Correcting the Oversupply of Specialists by Limiting Residen

[october]

by M. E. Whitcomb

It is estimated that there will be an excess of approximately 165,000 specialist physicians in the United States in the year 2000.1,2 Consistent with these projections are anecdotal reports that physicians completing residency training in some specialties are having difficulty finding suitable professional opportunities and that the growth of managed care is adversely affecting established specialty practices in some regions.

There is no consensus on how to address the problem of an oversupply of physicians. At issue are conflicting views on the appropriate roles of government and the market in restricting the supply of specialist physicians. Analysts who see the current size and specialty mix of the physician work force as irrefutable evidence that the market has failed to correct the problem are convinced that the government must begin to regulate both the number of new physicians and their specialty choices. Other analysts, primarily members of the medical profession, are adamantly opposed to any form of government regulation of medical education. They believe that market forces will ultimately correct the oversupply of physicians.

I believe there is a role for both the government and the market in restricting the supply of specialist physicians in the United States. I propose here the respective roles of government and the market in decreasing the number of physicians who enter practice and altering the specialty mix.

Determinants of the Supply of Physicians and the Specialty Mix

The primary factors that determine the future size and specialty mix of the physician work force are the number of medical school graduates who enter residency programs each year and their specialty choices. This relation persists even though residents may ultimately choose subspecialties or switch specialties. The majority of residents are graduates of allopathic and osteopathic medical schools in the United States. The number of such graduates who enter residencies (approximately 17,500 in 1994) has remained relatively constant for more than a decade. In contrast, there has been a marked increase in recent years in the number of graduates of foreign medical schools who enter residencies in the United States. In 1994, approximately 6750 graduates of foreign medical schools entered residency programs, or almost 40 percent of the number of graduates of U.S. medical schools who entered residencies.3 Seventeen percent of these graduates of foreign medical schools were U.S. citizens.

Graduates of U.S. and foreign medical schools do not generally compete for the same residency positions. The majority of graduates of U.S. medical schools compete for positions in residency programs participating in the National Resident Matching Program. In contrast, the majority of graduates of foreign medical schools fill residency positions either not offered in the matching program or offered in the program but not filled by U.S. graduates.4 Approximately 75 percent of the graduates of foreign medical schools who train in the United States ultimately establish practices here.5 If their number continues to increase, the specialty choices made by graduates of U.S. medical schools will have a diminishing influence on the specialty mix of the physician work force.

What would happen if medical students in the United States learned that opportunities to practice in certain specialties were soon going to decline dramatically? The number of students applying for residency training in those specialties would almost certainly decline as well. (An example is the downward trend in the number of U.S. students applying to anesthesiology programs.) Would the residency programs in those specialties respond by reducing the number of training positions? Would some programs even close? Hardly. Experience has shown that graduates of foreign medical schools would simply fill the extra positions. If U.S. students altered their specialty choices in response to market forces, the result would be a shift in the proportional representation of graduates of U.S. and foreign medical schools. There would be no change in the supply of future physicians or in the specialty mix.

The Role of Government

The number of entry-level positions filled in the graduate-medical-education system can be restricted by market forces only if those forces are powerful enough either to compel the institutions that sponsor residency programs to reduce or eliminate programs voluntarily or to dissuade a large number of graduates of foreign medical schools from entering U.S. residency programs. There is no reason to believe that program directors, department heads, and others whose individual decisions determine the number of entry-level positions will voluntarily reduce that number.6 Similarly, graduates of foreign medical schools who hope to practice in the United States are not likely to choose to forgo residency training because of concern about the availability of practice opportunities in the specialties with unfilled residency positions. It is therefore unrealistic to believe that market forces alone can substantially decrease the number of entry-level positions in residency programs each year.

To control the supply of physicians, the Council on Graduate Medical Education and the Physician Payment Review Commission recommended that the federal government limit the number of entry-level residency positions to 110 percent of the number of U.S. medical school graduates.7,8 This recommendation was embraced by the Clinton administration and included in the work-force provisions of its original plan for health care reform. Although the proposal for regulating residency positions was widely endorsed by medical educators and health policy analysts, it is unrealistic to expect serious consideration of this approach now.

I suggest that the federal government control the supply of physicians not by regulating the number of residency positions but by limiting the number of graduates of foreign medical schools who enter residency programs each year. In my view, it is not reasonable at this point to consider limiting access to residency training for graduates of U.S. medical schools. Because of the substantial public investment required to educate medical students and the extraordinary debt they accumulate, it would be unreasonable to prevent graduates of U.S. medical schools from acquiring the additional education required for licensure. Current immigration law cannot be used to limit access to residency training by graduates of foreign medical schools, because the majority of such graduates who enter residency programs in the United States are U.S. citizens or have permanent-resident status in this country.5 In recent years, only approximately one third of all graduates of foreign medical schools in U.S. residency programs have been exchange visitors. I believe that the federal government, guided by an appropriate advisory group (such as the Council on Graduate Medical Education), should determine how many graduates of foreign medical schools will be allowed to enter residencies in the United States. The responsibility of selecting the specific candidates to fill the allocated positions should be delegated to a professional group. Those selected would be granted "residency-training cards," which would allow them to enter any residency program to which they were accepted.

The Educational Commission on Foreign Medical Graduates (sponsored by the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, the Association for Hospital Medical Education, the National Medical Association, and the Federation of State Medical Boards) is the most logical choice for the group that selects the candidates for residency-training cards. The commission currently certifies graduates of foreign medical schools who are eligible to enter U.S. residencies. Because the commission administers standardized examinations for this purpose, it should not be difficult to develop criteria to determine who should receive training cards. Although performance on standardized examinations should be the primary criterion, an effort should also be made to maintain a balance between applicants who are obligated to return to their native countries (i.e., applicants with J-1 visas) and those who are not. This approach will ensure that the United States continues to provide residency training to physicians who will use the knowledge and skills they acquire in their own countries. In my view, no preference should be given to U.S. citizens who are graduates of foreign medical schools, most of whom failed to gain entry to medical schools in the United States. Although the policy will be controversial, the performance of this group on the examinations administered by the Educational Commission on Foreign Medical Graduates and on specialty-board examinations is not as good as that of other graduates of foreign medical schools.

Only graduates with training cards would be allowed to enter U.S. residency programs. If the proposed policy of limiting entry-level positions to 110 percent of the number of U.S. graduates had been in place in 1994, only about 1750 graduates of foreign medical schools would have entered U.S. residencies, or slightly more than a quarter of the 6750 who actually began residency training that year. To ensure compliance with this policy, the Medicare program would have to be changed so that any hospital that accepted residents without training cards would not receive direct and indirect medical-education payments. Medicare funds are a crucial source of support for hospital residencies; the potential loss of these funds would provide a compelling reason for hospitals to comply with the policy.

Limiting the number of graduates of foreign medical schools in residency programs may seriously affect the continued provision of patient care by some hospitals, primarily those that provide care to underserved populations. According to accreditation standards, residency programs cannot be justified on the basis of hospital service needs. Research is needed to determine how many institutions depend on graduates of foreign medical schools to provide care to the poor and how many of those institutions would be adversely affected by the new policy. The problem could be addressed in part by making federal funds available to hospitals with a demonstrated need for assistance; the funds would be used to hire nurse practitioners, physician's assistants, or staff physicians to replace residents.9 Such a mechanism was included in the Clinton administration's proposal for health care reform. During a transitional period, selected hospitals could be granted temporary waivers that would allow them to continue to accept residents without training cards. This approach was used in the late 1970s, when limits were placed on the number of foreign medical graduates with J-1 visas who were allowed to enter residencies.

The Role of the Market

If the federal government limits the number of graduates of foreign medical schools entering residency programs so that the total number of entering residents is approximately equal to the number of graduates of U.S. medical schools, the specialty mix of the work force will ultimately reflect the specialty choices of students in U.S. medical schools. There is no reason to believe that these students will choose specialties without regard to market forces. Their choices in recent years have reflected the market ? that is, the availability of many high-income opportunities in procedurally oriented specialties ? quite accurately. Now that the market appears to favor generalists, there is evidence that career choices are beginning to shift.10 Indeed, this year the number of students in U.S. medical schools who chose residency programs in family practice through the National Resident Matching Program was the highest in the history of the specialty. The number of students who chose residency training in internal medicine or pediatrics also increased, as compared with the number in 1994. These trends suggest that market forces, rather than government regulation, should be allowed to determine the specialty choices of graduates of U.S. medical schools.

The success of this proposal depends on two factors. First, medical students must be provided with up-to-date, accurate information about practice opportunities for each specialty in each region of the country. The choices students make can reflect the market only if they are well informed. Such information has not been as important in the past, because there have been plenty of practice opportunities available in most, if not all, specialties.

To meet this need, both the directors and the recent graduates of residency programs could be surveyed regularly to obtain information, based on their personal experiences, about the influence of market forces on professional opportunities. In fact, the American Medical Association, with support from the Robert Wood Johnson Foundation, is currently conducting surveys of this kind. A national network of group-practice physicians or administrators could also be established to collect information on professional opportunities.

Second, the effect of the market on students' choices must not be distorted by federal regulation of the specialty mix of residency positions (as opposed to the number of positions filled), despite the recent proposal for such regulation.11 Medical students who have reliable market information must be free, within reasonable limits, to choose their specialties. The extremely large number of entry-level positions now available in the system is an advantage in this respect.

Conclusions

The problem of the oversupply of specialist physicians will not be solved if the parties involved in the current policy debate continue to frame the solution as a choice between government regulation and market forces. My proposal requires both sides to cast off some strongly held views. Those who believe in the effectiveness of market forces must acknowledge that the market will not restrict the flow of graduates of foreign medical schools into U.S. residency programs. Those who believe the federal government should solve the problem must relinquish the notion that the government can decide the appropriate specialty mix for the physician work force.

The effects of a continued stalemate are clear: the United States will invest substantial sums of money to educate physicians who are not needed, and some of the young men and women who pursue careers in medicine may find few professional opportunities when they finish their education. Since neither of these outcomes is acceptable, there are compelling reasons to agree on a strategy that incorporates federal regulation and market forces to correct the oversupply of specialist physicians.

Michael E. Whitcomb, M.D. Association of American Medical Colleges Washington, DC 20037

Dr. Whitcomb was formerly the director of the Graduate Medical Education Division, American Medical Association, and is currently senior vice-president for medical education, Association of American Medical Colleges. The opinions and views expressed in this article are those of the author and do not necessarily represent the policies or positions of either the American Medical Association or the Association of American Medical Colleges.

References

1. Summary report of the Graduate Medical Education National Advisory Committee. Vol. 1. Washington, D.C.: Department of Health and Human Services, 1980.

2. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA 1994;272:222-230.

3. Medical education research and information database. Chicago: american Medical Association, 1994.

4. Report from the NRMP: results of the National Resident Matching Program for 1994. Acad Med 1994;69:508-510.

5. Mullan F, Politzer RM, Davis CH. Medical migration and the physician workforce: international medical graduates and American medicine. JAMA 1995;273:1521-1527.

6. Whitcomb ME, Caswell J. The market structure of residency training. N Engl J Med 1986;314:710-712.

7. Council on Graduate Medical Education. third report: improving access to health care through physician workforce reform: directions for the 21st century. Washington, D.C.: Department of Health and Human Services, 1992.

8. Annual report to Congress. Washington, D.C.: Physician Payment Review Commission, 1993.

9. Stoddard JJ, Kindig DA, Libby D. Graduate medical education reform: service provision transition costs. JAMA 1994;272:53-58.

10. Altman DF. Medical student career choice: will the market provide the solution to our health care workforce needs? Am J Med 1994;97:407-409.

11. Mullan F, Politzer RM, Gamliel S, Rivo ML. Balance and limits: modeling graduate medical education reform based on recommendations of the Council on Graduate Medical Education. Milbank Q 1994;72:385-398.

[agnostic]

October (Van Winkle), or dare I call you January?

Would you tell us the reason for the inclusion of your substantial historical contribution, most of whose references are at least ten years old? Incidentally, when and where did it first appear and who is its revival (disinterment) intended to help?

[tRmedic21]

Of course!

While reading this lengthy dissertation on how IMGs are ruining healthcare in the United States, I kept wondering why this person was so anti-IMG... then at the end, I saw it....

Michael E. Whitcomb, M.D. Association of American Medical Colleges Washington, DC 20037

Makes plenty of sense now.... boy, they really despise us, don't they?

no preference should be given to U.S. citizens who are graduates of foreign medical schools, most of whom failed to gain entry to medical schools in the United States.

I guess making an end-run around their elitist, good-old-boy system, really pisses 'em off, eh?

the performance of this group on the examinations administered by the Educational Commission on Foreign Medical Graduates and on specialty-board examinations is not as good as that of other graduates of foreign medical schools.

hmmm, no citing of source on this one.... anyone know where this 'statement of fact' came from? Call me crazy, but I was taught that when citing specific data in writing a paper, the source should be included in the bibliography and annotated after the stat. I guess when you're Grand Poobah of American Medical School X, then you're word is just accepted as gold, with no proof being necessary.

I certainly hope that IMGs can build a powerful lobby, because without it, we may see exactly this kind of thing happening in the future.

Interesting, though, to me, that the emphasis was on decreasing the number of physicians in general, but not of US grads. Sounds like an attempt to keep salaries up, in spite of market demand. The fact is, these people who are completing residencies and can't find a job are simply not looking in the right places. Every day you can find sotries in the news about underserved populations who have no doctor. Everyone who finishes residency seems to want to practice in Miami, Cali, or NY, or some similar large city.

Rural America has a shortage of physicians in many many areas. Go ask the people in Utah, in Nevada, in New Mexico, in Oklahoma and Texas, in Mississippi, Georgia and Alabama. I suspect you'll find the same sentiments in the Pacific Northwest, as well as the extreme NorthEast, like Maine. Central Kanas has a shortage, as do Missouri, Arkansas, and Louisiana. Go ask the old folks in Florida who have to wait 3 weeks to get in to see their family physician. Heck, I worked at a hospital and couldn't get into a family doc in less than 2 weeks, so I'd just catch 'em on rounds at the hospital, or get the ER doc to write me a script for Keflex for my bronchitis. These are just places I know about personally from travelling and talking to people. It's a no-brainer (oh, wow, there's a flashback from an old prof *shiver*)!

The point is that it seems to me the AMA and AAMC are focusing on blaming IMGs for taking away lucrative specialty positions from the poor, downtrodden US grads. If IMGs were 90% content to work in underserved areas in FP, Peds, and the occasional IM, then I don't think the AAMC would whine a bit about it, because the competition factor just wouldn't be there. US grads would get all the specialty spots, and would have much higher salaries, more power in lobbying, and in general be the 'elite' physicians of the US. But the fact that many IMGs are consistantly outperforming US grads, after having been rejected (in many cases) by the US Med-Ed establishment just really chaps the hide of the AAMC.

I hope we can, as IMGs, band together and make our (substantial) voices heard as a real force in politics, fighting for both the right to prove ourselves, and for the patients who need our care.

[AUCMD2006]

those sources are over ten years old. couple of points:

- we don't get ANY breaks as IMG's so if we are gettiing such low scores why are we taking some specialty spots higher than the mighty USMG's
-underserved areas are desperate for docs: case in point the post on the kigezi forum where a hospital in kentucky was so desperadt to get help they agreed to take kigezi students who were studying part time in a US campus set up by kigezi that was under fire for "operating an unlicensed" med school in the US. i know the hospital in miami where ross students rotate its in a bad area just like wyckoff (heard)...they are probably greatfull to get the help b/c the snooty UM students refuse to go anywhere but jackson.

there is no over supply unless you are a rich republican who has no problems calling his old chap from prep school when they get sick...hehe

[october]

Originally Posted by agnostic

October (Van Winkle), or dare I call you January?

Would you tell us the reason for the inclusion of your substantial historical contribution, most of whose references are at least ten years old? Incidentally, when and where did it first appear and who is its revival (disinterment) intended to help?

Sometime historical data is helpful as it seems others have already extracted some meaningful information from it.

http://www.imgi.org/corovofspecb1.html


You may call me January, October, April, or May, just don't call me sweetheart.




I'm just a dyslexic agnostic insomniac unable to sleep wondering if there really is a dog.