nearly all GME training occurs in the hospital—even in primary care residencies. Wynn and colleagues (2013) analyzed the GME data that teaching hospitals submitted to Medicare in 2012. The researchers found that only 53 percent of primary care residents train in hospitals that provide training opportunities in non-hospital settings.

The Teaching Health Center (THC) program,7 established in the ACA, is one step toward expanding residency training in community settings. Unlike the Medicare program, which funnels GME funding through teaching hospitals to support residency training, the THCs receive GME funding for primary care residencies directly from the Health Services and Resources Administration (Chen et al., 2012). It is too soon to know if training in these sites will ameliorate some of the readiness issues, and evaluation of these outcomes is important. Unfortunately, however, the authorization for the program’s appropriations will expire in FY 2015 and its long-term prospects are uncertain. In academic year 2013, 333 residents in 45 residency

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6 See Chapter 4 for a discussion of GME governance including accreditation.

7 Chapter 3 provides more details on the funding of the THC program.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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programs in 21 states were supported by THC awards (HRSA, 2013). Most of the funded programs are in family medicine.

Diversity of the Physician Trainee Pool

Producing a physician workforce that reflects the diversity of the American population has been a goal of medical schools, teaching hospitals, policy makers, and the health care professions for many years (AAMC and ASPH, 2012; COGME, 1998, 2005b; Grumbach and Mendoza, 2008; IOM, 2003a, 2004; Nivet and Berlin, 2013; Saha, 2014; Saha and Shipman, 2008). The importance of these efforts is underscored by strong evidence that racial, ethnic, and linguistic diversity among health care providers is correlated with better access to and quality of care for underserved populations (Grumbach and Mendoza, 2008). In addition, nearly two decades of research have documented that non-white physicians disproportionately care for underserved groups and racial and ethnic minority populations (IOM, 2003b; Komaromy et al., 1996; Marrast et al., 2013; Moy and Bartman, 1995). Recent studies also suggest that a more diverse student and faculty presence can enhance the learning environment of all students by providing formative multicultural experiences (Saha et al., 2008; Shaw, 2005).

The challenge in ensuring a diverse physician workforce is daunting. Real progress has been made; the numbers of underrepresented minorities in U.S. medical schools have increased. However, with the growing diversity of the overall U.S. population, the racial and ethnic differences between medical school graduates and the overall population is actually widening (as illustrated in Figure 2-2). In 2012, there were 5,630 African American and 7,225 Hispanic students in U.S. medical schools, representing 6.9 percent and 8.8 percent of total enrollment, respectively (AAMC, 2012c). The Census Bureau projects that, by 2015, 38 percent of the U.S. population will be persons who identify as a racial minority or of Hispanic background, and this proportion will rise to 51 percent by 2045 (U.S. Census Bureau, 2012). In some states and geographic regions, the contrast between the racial and ethnic makeup of the physician and overall population is especially striking. In California, for example, 36 percent of the population is Hispanic, compared with only 5 percent of the state’s physicians (UCLA International Medical Graduate Program, 2013).

Achieving greater income diversity in the GME pipeline is also a concern. More than 75 percent of medical students come from the two highest quintiles of family incomes, and only 5.5 percent have come from families in the lowest quintile of income ($19,178 or less in 2006) (AAMC, 2013b; Jolly, 2008).

There is promising evidence that GME programs can modify recruitment practices to attract competitive underrepresented minorities (Auseon

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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image

FIGURE 2-2 Trends in the proportion of underrepresented racial minorities (URMs) among medical school graduates and the U.S. general population.

SOURCE: Sullivan, 2010 (AAMC).

et al., 2013). However, the GME system has limited leverage because the trainee population depends on the pipeline that begins with premedical education. Therefore, most diversity initiatives focus on interventions early in the physician education continuum—during application to medical school, college, or even earlier (Nivet and Berlin, 2013).

The lack of research on the effectiveness of diversity interventions is a major barrier to progress. Despite the decades of efforts to address the problem, little is actually known about what works.

Geographic Maldistribution

Physicians—whether primary care clinicians or subspecialists—live and practice primarily in suburban and metropolitan areas. Although about 19 percent of the U.S. population live in rural areas8 (U.S. Census Bureau,

________________

8 The U.S. Census Bureau defines rural as any population, housing, or territory outside urban areas.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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2013), just 11 percent of physicians practice in these areas9 (Chen et al., 2010) and only 2.9 percent of medical students envision practicing in a rural or small-town environment (Fordyce et al., 2012; Rabinowitz et al., 2008; Rosenblatt et al., 2010). The proportion of medical students with rural backgrounds has declined in the past decade: In 1999-2001, 6.7 percent of medical students had rural backgrounds compared with 4.1 percent in 2009-2011 (Shipman et al., 2013).

The lack of sufficient numbers of all types of health care personnel in less populated areas has been a constant and seemingly unyielding problem in the United States (IOM, 1996; Rabinowitz et al., 2012; Ricketts, 2013). Indeed, it is a persistent and largely unsolved issue worldwide. It is unlikely that improving access to health care in American rural (or other underserved) areas can be achieved solely by expanding the overall pool of physicians. Recent experience demonstrates that simply producing more physicians has little impact on the problem. Most new physicians locate in cities and suburbs, including areas with a surplus of clinicians in their particular specialty.

The location of one’s medical school and GME training are predictive of practice location, and the longer the period of training is in a particular geographic area, the more likely the individual is to practice there, although it is not clear what factors actually drive this relationship (such as the relative influence of college, medical school, or residency training location). In 2012, states retained nearly half of the physicians (47.4 percent) graduating from the state’s residency programs and 66.6 percent of those who completed both undergraduate and graduate medical education in the state (AAMC, 2013a). Other influences on practice location in underserved geographic areas include exposure to rural or underserved populations during training, related curriculum and experience during training, growing up in a rural or underserved area, and closeness of a prospective practice location to one’s hometown (Barrett et al., 2011; Bazemore et al., 2009; Chen et al., 2010; Phillips et al., 2013; Quinn et al., 2011; Rabinowitz et al., 2005, 2008, 2012).

As with the challenge of improving diversity, no interventions have been tested to identify effective ways of deploying physicians in rural health care settings. Conducting the necessary research will depend, in part, on modifying current Medicare GME payment rules because, under the current system, the geographic distribution of Medicare-funded GME training slots primarily is essentially frozen based on the location of residencies in 1996.10

________________

9 Chen et al. (2010) mapped zip codes to Rural-Urban Community Area codes to determine rural residence.

10 Chapter 3 describes Medicare payment rules that affect the geographic location of trainees.

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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CONCLUSIONS

The United States has a robust GME system, emulated by many other nations, with significant capacity to produce the nation’s physician workforce. GME programs are increasingly producing a highly specialized workforce. It is notable that growth in the number of specialties and subspecialties is occurring without any coordinated planning. This chapter’s examination of the makeup and output of the GME pipeline indicates that the trend toward greater specialization has occurred with little strategic direction—at least with respect to local, regional, and national needs for a balance of primary care practitioners and subspecialists. The number of physician trainees is increasing, but there is little evidence to suggest that the expansion in training capacity is in areas—either geographically or by specialty—where they are most needed.

The proportions of internal medicine residents pursuing careers in general internal medicine and of surgery residents pursuing careers in general surgery have markedly declined. Less than 3 percent of medical students expect to practice in a rural or small-town environment, where physician shortages are most acute.

The United States is rapidly becoming one of the most racially and ethnically diverse nations in the world, but the gap between the diversity among physician trainees compared with the overall population is actually widening. In addition, residents report that they feel ill-prepared to provide culturally competent care to diverse populations.

Much attention of late has focused on the possibility of future shortages in primary care and other specialties nationwide. But this concern is based on studies with unreliable methodologies that do not adequately relate the demand for physicians to the features of a high-performing system of care and that also ignore the regional variations in workforce supply. In contrast, too little focus has been given to how best to organize and deploy physicians through innovative approaches to care delivery. Much remains to be learned. But no interventions have been tested to identify what works to resolve persistent problems such as how to motivate young physicians to train in specialties and locate in areas where they are most needed or ways to reverse the widening gap between the diversity of the physician trainee population compared with the overall population.

Finally, and particularly concerning, is the evidence that recent GME graduates do not have some of the essential skills for office-based practice, where most of them will spend their careers. This is likely due, in part, to the overwhelming emphasis of current GME programs on training physicians in hospitals rather than in community settings.

In summary, there is a clear and compelling imperative for the nation to leverage its investment in GME toward producing a physician workforce

Suggested Citation:"2 Background on the Pipeline to the Physician Workforce." Institute of Medicine. 2014. Graduate Medical Education That Meets the Nation's Health Needs. Washington, DC: The National Academies Press. doi: 10.17226/18754.
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ready to provide high-quality, patient-centered, and affordable health care in all regions of the nation.

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Today's physician education system produces trained doctors with strong scientific underpinnings in biological and physical sciences as well as supervised practical experience in delivering care. Significant financial public support underlies the graduate-level training of the nation's physicians. Two federal programs--Medicare and Medicaid--distribute billions each year to support teaching hospitals and other training sites that provide graduate medical education.

Graduate Medical Education That Meets the Nation's Health Needs is an independent review of the goals, governance, and financing of the graduate medical education system. This report focuses on the extent to which the current system supports or creates barriers to producing a physician workforce ready to provide high-quality, patient-centered, and affordable health care and identifies opportunities to maximize the leverage of federal funding toward these goals. Graduate Medical Education examines the residency pipeline, geographic distribution of generalist and specialist clinicians, types of training sites, and roles of teaching and academic health centers.

The recommendations of Graduate Medical Education will contribute to the production of a better prepared physician workforce, innovative graduate medical education programs, transparency and accountability in programs, and stronger planning and oversight of the use of public funds to support training. Teaching hospitals, funders, policy makers, institutions, and health care organizations will use this report as a resource to assess and improve the graduate medical education system in the United States.

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