STEVEN A. SCHROEDER, MD Training an Appropriate Mix of Physicians to Meet the Nation’s Needs Abstract—Although the lack of a national policy on medical manpower has served U.S. medicine well in some ways has created problems, the most important of which ist jtribution of physicians in the various special many specialists and not nearly enough geners ‘explain why this imbalance isa problem and why itis receiving ‘80 much attention, describes three types of forces—economi practice-related, and scientific—that favor the:practice of 6 Cialty medicine, and demonstrates that the medical school expe- rience itsolf may be a ertical areer deci change might come about, which range from doing nothing to ‘making a number of fundamental changes within academic med- icine’s institutions to having external financial pressures for change brought to bear by the states and the federal government. Tn conclusion, the author notes that some combination of these scenarios will occur, because spending for medical care in the United States is out of control and eannot be reduced unless the distribution of physicians by specialty is rebalanced to have a ‘much greater percontage of generalists. His hope is that aca~ demic medicine will accept this challenge and bring about the beat mix of physi 8(1998):118-122. ‘he proposes five detailed alternative scenarios of how correct ‘The most vital component of any na- tion's system of medical care is its health professionals are essential to the public's well-being, as is an ade- quate supply of facilities and equi ment. Yet it is the type, distribution, dogree of training, and quality of phy- sicians that most affect: what tran- spires in hospitals, outpatient set- tings, and other sites where medicine is practiced. In all of the other developed coun- tries, the supply and specialty distri- bution of physicians follow a national plan, in some instances enforced by a governmental authority, in others by ‘8 quasi-public body. But the United States, which departs from other na- tions in how it organizes and finances medical care, also differs in never having had a national policy on med ‘cal manpower. Instead, we have dele- gated the production of physicians: . Schroeder is president of the Robert ‘Wood Jobson Foundation, Princeton, New Sersey. ‘Correspondence and requests for reprints shoul be addressed to Dr. Schroeder, Presi- ‘ent, Robert Wood Johnson Foundation, P.O. Box’ 2816, College Road, Princeton, NJ (08543-2516. “Another article obout the production of gener alist physicians oppears on page 113 that, most crucial component of medical care—to a loosely connected confederation of voluntary agencies: academic medical centers, the na- tion’s teaching hospitals, the Ameri can Board of Medical’ Specialties, and the Accreditation Committee for Graduate Medical Education (ACGME). ‘Phe result of this arrangement has been the uncoordinated, de facto de- volution of physician manpower planning to the clinical leaders of aca- demic medicine. ‘Though medical manpower planning has been clearly located within the private sector, the fands to support it have been largely public, currently estimated to be close to $6 billion annuall In many ways, this voluntary s tem of medical manpower has served the country well. The quality of un- dergraduate and graduate medical ed- uucation is superb. Our teaching hospi- tals are magnets that draw the best physicians from all over the world. And certainly the technical quality of medical care and the technological ca- pacity of our health care system set the pace for the rest of the world, In addition —as judged by international standards as well as by recent expert committees—we have somehow ar- rived at a ratio of doctors per popula- tion that may be about where it, should be, currently about 255 nonfe- deral physicians per 100,000 people. However, we do have problems. ‘to meet the nation’s noods. Acad. Med, One is the geographic maldistribution of physicians, with too many doctors located in the suburbs and the fash- ionable parts of urban areas, and too few in rural areas and in the inner city. Though few countries have been able to achieve optimal geographic persion, most have not expo enced the deterioration of availability in inner-city areas that has occurred here during the past decade. Another problem is the paucity of U.S. physi- cians from underrepresented minor- ity groups—blacks, Hispanics, and native Americans. Through the 3000 ‘by 2000 plan of the Association of ‘American Medical Colleges (AAMC), the leadership of academic medicine hhas made a promising effort to help address this problem; other count in the developed world would do well to emulate this effort. While these problems are impor- tant, our most serious medical man- power defect lies in the distribution of physicians according to specialty. To put it simply, we are flooding the country with specialists at the ex- pense of generalists. In every other developed nation the proportion of generalist physicians, that is, general internists, family physicians, and goneral pediatricians, is at least 50%, and often as high as 70%. But in the United States the proportion of gen- eralists is only 29% and declining. Even more ominous are recent trends compiled by the AAMC of the career [ACADEMIC MEDICINE.plans of graduating medical students. Less than 15% of the graduating classes of 1991 and 1992—com- prising about 31,000 students. intended to pursue generalist careers. Even that number may overstate gen- ‘eralist preferences, since many sur- gery subspecialties are so oversub- scribed that some students are not able to secure residency positions in them anywhere in the eountry. Confronted with this specialty im- balance, three questions come to mind: How did it come about? Is it, really a problem? What could be done to correct it? HOW DID THE SPECIALTY IMBALANCE COME ABOUT? Our nation never had a master plan to create a health care system domi- ialty mix occurred passively, a result of a combination of factors’ that af- fected the practice of medicine and the conduct of academic medicine. At least three types of forces favor the practice of specialty medicine. economic, practice-related and scientific. ‘The most important economic fac- tor is a fee-for-service payment sys- tem that consistently and increas- ingly pays physicians more for performing specific tests and proce- dures than for nontechnologic ser- vices. Also important is the mounting burden of cost-containment responsi- bilities placed upon all physicians but, disproportionately felt by office- based practitioners, which most gen- eralists are. Whether they are labor- ing under the strain of serving as gatekeepers to more expensive ser- vvices or enduring the hassles imposed by third-party payers, generalists seem to feel more encumbered by the forces of medical cost containment than do specialists. A generalist’s practice tensive and populated with patients with chronie illnesses. The long-term relationships with these patients en- ‘mesh the conscientious generalist in a tangle of red tape—referrals, forms, eligibility determinations, and so on. Students correctly perceive that the ‘VOLUME 68 # NUMBER 2 # FEBRUARY 1993 lifestyle of a generalist is more de- manding and intrusive, requiring time spent on tasks irrelevant to why they chose a medical career. Finally, as the scientific base for medicine’ has expanded, students have become increasingly wary about accepting the seemingly limitless knowledge accountability that comes with the generalist label. At the same time, new scientific developments have enlarged the diagnostic and therapeutic opportunities for spec ists, even as their core responsibilit have become more and more narrowly defined. Despite these factors that favor choosing careers as specialists, good evidence suggests that the medical school experience itself may be a crit ical influence on students’ career de- cisions, First, many medical students, possibly more than half, start out in- tending to become generalists. Sec- cond, huge variability exists among medical schools in the proportions of generalists they produce. A recent AAMC study of career choices of the graduating class of 1987 found more than a sixfold variation among medi- cal schools in the proportions of grad- uates choosing generalist careers. The top two schools each had 54% of their graduates in one of the three general- ist fields, while the lowest-ranked school produced only 9%.* A recent article in Academic Medicine com- pared the top 25 and the bottom 25 medical schools according to the per- centages of their 1981-1985 gradu- ates who had selected generalist ca- reers.‘ Twenty-one of the top 25 generalist-producer schools were pub- lic institutions; conversely, 21 of the bottom 25 were private. The top 25 generalist-producers were twice as likely to have departments of family medicine, and they received fewer ‘National Institutes of Health (NTH) research dollars, as well as fewer ‘Medicare direct’ medical education payments for residency training. ‘There were important, exceptions to this trend. For example, four of the top 26 generalist producers were in the upper 30% of the NIH-funding recipients, Two highly successful public research institutions, the Uni- versity of California, San Francisco, School of Medicine and the Univ sity of Washington School of Me cine, were among the top 13 general- ist-producing schools according to the ‘AAMC's 1987 list. ‘A number of factors determine the kinds of specialists a medical school graduates. Perhaps the most impor- tant is the type of student accepted. ‘Schools wishing to increase their pro- portions of generalist graduates have searched for personal and academic predictors of generalist careers and factored these into their admission procedures. Other important. infu- ences are the preclinical curriculum, the clinical clerkships and exposure to generalist role models, the configu- ration of the institution’s residency programs, and the degree of integra- tion with community-based gener- alists. Thus, although societal factors clearly ‘influence medical students’ career choices, the medical schools themselves can affect the trends, and could begin to do so more strategi- cally, with social as well as institu- tional goals in mind. IS MEDICAL SPECIALTY IMBALANCE A PROBLEM? Not everyone would agree with the growing consensus that too many spe- cialists and too few generalists repre- sent a problem for our eountry. Those who demur might argue for the appro- priateness of letting the market de- {ermine specialty mix, claiming that the current distribution has resulted from the desires of the American public. One problem with this argu- tment is that although the American public finances graduate medical edu- cation, it has no say about its out- come. Meanwhile, a growing number ‘of national bodies have recently come ‘ut in favor of increasing the propor- tion of generalist physicians, and some have gone so far as to specify a target goal that 50% of all physicians should be generalists. ‘These groups include the Council on Graduate Medical Education, the Federal Bu- reau of Health Professions, the Ac- ereditation Committee on Graduate 119Medical Education (ACGME), the American Medical Association, the ‘American Academy of Family Physi- ‘cians, the American College of Physi- cians, the Pew Health Professions Commission, the National Governors Association, the National Council of State Legislatures, and many individ- ual state legislatures. (See also Robert G. Petersdorf’s comments about the {50% goal in his essay in this issue of the journal.) The Robert Wood John- son Foundation has also argued for redressing the specialty imbalance, and within the past year has an- nounced a $32 million program to support medical schools that wish to increase their production of general- ists, a $14 million faculty develop- ment program for generalists, and $16 million program to improve the practice support and the distribution of generalist physicians and midlevel practitioners in underserved areas. Increasing interest in this issue has ‘been shown in both the House and ‘the Senate, although no legislation hhas yet been passed. And finally, as you know, the AAMC has just devel- oped a strong policy position calling for a majority of students to select generalist careers.* ‘What is it about the specialty im- balance that has impelled these groups to clamor for change? Too ‘many specialists means more expen- sive health care, poor coordination of care for patients with a variety of problems as they ricochet from one doctor to another, and poor medical duality if specialists have insufficient, numbers of patients to maintain technical proficiency. The epidemio- logic realities of the numerical dor nance of specialists mean that much generalist care must be given by spe- cialists, and that is both costly and inefficient. Many specialists who are forced to practice outside their special areas of competence will not. take pleasure at straying from their fields. At the same time, having too few gon- eralists means that Americans have less access to primary care, miss op- portunities for prevention, and re- ive i 2, uncoordinated WHAT CAN BE DONE TO. CORRECT THE IMBALANCE? Certainly some of the steps necessary to correct the specialty imbalance are outside the purview of medical acade- mia. Payment of physicians must be- come more neutral with respect to technology use, the economic burden of cost-containment measures. must, be shared equally among all physi- cians, health maintenance organiza- tions (and their variants) must make it clear to students that there are more openings for generalists than for specialists, and the essential worth of generalism must be better appreciated. Still, academic medical centers can do much to help produce and main- tain an appropriate mix of physicians. Here are five scenarios for how medi- cal academia could respond to this challenge. ‘Scenario A is to maintain the status quo. Those who favor this scenario argue that the current mixture of physicians is a response to the de- mands of the public and maintains American medicine at its high-tech nology best, and that any steps to es- tablish @ national health manpower plan would do more harm than good. A variant of this scenario can be found at many teaching hospitals, where clinical leaders agree with the goal of more generalists, but ask that other institutions produce them. Often this argument is coupled with the assertion that their own institu- tions train leaders, which assumes that leadership and generalism are somehow incompatible. But, since very few schools see their mission to be the production of followers, the re- sult is no change. Even in the most research-intensive medical center more than 80% of the graduates be come community-based practitioners, and generalists need leaders as much as specialists do. One would also think that it would be in the teaching hospital’s self-interest to show some restraint in producing all those sub- specialists, many of whom promptly go out and compete with the mother institution. Finally, if one acknow!- edges a maldistribution problem, this scenario ignores the fact that medical academia’s substantial public trust requires that it respond to that problem. ‘Scenario B accepts the reality of a declining generalist pool but attempts to increase the generalist capability of specialists. To a large extent, the fact that there is not enough patient vol- ume to keep all subspecialists fully ‘occupied within their own specialties means that there is a hidden pool of part-time generalists with subspe- cialty training. One example is in gynecology: gynecologists are used by any women ae their generelist phy- sicians. From time to time T have heard gynecologists describe their field as “the primary care specialty for women.” If we are serious about this scenario, the Residency Review Committee for Obstetrics and Gyne cology, for example, should hold resi dency’ programs ‘accountable for training residents as generalists as well as. specialists. The special re- quirements for gynecology residency programs would include such process skills as interviewing, patient compli- ance, and principles of screening. Clinical training would have to in- clude the diagnosis and management of such common syndromes as hyper- tension, asthma, diabetes, depression, arthritis, heart disease, dermatologic conditions, and common orthopedic problems. Then, the certifying board exam should hold the residents ac- countable for competency in these areas. Ret ist i as genera by including more generalist mate in both the continuing medical educa- tion courses in each specialty and the specialty journals. The chief advan- tages of this scenario are that it would be minimally disruptive and that it could improve the quality of general- ist care given by specialists, It has two major disadvantages: first, it does nothing to address the problem of the excessive costs of having a medical care system dominated by specialist physicians; second, it is not at all clear that most specialists really wish to be held accountable for general clinical care. ‘Scenario C also accepts as inevita- ACADEMIC MEDICINEble the decline of generalist physi- cians, but replaces the missing gener- alist capability not with specialists but, with nonphysician substitutes, such as nurse practitioners and phy- sician assistants. A possible variant of this scenario would be to increase the enrollment of schools of osteopathic medicine, which have a better track record of producing generalists than do allopathic schools. Though Sce- nario Cis not my first choice it would merit serious consideration if coupled with @ substantial decrease in allo- pathic medical school enrollment from the current annual graduating size of 15,500 students to around 10,000, some of whom would still need to become generalists. Otherwise, the cost-inflating effect of excessive num- bers of specialists would be further exacerbated by continuing to produce more of them. Scenario D calls for energetic ef- forts by academic medicine to achieve a more appropriate generalist— specialist balance, perhaps the 50% for each suggested by some of the groups mentioned earlier. Compo- nents of the plan would necessarily include changing medical schools’ admission policies, reorienting the preclinical and clinical curricula, and reconfiguring graduate medical education. In order for this scenario to be successful, it must involve the Liaison Committee on Medical Edu- ‘cation at the undergraduate level and the ACGME and the various resi- dency review committees, because the number of specialty positions would need to shrink in order to accommo- date more generalist residency slots. In addition, because of the long time Jag between changes in residency out- put and changes in manpower distri- bution, many of the suggestions about retraining specialists discussed in ‘Scenario B also should occur. In other words, retraining would be needed be- cause even if 50% of all residents were generalists by 1995, not until the year 2040 would 50% of all physicians be generalists. ‘The shift in residency allocation would have to conform with antitrust regulations, a barrier often invoked in discussions ebout changing graduate VOLUME 68 # NUMBER 2 # FEBRUARY 1999, ‘medical education but not well under- stood. Mechanisms would be needed to heip teaching hospitals cover the service load currently met. by sp cialty residents. For this purpose, po- tential resident substitutes include fellows, the faculty, nonphysicians, and salaried clinicians. Finally, changes in the funding of residency training would be needed to assure the shift in types of positions and to cover the increase in ambulatory care education. The new AAMC policy po- sition on’ generalist, physicians® re- sembles Scenario D in many respects, but it omits any discussion of how to decrease the number of specialty po- sitions in residencies and fellowships. ‘To be credible, Scenario D must be linked with explicit goals and timeta- bles, and with alternative actions planned should the timetable prove unattainable. Scenario E, the final scenario, would have the same overall goals as Scenario D but would shift the ac- countability for change from acade- mia to the public sector. Scenario E could come about in a number of ways, but may be thought of as the scenario that continued inaction by medical academia could bring about. For example, academia could reject the opportunity to work for changes residency composition, perhaps citing antitrust concerns. Yet, federal and/or state governments could con- clude that the problem demands prompt action. In any case, this sce- nario calls for explicit financial sticks and carrots involving changes in the funding of graduate medical educa- tion, in loan forgiveness, and in state funding of public medical schools. It has been suggested that payment for the indirect costs of research dollars be linked to a school’s performance in producing generalists, but in my opinion this is not a reasonable solu- tion, since it confuses the knowledge- generation component of medical academia with its role as producer of, the nation’s medical manpower. Per- haps a commission would be desig- nated to allocate residency positions ‘according to some national formula, with specific assignments to regional districts. This commission could in- clude. representatives of several sec- tors, including federal and state gov- ermment, physicians, academia, other health professionals, business, and ‘the general public. A national dat tracking system should be estab- lished, and the manpower goals could bbe reassessed periodically in response to changes in perceived need, de- mand, and supply. Of course, these educational changes must be coupled with improvements in the enviro ment for practice of generalist medi- cine, including payment reform. Tt is not clear to me which of these five scenarios will eventually occur. ‘As recently as 12 months ago I would have predicted Scenario A, maintain- ing the status quo. But increasing rec- ognition that. specialty maldistribu- tion lies at the heart of our national access and cost problems raises the likelihood that some variants of Sce- narios B through E may come about. Spending for medical care in the United States is out of control. It now accounts for 14% of our gross na- tional product—one out of every seven dollars spent in this country. Our nation will not be able to resolve the problem of runaway medical spending unless it changes its mix of physicians. Academie medicine has always en- joyed a special position in the United States. It has been well supported by public dollars, has enjoyed great au- tonomy, and has been responsible for much of the excellence that charac- terizes American medicine. It is now faced with the challenge of how to respond to a national problem that strikes at the core of its mission— designing the best. mix of physicians to meet the nation’s needs. For the good of the country, as well a for the integrity of academic medicine, I hope that it will accept that challenge. References 4 Schroeder, S.A, Western Buropean Re- spontes to Physician Oversupply: Lessons fr the United States, JAMA 252(1984) 374-384, 1Half Full or Hale Empty? Ann, Intern, Med. 116(1992} 58-592, 8, Willinms, D. J, Sanderson, S.C, and Kre- ower, (compilers). 1982 Institutional Goals Ranking Report. Washington, D.C: ‘Assocation of American Medical Colleges, 192. 4. Whitcomb, MB, Cullen, 7 J, Hart, LG, Lishner, D.M, and Rovenbiat, R.A. Com- paring the Charactritics of Schools ‘That Produce High Percentages and Low Per- ‘contagen of Primary Care Physiians. Acod. ‘Med, 871992)587-581. 6, Generalist Physician ‘Task Force. AAMC Policy-on the Generalist Physician. Acad, ‘Med. 68(1999):1-6. SPECIAL ARTICLE ALLAN ROBERTS, PhD, ROBERT FOSTER, DO, MARGARET DENNIS, EdD, LAURENCE DAVIS, PhD, JAMES WELLS, PhD, MARY FRANCES BODEMULLER, MLS, and CAROLYN A. BAILEY, MA An Approach to Training and Retaining Primary Care Physicians in Rural Appalachia Abstract—The West Virginia School of Osteopathic Me ine (8) it emphat (WVSOM) educated and retained more primary care physicians for practice in rural Appalachia than did any other U.S. medical school from 1978 through 1990. This article describes the most important methods used at WVSOM to place physicians in rural ‘areas: (1) The school has a focused, achievable mission (to pro- ‘vide primary eare physicians who are trained to meet the medi- ‘eal needs of rural Appalachia and to improve the health care of sion, and placement processes ‘rural students; (4) it provides early and lo ing in rural sites (both hosp dedicated primarily 0 the education of medical students rather than to research or other goal; and (6) its a freestanding school in a rural environment. ‘The authors state that although WVSOM is unusual in some respects, at least some of its ‘methods may be useful to other medical schools as they seek to ()itis ‘the rural Appalachian population) that is agreed upon by the administration, faculty, and students; (2) it participa multistate educational exchange program A recent study demonstrated that Dr. Roborts is profesor of anatomy, Divi- sion of Structural Biology; Dr. Fostr is essist- fant desn of lineal education and professor of femly prac, Dr. Dena is deer, Ofiee of Family Pr {ewor of biochemistry, Division of Functional Biology, Jr. Wels is profesor of anatomy, Di- Ms, Boderullr is brarian-director, ing. Resource Center; and Ms. Bailey is aasoeate dean of sien ail ae at the Wat Vig School of Osteopathic Medicine, Lewis Cormespondence and sequests for reprints should be addressed to Dr. Roberts, West Vir- finia School of Osteopathic, Medicine, 400 ‘North Lee Stroct,Lawisberg, WV 24801. m a similar mission; from 1978 to 1990 the West Virginia School of Osteopathic Medicine (WVSOM) educated and retained more primary care physicians for practice in the rural and underserved regions of Appalachia than did any other U.S. medical school! ‘The present article discusses the most. important methods used by WVSOM that fostered, and continue to foster, these achievements: (1) the school has a focused, achievable sion; (2) it participates in a multistate educational exchange program with a similar mission; (3) itemphasizes per- sonelized, interactive recruiting, ad- produce more primary care phys served areas, Acad. Med, 68(1993) 38 for rural and other under- 2-125, mission, and placement; (4) it pro- vides early and extensive clinical ‘training in rural areas; (6) it is dedi- cated primarily to the education of medical students; and (6) it is a freestanding school in a rural envi- ronment. ‘We realize that WVSOM is un- usual in some respects, but we present this overview of our methods in the hope that at least some of them may be useful to other medical schools as they seek to produce more primary care physicians, particularly those who will practice in rural and other underserved areas. ACADEMIC MEDICINE