U.S. medical school enrollment has increased by 31% since 2002, according to Results of the 2018 Medical School Enrollment Survey, a new AAMC report. Combined with first-year matriculation at osteopathic schools, medical student enrollment is now 52% higher than in 2002-03.
In response to concerns that a projected doctor shortage could impact patient care, the AAMC in 2006 called on medical schools to increase first-year enrollment by 30%. That target was reached in 2018-19, when first-year matriculation reached 21,622 students. Osteopathic schools increased their enrollment by 164% during this same time period, with 8,124 first-year students enrolled.
“From a supply side perspective, what we really need to focus on now is the residency slots. The federal government needs to resume covering its fair share of the costs. That starts by lifting the caps.”
Atul Grover, MD, PhD
AAMC executive vice president
“From a supply side perspective, what we really need to focus on now is the residency slots,” says Atul Grover, MD, PhD, executive vice president of the AAMC. “We’ve done everything we can on the medical school front to reduce the physician shortage, and I think the numbers bear that out. The federal government needs to resume covering its fair share of the costs. That starts by lifting the caps.”
Residency training positions have expanded at a rate of just 1% a year, due in large part to a congressional cap on federal funding in the Balanced Budget Act of 1997. Most of the costs of residency training — about $171,855 per year, per resident on average, according to AAMC data — are supported by teaching hospitals and their faculty. Medicare (U.S. Department of Health and Human Services) has historically paid for 21% of the training. However, that support has been largely frozen since 1997. A house bill introduced in March – the Resident Physician Shortage Reduction Act of 2019 (H.R. 1763) – would add up to 15,000 Medicare-funded residency positions over five years, similar to an AHA-supported bill introduced in April in the Senate.
Concerns about residencies
The AAMC administered the 15th annual Survey of Medical School Enrollment Plans in November 2018 to the deans of 151 accredited U.S. medical schools. In the survey, 44% of deans voiced concerns about their students’ ability to find residencies. Sixty-eight percent of deans voiced concerns about available residency slots in their states, and 75% were concerned about residencies nationally.
A shortage of residency positions ultimately has a big impact on the doctor shortage, Grover says. “We have concerns in the long run about the slow growth in residency positions because we need more doctors,” he says. “That’s the bigger issue.”
A 2019 study conducted for the AAMC by IHS Markit predicts that the United States will face a shortage of between 46,900 and 121,900 physicians by 2032.
“I’m really very proud of what our medical schools have done to expand enrollment and, at the same time, looked for ways to make care more efficient,” says Karen Fisher, JD, AAMC chief public policy officer. “But we need more graduate medical education (GME) slots because we need more physicians. We just don’t have enough to be able to produce the number of physicians to deal with the projected shortage.”
Competition for clerkship sites
A shortage of residency slots is not the only concern raised by the survey. Deans also are worried about the dearth of clinical training sites for clerkships and rotations. As enrollment of students across the health professions expands to meet the health care needs of a growing and aging population, schools are finding it harder to find high-quality sites for education across their communities.
According to the survey, 85% of respondents were concerned about the number of training sites, while 88% were worried about the supply of qualified preceptors.
“As our medical schools have expanded, they need more training opportunities for students,” Grover says. “Everyone is competing for the same clerkship sites. It’s certainly something we hear more and more about all the time.”
The survey found that 46% of respondents felt moderate to severe pressure to pay for training slots. However, 53% of schools do not do so. The top three specialties that see the biggest shortages in training spots are obstetrics and gynecology at 55%, pediatrics at 52%, and family medicine at 47%.
Possible solutions
Though concerns about the availability of residencies and clinical training sites are rising, schools are trying to offset some of the negative effects.
On the residency front, there are a few options, according to John Prescott, MD, AAMC chief academic officer.
The ideal solution, he says, includes more federal funding for physician training as well as increased efficiency in care. Teaching hospitals are actively pursuing new models of team care and greater use of technology, and are supporting nearly 15,000 residency positions over their ‘caps’ without any federal support. They are also working with hospitals that have never been teaching hospitals to establish new residency training programs, he says.
“We know that there are benefits to having learners in our practice plans and hospitals,” Prescott says. “If you’re a family medicine doctor and you have residents and students working with you in clinic, you’re constantly being asked about ways to treat patients more effectively. The residents force all of us to continually learn and improve.”
“We know that there are benefits to having learners in our practice plans and hospitals. The residents force all of us to continually learn and improve.”
John Prescott, MD
AAMC Chief Academic Officer
The lack of clinical training sites for third- and fourth-year students, though, continues to be a challenge. “Within our academic health centers, we can often ensure that we have faculty and patients to maintain the highest educational standards,” Prescott says. “However, we also want to ensure high-quality experiences across the community — in outpatient clinics, homes, and other settings. Finding and supporting voluntary clinical faculty can be a significant challenge.”
Prescott says it would help schools to enter multiyear agreements with clinical training sites rather than doing it on a year-by-year basis.
“They’re looking for a more long-term commitment,” Prescott says. “Long-term agreements provide some needed stability for medical schools and medical educators. And we believe the learners continue to add to the quality of care provided throughout our community. Affiliation with a medical school is a sign of excellence.”