Post by Amsa Geriatrics on Jan 10, 2007 17:02:46 GMT -5
Chronicle of Higher Education
Dozens of new institutions are in the works to help remedy the predicted shortage of doctors. When Florida State University opened a new medical school in 2001, experts who believed the nation would soon be drowning in a sea of doctors questioned whether it was needed. Five years later, many of the same experts are welcoming plans for at least a dozen new medical schools and the expansion of dozens more. Instead of a glut, experts now fear the nation will face a serious shortage of physicians just when the aging population will need them most.
That stunning about-face began in 2002 with an admission by the Association of American Medical Colleges and other groups that the surplus projections by health-care analysts and policy makers may have been a mistake. "It is now evident that those predictions were in error," the association stated last year in a report that called on medical schools to increase their enrollments by 30 percent by 2015, both by expanding existing schools and creating new ones. Unless schools start training and graduating more doctors, the association warned, the nation could face a 20-percent shortfall of physicians by 2020. Patients will face longer delays and have to travel farther to see a doctor--barriers that would be particularly problematic for elderly and poor patients.
After a 20-year period in which the number of accredited [allopathic] medical schools held steady at 125...and federal money for on-the-job physician training was limited, new medical schools are in various stages of planning in several states, including Arizona, Florida, and Pennsylvania. Their champions are counting on an influx of state and local money, tuition, clinical revenue, research grants, and private donations to cover the billions of dollars they are expected to cost.
In the last year alone, the board in charge of Florida's public universities has approved new medical schools at Florida International University and the University of Central Florida. The University of California regents signed off on a new school at the system's Riverside campus, the first new medical school in that state in 40 years. The University of Arizona and Arizona State University joined forces to open a medical school campus in Phoenix. Michigan State University is planning a new school in Grand Rapids. A new medical school associated with Virginia Tech was announced last week. And an independent medical school is on the drawing board in Scranton, PA. In addition, Texas Tech University is moving ahead with plans for a four-year medical school on the U.S.-Mexico border, to be located in El Paso. A graduate health-care institution, A.T. Still University, is opening a new osteopathic school in Mesa, about 25 miles from the University of Arizona's new allopathic medical campus in Phoenix...
Richard A. Cooper, a professor of medicine and a senior fellow in health economics at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, says he knows of at least 20 allopathic and osteopathic medical schools that are in various stages of development. "Back in the 1990s, when health-policy analysts were talking about a physician surplus, it was all fictitious, based on funny numbers made up to support a political objective," he contends. That objective was "to support the notion that to contain health-care spending, you had to constrain the supply of health care. As a result, we lost 10 to 15 years of training physicians, and now we're in a terrible predicament."
A Cap on Federal Dollars
Even if medical schools start churning out new graduates, the number of doctors may still be constrained unless the federal government lifts its cap on the number of residency training positions it pays for through Medicare. That cap is set at 1996 levels, which means that if a teaching hospital wants to increase the number of residency positions it offers to train new physicians, it will need to pay for them itself. (All new doctors must complete a residency in order to become licensed.) The Association of American Medical Colleges [AAMC], which accredits medical schools, is lobbying to have the cap lifted as part of its strategy to increase the number of doctors. There are now about 744,000 doctors practicing in the United States.
"America is growing by 25 million every decade, and with the aging of the baby boomers, we need to consider that the elderly use twice as many services as others," says Edward Salsberg, who heads the association's Center for Workforce Studies. "We may have overproduced physicians in the 1980s and turned off the growth, but we've been a little slow in turning it back on."
A More Efficient System
But skeptics of the projections argue that what is needed is a more efficient system, not just more doctors. "There's a lot of shroud waving and fear mongering that's not based on evidence and will lead us on a costly expansion," says David C. Goodman, a professor of pediatrics and community and family medicine at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School. "Rather than spending more resources on training more physicians, we should be focusing on building more-efficient delivery systems." His team at Dartmouth recently studied the care patients received in the final six months of their lives at 79 academic medical centers across the country. The number of physicians ranged from six per 1,000 patients to 28 per 1,000. In terms of the quality of care they experienced, patients fared just as well, or even better, in hospitals with fewer doctors per patient, the researchers found. That's because those hospitals, some of which have large group practices, are less likely to subject patients to unnecessary procedures or treatments and more likely to have well-organized offices that make effective use of electronic records.
Simply graduating more physicians will not ensure that care is getting to the people who need it most, the Dartmouth researchers argued. Most will probably crowd into regions of the country that already have large numbers of doctors, rather than moving to rural areas or inner cities where more medical care is needed. A larger number of graduating physicians also does not guarantee that the physician work force will be appropriately distributed among specialties. In the future, the nation is likely to need more geriatricians and primary-care physicians, for instance, but may need a smaller proportion of surgeons or other specialists.
Another researcher who shares Dr. Goodman's skepticism about the need for a major expansion is Jonathan P. Weiner, a professor of health policy and management at the Johns Hopkins University. Taxpayers end up paying $500,000 to $1-million to train each new doctor through programs such as Medicare and subsidies to state medical schools, he says. "We're talking about spending many billions of dollars more per year" without considering whether the population really needs as many doctors as it thinks it does, he says.
Mr. Salsberg, of the medical colleges' association, agrees that efficiency is important and points out that the association is working to fix the distribution problem in part by working to aggressively recruit black and Hispanic medical students, who are more likely to work in underserved areas. But, he says, several factors have converged to make increasing overall enrollment essential. Thousands of baby-boomer physicians are nearing retirement at a time when the patient population is growing, aging, and demanding more specialized services. The number of people over age 65 is expected to double within the next 25 years, according to the U.S. Census Bureau.
At the same time, many young physicians today are choosing to work fewer hours in order to spend more time with their families. That's especially true of the growing number of female physicians. Predicting work-force needs requires a certain amount of guesswork. Medical advances mean that patients are living longer, often with chronic conditions such as diabetes that require extensive and long-term treatment. More doctors might be needed to treat them. But at the same time, technological advances could make medical treatment more efficient and allow technicians to perform procedures previously limited to physicians.
Growing Enrollments
For the most part, medical schools are heeding the cry to produce more physicians. In the 2006-7 academic year, 28 of the nation's 125 accredited medical schools expanded their enrollments by at least 5 percent by increasing the sizes of their entering classes. By 2012, about 80 of the association's 125 accredited medical schools will have expanded their enrollments over what they had in 2002, Mr. Salsberg says. But in rapidly growing states like California, Florida, and Arizona, the relatively static number of medical-school seats has discouraged potential applicants and worried many health-care advocates. Over the past three decades, California's population has jumped by 52 percent, to 36.5 million, while enrollment in health-sciences programs at universities has remained constant. The University of California at Riverside used that statistic to its advantage in winning approval for a new medical school, which is expected to begin enrolling students in 2012. An advisory group appointed by the university concluded that the state would face a shortage of 17,000 doctors by 2015, and it recommended that the system expand medical-school enrollments by 34 percent by 2020. Even with that expansion, it also suggested that the state open at least one new medical school.
France A. Córdova, chancellor of the Riverside campus, says the new school is expected to cost about $1.4-billion in combined operating and capital expenses over 15 years. Ms. Córdova is optimistic that the university will raise the money through state appropriations, grants, and private donations. The new school will conduct research on obesity, diabetes, and heart disease, and will seek to increase the number of black and Hispanic physicians in the state. The five medical schools in the University of California system each receive 4,000 to 5,500 applications for classes of 100 to 150 students, she says. "There's no way they can meet the demand simply by increasing their enrollments."
Arizona is the nation's fastest-growing state, but it ranks 45th in the number of physicians per 100,000 residents, according to Judy Bernas, the University of Arizona's associate vice president for external relations for the Phoenix medical campus.
The Money Chase
The university operates the state's only accredited allopathic medical school. Located in Tucson, it graduates 110 doctors a year. That number will eventually more than double with the addition of a new medical school in Phoenix, which opened in October.
State lawmakers allocated $6-million to the University of Arizona and $1 million to Arizona State to collaborate on the four-year medical college, which will focus on biomedical research, with particular emphasis on diabetes, heart disease, neuroscience, and cancer. The first class of 24 students is scheduled to start in July 2007, and it will eventually graduate 150 physicians per year.
But the two universities still do not have all the money they will need to operate the campus. The University of Arizona will ask the Legislature for $12 million this year, but the annual appropriation it will need from the state is expected to grow to $45 million over the next 15 years. The rest of the operating budget, which is predicted to be more than $200 million a year, will come from tuition, clinical care, research grants, and private donations.
While allopathic medical schools are getting most of the attention in the race to increase their class sizes, several osteopathic medical schools are also eager to tap into the growing demand for doctors. In Arizona, for instance, A.T. Still's new college of osteopathic medicine in Mesa will prepare students to work in underserved rural and inner-city areas and will train them in community health centers, rather than large teaching hospitals. Second-year medical students will be assigned in groups of 10 to community health centers, where they will spend half their time in classes and half shadowing doctors. "We don't want to be reproducing the same old product," says Craig M. Phelps, the college's provost. The inaugural class of 100 students will start in July 2007. "We are trying to address a deficit in a very particular part of the physician population," said the medical dean, Douglas L. Wood. "The mission of this medical school is to produce physicians who will hopefully end up caring for the underserved."
More Than Just Doctors
Meanwhile, the debate over the future of the physician work force continues to rage. Daniel S. Greenberg, a Washington journalist and author who has written about science policy and politics and describes himself as a "longtime skeptic of the need for more physicians," says he is "willing to entertain the possibility that a shortage does loom down the road." But he adds that some of the pressure can be alleviated by expanding the pool of advanced health-care workers like physician assistants or nurse practitioners. "We don't need to have people trained as brain surgeons taking splinters out of people's feet," he says.
At Florida State, where educators were ridiculed not too long ago for opening a new medical school, watching the scramble to educate more physicians has been satisfying, says Nancy Kinnally, director of public affairs and alumni relations for the medical school, whose first-year class will grow next year to 120, from 30 in 2001. "It's quite fun to see the turnaround in the consensus," she says.
By Katherine Mangan, Chronicle of Higher Education
Section: Money & Management
Volume 53, Issue 19, Page A27
Dozens of new institutions are in the works to help remedy the predicted shortage of doctors. When Florida State University opened a new medical school in 2001, experts who believed the nation would soon be drowning in a sea of doctors questioned whether it was needed. Five years later, many of the same experts are welcoming plans for at least a dozen new medical schools and the expansion of dozens more. Instead of a glut, experts now fear the nation will face a serious shortage of physicians just when the aging population will need them most.
That stunning about-face began in 2002 with an admission by the Association of American Medical Colleges and other groups that the surplus projections by health-care analysts and policy makers may have been a mistake. "It is now evident that those predictions were in error," the association stated last year in a report that called on medical schools to increase their enrollments by 30 percent by 2015, both by expanding existing schools and creating new ones. Unless schools start training and graduating more doctors, the association warned, the nation could face a 20-percent shortfall of physicians by 2020. Patients will face longer delays and have to travel farther to see a doctor--barriers that would be particularly problematic for elderly and poor patients.
After a 20-year period in which the number of accredited [allopathic] medical schools held steady at 125...and federal money for on-the-job physician training was limited, new medical schools are in various stages of planning in several states, including Arizona, Florida, and Pennsylvania. Their champions are counting on an influx of state and local money, tuition, clinical revenue, research grants, and private donations to cover the billions of dollars they are expected to cost.
In the last year alone, the board in charge of Florida's public universities has approved new medical schools at Florida International University and the University of Central Florida. The University of California regents signed off on a new school at the system's Riverside campus, the first new medical school in that state in 40 years. The University of Arizona and Arizona State University joined forces to open a medical school campus in Phoenix. Michigan State University is planning a new school in Grand Rapids. A new medical school associated with Virginia Tech was announced last week. And an independent medical school is on the drawing board in Scranton, PA. In addition, Texas Tech University is moving ahead with plans for a four-year medical school on the U.S.-Mexico border, to be located in El Paso. A graduate health-care institution, A.T. Still University, is opening a new osteopathic school in Mesa, about 25 miles from the University of Arizona's new allopathic medical campus in Phoenix...
Richard A. Cooper, a professor of medicine and a senior fellow in health economics at the Leonard Davis Institute of Health Economics at the University of Pennsylvania, says he knows of at least 20 allopathic and osteopathic medical schools that are in various stages of development. "Back in the 1990s, when health-policy analysts were talking about a physician surplus, it was all fictitious, based on funny numbers made up to support a political objective," he contends. That objective was "to support the notion that to contain health-care spending, you had to constrain the supply of health care. As a result, we lost 10 to 15 years of training physicians, and now we're in a terrible predicament."
A Cap on Federal Dollars
Even if medical schools start churning out new graduates, the number of doctors may still be constrained unless the federal government lifts its cap on the number of residency training positions it pays for through Medicare. That cap is set at 1996 levels, which means that if a teaching hospital wants to increase the number of residency positions it offers to train new physicians, it will need to pay for them itself. (All new doctors must complete a residency in order to become licensed.) The Association of American Medical Colleges [AAMC], which accredits medical schools, is lobbying to have the cap lifted as part of its strategy to increase the number of doctors. There are now about 744,000 doctors practicing in the United States.
"America is growing by 25 million every decade, and with the aging of the baby boomers, we need to consider that the elderly use twice as many services as others," says Edward Salsberg, who heads the association's Center for Workforce Studies. "We may have overproduced physicians in the 1980s and turned off the growth, but we've been a little slow in turning it back on."
A More Efficient System
But skeptics of the projections argue that what is needed is a more efficient system, not just more doctors. "There's a lot of shroud waving and fear mongering that's not based on evidence and will lead us on a costly expansion," says David C. Goodman, a professor of pediatrics and community and family medicine at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School. "Rather than spending more resources on training more physicians, we should be focusing on building more-efficient delivery systems." His team at Dartmouth recently studied the care patients received in the final six months of their lives at 79 academic medical centers across the country. The number of physicians ranged from six per 1,000 patients to 28 per 1,000. In terms of the quality of care they experienced, patients fared just as well, or even better, in hospitals with fewer doctors per patient, the researchers found. That's because those hospitals, some of which have large group practices, are less likely to subject patients to unnecessary procedures or treatments and more likely to have well-organized offices that make effective use of electronic records.
Simply graduating more physicians will not ensure that care is getting to the people who need it most, the Dartmouth researchers argued. Most will probably crowd into regions of the country that already have large numbers of doctors, rather than moving to rural areas or inner cities where more medical care is needed. A larger number of graduating physicians also does not guarantee that the physician work force will be appropriately distributed among specialties. In the future, the nation is likely to need more geriatricians and primary-care physicians, for instance, but may need a smaller proportion of surgeons or other specialists.
Another researcher who shares Dr. Goodman's skepticism about the need for a major expansion is Jonathan P. Weiner, a professor of health policy and management at the Johns Hopkins University. Taxpayers end up paying $500,000 to $1-million to train each new doctor through programs such as Medicare and subsidies to state medical schools, he says. "We're talking about spending many billions of dollars more per year" without considering whether the population really needs as many doctors as it thinks it does, he says.
Mr. Salsberg, of the medical colleges' association, agrees that efficiency is important and points out that the association is working to fix the distribution problem in part by working to aggressively recruit black and Hispanic medical students, who are more likely to work in underserved areas. But, he says, several factors have converged to make increasing overall enrollment essential. Thousands of baby-boomer physicians are nearing retirement at a time when the patient population is growing, aging, and demanding more specialized services. The number of people over age 65 is expected to double within the next 25 years, according to the U.S. Census Bureau.
At the same time, many young physicians today are choosing to work fewer hours in order to spend more time with their families. That's especially true of the growing number of female physicians. Predicting work-force needs requires a certain amount of guesswork. Medical advances mean that patients are living longer, often with chronic conditions such as diabetes that require extensive and long-term treatment. More doctors might be needed to treat them. But at the same time, technological advances could make medical treatment more efficient and allow technicians to perform procedures previously limited to physicians.
Growing Enrollments
For the most part, medical schools are heeding the cry to produce more physicians. In the 2006-7 academic year, 28 of the nation's 125 accredited medical schools expanded their enrollments by at least 5 percent by increasing the sizes of their entering classes. By 2012, about 80 of the association's 125 accredited medical schools will have expanded their enrollments over what they had in 2002, Mr. Salsberg says. But in rapidly growing states like California, Florida, and Arizona, the relatively static number of medical-school seats has discouraged potential applicants and worried many health-care advocates. Over the past three decades, California's population has jumped by 52 percent, to 36.5 million, while enrollment in health-sciences programs at universities has remained constant. The University of California at Riverside used that statistic to its advantage in winning approval for a new medical school, which is expected to begin enrolling students in 2012. An advisory group appointed by the university concluded that the state would face a shortage of 17,000 doctors by 2015, and it recommended that the system expand medical-school enrollments by 34 percent by 2020. Even with that expansion, it also suggested that the state open at least one new medical school.
France A. Córdova, chancellor of the Riverside campus, says the new school is expected to cost about $1.4-billion in combined operating and capital expenses over 15 years. Ms. Córdova is optimistic that the university will raise the money through state appropriations, grants, and private donations. The new school will conduct research on obesity, diabetes, and heart disease, and will seek to increase the number of black and Hispanic physicians in the state. The five medical schools in the University of California system each receive 4,000 to 5,500 applications for classes of 100 to 150 students, she says. "There's no way they can meet the demand simply by increasing their enrollments."
Arizona is the nation's fastest-growing state, but it ranks 45th in the number of physicians per 100,000 residents, according to Judy Bernas, the University of Arizona's associate vice president for external relations for the Phoenix medical campus.
The Money Chase
The university operates the state's only accredited allopathic medical school. Located in Tucson, it graduates 110 doctors a year. That number will eventually more than double with the addition of a new medical school in Phoenix, which opened in October.
State lawmakers allocated $6-million to the University of Arizona and $1 million to Arizona State to collaborate on the four-year medical college, which will focus on biomedical research, with particular emphasis on diabetes, heart disease, neuroscience, and cancer. The first class of 24 students is scheduled to start in July 2007, and it will eventually graduate 150 physicians per year.
But the two universities still do not have all the money they will need to operate the campus. The University of Arizona will ask the Legislature for $12 million this year, but the annual appropriation it will need from the state is expected to grow to $45 million over the next 15 years. The rest of the operating budget, which is predicted to be more than $200 million a year, will come from tuition, clinical care, research grants, and private donations.
While allopathic medical schools are getting most of the attention in the race to increase their class sizes, several osteopathic medical schools are also eager to tap into the growing demand for doctors. In Arizona, for instance, A.T. Still's new college of osteopathic medicine in Mesa will prepare students to work in underserved rural and inner-city areas and will train them in community health centers, rather than large teaching hospitals. Second-year medical students will be assigned in groups of 10 to community health centers, where they will spend half their time in classes and half shadowing doctors. "We don't want to be reproducing the same old product," says Craig M. Phelps, the college's provost. The inaugural class of 100 students will start in July 2007. "We are trying to address a deficit in a very particular part of the physician population," said the medical dean, Douglas L. Wood. "The mission of this medical school is to produce physicians who will hopefully end up caring for the underserved."
More Than Just Doctors
Meanwhile, the debate over the future of the physician work force continues to rage. Daniel S. Greenberg, a Washington journalist and author who has written about science policy and politics and describes himself as a "longtime skeptic of the need for more physicians," says he is "willing to entertain the possibility that a shortage does loom down the road." But he adds that some of the pressure can be alleviated by expanding the pool of advanced health-care workers like physician assistants or nurse practitioners. "We don't need to have people trained as brain surgeons taking splinters out of people's feet," he says.
At Florida State, where educators were ridiculed not too long ago for opening a new medical school, watching the scramble to educate more physicians has been satisfying, says Nancy Kinnally, director of public affairs and alumni relations for the medical school, whose first-year class will grow next year to 120, from 30 in 2001. "It's quite fun to see the turnaround in the consensus," she says.
By Katherine Mangan, Chronicle of Higher Education
Section: Money & Management
Volume 53, Issue 19, Page A27