"Is it cool that I said all that? Is it too soon to do this yet?"
-- Taylor Swift
On Monday, March 11, I was eagerly anticipating the release of the administration's fiscal year 2020 budget proposal when an email popped up in my inbox. That email linked me to a commentary article in The American Journal of Medicine titled "More Sub-Subs are Coming!"
I was intrigued, so I opened the article, which changed the course of my day. This little pearl of protectionism came to us from three subspecialists -- two cardiologists and a pathologist -- who, from what I can tell, spent most of their careers in academia. These three individuals' careers happened to converge when they all worked at a medical school in the Southwestern United States.
The article starts off innocently enough with a nice overview of physician training in the United States dating back to the beginning of the 20th century. It also sketches out the various inflection points where major shifts in physician training occurred.
Then the article took an extremely sharp turn, and so did my attitude.
The authors correctly point out that the nation faces a physician shortage. There is little disagreement that population growth and our aging society require a larger physician workforce. They also correctly point out that there has been an explosion in the number of subspecialties and sub-subspecialties, noting that "in 2018, the ACGME (Accreditation Council for Graduate Medical Education) approved 4,697 fellowship programs in 123 different subspecialties."
One hundred and twenty-three different subspecialties!
Finally, the authors correctly note that the growth in fellowship positions has contributed significantly to the current trend of specialization in the physician workforce.
Here is the first of two portions of the article that I take exception with, both on the facts and on the sheer arrogance of the authors: "It is clear that more and more U.S. physicians are entering practice as sub- or sub-subspecialists. Nearly all of the 5,348 U.S. physicians who matched to a subspecialty fellowship in 2018 will enter practice as sub- or sub-subspecialists. This number of physicians must be compared with the 2,697 U.S. physicians (M.D.s and D.O.s) who entered family medicine residencies in 2017 and the 2,324 who entered family medicine residencies in 2018."
The numbers used by the authors are wrong or, at best, inappropriately manipulated to fit the narrative.
According to the 2018 National Resident Matching Program report, "a total of 6,569 U.S. seniors matched to categorical positions in family medicine, internal medicine and pediatrics, representing 37 percent of all U.S. seniors who matched to PGY-1 positions (17,740), and 48.4 percent of all applicants who matched in those specialties (13,584)." Furthermore, according to the same report, "family medicine has experienced position increases every year since 2008. In 2018, family medicine offered 3,629 positions and filled 3,510 (96.7 percent), both the highest on record." Seems the authors failed to include this growth in their "expert" analysis.
Which brings us to the second problematic section of the article: "Although we are now producing more and more specialists, subspecialists, and now sub-subspecialists, the number of generalists entering practice will continue to decrease. The solution to the decreasing number of primary care physicians is not to build more medical schools. The solution is in plain sight: Nurse practitioners and physician assistants are ready and able. Many are already providing primary care in retail clinics."
Whoa! This is a pretty audacious statement, especially coming from individuals who were in leadership positions in a medical school. There is a lot to unpack here, but I will try.
First, I would suggest that many of the workforce, delivery system and cost challenges in our health care system are due not only to the primary care shortage; the fact that we have too many subspecialists is also to blame. So here's a thought: Maybe we should stop overincentivizing the training of subspecialists and sub-subspecialists, and start aligning our financial investments to train the physician workforce best positioned to meet the needs of our population -- primary care, general surgery and psychiatry.
Second, I applaud the fact that they basically own up to the so-called Dean's Lie. For those who are unfamiliar, the Dean's Lie is when a medical school dean puts on a white coat, throws up some impressive-looking PowerPoint slides, and performs a magic trick that results in an outpouring of data that shows the medical school's graduates are entering primary care specialties at an astonishingly high rate. If the dean is really skilled, the press will actually help advance this narrative and the dean will be the envy of the academic crowd. The problem is (as the authors note) that most of those graduates who start in an internship or transition year move to residency programs in nonprimary care specialties, and many of those in primary care residencies move on to subspecialty fellowships. This is rightly called a lie, and it's done without shame.
Third, the statement that many nurse practitioners and physician assistants "are already providing primary care in retail clinics" shows a complete lack of understanding of primary care. Quite honestly, it is just embarrassing that a former dean of a major medical school would associate primary care with the low-acuity episodes of care provided in retail clinics.
The AAFP has a comprehensive policy on graduate medical education (GME) financing that would transition our GME and training system to be more equitable and certainly more reflective of the nation's workforce needs. We need subspecialists and subspecialty care. I am not arguing this point. What I am arguing is that the emphasis on and subsidization of subspecialty and sub-subspecialty care is contrary to the needs of our country and the population at large. Our GME system has been hijacked by hospital CFOs and the subspecialties that drive hospital revenue centers. It is time to change this dynamic. GME financing should support the workforce needs of the country, not the financial statements of a few hospitals.
As I mentioned, there is little disagreement among workforce analysts that there is a physician workforce shortage. But the size of the shortage and the medical specialties in which it is most acute are hotly debated. As a means of assisting you in understanding this shortage, I am supplying two resources on the issue.
Stephanie Quinn, AAFP Senior Vice President of Advocacy, Practice Advancement and Policy. Read author bio »