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ESSAYScarce Physicians Encounter Scarce Foundations: A Call For Action
The United States is in the early phases of a deepening shortage of physicians, a situation last experienced fifty years ago. As then, energy and creativity will be needed to meet the nation’s needs, and U.S. philanthropic foundations will again be called upon to play leadership roles. The issues are broad—extending from medical education to regulation and from building new schools to recruiting more international medical graduates. Throughout these issues, foundations are uniquely positioned to convene stakeholders, fund analyses, foster new medical education paradigms, and support the growth of its infrastructure. Foundations will be necessary partners in what is to come.
In the late nineteenth century a British historian, James Bryce, noted, "In works of beneficence, no country has equaled the United States."1 Yet it was during the twentieth century that philanthropy came to its full expression—and nowhere more profoundly than in medical education.2 Foundations played a central role in lifting medical schools from their proprietary roots to the scientific pinnacle they now occupy and in aiding their expansion from the small size of most schools before World War II to the current status of many as academic health centers. The time has come for foundations to focus their energy on the physician workforce once again. Now is a different time, but the problems are similar, ranging from inadequacies of supply to the organization of clinical practice. This brief review chronicles the past participation of foundations and lays out an agenda for them to once again influence medical education’s future.
Foundations were first active in medical education early in the twentieth century. This period is synonymous with Abraham Flexner, whose 1910 report brought science to the forefront and paved the way for a system of university-based medical education.3 Yet Flexner could not have done this alone. As Thomas Bonner describes in Iconoclast, his riveting biography of Flexner, success grew out of the synergy between Flexner’s dogged perseverance and the boldness and sagacity of his foundation partners.4 Had it not been for Henry S. Pritchett’s creative leadership of the Carnegie Foundation, Flexner would never have examined medical education, and had enlightened leadership not existed at both the Rockefeller Foundation and the General Education Board that it supported, Flexner could not have guided medical education to the science-based, full-time system that persists today. One can only wonder what the modern physician would be like if the combined power of Carnegie and Rockefeller, together with the Commonwealth Fund and others, had not transfigured medical education at important private institutions, such as Johns Hopkins, Yale, Columbia, and Washington Universities and the University of Chicago, and at state schools, including Iowa, Colorado, and Oregon.5 After all, what was accomplished there was not the norm. In the early 1900s U.S. medical schools were predominantly proprietary and mediocre, medical schools in Britain and France were little more than apprenticeship training programs, and schools in most other European countries were dominated by authoritative university professors.6 Inquiry, introspection, and inductive reasoning were the characteristics of a new, uniquely American system of medical education, and foundations proved to be a uniquely American way of attaining it. By 1925 virtually every U.S. medical school had adopted this new system.
Thirty years later foundations came to the fore again, this time not for purposes of transforming the nature of medical education but to aid in expanding its capacity.7 Most prominent was the Ford Foundation, which distributed $90 million to assist the eighty-two existing medical schools between 1955 and 1960. The Commonwealth Fund turned its energy to the development of new private medical schools, such as Dartmouth, Brown, and Mayo, and new state schools, including Florida, Kentucky, and Michigan State. Close behind was the W.K. Kellogg Foundation, which invested almost $10 million in medical schools’ basic science departments. Important contributions were also made by the Josiah Macy Jr., Andrew W. Mellon, and Markle Foundations. In 1965, as medical school expansion was gathering steam, Commonwealth supported the Coggeshall Report, which examined trends in health care and their implications for medical education; five years later the Carnegie Commission on Higher Education conducted a similar analysis. State governments also contributed to the growth of medical schools, but the federal government, which is generally given most of the credit, proved to be least effective. James Schofield characterized it as having offered funds that were late in the process, less than needed, briefer in duration than had been anticipated, onerous in their accompanying regulations, and intrusive in attempting to influence the curriculum.8 In retrospect, it was foundations that helped most in laying the groundwork, facilitating the expansion, encouraging periodic reexamination, and raising the standards.
Once again, the United States is entering a period of inadequate physician supply.9 This follows two decades during which government planners and others held the view that surpluses were impending and economists saw physicians as the cause of rising health care spending, notions that have largely been dispelled.10 Foundations have occupied a curious position throughout this period. In the early 1990s most funders with interests in health care embraced the notion that there would be too few generalists, too many specialists, and a surplus of physicians overall. Included among them were Macy, Kellogg, Commonwealth, the Pew Charitable Trusts, and, most notably, the Robert Wood Johnson Foundation, whose president dubbed specialists "the invisible drivers of health care spending."11 The curious aspect is that as the long-heralded surpluses of specialists failed to materialize, America’s foundations fell silent. Pew ceased its support for the San Francisco–based Center for the Health Professions, which had called for the closure of 20 percent of medical and nursing schools. In like manner, other funders removed concerns about physician supply from their radar screens, although themes such as physician distribution and primary care remain active. Most organizations that shared the belief that too many specialists were being trained have also been silent. Among them are the Institute of Medicine (IOM), the Medicare Payment Review Commission (MedPAC), the American Osteopathic Association, the National Medical Association, and the Association of Academic Health Centers. But a few have modified their stance, most notably the American Medical Association (AMA), which shifted in 2003 from concern about physician surpluses to a neutral view that recognized neither surpluses nor shortages, and the Association of American Medical Colleges (AAMC), which had adopted a "neutral" stance the previous year and in July 2004 called for an expansion of graduate medical education (GME).12 The most dramatic policy change was that of the Council on Graduate Medical Education (COGME), which for more than a decade had promoted the notion of specialist surpluses but which, in 2004, reversed that position entirely, citing shortages as the problem and calling for an expansion of both undergraduate and graduate medical education.13 These policy changes should alert foundations that change is in the wind and that help will be needed.
The physician planning model that we have used is based principally on economic and demographic trends.14 It projects that by 2020–2025 there will be 200,000 too few physicians, a gap of 20 percent. Using a somewhat similar approach, COGME has also projected large future shortages.15 Moreover, the magnitude of demand for physicians that these studies forecast is concordant with projections of the future needs for health care workers by the Bureau of Labor Statistics, forecasts of future medical spending by both the Centers for Medicare and Medicaid Services (CMS) and the Congressional Budget Office (CBO), and forecasts of the demand for nurses by the National Center for Health Workforce Analysis.16 One response could be to wait until the problem of inadequate physician supply worsens and the consensus broadens. However, because it takes eight to ten years to train a physician, that risks prolonging the period of intolerable shortages a decade or more from now. It seems more prudent to devote energy now to the issues at hand, recognizing that uncertainties exist. But the agenda is broad, including not only issues of undergraduate and graduate medical education, but also the processes by which care is given and the volume of care that nonphysician clinicians (NPCs) could provide. Even in terms of medical education, the agenda extends from numbers and resources to the applicant pool, the curriculum, and the U.S. dependency on international medical graduates (IMGs). Throughout this agenda, foundations have critical roles to play, from convening constituencies, supporting analyses, and fostering new educational paradigms to assisting in the expansion of medical school capacity. Expanding existing medical schools. One means of expanding capacity will be to enlarge existing medical schools. However, most current schools predate 1960, and most that existed then enlarged their class sizes during the last period of expansion, leaving little room for further growth.17 A recent survey of the deans of allopathic medical schools indicated that the aggregate growth capacity of today’s schools was only 8 percent.18 Impediments cited included limited preclinical teaching space, too few clinical sites, insufficient funds, and inadequate faculty numbers. Some schools have accommodated to these deficiencies by establishing satellite educational facilities. In a review published in 2003, the AAMC identified twenty-eight such schools with clinical satellites and six with preclinical satellites.19 A second approach has been to create four-year branch campuses under a single administrative structure. The University of Illinois at Chicago operates such a system elsewhere in the state, and three osteopathic medical colleges have recently established branch schools at even greater distances from their home campuses. Relying on existing infrastructure and expertise in these ways may prove to be an expedient means of expanding medical school capacity further. However, relatively little is known about the merits of various organizational approaches that have been undertaken or of the potential value of others. Foundations could provide a great service by stimulating dialogue and facilitating planning along these lines. Building new medical schools. The most difficult route to expanding capacity will be the construction of new schools. Although in the 1960s and 1970s most growth came from enlarging existing schools, building new ones will have to be the major strategy for the future. Because new schools tend to be relatively small, forty or more could be needed, an appreciable number when compared with the current 125 allopathic and 20 osteopathic medical schools. The cost implications of such growth have not been defined but are likely to be appreciable. Allopathic schools average 160 pre-clinical faculty members, 700 full-time clinical faculty, and budgets of $450 million that have been growing at 10 percent annually for two decades.20 Replicating this paradigm in forty-five additional schools would require 7,200 basic scientists, 31,000 full-time clinicians, and an aggregate operating budget of $20 billion, levels that must be juxtaposed against a National Institutes of Health (NIH) research budget that recently doubled and clinical revenues that are under increasing price pressures. The fiscal fabric of allopathic medicine clearly presents formidable challenges for future expansion, challenges that call for help from U.S. foundations. Osteopathic and international medical education. In considering financial needs, it is useful to note that osteopathic medical schools have only 12 percent as many preclinical faculty as allopathic schools, 5 percent as many full-time clinical faculty, and budgets that are only 10 percent as large.21 Moreover, in contrast with allopathic medicine, which has added only one school since 1980, osteopathic medicine established five schools during the 1990s and is adding a number of branch campuses, all with private funding. These fiscal realities raise vexing questions. So, too, do non-U.S. medical schools that train native U.S. citizens in Mexico, the Caribbean, Europe, Israel, and elsewhere. Approximately 1,400 U.S. citizens who attend such schools are certified annually by the Educational Commission on Foreign Medical Graduates (ECFMG), and most of them enter U.S. allopathic residency training programs. Their participation, plus that of osteopathic graduates, results in the fact that only 80 percent of first-year residents who graduated from a U.S. high school also graduated from a U.S. allopathic medical school. Given the cost structure of allopathic schools, it seems imperative to understand the comparative characteristics and outcomes of these other training pathways, a difficult and delicate task that could benefit from the active participation of U.S. foundations. Foreign-born IMGs. A more immediate alternative for expanding U.S. physician supply is to increase the number of foreign-born physicians. Such physicians now account for almost 20 percent of first-year residents, and the vast majority remain in the United States after training. Many excel, but some fall short, and despite the advanced licensing examination that has recently been implemented, concerns persist about the educational depth at many international schools.22 Increasing the number of foreign-born IMGs raises the further issue of balancing individual opportunity against the medical needs of donor nations, particularly when it is recognized that more than 5 percent of the physicians who graduate from medical schools in South Asia, the Middle East, and Sub-Saharan Africa practice in the United States, often depleting the health care systems of smaller and poorer nations.23 And there is the new reality that England, Canada, and Australia, which are also experiencing physician shortages, are competing for English-speaking physicians.24 In an era of nation building and terrorism alerts, this entire landscape has become intensely complex and is in need of thorough analysis from both domestic and international perspectives. A consortium of foundations interested in U.S. and global health could add immeasurably to such a process. Graduate medical education. Whether physician output is increased by expanding medical school capacity or by admitting more IMGs, the number of GME positions will have to be increased.25 Medicare support for residency training is the linchpin, but because of past concerns about impending physician surpluses, the number of residency positions that Medicare supports was capped in 1997. A partial remedy was included in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, which permits a redistribution of the approximately 2,000 unused residency positions. Yet COGME has proposed 15,000 additional positions, and our projections suggest a need for twice that number.26 Sadly, GME support is ensnared in the ambiguities that surround indirect medical education (IME) payments, which were instituted in 1984 when cost reimbursement for hospitals was supplanted by Medicare’s prospective payment system (PPS), and the controversy about whether GME should be a public responsibility or be borne by hospitals, medical schools, or residents themselves.27 On issues such as these, government and the academic community need guidance, leadership, and support of the kind that foundations could offer. Applicants and curriculum. If medical school capacity increased, there would be the expectation that the number of applicants would likely also increase. That expectation was met in the 1960s and 1970s because there was an equivalent expansion of colleges and universities, coupled with a growing interest in bachelor’s-level education among women. However, similar increases in the number of baccalaureates cannot occur again, and the current pool of first-time applicants to medical school is only 30 percent larger than the number of accepted students, which leaves few to fill an expanded number of medical school seats.28 Moreover, medicine is not alone in seeking highly skilled college graduates. The profession might attract more applicants if it dealt with issues such as tort reform, regulation, and managed care, but the root problems of declining applicant numbers have been long-standing and may relate as much to a medical curriculum that emphasizes facts more than values and that requires memorization more than inductive reasoning. Because of the correlation that exists between Medical College Admission Test (MCAT) performance and success on Step 1 of the U.S. Medical Licensing Exam (USMLE), applicants with quantitative skills are favored. Yet these benchmarks correlate poorly with clinical performance, which is tied more strongly to proficiency in the humanities and to personal characteristics such as a robust psychological constitution, conscientiousness, integrity, motivation, and empathy.29 While Flexner’s emphasis on scientific principles was profoundly important in transforming medical education a century ago, equal weight has not been given to the emphasis that he also placed on insight, empathy, culture, and philosophy.30 The IOM’s recent report on medical education moves the debate in this direction, calling for a more patient-centered perspective and increased attention to the social and cultural issues in health care.31 Such a change could affect not only the characteristics of tomorrow’s practitioners but the number of applicants who see medicine as a career option. Historically, foundations have been very effective in curriculum transformation, and they could be again. Nonphysician clinicians. An important influence on the necessary size of the physician workforce is the potential of NPCs to provide "physician services," a matter that is somewhat ambiguous because of the various ways that NPCs participate.32 The supply of NPCs is increasing, creating the potential for greater breadth of their participation; however, further expanding their scope of practice raises questions of quality, and additional studies are needed.33 Such studies are intrinsically interdisciplinary and demand the kind of professional neutrality that foundations can foster. Processes of care. Finally, planners have expressed the hope that through technology and systems management, physicians can become more efficient, thereby alleviating the need for more doctors. This strategy has worked in other industries, although it may not be as applicable to medicine, with its requirement for hands-on care. Nonetheless, improvements are possible, through technology and through managing patient flow; foundation-funded demonstration projects that test such solutions could be enormously valuable. In recent years the organization of clinical practice has also been influenced by a growing spectrum of administrative, regulatory, and legal measures, some related to managed care and others to the desire within both government and the private sector not only to control physician behavior but also to weed out fraud and abuse. Although certainly warranted under some circumstances, these measures not only hamper efficiency but also make the practice of medicine objectionable for growing numbers of physicians. Yet this need not be the case. The multidimensional characteristics of malpractice litigation have been the object of recent study funded by the Pew Charitable Trusts.34 Analogous studies of other administrative and regulatory components would be extremely useful. In the last analysis, the problem of physician shortages is not simply a matter of numbers, it is a matter of culture—the ability of physicians to function effectively within the current regulatory framework.35 Foundations could play a valuable role by supporting efforts to understand these dynamics and bring them to a rational plane. The United States rarely turns its attention to medical education or physician supply. Past experiences suggest a periodicity of forty years. Indeed, in his classic history of the 1960–1980 expansion, Schofield prophesied that "around 2010, in time for the centennial of Flexner’s report, the population increase could run ahead of physician supply and a whole new build-up could begin again."36 This time, however, the issues are more complex, and thus far, U.S. foundations have been silent. Yet there is much they could do to convene stakeholders, bridge disciplines, stimulate dialogue, support research, and underwrite a search for solutions. Historically, foundations have been a powerful force in the evolution of medical education. They are necessary partners now as the medical profession strives to assure that future U.S. health care needs can be met.
Buz Cooper (rcooper{at}mcw.edu) is a professor of medicine and health policy and director of the Health Policy Institute at the Medical College of Wisconsin, in Milwaukee.
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Phase Two: 1950-1975
