Reflections on medical education, medical practice and the underserved

I recently spoke at the Student National Medical Association’s (SNMA) Annual Medical Education Conference in Louisville, KY. Accompanying me was former SNMA President Bryant Cameron Webb, MD, JD. We covered three main topics in our workshop: medical education, the practice of medicine, and the underserved.

Medical education

Many people believe that there is, or soon will be, a physician shortage. There are nearly 1 million physicians scattered across America representing a ratio of 319 doctors per 100,000 Americans. According to estimates, the AAMC states that there are 13,700 too few physicians for our communities. In contrast to that, the GAO implies that adequate access exists for 97% of Medicare patients. So is there really a physician shortage? I suppose that depends on who you ask.

What we can likely agree upon is that there exists problems with the geographic and specialty distribution of physicians across the country. While our physician workforce appears to be about one-third primary care and two-thirds specialists, many experts would recommend a ratio closer to one primary care physician for every specialist. The presence of primary care physicians improves the quality of health care. Thus rebalancing this maldistribution of generalists and specialists constitutes a legitimate policy goal.

But even if we had more generalists, it is just as critical that physicians (especially specialists) become distributed geographically in a manner that best serves the needs of our communities. A study from 2011 in the journal Health Affairs showed that the distribution of cardiologists was skewed away from low-income areas, rural areas, and the Midwest. I would suggest that it is the maldistribution of physicians, not necessarily the lack of physicians, that is a more significant threat to the health of our nation.

So where do medical students go when they graduate? And why don’t they hang their shingles in the areas of the country with most need for medical expertise? Part of this answer rests on the fact that new physicians receive their training in academic medical centers, many of which are located in urban areas, the Northeast, or the West Coast. Upon completion of their training, physicians rarely venture away from these academic medical centers. While we need teaching hospitals to educate the newest generations of physicians, they subtly influences the production of medical oases and medical deserts across the country.

The other pertinent question to this policy dilemma is: why are many graduating medical students choosing to go into specialty care as opposed to primary care. Some of it may have to do with debt – the median debt for a graduating medical student is $170,000. But it also has something to do with the incentives surrounding graduate medical education (GME) which is required to receive an independent license to practice medicine.

GME funding – provided by the Medicare program to the tune of almost $10 billion dollars or $100,000 per resident – has capped the number of residency slots available to graduating medical students since 1997.  The Affordable Care Act does not work to lift this cap but it does work to redistribute 65% of unused residency slots to programs focusing on primary care.

Some groups have argued for lifting the cap on GME so that more physicians could be trained. Others, however, note that there are already more available residency slots than there are new graduates from U.S. medical schools. For example, over 16,000 U.S. medical graduates matched into the over 25,000 first-year residency slots open in the most recent National Resident Matching Program (“the Match”).

There were over 7,000 foreign nationals who obtained residency positions via the Match this spring. Opponents of lifting the cap on residency slots point to these numbers and to the idea of international “brain drain” as a reason to keep the cap in place. Instead, medical schools could continue to increase their enrollment without serious risk to U.S. medical graduates being unable to find advanced training.

But Dr. Atul Grover of the AAMC states that “since 2002 we have almost expanded enrollment [of medical schools] by 30%.” Yet, without lifting the cap on residency slots the total number of independently practicing physicians would still only change at its current rate. There are some other alternatives to physicians, however, in the delivery of health care.

Medical practice

Why spend over 7 years training someone to fill that void (4 years of medical school and at least 3 years of residency training) when other clinicians can be trained in less time? Nurse practitioners (NPs) and physician assistants (PAs) take a fraction of the time to train relative to physicians and produce similar outcomes in certain studies.

There are approximately 155,000 nurse practitioners and over 75,000 physician assistants in practice today. In fact, NPs are among the fastest growing clinician group entering the field of primary care. This becomes important considering the talks of doctor shortages and the looming expansion of Medicaid under the Affordable Care Act.

Are PAs and NPs efficient substitutes for physicians? Many anecdotes might suggest that NPs and PAs pose risk to patients, much of the published data supports the idea of clinical equivalence between these different health care providers in limited clinical settings. In light of these data, the Kaiser Family Foundation and the Institute of Medicine both argue that NPs should be allowed to practice at the top of their license.

What does this mean for medical students? If you happen to be going into primary care, you could find that as NPs gain independence, primary care doctors will have direct competition for patients with nurse practitioners.  As it stands today, in 23 states and the District of Columbia NPs can already practice independently of physicians. There will be increasing pressures for state legislatures to loosen regulations to accommodate access to care for their constituents.

Medical students interested in primary care need to know whether or not they will practice in a state with a competitive or a collaborative approach with NPs. Physician assistants, on the other hand, always must have a supervising physician with which to work. Thus, PAs and physicians  tend to collaborate without the threat of a “turf battle” as some perceive between NPs and physicians.

Might states that have allowed NPs to practice at the top of their license without physician supervision see fewer primary care physicians over time? Only time will tell. But until the financial incentives that drive physicians toward procedures and specialization are corrected, primary care physicians will continue to suffer.

The underserved

One of the major elements impacting the care of the underserved will be the implementation of the Medicaid expansion in 2014. Originally, the Affordable Care Act would have used Medicaid as a vehicle to provide health insurance coverage to approximately 16 or 17 million Americans under 138% of the federal poverty level.

While the Supreme Court upheld the Affordable Care Act as the law of the land, it also made the expansion of Medicaid optional for states. States can now either choose to keep their Medicaid programs as-is or could expand (with the first three years receiving 100% federal funding and ultimately costing the states only 10% of total costs in future years).

But Governors and legislators in various states – surprisingly those with the highest uninsured and worst levels of poverty – are threatening to opt out. So with the federal government refusing to allow for partial expansions, the all-or-none nature of the Medicaid expansion threatens to exclude about 5.4 million individuals in the 14 states firmly opposed to the idea.

In a previous analysis, I predicted that if citizens who will miss out on the Medicaid expansion go ahead and vote against politicians that will be denying them access to care, governors like Nikki Haley of South Carolina could lose her next election. Perhaps that is one reason why Rick Scott changed his mind and is now advocating that the state of Florida opt in to the Medicaid expansion, at least for the first 3 years.

In other jurisdictions, politicians like Mike Beebe are exploring using private insurance via the Affordable Care Act’s insurance exchanges to cover Medicaid’s newly eligible beneficiaries. It is an idea that may ultimately garner support from the health reform law’s current opponents. The Arkansas strategy  could become a private sector solution to health care reform and a palatable alternative for Republicans.

In the near term there will be several different paths for the underserved (i.e. the poor uninsured). Some states will expand Medicaid as planned and hopefully will find that getting an actual doctor’s visit is not too difficult. Other states will completely lock out their poor uninsured citiznes from both the Medicaid expansion and out of the insurance exchanges. People in this situation will wind up ineligible for Medicaid but unable to receive federal assistance for purchasing health insurance. Lastly, states like Arkansas may choose to expand Medicaid in non-traditional ways such as the currently proposed “private option.”

Depending on the state, it is crucial that health care providers understand how the Medicaid expansion (or lack thereof) might affect underserved patients in their communities. Physicians, medical students, and other clinicians must be aware of these rapidly changing situations if they desire to help their patients gain coverage.

Cedric Dark is founder and executive editor, Policy Prescriptions.

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  • SiMBa37

    Noot sure where you are getting your math from, but current data shows a significant residency shortage for the amount of domestic medical school graduates as well as the foreign ones:

    • Policy Prescriptions

      I would recommend you re-read this paragraph and follow the link to the NRMP press release about this years current match:

      ‘Some groups have argued for lifting the cap on GME so that more physicians could be trained. Others, however, note that there are already more available residency slots than there are new graduates from U.S. medical schools. For example, over 16,000 U.S. medical graduates matched into the over 25,000 first-year residency slots open inthe most recent National Resident Matching Program (“the Match”).’

      Remember, the AAMC is in the business of promoting the interests of teaching hospitals, which means hiring more “cheap labor” (aka “residents”) for their clinical services. Most people will agree that there *may* be a physician shortage (at least for primary care). Some people believe it’s more a distribution problem. Whether or not we need MORE residents is a matter of debate, especially if the new slots created go to create more specialists or concentrate docs in already over-doctors areas.

      • Guest

        In a free market, such as we have for lawyers, we’d let the market decide. Doctors have a vested interest at the moment, in creating and maintaining an artificial shortage of doctors. Supply and demand, baby.

  • Dave

    Nice piece!
    I disagree slightly with the possibility of PCPs having to compete for patients with NPs or PAs. Even in states where non-physician professionals can/could practice without physicians’ supervision, the competition may not be for patients, but for jobs themselves.
    We’ve all read countless articles about how hard it is for solo and small group physician practices to make ends meet. Don’t the same laws of economics apply to other professionals? As such, an all-NP practice will have the same headaches faced by an all-MD practice. Competition between them would probably be just like it is between group practices now and some patients would prefer one or the other.
    However, as more health care is delivered by large corporate entities, the game changes. In areas where the market is predominantly corporate, savvy HR managers will use their payroll dollars as efficiently as possible. If they can hire NPs for less than MDs (and the state grants them comparable scope of practice), why wouldn’t they do it and improve the bottom line?
    It’s a minor distinction, but one worth making. I don’t mind competing for patients (crudely put: “business”); MD vs NP group competition would likely lead to better products from both. Competing for jobs themselves is a very different animal.

  • Mengles

    Just as an aside, I laugh a little on the inside on doctors who post here about medical students not going into primary care and not working in areas that are needed, etc. but when you actually look up this author from his website, you see that he is an Emergency Medicine physician (a specialist) who will be practicing in Houston, an urban city. I realize it’s a personal decision, but still funny nonetheless. I did appreciate your Medical Practice section that really tells it like it really is for future medical students about the implications of going into primary care.

    • Policy Prescriptions

      I wish the incentives were better arranged to encourage medical students to pursue primary care. Unfortunately that is not the case.

      • Mandy

        What “incentives” would it have taken to get the author to pursue primary care, and set up a practice in a poor, rural, under-served area — as opposed to becoming a specialist servicing an already highly-serviced urban area with all the mod-cons? I am genuinely curious.

        • Policy Prescriptions

          Primary care, no incentives would work there for me. I don’t like continuity, I like doing procedures, I like critical patients. Practice area, my incentive is pro-sports teams (football and baseball at a minimum). Hope that fulfills your curiosity.

          Your question would be better served to ask internal medicine residents (or pediatrics) that ultimately decide to specialize into cardiology, nephrology, endocrine, etc. They at least have the option of staying primary care providers. Whether or not the “incentives” would sway them – some yes, some no, I guess.

        • Guest

          Loan repayment. High salary. Paid living expenses. And even then that might not be enough. I never would have chosen such a career primarily because I don’t want to live in some desolate area removed from the things that would make life enjoyable.

  • Chris

    If you simply wanted to decrease incidence of “depression”, there’d be ways of doing that which would cost less than seven trillion dollars. As Cato’s Michael Cannon writes, “For Medicaid to be cost-effective, it must (A) produce [health] benefits and (B) do so at the same or a lower cost than the alternatives.” There is no evidence to date that it does either.

    • Policy Prescriptions

      Where do you get that 7 trillion dollar figure? The entire health care costs for the nation are less than $3T annually.

  • Chris

    So it makes them happier, and saves them money, but does nothing for their health? If we want to make them happy and give them money, just cut out all the bureaucracies and hand them the cash we would otherwise be spending on their “health” and let THEM decide what to do with it. Hell, that’d make me happy too.

    • Policy Prescriptions

      Many would argue that mental health is health care too.

      • Chris

        Many would argue that anyone given “free stuff” paid for by other folks would self-report that they are “happier”, and that that has nothing to do with actual mental health. I too would be “happier” if my neighbors paid for my healthcare. That’s probably not any reason to make them do it.

        Remember, these are not people who were once diagnosed as clinically depressed and are now “cured” through liberal application of taxpayer dollars. It’s just people who self-report that they are happier than they used to be – even though the free healthcare they’ve been given has not made them one bit healthier.

  • Policy Prescriptions

    Thanks for the additional data. My impression (after briefly reviewing it) is that there are still more positions open to US medical grads and that match rates are nearly the same for US grads. The question is, should we want to replace non-US grads with US grads in residency programs. For the near future, that is my position.

    As for point #2 where you say we don’t train enough primary care providers, I would agree. But unless NEW residency slots are restricted to primary care, hospitals would rather use those positions to hire fellows or orthopedic residents or whatever else increases their bottom line.

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