Correspondence

Health Care Reform and Graduate Medical Education

N Engl J Med 1994; 331:879-880September 29, 1994

Article

To the Editor:

President Clinton's proposal to decrease the total number of residency training positions in an effort to increase the ratio of generalists to specialists (discussed by Iglehart in the April 21 issue)1 makes little sense for a growing population with ever-increasing health care needs2. Such a plan will have catastrophic repercussions for a large segment of children, elderly people, and minorities in this country. Political rhetoric aside, the harsh reality is that by decreasing the number of residents today, the Clinton proposal virtually guarantees fewer physicians -- and further fragmentation of medical services -- in the future.

Teaching hospitals and their community outpatient clinics, located primarily in urban areas and staffed by resident physicians, provide front-line health care to the low-income population. Residents serve as the principal providers for this patient population and are often the only doctors with whom low-income people have contact.

We agree that a larger percentage of primary care physicians is needed, but we believe that, just as important, more subspecialists will be needed as our medical knowledge increases exponentially. We must therefore accommodate expansion in both realms.

As Iglehart states, 20 percent of house-staff positions are filled by graduates of foreign medical schools. This suggests that the United States is simply not producing enough doctors to meet the current demand. As our population grows, so too must American medical school enrollments3. More federally funded scholarships must be created for deserving minority students and others who agree to make a commitment to primary care specialties. Medical schools must revise their curricula to maximize student exposure to primary care issues. By increasing the number of residency positions, teaching programs can modify call schedules to make the primary care specialties more attractive to students. Similarly, the government can make low-interest loans available to clinicians who want to establish practices that serve the needs of the disadvantaged. The possibilities are legion, given the incentive. The alternative is a future in which the patient-to-doctor ratio is overwhelmingly disproportionate and those most in need of care have less access to medical services. To support this part of the Clinton plan is ultimately to ensure the denial of care to many people.

We invite President Clinton to spend time with us at a teaching hospital -- in the real world, in a white coat, without fanfare in the media -- and only then decide whether fewer doctors can truly accomplish the enormous service currently provided by resident physicians.

Lou Rawls
United Negro College Fund, Los Angeles, CA 90005

Robert F. Perry, M.D.
East Carolina University School of Medicine, Greenville, NC 27858

3 References

1. 1

   Iglehart JK. Health care reform and graduate medical education. N Engl J Med 1994;330:1167-1171
   Full Text | Web of Science | Medline

2. 2

   Council on Graduate Medical Education. Fourth report to Congress and the Department of Health and Human Services: recommendations to improve access to health care through physician workforce reform. Rockville, Md.: Health Resources and Services Administration, 1994.
   

3. 3

   Behrman RE. The field of pediatrics. In: Behrman RE, Kliegman RM, Nelson WE, Vaughan VC III, eds. Nelson textbook of pediatrics. 14th ed. Philadelphia: W.B. Saunders, 1992:3.
   

Author/Editor Response

Mr. Iglehart replies:

To the Editor: The physician-to-population ratio has increased dramatically over the past three decades. The increasing size of the physician work force has certainly contributed to the rise in total medical expenditures, but it has done little to improve access to health care among our poorest citizens. Despite a net entry of 150,000 newly educated doctors into practice over the past decade, the number of areas with a shortage of primary care physicians, and thus areas where Americans are without adequate access to primary care services, actually increased from 2110 in 1982 to 2271 in 1992, as Figure 1Figure 1Number of Health Professions Shortage Areas (HPSAs) and Number of Generalist Physicians Needed to Correct the Shortages in 1982, 1986, and 1992. shows1. Even in the nation's capital, primary care is woefully inadequate in the most impoverished neighborhoods, some of which are only a few miles from the White House2. The number of scholarships awarded by the National Health Service Corps to place primary care physicians in underserved areas plummeted from 2300 in 1979 to fewer than 200 in 1991.

Most of the health problems that most people, particularly children, face most of the time can be addressed by competently trained generalists. Although President Clinton's Health Security Act is dead, the administration's policy of encouraging the training of a large number of generalist physicians in appropriate community-based ambulatory care settings is very much alive. The policy recognizes that the development of a system in which there are many more ambulatory care-based generalist physicians will not occur overnight. Thus, the administration's reform proposal provides for a transitional period and offers sizable subsidies to hospitals to replace the inexpensive labor pool that resident physicians currently represent.

I certainly agree with Rawls and Perry that the composition of the physician work force must more closely reflect the needs of the population. In the Clinton plan, the participation of underrepresented minorities would be an important criterion in allocating positions in graduate medical education programs. In addition, special scholarships, loans, and other federal programs would assist minority students and institutions in meeting this goal.

John K. Iglehart

2 References

1. 1

   Council on Graduate Medical Education. Fourth report to Congress and the Department of Health and Human Services: recommendations to improve access to health care through physician workforce reform. Rockville, Md.: Health Resources and Services Administration, 1994.
   

2. 2

   Goldstein A. Many doctors in few places. Washington Post. July 31, 1994:1, 20.
   

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