09 September 2011

The looming doctor shortage

Howard Dean wrote an op-ed defending the use of foreign international medical graduates:

Today, young physicians with degrees from international medical schools face skepticism from some in the American medical community. That strikes me as misinformed thinking, given the large number of international medical school graduates practicing in the United States, alongside American medical school graduates, and given that the American medical system depends on them to fill the growing doctor shortage. 
The federal Health Resources and Services Administration predicts there will be a shortage of approximately 55,000 physicians in the United States by 2020. We simply can't build the capacity to meet our growing needs for skilled physicians -- especially given budgetary constraints on schools receiving government subsidies. Even if the new medical schools now in the planning stages all come to pass, they won't turn out enough primary care physicians to meet urgent needs in urban and rural communities.
I actually don't have a lot to say about the IMG thing,  I have worked with and hired many IMG's and their skill and quality vary as much as US graduates. But this whole argument seems to miss the central point regarding the projected physician shortage. The supply of new medical graduates is not the choke point, under the current state of affairs. The choke point is the number of residency training slots.

The Balanced Budget Act of 1997 put a cap on the number of residency slots at 1996 levels. For those who don't know, pretty much all postgraduate medical education in the US is funded through medicare. That cap has remained in place ever since. Medical school enrollment has increased since that time, but the overall number of residencies has not (at least not by a meaningful measure).

There's a frustrating lack of information out there: a common misperception is that the AMA is somehow artificially restricting the number of doctors to keep reimbursement high. Nothing could be further from the truth. First of all, the AMA has essentially no say in the number of physicians trained -- that's largely the province of the AAMC, which has been warning of the physician shortage and calling for action for a long time. Furthermore, the AMA itself has been making the same call for years, too.

The problem is compounded by the fact that many residents, whose training is being paid for by the US taxpayer, are foreign-born and here on a type of student visas. When they are done training, they have to go home unless they can find an employer who is willing and able to sponsor them for a green card. I don't know how many US-trained foreign physicians actually do return to their country of origin -- not too many, I suspect -- but the wrongheadedness of the policy is maddening. If we are going to pay for their education, it should more or less automatically put them on a pathway to permanent residency.

Unfortunately, I don't see a solution in the works any time soon. In the current health care budget crisis, the likelihood that policymakers are going to increase funding for medical education is slim indeed. This means that physician extenders will continue to fill the gaps and provide more and more services. Some of this is just fine -- a PA or NP can be a great surgical assistant, fast track provider, or simple wellness care provider. But as medical students persist in their exodus from primary care, more and more complex disease management will fall on the shoulders of midlevel providers whose training is not intended to encompass it. Those patients who decompensate as a result, or who simply cannot access primary care services do to the shortage will be shunted to ... the ER, of course. The final dumping ground of American healthcare.

We are so screwed.


  1. Some of this will be solved by
    the reduction in hospital care in
    the future, some by closure of
    marginal hospitals. With the
    tightening of the screws forecast
    by medicare ($50B/yr?), refusals
    to pay for readmits, it won't be
    long before stressed hospitals
    begin to collapse and close.
    We are not exactly over run with
    nurses either.

  2. I would be shocked if that provision of the Balanced Budget Act was not inserted at the behest of a physicians group's lobbyist. Nobody else benefits from it.

  3. I've always wondered, what's the difference between foreign medical grad and international medical grad? I've seen them used interchangeably, but obviously that's not the case.

    Relatedly, do you happen to know the classification of non-citizen US grads? Several of my med school friends fall in that category, having come to the US in high school or college and stayed for med school.

  4. "The problem is compounded by the fact that many residents, whose training is being paid for by the US taxpayer, are foreign-born and here on a type of student visas. When they are done training, they have to go home unless they can find an employer who is willing and able to sponsor them for a green card."

    Unfortunately, it takes far more than just a willing employer. There are quotas in place which prevent many of those who have completed training from staying in the US, even if they have an eager employer.

    My department (pediatric EM) has had several fellows recently who graduated and wanted to continue working here who had to fight to stay; they're currently doing most of their shifts at one of our ancillary EDs, the location of which counts as an "underserved" population, in order to make it work.

  5. Over the last couple decades I've worked with ER docs imported from the Philippines, India, the Middle East, Mexico, Central America and Russia that I know of. I've never noticed any correlation between birth place and quality. There are three docs that come to mind that were what many people considered to be dangerous, mainly through failure to think or lack of confidence, and all were American educated. I figure who cares where a doc is from, as long as she can do the job.

    It does seem ridiculous to limit residency slots at the number needed 15 years ago. That number should be adjusted with demand. Also, there has to be some way to encourage doctors to go into primary care. I totally understand why they are more and more choosing specialties, and I like that PAs and NPs are doing so much primary care, but it's important to have an MD available and that is not always the case and is getting less so.

    Some years ago I got to know a doc who was in a family practice residency and spent time hanging out in the ER I was doing agency at. It was shocking how little he made when he went out into the world, about the same as me. He had an education that cost almost as much as my house and he was making what an RN can make. Absurd. He also tended to whine about it, which was annoying, if understandable.

    Dunno what the solution is. The changes coming around the bend don't seem to help the situation at all. Solution the must be though, or as our host says, we are so screwed.

    Oh, as far as the difference between international and foreign in this case, as far as I know, is that one is the nice way to say it, the other the not so nice way.

    Ah, I also lament the fact that like engineers, America is loosing the ability to create it's own doctors. I think out education system needs some work too.

  6. The immigration situation for skilled professionals is just ridiculous all the way around. I work in the software industry, so I've spent my entire career dealing with job candidates who can't get their visa transferred in a reasonable length of time, friends who must decide whether or not to get married, and where to hold the wedding, based on visa status and/or progress in the green card process, employers that have made hiring/firing decisions based on visa dynamics rather than merit, etc. etc. And why? Because we apparently don't want smart, employed immigrants?

  7. @offwhitecoat - BTW love the name!. International grads refer to American citizens who went abroad for their medical education (mostly Carribbean).

    Foreign med grads are citizens of other countries who received their degree from another country and are training/practicing here in the US.


  8. First, are schools prohibited from training doctors under the law with their own funds? If not, then it is about money and restricting the supply of doctors is beneficial to those in the profession.

    Second, if the government is funding the training of doctors it can surely specify what part of medicine they are to enter. Not going into primary care, no funding, for instance.

    Finally, I find it hard to believe we will have a shortage of doctors. Care to justify that with a breakdown of doctors per 1000 compared to other countries? We may have a shortage of doctors in certain specialties but that is not the same thing. I find it really hard to believe that you can't easily retrain a specialist to be a GP based on the quality of most I have encountered as a patient. If that won't work, using PAs or nurse practicioners certainly would not not harm care.


  9. Yes we ARE over run with nurses. Lots of new nurses. Just nobody will hire them. No residencies available really to speak of. All these nurses with no where to work will give up because they have to having defaulted on their college loans.


  10. the movement of American medical grads into primary care specialties has begun. This is not out of choice however. The larger number of student graduating from medical school has squeezed the medical school graduate population. That is the desirable residency positions are only available to those with excellent qualifications. Now all that is left for average applicants is primary care.

    I speak from personal experience. I didn't fail any courses, passed all board exams on first try. Now, I am stuck doing research for a year, making minimum wage with a MD after my name.

    The system truly works well!


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