NUMB cian Workforce and Future Challenges

There is much debate about the adequacy of the U.S. physician workforce and projections of its future size, distribution and composition. Beginning with 3 observations about the workforce we believe are largely not subject to dispute, we address the debate by providing an overview of the current state of the workforce and Graduate Medical Education in the United States; a brief history of both calls for graduate medical education reform since 1910 and the recent, intense debate about the reliability of workforce projections; and a discussion of the challenges to understanding the physician workforce. We draw 3 concluding observations: (1) Precisely because projections can be unpredictable in their impact on both physician workforce behavior and public policy development, policy makers need to devote more attention to workforce projections, not less. (2) More research devoted specifically to the workforce implications of delivery and payment reforms is strongly needed. (3) Such research must be pursued with a sense of urgency, given the rapid aging of the Baby Boom generation, which will put a disproportionate demand on the nation's physician workforce. Key Indexing Terms: Physician workforce; Graduate Medical Education; Public policy; Health policy; Medicare. [Am J Med Sci 2016;351(1):11–19.] There is much debate about the adequacy of the U.S. physician workforce. U.S. medical education, training, and healthcare delivery are referred to as: (1) the envy of the world, or (2) out-of-date and out-oftune with the needs of the nation and the reality of the market place, or (3) some combination of both. To address these conflicting views, we discuss the status of the nation's physician workforce, a brief history of calls for change affecting the physician workforce that have occurred for more than a century, the current workforce debate, and challenges facing the future physician workforce. We begin with 3 observations we believe are generally not subject to dispute: First, since the late 1800s, the U.S. physician workforce has continually evolved in response to a never ending series of social, economic, technological, demographic, and medical challenges that again and again have changed healthcare overall. This paper speaks to challenges facing U.S. healthcare posed by an ongoing national debate over whether we are collectively at risk of a serious physician workforce shortage within the next decade. The nature of these challenges may change over time, but the fact of change itself is an enduring reality. Second, U.S. healthcare and medical education have undergone numerous significant changes for more than a century. Still, the U.S. model of undergraduate medical education and graduate medical education (GME) remains primarily led by universities and teaching hospitals as recommended by the 1910 Flexner report. U.S. medical education is focused in its early years on rigorous, graduate level academic studies organized for NAL OF THE MEDICAL SCIENCES Copyright © 201 Inc. All rights reserved. ER 1 January 2016 www.amjmedsci.com ww the most part by university-affiliated medical schools, and it is focused in the later years on hands-on training in the care of a broad spectrum of patients in a variety of largely university hospital-related or other clinical settings, including primary care and other ambulatory care settings. Training is overseen by more senior medical faculty who often bridge the missions of care, education, and research. In the view of some academic leaders, today's GME programs take insufficient advantage of the academic setting for training physicians to become “scientific practitioners,” expert in “how to approach patients in a rigorous scientific way,” which was at the heart of the model of medical education Abraham Flexner championed. However, other leaders' concern about a lack of sufficient emphasis on primary and preventive care causes them to promote the need for more training in sites outside the university medical centers settings, even as ambulatory site training has become a common part of GME programs. Neither perspective precludes the other. No one would disagree with the view that modern medical education must produce physicians who are “critical thinkers” in the fast-changing worlds of both academic and non-academic medicine. Third, a distinguishing attribute of the U.S. physician workforce is that it relies in part on the collective result of individual physicians' personal choices to fulfill the nation's physician workforce needs. Their choices about where and what to study, to train, and to practice shape our physician workforce decade after decade far more than any single government dictate or incentive. 6 Southern Society for Clinical Investigation.