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The Moratorium on US Medical School Enrollment, from 1980 to 2005: What Were We Thinking?

      In the 25 years from 1980 to 2005 the US population increased by 70 million, but the number of MD graduates from US medical schools remained static at approximately 16,000 per year,
      • Salsberg E.
      • Grover A.
      Physician workforce shortages: Implications and issues for academic health centers and policymakers.
      and the number of first-year positions in US residency programs increased to 23,000.
      • Cooper R.A.
      • Getzen T.E.
      • McKee H.J.
      • et al.
      Economic and demographic trends signal an impending physician shortage.
      The residency positions not filled by US MD graduates were filled by international medical graduates and osteopathic graduates. The number of international medical graduates in US residency programs doubled from 11,424 in 1980 to 22,419 in 2000.
      American Medical Association
      IMGs in the United States.
      The percentage of IMGs in the US physician workforce increased to 25% in 2006.
      American Medical Association
      IMGs in the United States.
      Why did the US increase its dependence on imported physicians to deliver health care to Americans? It was not due to a lack of US applicants to medical schools. The number of applicants for the 16,000 first-year positions in US allopathic (MD) medical schools ranged from 26,702 in 1989 to 46,965 in 1997.
      Association of American Medical Colleges
      U.S. medical school applicants and students 1982-83 to 2006-07.
      Thousands of US applicants were rejected because US allopathic medical school enrollment did not increase.
      Many of the unsuccessful US applicants went “overseas” (actually to the Caribbean or to Mexico) to attend medical school, or they chose other careers. From 1983 until 2002, more than 2500 Americans entered foreign medical schools each year,
      • Salsberg E.S.
      • Forte G.J.
      Trends in the physician workforce, 1980-2000.
      and more than 18,000 American graduates of foreign medical schools returned to the US to take residencies and then enter the US physician workforce.
      • McAvinue M.B.
      • Boulet J.R.
      • Kelly W.C.
      • et al.
      U.S. Citizens who graduated from medical schools outside the United States and Canada and received certification from the Educational Commission for Foreign Medical Graduates, 1983-2002.
      The reason the number of US MD graduates did not increase from 1980 until 2005 was that there was a voluntary “moratorium” on allopathic medical school enrollment.
      • Mullan F.
      The case for more U.S. medical students.
      This moratorium was a result of multiple predictions of an impending US physician surplus.
      In 1976, the Graduate Medical Education National Advisory Committee (GMENAC) predicted that there would be a surplus of 145,000 physicians in the US in 2000.
      Graduate Medical Education National Advisory Committee
      Summary report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services. Vol 1.
      They recommended that the number of US medical school positions be limited.
      The moratorium began; US allopathic medical school enrollment remained stagnant for 25 years while the US population steadily increased. Osteopathic medical schools did not participate in the moratorium; they expanded from 1000 graduates per year in 1980 to 2800 in 2005.
      • Salsberg E.S.
      • Forte G.J.
      Trends in the physician workforce, 1980-2000.
      From 1980 until 1996 multiple reports agreed with GEMENAC that there was an impending surplus, including the Council on Graduate Medical Education (COGME),
      Council on Graduate Medical Education
      Report III: Improving Access to Health Care through Physician Workforce Reform: Directions for the 21st Century.
      and the Bureau of Health Professions.
      • Greenberg L.
      • Cultice J.
      Forecasting the need for physicians in the United States: the Health Resources and Services Administration’s physician requirements model.
      In 1997, a consortium including the American Medical Association (AMA), the Association of American Medical Colleges, the American Osteopathic Association, the National Medical Association, and the Association of Academic Health Centers issued a consensus statement that there was “compelling evidence that the United States is on the verge of a serious oversupply of physicians.”
      American Association of Colleges of Osteopathic MedicineAmerican Medical AssociationAmerican Osteopathic AssociationAssociation of Academic Health CentersAssociation of American Medical CollegesNational Medical Association
      Consensus Statement on Physician Workforce.
      Despite these predictions, a surplus of US physicians did not materialize. Quite to the contrary, in 2002, Cooper predicted just the opposite: a shortage of physicians.
      • Cooper R.A.
      • Getzen T.E.
      • McKee H.J.
      • et al.
      Economic and demographic trends signal an impending physician shortage.
      • Cooper R.A.
      There’s a shortage of specialists. Is anyone listening?.
      He estimated a shortage of 50,000 physicians by 2010 and 200,000 in 2020.
      • Cooper R.A.
      There’s a shortage of specialists. Is anyone listening?.
      Cooper based his estimates of needed manpower on economic and demographic trends. He noted that the demand for physicians is closely related to the economy. As the gross domestic product of a nation or a state increases, the number of physicians increases as demand for medical services increases.
      • Cooper R.A.
      There’s a shortage of specialists. Is anyone listening?.
      Recent surveys of state medical societies,
      • Cooper R.A.
      • Stoflet S.J.
      • Wartman S.A.
      Perceptions of medical school deans and medical society executives about physician supply.
      medical school deans,
      • Cooper R.A.
      • Stoflet S.J.
      • Wartman S.A.
      Perceptions of medical school deans and medical society executives about physician supply.
      and publications by US medical specialty groups
      Association of American Medical Colleges
      Recent Studies and Reports on Physician Shortages in the U.S..
      confirm Cooper’s prediction. It is apparent that in 2007 we have significant physician shortages, and these shortages will increase. All the agencies that predicted a surplus have now changed their course and predict a significant physician shortage.
      Association of American Medical Colleges
      The Physician Workforce: Position Statement- June 2002.
      American Medical Association
      AMA Revises Policy to Address Continued Demand for Physicians.
      Council on Graduate Medical Education
      Reassessing Physician Workforce Policy Guidelines for the U.S. 2000-2020.
      Workforce Analysis Branch, Bureau of Health Professions
      Changing Demographics and the Implications for Physicians, Nurses and other Health Workers.
      In 2005, the AAMC recommended a 15% increase in medical school enrollment by 2015.
      Association of American Medical Colleges
      AAMC calls for modest increase in medical school enrollment.
      In 2006, they increased their recommendation to a 30% increase in enrollment.
      Association of American Medical Colleges
      AAMC statement on the physician workforce.
      In the space of less than 10 years we have gone from a nearly universally predicted physician surplus to a universally lamented shortage!
      In retrospect, we should have recognized that as the US population increases the number of US medical graduates should increase. Another major clue to the lack of a surplus was the persistent excess of first-year residency positions as compared to the number of US MD graduates from 1980 until the present. Most observers, including myself,
      • Dalen J.E.
      US physician manpower needs Generalists and specialists: achieving the balance.
      assumed that this discrepancy indicated that too many residency positions were being offered. The fact that these positions filled each year (by a combination of US graduates, osteopaths, and international medical graduates), and that they were finding practice positions in the US should have told us that the discrepancy was due to a shortage of US MD graduates, not an excess of residency positions.
      In view of the evolving shortage of physicians in the US, it is clear that medical school enrollment needs to be expanded. A recent AAMC survey indicated that many medical schools are undergoing or planning expansion of class size, and new medical schools are being considered.
      Association of American Medical Colleges
      Medical school expansion plans: results of the 2006 AAMC survey.
      Given the time lag until increased medical school enrollment increases the number of practicing physicians, the US will further increase its dependence on international medical graduates. Most international medical graduates come to the US from countries that already have an inadequate number of physicians,
      • Hart L.G.
      • Skillman S.M.
      • Fordyce M.
      • et al.
      International medical graduate physicians in the United States: changes since 1981.
      so this will increase the shortage of physicians in those countries.
      • Mullan F.
      The metrics of the physician brain drain.
      The other real losers in our misjudgment of the number of physicians needed in the US are the countless numbers of well-qualified Americans who were rejected from US medical schools because of the voluntary moratorium on medical school enrollment. One must admire those unsuccessful applicants who persevered; attending foreign medical schools and then returning to the US for residency training and practice in the US.

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