While physicians teaching in medical schools and residency programs may sometimes feel like cogs in giant machines, they now have an especially important task: not just preparing tomorrow's physicians, but turning out more and more of them.

That's because the Association of American Medical Colleges (AAMC) and other key groups in American medicine have come to a consensus that there is at least a developing shortage of physicians in the United States, that it will get worse for the next 15 years or more, and that little is being done about it.

AAMC brought a conference together in Washington early in May 2005, drawing almost 90 attendees and presenters -- a significant turnout that indicates many medical schools and residency/fellowship programs know about the issue, expect to do something about it, and are researching it. About a sixth of those in attendance were from the federal government, although only one came from the Centers for Medicare and Medicaid Services in Baltimore, the main source of federal funds for physician education. State governments, some of which have sophisticated models of their clinical workforce needs, also were in attendance.  The purposes of the conference, said AAMC President Jordan Cohen, M.D., were to give the association's stamp to the importance of physician workforce issues, bring together points of view and researchers, and find new directions for research.

In over 50 research papers submitted at the AAMC conference, no single paper addressed academic physicians specifically nor did any paper explain how academic programs addressed rapidly spiking pay levels that prevailed in radiology and anesthesiology in 1999-2002 and several other fields since.  There were also no "how-to" papers explaining how to expand medical schools or residency programs. This information gap provides substantial opportunities for researchers and administrators alike to analyze the vacancy and fill this crucial void of information with new ideas regarding expansion in academic medicine programs.

There were several papers addressing each of the following issues:

• Women in the physician workforce.
• Racial and ethnic diversity in medical education.
• Specific specialties, including pediatrics and radiology.
• Physician productivity and staffing patterns.
• Determinants of physician satisfaction and retirement age.
• Generalist vs. specialist issues.
• Nationwide health systems such as military, veterans and Kaiser.
• State and metro area physician supplies and shortages in rural and inner-city areas.
• The role of NPs and PAs.
• Challenges in counting practicing physicians and retirements, etc..., and estimating future needs.

Some interesting papers on physician retirements addressed physician dissatisfaction -- showing that dissatisfied doctors were two to three times more likely to leave the profession -- and explored the implications of the simultaneous aging of both the medical workforce and the patient population. According to one paper, the intended retirement age of practicing physicians is an "informative" but far from determinative guide to when they actually retire; that affects planning from the local practice level to the national education level.

Richard Cooper, M.D., the former dean of the Medical College of Wisconsin in Milwaukee, told the AAMC conference that expanding existing medical schools and residency/fellowship programs is only a limited solution. He explained that there are limits on a single school's ability to attract and retain faculty, and on a single training location's ability to pull in patients. He added that the near-doubling of medical school and post-graduate training capacity that occurred in 1960-75 was accomplished mainly by expanding existing schools and programs. The maximum size of a medical school generally is 200 to 250 students per year, he said, and most schools today are in or near that size range. Cooper has been a consistent voice of the "shortage view" since the mid-1990s, when the gatekeeper managed care model caused the medical establishment to worry that we were overtraining doctors.

Tom Getzen, a Temple University economist and Cooper collaborator who is executive director of the 2,400-member International Health Economics Association, said the only real solution is 1% to 2% annual growth in U.S. medical school and residency output, achieved mainly by starting one or two new medical schools yearly for the indefinite future (plus concomitant growth in post-graduate programs). Getzen warned that the medical profession's failure to take the shortage seriously will result in the government's taking over standards and other key matters.

As for how bad the situation is now in light of the need to expand output, Getzen notes that from 1980 to 2000, the number of M.D. grads was essentially flat (growth of just 4%), while D.O. grads grew 118% and international medical graduates entering U.S. residency programs grew 110%. Only one new medical school has opened in the last 30 years, Florida State University's College of Medicine, while five or six new branches of osteopathic schools have opened or been announced in the last three years. According to Ed Salsberg, who recently joined AAMC as director of its new Center for Workforce Studies, the number of U.S. physicians per 100,000 of the population will begin falling in 2016 from a high of about 298, regardless of what we do now to lift future physician ranks.

Cooper stressed that the 1960-75 jump in capacity was ignited and supported by coordinated federal and state government action and that in contrast, today there is no federal and little state policy on the physician workforce. The last time national health policy was changed in a major way - the 2003 Medicare prescription drug law - discussing the physician shortage was "off the table" he added.

There are disagreements about the size of future shortages of doctors. Within the past year, AAMC and the Council on Graduate Medical Education both have taken the position that medical school enrollment (MD/DO) should be raised 15% from 2002 to 2015, with accompanying hikes in GME slots. That means an increase from 20,000 to 23,000 per med school year. Salsberg, who led the AAMC conference, said that trends since 2002 suggest this goal will be met. (COGME is an official congressional advisory committee, funded through the HHS budget, which consists of 15 medical education and health industry representatives.)

Cooper has predicted for some time that the U.S. will have a shortage of 200,000 physicians by 2020, and called the 3,000 per year increase in med school grads a "drop in the bucket." He added that dodging the shortage problem for the "baby boom is hopeless. We're talking about helping my grandchildren. If we had started 10 years ago, we might have done something for the baby boom." His forecasts take in a variety of economic growth scenarios and take full account of the roles of other medical professionals.

Where to go from here?

• Every school should have a policy statement and plan to address this issue. If the school can't grow or can grow just 5%, that should be stated and supported with data.
• In general, there may be more qualified college grads who are interested than get admitted to med school.  Should these students be admitted to expand class roles?
• As far as new jobs for residency and fellowship grads, there's essentially a wealth of opportunities in almost every specialty because of the growing shortages.
• If there is ample opportunity to expand class roles, there should be a steady flow of jobs for med school and GME teachers. But here's where the rubber really hits the road. Actually teaching med students and docs brings little money into med schools and residencies, and there's little explicit payment to faculty for teaching.
• These issues may need a new look -- and most importantly, a new source of money. More broadly, solutions to the shortage problems must buttress faculty pay competitiveness versus non-academic levels for a very simple reason: Teaching more docs needs more teachers, both in absolute numbers and as a percentage of the medical profession.
• Try to find ways to reduce med school tuition, and encourage undergrad schools in your universities to add premed programs for non-premed bachelor's and master's holders.

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