We have more students. Now what?

The largest medical school expansion since the 1970s is taking place, fueled by growing alarm that not enough new physicians are graduating each year to keep up with the needs of a surging U.S. population.

With some work force experts estimating that by 2020 the country will need anywhere from 85,000 to 200,000 more physicians than the existing pipeline can produce, nearly all of the nation's 149 medical schools have increased enrollment or are considering it. Among allopathic medical schools, at least 10 new ones are under discussion, eight existing schools have added new campuses and five new schools are in the process of opening. Osteopathic medical schools have added 10 new campuses since 2003.

One health policy watcher estimates that the public will spend $3 billion to $5 billion annually to cover the expansion. That's on top of private donations in the hundreds of millions.

Aware that generations of Americans' health is at stake, medical leaders and health policymakers are debating how to expand the physician work force. They're asking how the work force should be structured, whether there should be an overarching national policy or guideline to shape growth, and what any policy should look like.

So far, medical schools seem to be expanding in areas experiencing some of the largest population booms, said Edward Salsberg, director of the Assn. of American Medical Colleges' Center for Workforce Studies. This would be the southern belt of the United States, including California, Florida and Texas, he said.

In addition, diversity has not been overlooked. A Center for Workforce Studies survey found at least 23 schools are targeting part of their expansion to specific minorities.

But some say such rational planning is not taking place on the federal level. Hospitals already are faced with increasing patient loads, but this has not triggered an increase in medical residencies. At least not through Medicare, the traditional funding source.

Darrell Kirch, MD, AAMC president, said part of the problem is a decade-old Medicare cap on resident education funding. In addition, this year Medicaid announced it would end its contributions to resident education, a change that the AAMC and other stakeholders, including the American Medical Association, are fighting.

Discussions brewing

While the AAMC has been working to expand medical student numbers, the Council on Graduate Medical Education -- the organization Congress charged to keep tabs on physician work force trends, training issues and financing policies -- lost its funding and its voice, at least temporarily.

After issuing a 2003 report predicting a physician shortage, funding cuts left COGME's existence uncertain. Congress has renewed its authorization annually since, but with a drastically reduced budget. Though no longer able to afford outside analysts, COGME's members have produced two reports they plan to release next year that will recommend regulatory and legislative changes to direct more federal funds into resident training.

Robert Phillips Jr., MD, MSPH, COGME vice chair and director of the Robert Graham Center, said the organization's top agenda item is addressing the disconnect between the nation's need for more medical residents and the government's continued efforts to reduce its contribution to resident training.

One recommendation under discussion is the creation of local and regional planning bodies to help identify the size and location of medical student and resident training.

"We've got to be more purposeful about this or we'll wind up with more of the same, a maldistribution by specialty and a maldistribution by location," Dr. Phillips said.

Groups on the local and regional level would identify community needs, such as for more rural applicants or residency slots for specific specialties and geographic locations.

A national body would ensure that resources were available to support regional decision-making and to coordinate studies examining what is happening across the country. Such ideas are the basis for the two upcoming COGME reports.

"Our next step is to finalize these reports and get them into the hands of Congress and [the Medicare Payment Advisory Commission]," Dr. Phillips said.

Russell Robertson, MD, COGME chair and family medicine department chair at Northwestern University's Feinberg School of Medicine in Chicago, said the organization also is gearing up to recommend that Congress approve a 15% expansion of residency and fellowship slots. Congress must lift a 1996 cap it placed on Medicare's GME funding for the expansion to become a reality.

Dr. Robertson said COGME also hopes to coordinate a meeting with three other committees Congress authorized to advise it on dental, nursing and community health issues, so they might present a united voice on work force concerns.

Dr. Robertson and other work force watchers agree that if resident numbers do not increase, U.S. medical school expansion will simply decrease the number of residents who are international medical graduates.

More physicians or revamp system?

Jonathan Weiner, DrPH, professor at Johns Hopkins Bloomberg School of Public Health in Baltimore said COGME does not go far enough. One shortcoming, he said, is that it is made up primarily of physicians, mostly in primary care.

"We need a global perspective," Dr. Weiner said. "COGME is controlled mostly by medical school deans and residency directors, not the consumers, the customers, like the directors of Medicare."

A national forum on work force and health care delivery reform should include insurers, nurses and other health professionals, he said.

To better address access for the underserved, he'd like to see greater public investment in tuition forgiveness programs tied to public service for physicians.

The distribution of resident training funds also should be reworked, Dr. Weiner said. The government spends more to produce a surgeon than it does to train a family physician, he said, because surgeons take longer to train and the government subsidizes each year of their salaries. Instead, he suggested that the government could give programs a certain amount for each resident regardless of whether they train for three years or seven. This would create more equity between primary care and subspecialty residency programs, he said.

"If you think we need more primary care physicians, and I do, then we need to fix this market imbalance," Dr. Weiner said.

Richard Cooper, MD, a physician work force expert and member of the Council on Physician and Nurse Supply, a think tank supported with a grant from San Diego-based AMN Healthcare, a physician and nurse recruiting firm, sees the situation from the opposite angle.

"The policy is very simple," he said. "It is to expand the work force. You can't go into greater detail. ... The only thing we know is that we need more physicians and they will need to do what people ask them in the future."

He would like to see enough residency positions created so that 10,000 more physicians would enter the work force each year.

"We need a national effort to expand the financing of medical schools and residencies," he said. "It's a tragedy to wait."

Outside the chorus calling for work force expansion, David Goodman, MD, a pediatric and community and family medicine professor at Dartmouth Medical School in Hanover, N.H., is a voice advocating for reworking the health care system instead. Dr. Goodman states in an editorial in the Aug. 3 British Medical Journal that with limited national funds, the public may be better served by improving health care delivery and promoting evidence-based care.

"The result of larger doctor training programs will probably be disappointing," Dr. Goodman states in his editorial.

Regardless of experts' positions, all agree on this: Doing nothing is the worst option of all.