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Week: 565.6 Guest: Dr. Jordan Cohen, President, American Association of Medical Colleges Topic: Historic joint effort to reduce American medical residencies, prevent oversupply of doctors Producer/Host: Steve Girard

NEMA: Do we have too many doctors? The nation's medical community thinks so, as six of the most prominent medical organizations recently released a consensus statement aimed at exposing what they believe is a potentially serious oversupply of physicians, and a bloated training hospital residency system. With me today is Dr. Jordan Cohen.... President of the Association of American Medical Colleges, which along with the American Medical Association, American Association of Colleges of Osteopathic Medicine, the National Medical Association, the American Osteopathic Association, and the Association of Academic Health Centers, released the statement....Dr. Cohen, fill me in on how this historic stand was developed....

COHEN: ....that drafting process really began, in a way, last summer...and it was stimulated by the release by the Institute of Medicine of a report on the physician oversupply, and the Institute of Medicine, among many other organizations before it, had come to the conclusion... based on the data that are available...that we are, if not presently, certainly very soon, going to be facing a very serious oversupply of physicians. And the Institute of Medicine, which is a very highly respected organization that involves experts from, not just within medicine...but many stake holders in medicine as well...and science convened a group to look at this issue, and concluded - as did others - that the oversupply was quite serious and that what they recommended was that there be mechanisms adopted by the federal government to try to reduce the number of training positions in teaching hospitals...and at the same time argued that there should be no increases in the number of medical schools or number of positions within medical schools. And maybe if I could use that as an important background statement for your listeners. The medical education is sort of a two part process. From the time a student graduates from college, to the time that they enter practice as a fully qualified physician, there are two major segments of the education that's required: the first is medical school...from college to the MD degree that's generally four years in duration. Following the MD degree, which is only halfway through the process, is the second phase, which is called residency training... which occurs in teaching hospitals. And that is the period of time that stretches from 3 years to as long as 8 or 9 years. That's the period of time that the graduate of a medical school gets the specialized training that is required in order to be fully competent in one of the many areas of medicine, such as surgery... or obstetrics...or pathology... or psychiatry, or whatever it may be. So that training period is called residency training. Now, what has happened in this country over the past few years is that the number of graduates of medical schools, the number of MD's that medical schools produce each year, has been incredibly stable. It's been about 17 thousand a year for over a decade...almost 15 years now that number has been essentially unchanged. But over the past 8 or 10 years, the second segment .... the residency segment of the pipeline, has enlarged enormously. We now have 25 thousand... roughly, 25 thousand entry level positions in this second segment of the pipeline, in comparison to the 17 thousand graduates of U.S. medical schools that enter that second segment of the pipeline. What that means is, that we have almost 8 thousand medical school graduates from other countries...that is, graduates of foreign medical schools who come to this country each year to join the 17 thousand graduates of U.S. medical schools in this second phase of training and emerge on the other end of that pipeline as fully qualified practicing physicians. It's that aspect of the problem that has been recognized by the Institute of Medicine and a host of other organizations and individuals that have focused on the issue of the oversupply of physicians and recognizing that it's that second segment of the process that has gotten overblown, and that some public policy ought to be adopted to address that issue.

NEMA: Is the number of residency positions at the teaching hospitals so much out of line? It seems if 25 thousand positions are open...then there must be some need...but if that number is inflated, how does it get that way....and how do you possibly begin to bring it down....?

COHEN: Well, that's a very good question - let me take the first part. What caused it to inflate? Residency training occurs in this country, unlike medical schools where there are...as I mentioned before, 125 medical schools...there are over a thousand teaching hospitals in this country that have approved, accredited residency training programs. Many of those hospitals have only a small number of residency programs, but in the aggregate, those one thousand institutions that sponsor residency programs have these 25 thousand entry level positions available. For an institution to create a residency program or to expand the number of residents in a given program, is an institutional decision - as long as they have the resources and can mount the programs that qualify for the accreditation mechanism, there is no limit on the number of positions that they can establish. And when they establish a new position in residency training, the way the Medicare program has been constructed, automatically there is an additional reimbursement to the teaching hospital as a consequence of the increased number of residents. So that institutions who are faced, as they have been over the past decade, with a very significant increase in the need for physician's services, because of the nature of medicine...and particularly in our inner city areas, where residents supply a lot of the indigent care that is available to - and is the only source of health care, in some cases, available to a very needy, vulnerable population. Institutions have increased the number of residents to meet that need, all the while gaining more financial support for that residency training because of the way the Medicare program, and in some cases, the Medicaid program in various states, is constructed. So, the incentives for an institution that's sponsoring a residency program to increase the number of residents is quite strong, and there's been a very ample supply of graduates of foreign medical schools to fill this expanded number of positions, those positions having been increased because the institutions have had a need for the services of the residents, and at the same time, have gotten very generous reimbursements from the Medicare program in order to allow that expansion to occur. So, what is needed in order to fix this problem....or to prevent further expansion, and hopefully to bring the second segment of that pipeline back into closer relationship to the number of medical school graduates we have in this country...is to uncouple the payments for patient care services from the payments for graduate medical education. To try to limit, in some fashion, the federal tax dollar generated support for these unnecessary surplus residency positions. Now, embedded in your question is another issue, and that is...."how do we know how many doctors we need in the country"?

NEMA: Precisely why I embedded that question.....and it can't be an easy question to answer.....

COHEN: We can certainly predict with great accuracy the number of physicians who are going to be in practice, just by extrapolating from the number that are in training and knowing about the length of time that a physician remains in practice and things of that kind. It's very, very much more difficult to predict precisely what the demand or need for physician services is going to be... particularly so in the circumstance that we're in at the moment in this country... where medical care is undergoing tremendous transformation as a consequence of managed care and other changes, technological changes that are occurring that make it that much more difficult to be accurate in predicting how many doctors we need. But that being the case, the fact remains that if one does the arithmetic and tries to account for as many factors as one can reasonably predict for the future, virtually everything that we can envision, that is happening in this country, is working in the direction of reducing the need for more physicians. One is managed care itself. One of the most compelling arguments that we are facing an oversupply of physicians comes from the recognition that managed care organizations utilize fewer physicians for the subscribers to those programs... managed care programs...than are required in the open ended, fee-for-service world.

NEMA: Dr. Jordan Cohen of the Association of American Medical Colleges. The consensus statement of the six medical organizations suggests a reduction in funding of resident positions at the nation's teaching hospitals, bringing the number more in line with the number of U.S. med school graduates. That would result in sending foreign med school graduates back to their countries to practice after their training here. we'll talk more with Dr. Cohen on our next program.

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...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.


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