The number of medical students continues to rise, but without a corresponding increase in residency training slots, experts worry that there will not be enough physicians to meet demand. An aging population and the demand that could be created if health insurance reform is enacted could overwhelm any gains made in adding new doctors to the pool.
Med school numbers rise, residency slots stay flat
There is also concern that, as medical students graduate with heavier debt loads, the trend away from primary care and to higher-paying specialties will continue.
According to figures released last week by the Association of American Medical Colleges, the number of first-year medical students increased 2% to 18,390 from 18,036. Also, the average medical school debt grew by 1%, to more than $156,000 from about $155,000. In comparison, that last figure was an 11% increase from the average debt of $139,517 recorded in 2007.
The enrollment increase was due in part to the opening of four new medical schools: Commonwealth Medical College, Scranton, Pa.; Florida International University Herbert Wertheim College of Medicine, Miami; Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso; and the University of Central Florida College of Medicine, Orlando. In addition, 12 existing schools expanded their 2009 class size by 7% or more. With the exception of a 1.6% increase last year, enrollment increases have been 2% or higher since 2005.
AAMC President and CEO Darrell Kirch, however, warned that without an increase in the number of graduate medical training or residency slots, there could be a “bottleneck” in the new physician pipeline that could result in a shortage of between 124,000 and 159,000 physicians by 2025. The number of residency positions supported by Medicare has been capped at the 1996 level of about 100,000 since the passage of the Balanced Budget Act of 1997.
New legislation, called the Resident Physician Shortage Reduction Act of 2009, has been introduced that would increase this number by 15,000. Kirch said it is “disappointing” that, although there was some reference to redistributing unfilled slots, there were no provisions to increase the number of residency positions in any of the reform bills introduced in Congress.
Kirch also voiced little optimism for the reduction act's passage as it would add some $12 billion in costs to the Medicare program, and there was reluctance in Congress to add any more new expenses for Medicare to pick up. Kirch added that, while he never thought he would come to think of $12 billion as a “modest” total, compared with the entire scope of healthcare reform, he said it actually was. Kirch also suggested that maybe it was time to look at a different financing source for resident training other than Medicare—such as an all-payer trust fund.
With insuring most Americans as “the centerpiece goal” of healthcare reform, Kirch said passage of reform legislation has the potential to exacerbate existing difficulties many have with access to healthcare—particularly primary-care services.
According to the 2009 Modern Healthcare physician compensation survey, a graduating medical student's debt load is very close to a year's pay for a primary-care doctor (July 13, p. 20). Family medicine specialists had the lowest pay with an average of $181,536 (up 4.5% from last year), and ranged from $166,848 to $212,032. Second-lowest were pediatricians, whose average compensation was $183,834 (up 6.5%), and their pay ranged from $150,000 to $217,000. They were followed by internists who had an average compensation of $196,495 (up 5.7%), and whose pay ranged from $179,958 to $222,377.
Lauren Hughes, president of the American Medical Student Association, has a medical degree from the University of Iowa Carver College of Medicine and a master's in public health from George Washington University in Washington. She also owes $200,000. “When I applied to medical school in 2003, I was told my debt would be about $120,000,” she said. The average debt is $156,000, which “is quite a jump in six years,” she said.
Until the next resident match day, set for March 18, 2010, Hughes will have no idea where she will receive training. She does know it will be in family medicine and expresses no regrets in her chosen career path. While expanding residency training has not been a priority for Congress, Hughes said she is pleased that funding for the National Health Services Corps has been emphasized in reform bills—except, however, the one coming out of the Senate Finance Committee.
Under the NHSC program, primary-care doctors and related professionals receive $50,000 to help pay student loans if they agree to practice in a high-need area that has been designated a “Health Professional Shortage Area” for two years.
Hughes acknowledges that many in her peer group are abandoning primary care for higher-paying specialties—often in order to pay off debt. But Hughes said she is encouraged that the new medical school at Florida International University has a curriculum “designed to be primary-care focused with an emphasis on serving the underserved.”
According to national totals released by the AAMC, this fall's first-year class is made up of 9,573 men and 8,817 women for a 52.1% to 47.9% split. There are 12,045 white students, up from 11,928 in 2008; 4,114 Asian students, up from 3,941; 1,412 Latino students, down from 1,416; and 1,312 black students, up from 1,293.
Total medical school applications were up only 0.1% to 42,269 from 42,231, and included 22,014 men and 20,252 women to equal the 52.1% to 47.9% split found in first-year students. Kirch noted that women outnumber men among black and Latino medical school applicants.
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