Not enough doctors

Health care reform means a lot more patients in the system, but the nation doesn't fund enough residency slots to meet the need

May 10, 2012|By Monae Johnson

The Supreme Court's ruling on the Patient Protection and Affordable Care Act, expected in June, will determine the future for countless Americans. Health care reform debates have elevated the plight of millions of uninsured Americans to the national consciousness. However, the physician workforce that would be needed to care for millions of newly insured people deserves equal attention.

There is a growing shortage of primary care physicians in the U.S., and it has been forecasted for decades. The American Association of Medical Colleges (AAMC) projects a shortage of 124,000 physicians by 2020, 37 percent of them primary care doctors. This growing shortage predates the coming squeeze due to the Affordable Care Act, whereby 16 million to 32 million newly insured will enter our health care system and another 45 million will vie for consistent primary-care access in underserved areas.

Some might ask how a shortage of this magnitude is possible in a country with such a wealth of medical schools, teaching hospitals, health systems and academic societies — along with so many faculty, medical students and resident physicians.

The answer lies in understanding the root cause of the shortage: Although the Council on Graduate Medical Education has kept pace with projections to increase medical school enrollment by 15 percent over the next ten years, there is a bottleneck in training doctors. Problem No. 1 is that for the past 15 years, the U.S. has capped the number of residency positions at 22,000 openings, with no funding for new residency slots.

The private market has cried out in unison, "We need more residency slots," and the federal government knew that this day would come. U.S. medical schools have enrolled thousands of international medical students and increased the number of women applicants by 3 percent; American Indian and Asian applicants are also up.

However, the total cost of medical student debt is too high and is not sufficiently subsidized by current government programs — that's problem No. 2. The Journal of the American Medical Association reported in 2008 that only 2 percent of fourth-year med students plan careers in general internal medicine, largely because of debt. The exorbitant cost and outrageous financing options deter many African-American and Hispanic students, in particular, from pursuing careers in general medicine. Ironically, minority primary-care physicians are most desperately needed in underserved areas.

Many minority students are first-generation would-be doctors not competitively prepared in public high school premed curricula, and therefore they need two years of post-baccalaureate training (with even more debt) after incurring four years of college debt just to make the cut to get into medical school. Yet, our current system sustains only 22,000 first-year residency slots for approximately 38,000 degreed physicians annually.

True, the Affordable Care Act does offer a 10 percent Medicare pay boost to entice residents into primary care training — but let's do the math. How could a new graduate pay off $400,000 in educational debt as a primary care physician with an annual salary of about $47,000 (the mean first-year residency stipend)? After loan repayment, this doctor has a possible $700 left per month. And frankly, 30-somethings with $400,000 of debt want to begin repayment just so they can aspire to the American dream of marriage, a family, buying a home and even affording decent clothes and meals.

In 2010, more than half of all graduating medical students in the U.S. had this type of debt. And if the Supreme Court upholds the Affordable Care Act, we will need these graduating medical students to buttress the influx of millions of newly insured into our national health care system.

If federal regulators adopted any of the following solutions, we would be in a much better situation:

•Encourage the Center for Medicare & Medicaid Services to remove the current cap on residency slots nationwide, thereby funding more slots.

•Require all private insurers to contribute to residency training funding.

•Provide tuition remission for medical school students who attend one of the 78 public U.S. medical schools, with annual enrollment of 79,000 students.

•Allow all medical schools to create a primary care physician education track funding students for four years of tuition in exchange for primary care practice post-graduation.

During the Great Recession, our federal government spent more than $150 billion bailing out A.I.G. and $50 billion for General Motors. In recent years, our federal government spent $140 billion annually fighting wars overseas. The cost of not addressing this problem far exceeds the cost of solving it, and the medical education community understands this.

Monae Johnson is a doctoral candidate in public health at New York Medical College. Her email is monae_johnson@nymc.edu.

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