Although total U.S. medical school enrollment increased nearly 23 percent between 2000 and 2010, many of those newly minted physicians won't choose primary care specialties and they won't settle in states with the most severe primary care shortages. Those issues are discussed in a new study in the December issue of Academic Medicine.
According to study co-author Andrew Bazemore, M.D., M.P.H., director of the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the opening of more allopathic and osteopathic medical schools in the past decade was a direct response to widespread concerns about a U.S. physician shortage. "We've seen an unbridled expansion of medical schools without anyone guiding or overseeing that overall expansion," says Bazemore.
"This research is important, because states are making decisions right now about what they want and, more importantly, what they need, to take care of the people in their states. We've taken a midstream look at whether medical schools are being built where there is the greatest need."
In the study "State Patterns in Medical School Expansion 2000-2010: Variation, Discord and Policy Priorities,(journals.lww.com)" Bazemore and his co-authors note that the reality of budget constraints at the state and federal level, combined with calls for lower costs and more accountability in the health care system and in physician training, have added urgency to a growing problem.
- Researchers found that despite a total U.S. medical school enrollment that increased by 22.9 percent between 2000 and 2010, many states still face primary care shortages.
- Data indicate that uncoordinated expansion of medical schools may not solve health care access challenges.
- States should develop and implement policies that make primary care more attractive to students and encourage new physicians to remain in the state in which they train.
"Despite evidence tying access to primary care physicians to improved community health outcomes and decreased costs, medical student interest in primary care and, thus, medical school output of primary care physicians, has been declining," say the researchers.
For the study, the researchers calculated population growth and medical school enrollment in individual states and examined the relationship between medical school expansion and states' needs. They wanted to know how many medical students return to practice in the states where they graduate and what states were successful in increasing their primary care workforces.
The authors knew from previous research that students who attend both medical school and residency training in the same state are more likely to remain in that state to practice medicine. They found that although 63 percent of medical students enter a medical school in their home state, only 39 percent of M.D. and D.O. graduates who complete an out-of-state residency return to their home state to practice. This retention rate was higher (47 percent) among students who attend public schools.
"Increasing medical school enrollment in states without sufficient GME (graduate medical education) positions and with medical student retention rates below the national median may not be a prudent investment," say researchers.
"Although the 22.9 percent increase in total U.S. medical school enrollment from 2000 to 2010 will increase supply of physicians, as the COGME (Council on Graduate Medical Education) suggested, an increase in supply 'will not in and of itself address issues of maldistribution of physicians,'" they conclude.
Research by the Numbers
Researchers determined that from 2000-2010, median state population growth was 7.4 percent and median medical school enrollment growth was 14.7 percent, but there were wide variations across states. For example, Nevada had a population surge of 35 percent, while medical school enrollment increased by 274 percent. West Virginia's population grew by just 2.5 percent, and yet, the state expanded its medical school enrollment by 80 percent.
Study authors also compared states' primary care physician supply with medical school enrollment in 2010. Michigan and New York, for example, reported a good number of M.D. and D.O. students per 10,000 people and a larger-than-median number of primary care physicians in practice.
Other states, including Missouri and Nebraska, were above the national median for medical students per capita but fell below the median for the number of primary care physicians per capita. And some states, such as Florida and Utah, didn't have sufficient numbers of medical students or practicing primary care physicians to serve the populations in those states.
When researchers looked at the rate at which graduates return to the states where they graduated from medical school to practice primary care, they found that retention rates varied widely -- from just 10 percent in New Hampshire to 67 percent in Wyoming.
Recommendations for Future Planning
Bazemore says he was not surprised that the expansion of medical schools did not correlate at the state level with primary care population ratio measures of need.
"Some would say expansion of training in the United States is driven as much by market and political forces as it is by demonstrated population need and effective policymaking," says Bazemore. "This is just one more piece of evidence that highlights the need for policy coordination if we're going to produce the physician workforce capable of serving in the medical specialties and locations of greatest need."
Bazemore suggests that the research findings could be useful in conversations between family physicians and their state legislators -- who are funding medical school expansion with state tax dollars -- about how to direct and allocate state resources most effectively.
The research team also asks policymakers to
- look at local and regional health care needs and study population growth, access to care and the geographic distribution of physicians before making decisions about medical school expansion;
- consider replicating the coordinated training model used by the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) program in which neighboring states share resources with the University of Washington School of Medicine in Seattle;
- implement policies that encourage primary care at medical school preadmission, admission, and curriculum levels, and prioritize the admission of students "with known intentions and characteristics conducive to choosing primary care"; and
- assess medical schools' success in turning out primary care physicians by following graduates five years after graduation.
Finally, the researchers call on state and federal stakeholders to learn from past mistakes, including the uneven manner in which medical school expansion occurred after warnings were raised a decade ago about physician shortages.
"When GME training slots are increased … we recommend that state and federal stakeholders find ways to coordinate expansion to meet societal needs for more equitable distribution of physicians according to specialty and geographic location," the authors conclude.
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