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United States Medical School Expansion: Impact on Primary Care

      In the 25 years from 1980 until 2005 the number of allopathic medical schools and the number of MD students in the US did not increase, despite the fact that the US population increased by 70 million over this time period.
      • Dalen J.E.
      The moratorium on US medical school enrollment, from 1980 to 2005: what were we thinking?.
      There was no increase in MD medical students because of multiple predictions of a pending surplus of physicians.
      • Dalen J.E.
      The moratorium on US medical school enrollment, from 1980 to 2005: what were we thinking?.
      The Council on Graduate Medical Education (COGME), which was established by Congress to assess physician workforce needs, recommended a decrease in physicians and an increase in the percent of generalists in 1992,
      Council on Graduate Medical Education
      Third Report: Improving Access to Health Care Through Physician Workforce Reform.
      1996,
      Council on Graduate Medical Education
      Eighth Report: Patient Care Physician Supply and Requirements: Testing COGME Recommendations.
      and again in 1999.
      Council on Graduate Medical Education
      Fourteenth Report: COGME Physician Workforce Policies: Recent Developments and Remaining Challenges in Meeting National Goals.
      In 2005 COGME made an abrupt change in their recommendations to Congress.
      Council on Graduate Medical Education
      Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
      They recommended a 15% increase in enrollment over the 2002 enrollment in US medical schools (MD and DO together). In 2006 the Association of American Medical Colleges responded by recommending a 30% increase in first-year MD medical students (from a 2002 baseline) by 2019.
      Association of American Medical Colleges
      AAMC statement on the physician workforce, June 2006.
      They recommended that the increase should be achieved by increased enrollment at existing Liaison Committee on Medical Education schools and an increase in the number of medical schools.
      In 2010 COGME recommended an increase in the percentage of generalists from the then 32% to 40%.
      Council on Graduate Medical Education
      Twentieth Report: Advancing Primary Care.
      They recommended that the number of primary care Graduate Medical Education positions and programs be increased “to accommodate the increased production of medical school graduates.”
      Council on Graduate Medical Education
      Twentieth Report: Advancing Primary Care.
      The percentage of generalist physicians (family practice, general internal medicine, and general pediatrics) in the United States decreased from 58% in 1965 to 32% in 2010.
      Council on Graduate Medical Education
      Twentieth Report: Advancing Primary Care.
      The percentage of US physicians who are specialists—68% in 2010
      Council on Graduate Medical Education
      Twentieth Report: Advancing Primary Care.
      —is much higher than in other nations. In Canada the percentage of specialists in 2009 was 49%.
      • Starfield B.
      Reinventing primary care: lessons from Canada for the United States.
      There is an imbalance; the United States has a shortage of generalists and an apparent surplus of some specialists.
      By 2016 the 2006 Association of American Medical Colleges recommendation has essentially been met. As shown in Table 1, first-year enrollment in US allopathic medical schools has increased from 16,488 in 2002 to 21,064 in 2016, a 28% increase.
      Association of American Medical Schools
      Results of the 2015 Medical School Enrollment Survey.
      Table 1US Allopathic and Osteopathic Schools
      Variable20022016
      Allopathic schools125145
      Osteopathic schools2033
      Allopathic first years16,48821,064
      Osteopathic first years29687219
      Total first-year students19,45628,283
      Allopath graduates14,33617,057
      Osteopaths graduates26425420
      Total MD/DO graduates16,97822,477
      See references.
      Association of American Medical Schools
      Results of the 2015 Medical School Enrollment Survey.

      American Association of Colleges of Osteopathic Medicine. http://www.aacom.org/docs/default-source data-and-trends. Accessed June 24, 2016.

      In addition, there has been a major increase in the number of US osteopath students.

      American Association of Colleges of Osteopathic Medicine. http://www.aacom.org/docs/default-source data-and-trends. Accessed June 24, 2016.

      The number of osteopathic (DO) schools has increased from 20 in 2002 to 33 in 2016. First-year enrollment in DO schools increased from 2968 in 2002 to 7219 in 2016, a 143% increase.

      American Association of Colleges of Osteopathic Medicine. http://www.aacom.org/docs/default-source data-and-trends. Accessed June 24, 2016.

      The total first-year enrollment in US medical schools (MD and DO) increased from 19,456 in 2002 to 28,283 in 2016, an increase of 45% (Table 1).
      Has this “increased production of medical school graduates”
      Council on Graduate Medical Education
      Twentieth Report: Advancing Primary Care.
      produced an increase in generalist physicians? The three sources of generalists are internal medicine, pediatrics, and family medicine residencies. The percentage of all physicians who matched in 1 of these 3 disciplines in 2016 has not changed from the percentage in 2002, as shown in Table 2.

      National Resident Matching Program, 2016. Available at: www.nrmp.org/match-data/main-residency-match-data/. Accessed May 15, 2016.

      However, the percentage of these residents who enter practice as generalists when they complete their residency is diminishing, as shown in Table 3.
      Table 2Physicians Entering Primary Care Residencies in NRMP Matches
      Discipline20022016
      Family medicine23423083
      Internal medicine43956938
      Pediatrics19922675
      Total872912,696
      % All positions47%47%
      See references.

      National Resident Matching Program, 2016. Available at: www.nrmp.org/match-data/main-residency-match-data/. Accessed May 15, 2016.

      Includes all physicians in 2002 and 2016 match: US MDs and DOs, US IMGs, and IMGs.
      IMG = International medical graduates; NRMP = National Resident Matching Program.
      Table 3Estimated Number of Generalists
      Variable20022015
      Includes DOs matching in Osteopath Match in 2002 and 2015.
      Match to primary care

      National Resident Matching Program, 2016. Available at: www.nrmp.org/match-data/main-residency-match-data/. Accessed May 15, 2016.

       Family medicine30023588
       Internal medicine50037195
       Pediatrics21502654
       Total10,15513,437
      Match to subspecialty
       Family medicineEst. 5%Est. 5%
       Internal medicine
      • Hauer K.E.
      • Durning S.J.
      • Kernan W.N.
      Factors associated with medical students' career choices regarding internal medicine.
      62%81%
       Pediatrics
      • Dalen J.E.
      US physician manpower needs: generalists and specialists: achieving the balance.
      30%41%
      Estimated number who enter practice as generalists
       Family medicine28523409
       Internal medicine19011367
       Pediatrics15051565
       Total62596341
      Includes DOs matching in Osteopath Match in 2002 and 2015.
      Nearly all family medicine residents practice as generalists when they complete their residency. In our projections we estimate that 95% will enter practice as generalists. However, an increasing number of pediatric
      American Board of Pediatrics
      American Board of Pediatrics 2015-2016 workforce data.
      and internal medicine residents
      American Board of Internal Medicine
      Number of candidates certified.
      proceed to subspecialty residencies and enter practice as specialists. As shown in Table 3, the percentage of pediatric residents who enter subspecialty residencies increased from 30% in 2002 to 41% in 2015.
      American Board of Pediatrics
      American Board of Pediatrics 2015-2016 workforce data.
      In internal medicine there has also been a marked increase in those selecting subspecialty practice, from 62% in 2002 to 81% in 2015.
      American Board of Internal Medicine
      Number of candidates certified.
      As a result of the increasing percentage of pediatric and internal medicine residents who will enter practice as specialists, the number of generalists entering practice will show minimal change despite the 33% increase in US MD and DO graduates from 2002 to 2015. We estimate that less than 6341 of the 13,437 who entered a first-year residency in family medicine, internal medicine, and pediatrics in 2015 will enter practice as generalists, nearly the same as the 6259 2002 graduates. The vast majority (19,911) of the 2015 graduates will become specialists.
      The dramatic increase in US medical students (MD and DO) since 2006 will increase the number of physicians entering the US physician workforce. However, it will not increase the percentage of physicians practicing as generalists. It will not correct the long-standing US generalist/specialist mismatch,
      • Dalen J.E.
      US physician manpower needs: generalists and specialists: achieving the balance.
      as recommended by COGME in 2010.
      Council on Graduate Medical Education
      Twentieth Report: Advancing Primary Care.
      The percentage of US medical school seniors (MD and DO) planning a career as generalists continues to decrease.
      • Hauer K.E.
      • Durning S.J.
      • Kernan W.N.
      Factors associated with medical students' career choices regarding internal medicine.
      • Shannon S.C.
      • Ferretti S.M.
      • Wood D.
      • et al.
      The challenges of primary care and innovative responses in osteopathic education.
      This is despite long-standing recruiting and admissions policies in many medical schools designed to attract those most willing to enter primary care and practice in underserved areas.
      Recently, a few schools have experimented with accelerated (3-year) primary care curriculum tracks, which offer lower debt at graduation and guaranteed Graduate Medical Education placement in a family medicine residency. It is too early to judge the effectiveness of this approach, but the number of students willing to finalize their career options in the first year of medical school does not seem to be large.
      As the US population increases and the number of generalist physicians fails to increase, the Health Resources and Services Administration projects a shortage of 20,400 primary care physicians in 2020.
      US Department of Health and Human Services
      Projecting the supply and demand for primary care pracitioners through 2020.
      In the future we must deliver primary care with fewer generalist physicians and a much greater use of nurse practitioners and physician assistants.
      Kaiser Foundation
      Tapping nurse practitioners to meet rising demand for primary care.
      Multiple studies have shown that primary care outcomes are comparable between patients served by nurse practitioners and patients served by primary care physicians.
      • Naylor M.D.
      • Kurtzman E.T.
      The role of nurse practitioners in reinventing primary care.

      References

        • Dalen J.E.
        The moratorium on US medical school enrollment, from 1980 to 2005: what were we thinking?.
        Am J Med. 2008; 121: e1-e2
        • Council on Graduate Medical Education
        Third Report: Improving Access to Health Care Through Physician Workforce Reform.
        Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD1992
        • Council on Graduate Medical Education
        Eighth Report: Patient Care Physician Supply and Requirements: Testing COGME Recommendations.
        Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD1996
        • Council on Graduate Medical Education
        Fourteenth Report: COGME Physician Workforce Policies: Recent Developments and Remaining Challenges in Meeting National Goals.
        Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD1999
        • Council on Graduate Medical Education
        Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000-2020.
        Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD2005
        • Association of American Medical Colleges
        AAMC statement on the physician workforce, June 2006.
        (Available at:) (Accessed May 16, 2016)
        • Council on Graduate Medical Education
        Twentieth Report: Advancing Primary Care.
        Department of Health and Human Services, Health Resources and Services Administration, Rockville, MD2010
        • Starfield B.
        Reinventing primary care: lessons from Canada for the United States.
        Health Aff (Millwood). 2010; 29: 1030
        • Association of American Medical Schools
        Results of the 2015 Medical School Enrollment Survey.
        AAMS, Washington, DC2016
      1. American Association of Colleges of Osteopathic Medicine. http://www.aacom.org/docs/default-source data-and-trends. Accessed June 24, 2016.

      2. National Resident Matching Program, 2002.
        (Available at:) (Accessed May 15, 2016)
      3. National Resident Matching Program, 2016. Available at: www.nrmp.org/match-data/main-residency-match-data/. Accessed May 15, 2016.

        • American Board of Pediatrics
        American Board of Pediatrics 2015-2016 workforce data.
        (Available at:) (Accessed May 17, 2016)
        • American Board of Internal Medicine
        Number of candidates certified.
        (Available at:) (Accessed May 17, 2016)
        • Dalen J.E.
        US physician manpower needs: generalists and specialists: achieving the balance.
        Arch Intern Med. 1996; 156: 21-24
        • Hauer K.E.
        • Durning S.J.
        • Kernan W.N.
        Factors associated with medical students' career choices regarding internal medicine.
        JAMA. 2008; 300: 1154-1164
        • Shannon S.C.
        • Ferretti S.M.
        • Wood D.
        • et al.
        The challenges of primary care and innovative responses in osteopathic education.
        Health Aff (Millwood). 2010; 29: 1015-1022
        • US Department of Health and Human Services
        Projecting the supply and demand for primary care pracitioners through 2020.
        (Available at:) (Accessed May 24, 2016)
        • Kaiser Foundation
        Tapping nurse practitioners to meet rising demand for primary care.
        (Available at:) (Accessed May 24, 2016)
        • Naylor M.D.
        • Kurtzman E.T.
        The role of nurse practitioners in reinventing primary care.
        Health Aff (Millwood). 2010; 29: 893-899