Until the end of World War II, allopathic GME was conducted public teaching hospitals and a few university hospital-medical school complexes in major cities, principally in the East. Five new schools, located mainly in the West and South, were accredited in the immediate post-war period, but the rush of medical school construction occurred in the late 1960s and the 1970s. Following the Carnegie Commission report, 30 new allopathic schools opened (seven as VA-supported initiatives), citing a mission to graduate physicians who would practice primary care in their state or region. From 1979 to 1999, only one allopathic school opened (a second, Oral Roberts University in Tulsa, opened and closed during that period).
Osteopathic GME followed a very different pattern as it spread from its beginnings at the A.T. Still School in Kirksville, Missouri, in 1892. The early schools were in Des Moines, Kansas City, Philadelphia, and Chicago in accord with the profession’s “one trainer, one trainee” philosophy and the fact that most DOs entered practice upon completion of the one-year “internship” required for licensure in all states. No new DO schools were accredited from 1916 until 1969. Over the next 30 years, 14 new DO schools were created; in the first twelve years of the 21st century, another 15 DO schools have been accredited. In 2002, there were 125 accredited allopathic schools and 19 accredited osteopathic schools. Since then 15 new allopathic schools and 10 new osteopathic schools operating 18 campuses have been accredited. (The 29 DO schools operate 37 campuses.) More schools—allopathic and osteopathic—are under initial review by accrediting bodies; local public and private sponsors are discussing plans for at least another 10.
All but two of the 33 new schools and campuses share a common geographic denominator: location in congressional districts and states that went to the Republicans in the 2012 Presidential Election, principally in the South and rural and suburban areas in Michigan and the mid-Atlantic. The exceptions are Oakland University School of Medicine (Rochester Hills, MI), which affiliated with two powerful and merging health systems, Henry Ford and William Beaumont, located just north of Detroit in arguably the most economically advantaged area of Michigan; and Quinnipiac University School of Medicine, which has clinical sites in several community hospitals in south central Connecticut.
Is it possible to change the game? Medical education has two formal but inseparable stages: medical school and graduate medical education. There are no shortcuts and there is no way for medical schools and teaching hospitals to pay an increased share of GME costs, especially when their patient care revenues are also a target for federal and state health care expenditure reduction.
According to the 2012 AAMC Enrollment Survey, 56 percent of projected medical student enrollment growth for 2002 to 2016 has already occurred. Of the projected growth, 58 percent will occur at the schools that were accredited by 2002; 25 percent will come from schools accredited since 2002; and 17 percent will come from schools that are now in “applicant/candidate” status. In short, 42 percent of the projected growth is expected to come from new schools located in congressional districts where Republican members of Congress were elected in 2012. These new schools aim to improve access to health care for the people who live in those districts. The new schools face a shortage of inpatient and outpatient clinical sites (and faculty) for both undergraduate medical education and graduate medical education. (Existing legislation makes it extremely unlikely that Medicare will approve new GME positions in institutions that have, or previously had, GME positions.)
Nothing could be worse for students, parents, schools, and the interest groups that have banked on a medical school bringing improved health care and economic benefits to their community: graduating an estimated 5,000 new MDs (2,000) and DOs (3,000) who can’t find GME positions to continue their training. (They are also competing for those positions with growing numbers of USIMG and IMG applicants.) Five thousand is, of course, just one-third of the 15,000 new GME positions that will be required for residency programs that average three years in length. Nor does that number account for future graduates of schools that are just now beginning to prepare their applications for accreditation.
Over the past four decades, the patient-as-voter (often the “impatient voter”) has been very successful at gaining increases in federal and state government funding for disease-specific research and care programs. Perhaps taking a larger view of the GME funding issues will help spawn new, and activate established, interest groups that can carry the message to Congress in the hope of achieving results that benefit the nation as well as a particular congressional district. This strategy has worked successfully for many other issues; why not graduate medical education?
—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, teaching hospitals, cardiovascular and cancer research and clinical programs, medical professional associations, disease oriented foundations, consulting firms, pharmaceutical companies, components of the National Institutes of Health, the Centers for Communicable Diseases, and the predecessors of the Center for Medicare and Medicaid Services. Previously he served as Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, New York City, where his academic title was Professor of Medicine and Health Policy; and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham, where his academic titles were Professor of Medicine and Adjunct Professor of Sociology. He can be reached at firstname.lastname@example.org.