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July 03, 2013 12:10 PM The Association of American Medical Colleges Responds to Phillip Longman’s “First Teach No Harm”

By Atul Grover

The AAMC is very disappointed that Mr. Longman did not contact the AAMC for information or comment when he was writing his article. We are writing to clarify a number of important points that his article fails to reflect.

- The AAMC supports an increase in both the number of primary care physicians and the number of specialist physicians. Our most recent policy position on the physician workforce calls for an increase in 4,000 federally supported residency training positions, divided equally between primary care and specialty physicians.

- The need for increasing the number of primary care and specialty physicians has been documented by both the AAMC Center for Workforce Studies and the Health Resources and Services Administration (HRSA). According to AAMC projections, the doctor shortage is nearly evenly split between primary care physicians (45,000) and specialists (46,000). In a 2008 analysis, HRSA also projected a growing shortage across the entire physician workforce, with a shortfall of 35,000 surgeons and 27,000 medical specialists by 2020. Additional primary care providers are essential, but this nation cannot ignore the need for oncologists, endocrinologists, trauma surgeons, neurologists and other specialists who will need to provide care for the more than 10,000 baby boomers who will turn 65 every day for the next 10 years.

- Approximately half (or 13,000) of first-year residency training positions are in primary care disciplines (family medicine, internal medicine, and pediatrics). Another 5,000 out of the 26,000 are in psychiatry, emergency medicine, general surgery, and obstetrics/gynecology - specialties that also provide some “primary care.” While many residents will subspecialize, the number of subspecialty (or fellowship) training positions accounts for approximately 20 percent of all available graduate medical education slots. Even the largest internal medicine subspecialty, cardiology, trains fewer than 1,000 physicians a year; nationwide, fewer than 500 oncologists are trained annually. These are relatively small numbers of physicians to care for our nation’s growing and aging population The AAMC believes that attempting to increase physicians in targeted specialties by reducing training of other specialists would jeopardize timely access to care for patients who require a particular type of physician.

- Also driving the need for additional specialists is our success in developing new therapies and treatments at medical schools and teaching hospitals. Children with acute leukemia now live to be adults with heart disease and often live long lives with multiple chronic illnesses that are no longer fatal thanks to research supported by the National Institutes of Health and academic medical centers. Often, this research is led by physician-scientists who have subspecialized.

- In citing the amount of federal support provided to teaching hospitals, Mr. Longman counts funds that help support the highly specialized and complex care only teaching hospitals can provide, not just funds that help support physician training. Teaching hospitals provide life-saving care 24 hours a day, 365 days a year in Level 1 trauma centers, burn care units, and transplant facilities. As we saw recently in the response to the Boston Marathon bombing, teaching hospitals are ready and able to respond to any disaster, man-made or natural, as well as to provide care to patients when no one else can - or will - treat them. What’s more, these institutions provide this care in teams of health professionals while conducting research to improve and enhance patient care, making teaching hospitals an excellent environment in which to train the nation’s health care workforce.

- Medical schools, including some of the institutions mentioned in Mr. Longman’s article, have created new programs to encourage primary care practice. Institutions such as Johns Hopkins have created urban health primary care tracks for residents that emphasize training in community-based settings. Columbia University College of Physicians and Surgeons in New York and other institutions have created rural medicine programs to boost primary care practices in small-town settings. Research-intensive institutions, including University of Maryland School of Medicine, Duke University School of Medicine, and University of California, San Francisco, have built primary care tracks to encourage students to enter family medicine. And two new medical schools, Texas Tech School of Medicine and Mercer University School of Medicine, offer three-year programs in primary care that make it possible for medical students to leave school with less debt and enter practice more quickly.

While medical schools have increased enrollment to help alleviate some of the looming doctor shortage, these efforts will not translate into a single additional doctor unless Congress lifts the cap on residency programs. Pitting one specialty or health profession against another is not going to help our communities get the care they need. The magnitude of the health care workforce shortages facing our nation means that good health care in the future will require a team approach in which physicians and other health professionals, including nurses, nurse practitioners, physician assistants, and others all work together to care for patients and keep them healthy. Meeting the needs of a growing and aging population means training more primary care physicians, as well as surgeons, oncologists, neurologists, and other specialists. It is not an either/or proposition.

Atul Grover , M.D. Ph.D., is the Chief Public Policy Officer of the Association of American Medical Colleges.

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