Correspondence

The Case for More U.S. Medical Students

N Engl J Med 2000; 343:1573-1575November 23, 2000

Article

To the Editor:

In his thought-provoking Sounding Board article (July 20 issue)1 Mullan suggests that the number of U.S. medical schools and medical students be increased. By any combination of standard measures of health in developed countries, the United States ranks at or near the bottom of the list.2 Throwing more homegrown physicians and expensive medical schools into this malfunctioning system will have a miniscule effect on our overall health. We already far exceed any other society in terms of the cost of health care and the number of physicians per capita. Unfortunately, despite the advent of managed care, the market for new physicians in the United States remains almost insatiable.

The United States obviously benefits in many ways from the immigration of foreign-trained physicians, most of whom are highly motivated and outstanding. Those who stay in the United States or eventually return here add to our enviable reputation as an international medical melting pot. Many pursue careers in academic research that would be unavailable to them in their countries of origin. Those who return home often become medical leaders. I have little guilt about this so-called brain drain; frequently, the exchange benefits all parties.

Ferris M. Hall, M.D.
Beth Israel Deaconess Medical Center, Boston, MA 02215

2 References

1
Mullan F. The case for more U.S. medical students. N Engl J Med 2000;343:213-217
Full Text | Web of Science | Medline

2
Starfield B. Is US health really the best in the world? JAMA 2000;284:483-485
CrossRef | Web of Science | Medline

To the Editor:

I was astonished by Mullan's call to increase the number of medical students. The fact that the number of entry-level residency positions substantially exceeds the number of graduates of U.S. medical schools is not evidence of a mismatch between training capacity and the health needs of the population. Rather, it reflects two other phenomena: the reliance of teaching hospitals (at substantial expense to the public) on residents as cheap labor to staff inpatient services and the ability of the U.S. health care system to absorb additional practicing physicians. Despite the fact that many bright young people cannot get into medical school, Mullan's proposal for expanding their career opportunities carries a hefty price tag. Given issues such as the growing number of uninsured persons, the inadequate health care infrastructure in our inner cities and rural areas, and the high cost and limited benefit of expanding medical education, this item should be low on the list of national health priorities.

Anne L. Schwartz, Ph.D.
Grantmakers in Health, Washington, DC 20036

To the Editor:

There are a number of problems with Mullan's proposal. First, increasing the number of U.S. medical students would substantially increase costs and further decrease the pool of teachers and patients available for clinical training. Who would pay these extra costs, especially in these times when there is serious concern about the overall cost of health care and graduate medical education? In contrast, the cost of training graduates of foreign medical schools is borne by other countries.

Second, it is very difficult to get graduates of U.S. medical schools to enter residency programs or practice in underserved areas. Loan-forgiveness programs and other maneuvers clearly have not attracted substantial numbers of these graduates to apply to training programs or to practice in the inner city. In fact, recently, graduates of U.S. medical schools have been unable either to enter or to get paid by these programs. Therefore, graduates of foreign medical schools remain virtually the sole source of residents as well as practicing physicians in inner-city hospitals, facilities that are vital for the provision of health care to the poor.

Third, since there are many more applicants who are graduates of foreign medical schools than there are positions, programs that accept these graduates can recruit excellent, often superior, physicians, rather than the graduates of U.S. medical schools who are least able to compete. This point is reflected by the fact that scores on National In-Training examinations and rates of passage of board examinations in inner-city residency programs rival or even surpass those of residency programs in which graduates of U.S. medical schools predominate. In the face of such competition, it is not clear that expanding the pool of graduates of U.S. medical schools without restricting visas will lead to the placement of all such graduates in residency programs; some will be displaced by more talented graduates of foreign medical schools.

Fourth, each year, in many inner-city programs, a number of graduating residents who were educated at foreign medical schools go into practice either at their hospital or in the immediate underserved area. Others go to underserved areas outside the city. It is unclear whether graduates of U.S. medical schools will ever fill these slots.

Gerald Posner, M.D.
Eric A. Jaffe, M.D.
Interfaith Medical Center, Brooklyn, NY 11238

To the Editor:

A very important factor that Mullan does not consider is that physicians have no monopoly on the provision of medical care in the United States. Physicians' assistants and nurse practitioners are in direct competition with doctors for patients. As their numbers continue to grow and health care facilities continue to employ them, it will lessen the demand for new physicians, especially those in primary care.

Ashok Vaghjimal, M.D.
3201 Hargrove Rd. E., Tuscaloosa, AL 35405

Author/Editor Response

Dr. Mullan replies:

To the Editor: One can certainly agree with the concern of Hall about the cost of health care in the United States and the implied role of physicians in it. However, training more U.S. medical students would not increase the number of physicians in practice, since it is the number of residents rather than the number of medical students that determines the number of physicians who enter practice. Several European nations, in fact, surpass the United States in terms of the number of physicians per capita, and our physician-to-population ratio is stabilizing in the range of 270 per 100,000.1

Schwartz points out, quite accurately, that Medicare funds for graduate medical education underwrite the costs of residency training. The question that might fairly be asked is why a quarter of the trainees who benefit from these expenditures (approximately $6 billion in 1999) are graduates of foreign medical schools when thousands of young people in the United States with excellent qualifications are being denied opportunities to study medicine and benefit from this support.

Schwartz raises an important related matter by citing the “hefty price tag” associated with the cost of medical school education. Accounting practices related to the cost of medical education are so variable that little can be said with specificity about the real cost of educating a medical student.2 However, the national experiment that has been performed over the past 20 years, in which the osteopathic medical school community has succeeded in opening some 12 new medical schools and filling their classes on a tuition-driven basis, suggests that the costs of expanding opportunity in medicine are not prohibitive.

Posner and Jaffe are incorrect in stating that loan-forgiveness programs and other maneuvers have not attracted substantial numbers of graduates of U.S. medical schools to practice in the inner city. In fact, both the scholarship program and the loan-repayment program of the National Health Service Corps are substantially oversubscribed and underfunded. The issue is not the absence of U.S.-trained physicians who are willing to work in poor communities but the lack of political will to fully fund incentive programs for service in these communities. The growing willingness of the medical community and of U.S. policymakers to rely on medical education systems from abroad to train people to serve the poor of the United States is simply an abdication of responsibility.

Training more U.S. medical students would increase opportunities for young people in this country — especially members of minority groups — and would foster self-sufficiency in our system, so that we could continue to rely on the public budgets and medical schools of other countries to train a quarter of our physician workforce.

Fitzhugh Mullan, M.D.
, Bethesda, MD 20814

2 References

1
Organization for Economic Co-operation and Development (OECD). OECD health data 2000: a comparative analysis of 29 countries. II. Health care resources: health employment (CD-ROM).