David J. States, MD PhD FACMI
August 5, 2014
As a result of an aging population, the United States faces substantial increases in demand for medical care over the coming two decades. The AAMC has argued that in the next 6 years there will be a need for 90,000 new physicians, roughly a 12% increase in the physician workforce (1), and they have argued that a dramatic increase in the number of graduate medical education (GME) positions is needed to meet this need. In fact, these estimates for the demand for medical care may significantly understate the need. Not only is the US population expanding, it will also become increasingly elderly. Further, while there are some encouraging signs that the number of obese children has stabilized and may actually be declining, more than a third of American adults are now obese and the number of obese adults continues to increase (2). These obese patients are at increased risk for arthritis, orthopedic injury, diabetes, coronary artery disease and cancer, and likely will require more medical care than historical averages. The AAMC estimates were also made prior to the implementation of the Affordable Care Act. The ACA has led to a dramatic increase in the number of insured patients. These newly insured patients are not unexpectedly utilizing health care services at a greater rate because these services are now more accessible to them.
There are two problems with increasing GME slots to meet the anticipated need for additional medical services. First, we cannot increase GME slots quickly enough to meet the need. Second, while there is no dispute that we are facing increasing demand for medical services, the assumption that this can only be met by increasing the number of physicians ignores substantial changes in the organization and technology of care delivery that have occurred over the past decade and are continuing to occur.
Can we ramp up GME slots quickly enough to meet the need?
Adding additional slots to an existing GME program is not a trivial endeavor and establishing a new GME program is even more demanding. To increase the number of training slots, a program would first need to add training faculty. Faculty hiring is a slow process beginning with the development of a plan to pay for the faculty salary, advertising, interviewing candidates and making offers. Once hired, a faculty member is expected to remain with an institution for decades. Programs cannot simply say “We will need 90,000 new physicians in 6 years so let us increase GME training slots by 15,000 per year from 25,000 currently to 40,000”. And then somehow shut the system down after these new physicians were trained. The barriers to establishing new GME training programs are even greater. Accreditation alone can require years to complete. It is not unusual for a decade to pass between the decision to create a GME training program and graduating the first successful trainee.
Even if the AAMC request to add an additional 4,000 GME slots were granted and programs could expand immediately (meaning add 4,000 new slots to the incoming class for 2015), these physicians would not complete their training until 2018. In other words, we would only have 12,000 additional physicians while the anticipated need is for at least 90,000 new physicians in 2020. The fact that Congress essentially froze GME funding in 2002 and declined to increase GME slots as part of the Affordable Care Act in 2012 (3) means that we long ago passed the time when increasing GME slots would allow us to produce the numbers of fully trained physicians that will be required to meet the increase in demand for health care services of our aging, obese and newly insured population using our current health delivery approaches. The relevant question is not “How many physicians and GME training positions do we need?” but instead, “How do we meet our rapidly increasing health care needs given a relatively fixed supply of physicians?”
Organizational and technological changes in health care
The real impact of technology on organizational productivity is rarely seen at the level of the individual worker. Rather it is through the structural changes in the organization that technology enables. Secretaries do not type all that much more quickly on word processors than they do on typewriters. Instead, the boss now communicates by email, blogs, text messages and twitter and no longer has a secretary. We are changing the organization and structure of health care delivery more quickly than we can ramp up GME training. Only a few years ago, the vast majority of physicians were independently practicing professionals. Today, more than a third of hospitalists are hired as employees and the fraction of physicians in all specialties working as employees is increasing rapidly (4). Modern corporate health care organizations cannot ignore the economic imperative to achieve efficiency by replacing expensive employees with less expensive staff supported through improved automation. Rather than hire 6 physicians to staff a clinic, we will see teams with two physicians, 6 physician assistants (PA) or nurse practitioners (NP) and several lower skilled medical assistants. Effectively, the organizational change will triple physician productivity even though much of the care is now being delivered by PAs and NPs. We are also seeing standalone “Minute Clinics” and similar solutions where one physician medical director may supervise a network of hundreds of PAs and NPs offering limited but rapidly accessible care. Some states are also beginning to allow MD and DO graduates who have not received GME training to practice as “assistant physicians”. In rural areas, telemedicine and telemedicine supported PAs and NPs offer an attractive solution to address long standing needs. Modern telecommunications, electronic medical records and clinical decision support systems are critical in making these changes possible. Many studies have shown that patient satisfaction is determined mostly by the accessibility of care and relatively less by the credentials of the person delivering the care. While scope of practice laws currently limit the roles of NPs and PAs providers, patient demand combined with insurance company and corporate provider lobbying are likely to relax these limits in the near future, as the Institute of Medicine has recommended (5). The market can and is adapting to meet the changes in demand.
The changing role of Graduate Medical Education
To address our rapidly increasing need for health care services, the solution is not to increase the number of GME slots or federal funding for these positions. Instead, GME programs need evolve their curricula to better match the needs of a dramatically changing physician work environment. Knowledge of organization behavior and personnel management are becoming more important for physicians as is an understanding of team dynamics and ethical behavior in a corporate environment. These are skills that have not traditionally been a major focus of graduate medical education. Similarly, it will be critical for physicians to understand information technology so that they can effectively deploy computational tools and use IT to drive organizational innovation. We need to redirect public funding for GME to support new and innovative solutions (6).