May 1, 2011

Treating the healthcare crisis by increasing medical school enrollment

AUTHOR: Adam E. M. Eltorai

Caring for the sick is not only a responsibility that we share as people of one nation but a moral issue. The millions of Americans who are uninsured, under-insured, or who have to declare bankruptcy due to medical expenses are a growing reminder of the distorted healthcare system that has evolved in our country. The ever-rising costs of insurance, the mounting healthcare costs burdening employers, the denial of coverage for pre-existing conditions, as well as the lack or portability of existing coverage are all due to the “money-driven” political influence of the health insurance industry, for-profit hospitals, and the pharmaceutical industry. After decades of discussion in Washington, insufficient healthcare reform legislative changes have occurred. Without fundamental reform, the collective health of the American public suffers.

The healthcare crisis is exacerbated by an increasingly severe primary care physician and nursing shortages. Even if more individuals are covered by insurance, there will be too few physicians to provide the necessary primary care. Insuring more patients but not increasing the number of physicians will result in higher service demands and longer patient waiting periods.

Looking at the grossest measure of national health, life expectancy, people in Switzerland, South Korea, Iceland, Belgium, Greece, Italy, France, Germany, Spain, Sweden, Finland, Netherlands, and Ireland are living longer than us because they have more practicing physicians per capita.

Today, 30 million people live in areas deemed to have too few physicians, according to the American Association of Medical Colleges (AAMC). The U.S. only trains about 27,000 new doctors per year. Consequently, the AAMC says that by 2025, the U.S. will be facing a shortage of as many as 150,000 physicians.

A particularly worrisome trend is the shortage of primary care physicians. The U.S. is already in need of an additional 16,000 primary care physicians, according to the U.S. Department of Health and Human Services. This need of additional primary care physicians is expected to grow to 45,000 by 2020, according to the AAMC. However, fewer medical school graduates are entering primary care. Between 2002 and 2007, there was a 25% decrease in the number of medical school graduates opting for careers in family medicine. As the healthcare gatekeepers, too few primary care doctors may result in increased patient waiting periods and altogether decreased healthcare access. Compared to other developed nations, the percentage of primary care physicians in the U.S. is significantly lower.

The physician shortage is even more troublesome given America’s changing demographics. The American Medical Association (AMA) noted that the U.S. population grew by 31% from 1980 to 2003. In addition to growing in number, the U.S. population is aging. The baby-boomer generation is approaching an age of increased health demands. Older individuals are more likely to have more chronic and complex ailments, requiring more involved treatment, operations, and hospital visits. By 2025, the number of people older than 65 is expected to increase by approximately 75%—37 to 64 million.

As the population ages, so do the physicians. The AMA says that two-thirds of all practicing physicians (about 800,000 today) are of the baby-boomer generation or older. The remaining one-third of practicing physicians, ages 27 to 41, possess different work habits. The younger generation of physicians increasingly prioritizes quality of life. Some of these physicians work less and are not as willing to see as many patients at the expense of their personal lives.

A direct approach to drive down the cost of healthcare, to decrease appointment waiting times, and to increase the opportunities for access to healthcare, is to increase the number of practicing physicians. More physicians would mean more competition. More competition would mean lower costs of care. Lower costs would enable more people to pay for healthcare. Poorer Americans would be more inclined to visit the doctor when their health problems are preventable or treatable, rather than waiting until the last, most expensive moment to visit the emergency room.

In the U.S., there is an obvious bottleneck when it comes to producing physicians: medical school enrollment. In 1980, the AAMC expected there to be a surplus of physicians, so a policy of capping medical school enrollment was enacted. Since then, the need for physicians has surpassed the number of physicians being admitted to medical school.

Unlike entrenched special interest groups (i.e. pharmaceutical or healthcare insurance industries) which have profound financial clout over members of congress, medical schools are relatively autonomous and therefore can offer a potential avenue for effective change.

Although some medical schools are catching on to the idea of increasing enrollment, the increased class sizes have not been large enough. Over 40 thousand students apply to medical school every year and less than half are offered admission. According to the AAMC, in fall 2009, only 18,000 students entered U.S. medical schools. Most medical schools have class sizes of less than 200 students. Many medical schools consist of classes of less than 100 students. Several schools have only 40 students per class.

Why are class sizes so small? Smaller class sizes mean that acceptance rates are lower (in some cases, less than 3%). Lower acceptance rates mean the school appears to be more selective. Being perceived as a highly selective institution is good for business. Selectivity can easily be mistaken for quality of patient care.

These incredibly low acceptance rates results in a peculiar and worrisome sociological side effect. Such medical school admissions selectivity produces applicants who become blinded by their desire to actually gain admission that they lose sight of the purpose of medicine: to help those in need. The medical school admissions process is becoming so focused on relatively arbitrary “measures of quality” (i.e. high GPA and MCAT scores) that they are losing sight of essential qualities of good healers. I am concerned that the medical school admissions process is selecting for increasingly neurotic nerds, who may lack the essential human qualities of empathy and compassion of great physicians.

The U.S. has the capacity to train more physicians. Each year, residency spots go unfilled. American residency programs can and should train more U.S. medical school graduates. According to the AMA, nearly 40 percent of the medical students entering U.S. residency programs were foreign medical school graduates. Many of these foreign medical school graduates return to their home countries after being trained in the U.S., thus not helping with the physician shortage in the U.S. Increasing U.S. medical school enrollment and therefore resident physicians who are more likely to practice in the U.S. may help alleviate the physician shortage.

To further increase the total number of practicing physicians, the number residency training slots should also be increased. Residency programs are funded by Medicare. This funding accounts for less than 1% of all Medicare expenses. Increased residency slots can be achieved by increasing this funding.

Although a worthy long-term goal, increasing the total number of residency training slots in the U.S. will have to overcome significant financial and bureaucratic obstacles. In the mean time, increasing the number of U.S. medical school graduates entering U.S. residency programs may provide a more immediate solution.

Furthermore, I propose that increasing medical school enrollment will have another particularly important consequence. Larger medical school class sizes will allow medical schools to lower their tuition costs per individual. Lower tuition will result in decreased medical student debt. Some medical schools’ tuitions are $50,000 per year for four years. Many physicians begin practicing with several hundred thousands of dollars debt. Consequently, students are more inclined to choose higher paying, procedural-based specialties. In other words, medical school graduates cannot afford to go into lower-paying primary care positions. Smaller debt burdens from decreased tuition rates would allow more medical school graduates to enter primary care.

With more primary care practitioners, the national focus can shift more towards prevention rather than more costly treatments. More primary care physicians will reduce the need for more expensive emergency room visits.

Simply increasing medical school enrollment with well qualified students promises to have a significant effect on the number of practicing physicians, improved access to primary care, lower cost of health care, and therefore the health of the nation.

About the Author: Adam E.M. Eltorai is the author of the book "The Pre-Med Bible"