By Shana F. Sandberg, Ph.D, Research Writer, Center for Workforce Studies, Association of American Medical Colleges
In a commencement speech addressed to the graduating class of Brown Medical School published in his most recent book, To Repair the World, anthropologist-physician Paul Farmer poses a series of questions to his audience of freshly-minted MDs. The fourth, and last, is “what will be the yardstick by which we gauge our success as a profession?” (2013:17).
Farmer’s question to those about to embark on graduate medical education (GME, more commonly known as residency training) came to mind as I read two research reports to appear in an upcoming issue of Academic Medicine. Both articles affirm the need to train large numbers of residents in light of projected physician shortages, which are expected to grow worse with the expansion of insurance coverage under the Affordable Care Act. They also underscore the point that merely training more physicians without attention to specialty choice and practice location will not necessarily succeed in bringing medical care to underserved populations.
Norman H. Edelman and colleagues report the results of a survey of ACGME sponsoring teaching hospitals in New York State about whether and how they plan to expand GME core residencies under different funding scenarios. They found that, in the absence of additional funding for GME, less than a quarter of institutions surveyed were planning to add new positions to existing programs. A few institutions were contemplating downsizing or even eliminating existing residency programs. If additional funding were available, on the other hand, nearly half would add additional residency positions. As the authors point out, these findings have implications for training sufficient numbers of physicians to serve growing health care needs.
Edelman et al. also found that hospitals differ in which programs they would choose to add or expand, tending to favor hospital-based fields such as emergency medicine that produce residents of value to the institution. Candice Chen and colleagues propose an alternate goal for evaluating outcomes of GME training—namely, tracking where and in what fields graduates go on to practice. Although the authors focus on just a couple out of a multitude of possible outcomes of GME programs, their analysis shows that it is possible to calculate key outcome measures, such as the percentage of graduates who practice in primary care or general surgery, or who practice in rural areas, Health Professional Shortage Areas (HPSAs) or Federally Qualified Health Centers (FQHC). They suggest that this information could be used to put in place training policies that could help solve problems of misdistribution or address shortages.
While attention to workforce needs is important, Chen and all do not seem to acknowledge that medical schools have diverse missions that may benefit society in different ways. For example, while the authors include psychiatry and obstetrics-gynecology among the specialties they track, they do not include other specialties further afield from primary care. Yet there is growing evidence that shortages are emerging in a number of non-primary care fields so that the shortage of specialists will nearly equal the shortage of primary care physicians by 2025. Some of the specialty fields in which a robust workforce will be critical to caring for an aging national population that increasingly suffers from chronic conditions include cardiology, critical care, diagnostic radiology, neurology, and oncology. In addition, demand for pediatric subspecialists often exceeds supply, especially in poor and rural areas. Caring for vulnerable populations in the years to come will require a robust workforce that consists of both primary care physicians as well as specialists—and increasingly, will necessitate that generalists and specialists are trained to work together to improve the health of all.
In the closing of his commencement address, Farmer answers his own question about yardsticks, issuing a call to the future physician workforce. He urges the generation of young physicians graduating that day to make their mark in medicine, to “shape the profession so that there’s commitment to equitable service in the face of growing inequalities of outcome,” and to maintain “humility and resolve in the face of bold technological advances” (2013:18). “For science and technology will and should be the heart of modern medicine,” he continues later, “but you must add the soul” (2013:19).
Farmer’s words remind us to remain mindful of the needs of all the medically underserved in contemplating our future workforce needs.
Famer P. To Repair the World: Paul Farmer Speaks to the Next Generation. Berkeley: University of California Press; 2013.