By James E. Lewis, PhD
Everyone, it seems, agrees that many more physicians are needed over the next 20 to 30 years to respond to more, older Americans, physician retirements and deaths, reduced doctor work hours, and other factors. Both new medical schools and expanded enrollments in existing medical schools are being pursued as ways to increase the physician workforce by 30 percent at minimum. The question is, where is academic medicine going to find the additional faculty to teach more students, and how does that number affect physician workforce calculations and projections? My analysis suggests that question is both critical and lacking attention.
In 2002, there were 125 allopathic and 19 osteopathic medical schools accredited by the LCME and AOA mechanisms respectively. Currently, there are 16 (13 percent) more allopathic schools—1 fully accredited, 10 with preliminary accreditation permitting them to admit students, and 5 with provisional accreditation—all with websites announcing their missions and encouraging applications, or inquiries at least, from prospective students. In comparison, the percentage growth in the number of osteopathic schools in the same period of time is startling—10 more schools, a 53 percent increase, and 18 more school “locations,” a 95 percent increase. (A “location” is another four-year school operating in a second location, often several hundred or a thousand miles from the existing parent school.) More MD and DO schools are in “applicant” status or under discussion at this time.
For discussion purposes, assume the average number of MD or DO students per class per new school is 80. At full operation, these 34 new schools/locations would enroll about 12,000 students in medical school years 1 through 4; and add about 3,000 new physicians per year to the overall supply after the graduates complete 3 to 8 years of residency, ignoring the number who would go on to fellowship training before entering practice.
Medical school faculty/student ratios range from 1-2:1 to 12-14:1. The numbers aren’t standardized: Two different websites for one well-known, elite school report almost a tenfold difference in the school’s faculty/student ratio. DO schools report that, in 2011-2012, 90 percent of their 33.6 thousand clinical faculty members were volunteers. If we arbitrarily choose a conservative 5:1 ratio, the new schools will create a demand for about 60,000 new faculty members, including basic (say 20 percent) and clinician scientists (say 80 percent) at all levels, plus another 3,000 or so MD/DO deans, department chairs, and other high-level administrators. In round numbers, we need 63,000 new MD/DO faculty and administrators for undergraduate medical education alone, in addition to the estimated 100,000 MD/DO full- and part-time faculty we already have. The number of clinician faculty required for GME would be an add-on if it were known. (This is not a trivial issue. Everyone except Congress seems to agree that meeting the need for an expanded physician workforce will require funding a corresponding increase in the number of GME slots. Some number of physician faculty FTEs is already committed to GME but not identified separately in the workforce data. Expanding the number of GME programs/slots will require a to-be-defined expansion of the teaching/supervising physician cadre and cut further into the overall FTE work force.)
I have been unable to find any discussion in the literature that acknowledges the existing, let alone this additional, claim of academic medicine on a portion of the physician workforce. Physician supply data do not appear to separately identify faculty physicians within the aggregate supply. Indeed, the major challenges to enrollment expansion reported in the AAMC Center for Workforce Studies report (May 2009) were the need for additional clinical training sites and for classroom and laboratory space. Two years later, however, the AAMC Enrollment Survey for 2011 asked more specific questions of the responding deans (95 percent response rate). They were “concerned” about the “adequacy” of clinical training sites (65 percent), the supply of qualified primary care preceptors (74 percent), and the supply of qualified specialty preceptors (53 percent). A lesser level of concern was expressed as to whether the volume and diversity of patients in the clinical training sites would be sufficient (36 percent).
As has been the case for the past 35 years or so, most, if not all, of the workforce studies call for more primary care physicians. The mission statements of the new MD/DO schools, in particular, exhibit a heavy emphasis on educating primary care physicians and eliminating health care disparities, especially access, in underserved urban and rural areas. Given that the numbers of trained primary care physicians have never met the estimated need, the deans cited above are asking the difficult, but correct, question: Where are the additional primary care faculty members going to come from? It seems unlikely that there is a source other than the community of practicing primary care physicians and, if they can be recruited for academic careers, how long will it take, how much will it cost to develop the necessary teaching talents and skills, how big will be the “backfill” needed to replace those drawn into academic medicine, and what will be the impact on the overall supply of primary care physicians in the seven-year short term (four years of medical education and three years of residency) and longer?
AAMC and AACOM data could increase the precision of these numerical estimates, but they won’t change the questions and the policy issues. We are in need of answers and discussion among the leaders of academic medicine, physician workforce analysts, and health care policymakers if there is to be full understanding of the gap between the size of the existing physician workforce and the projections of future needs when the demands for new clinician faculty are taken into account.
—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.