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Letters

Another Focus On Workforce Issues

The thoughtful editorial by John Iglehart (Sep/Oct 02) and the accompanying papers are important contributions to the health work-force debate. Rather than being "neglected," however, the issue has been exhaustively analyzed using different methodologies that predictably lead to different conclusions.

I highlight here several observations from my chair’s address to the Association of American Medical Colleges at the November 2001 annual meeting. A multiplicity of studies, from Samuel Bard’s study in 1819 through the 1981 report of the Graduate Medical Education National Advisory Committee (GMENAC), have counted medical school graduates but failed to predict the services needed, how the science would evolve, and the unforeseen arrival of diseases such as AIDS.¹ Moreover, soft data from the American Medical Association (AMA) have contributed to some of the numerical problems. For example, the general surgeon workforce numbers cited by the AMA have consistently been twice the number certified by the American Board of Surgery.²

When the Council on Graduate Medical Education (COGME) was established in 1985, some founding members questioned the methodology, available database, and conclusions about workforce predictions that followed. In fact, COGME’s early reports listed six "stress specialties" expected to be vulnerable to shortage. These included general surgery, a specialty that is again of concern. Emphasis changed in subsequent reports as health planners presumed a workforce modeled on use of staff-model HMO clinicians. Unfortunately, the staff-model HMO did not become the predominant form of practice. Moreover, we double and redouble the NIH budget and then seem surprised that the science and technology developed (1) lead to public expectations that the innovations be applied to their health, (2) require the training and skills of "specialists," and (3) are expensive.

Despite these developments, the need for generalists will continue, but much will be done by nonphysician clinicians such as nurses, in lieu of primary care doctors.

A problem of major import is the continuing decline of interest in health careers among our youth. The nursing shortage is well documented; medical school applications, too, continue to fall, from 47,000 in 1996 to 34,859 in 2001—9.5 percent fewer applicants than in 2000.³

Our shortfall in physicians is addressed after medical school, during GME programs, when about 5,000 international medical graduates (IMGs) join all U.S. medical school graduates in residency programs. IMGs, who constitute about 25 percent of our residents and practicing physicians, have served us well but encounter visa problems and contribute to brain drain from developing countries. We need a comprehensive review of the role of IMGs in future workforce planning, including policies regarding their education and immigration.

George F. Sheldon

University of North Carolina, Chapel Hill, Chapel Hill, North Carolina

NOTES

 

1. J.B. Langstaff, Dr. Bard of Hyde Park (New York: E.P. Dutton and Co., 1942), 276; and Graduate Medical Education National Advisory Committee, Summary Report, DHHS Pub. no. (HRA) 81-651 (Washington: GMENAC, 1981).
2. O. Jonassen, F. Kwakwa, and G.F. Sheldon, "Calculating the Workforce in General Surgery," Journal of the American Medical Association 274, no. 9 (1995): 731–734.[Abstract]
3. B. Barzansky and S.I. Etzel, "Educational Programs in U.S. Medical Schools, 2001–2002," Journal of the American Medical Association 288, no. 9 (2002): 1067–1072.[Abstract/Free Full Text]

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