Expanding the US medical workforce: global perspectives and parallels

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Abstract
US workforce supplyThe supply of US doctors has grown faster than the patient population for many decades (fig 1⇓). The proportion of doctors that are generalists has been falling fast. The ever growing importance of specialists in the US, and the plummeting popularity of primary care among new medical graduates has been understandably disquieting to the primary care specialty societies.6 7View larger version: In this window In a new window Fig 1 Actual and forecasted US non-trainee doctors (MD and DO degrees) per 100 000 population, 1975-2015 (American Medical Association, American Osteopathic Association, 2006).4 Primary care includes family physicians, general internal medicine, and paediatricsThe pipeline for new American medical practitioners is multifaceted (box 1). Although the output of programmes training medical doctors has been level over the past few decades, schools training nurse practitioners, physicians assistants, and doctors of osteopathy (a uniquely American qualification) have grown exponentially.US clinicians Medical doctor (MD)—The degree takes four years of medical training after graduating from a four year baccalaureate. About 17 000 MD students entered medical school last year. There are currently about 800 000 trained MDs working in the US Doctor of osteopathy (DO)—A physician trained equivalently to an MD, although originally based on a more holistic approach involving osteopathic manipulation. The US has around 50 000 trained DOs, and about 3800 entered osteopathy school last year Nurse practitioner—Requires 1-3 years of training after obtaining registered nurse certification (which requires 3-4 years of training). 85% of nurse practitioners provide primary care. Around 70 000 are currently working in the US and 6500 graduate annually Physicians assistant—A quasi-independent clinical practitioner who, with minimal supervision (from a doctor), can offer both primary and specialised clinical services including prescriptions. The training is generally four years at the baccalaureate level. Many courses were developed in close alliance with medical schools. About half of physician assistants practise in specialty areas and half in primary care. There are around 50 000 currently working, and 4600 graduate each year Of the roughly 35 000 new clinical trainees who entered practice in 2006, less than half (43%) had a MD degree from the US; about 8% were osteopathic doctors, 32% were nurse practitioners or physician assistants, and 17% were doctors who trained outside the US. Currently more than 100 000 nurse practitioners and physician assistants are practising in the US. If these non-doctors are added into the mix, the number of clinicians per population increases by around 15% (from 240/100 000 to 277/100 000 in 2005).8This unabated non-MD growth is, some believe, a major unspoken reason for the AAMC's call for expansion. In its doctor oriented analysis, the association (which represents only schools that grant MD degrees) does not explicitly consider the potential of these clinical trainees to do some of the work of medical doctors or whether expanding their numbers would be more cost effective than training more doctors.The issue of international medical graduates is controversial. The US has long been a magnet for all types of well educated immigrants, including doctors. Today about 25% of all practising doctors in the US were trained abroad, and international graduates fill about the same proportion of postgraduate (residency) training slots. Calls are also growing for reassessment of the role of international graduates, not (overtly at least) because of protectionism or quality concerns but because of the ethical considerations of a global “brain drain.”9 10Many parties believe that allowing the US to become more self sufficient is a valid reason to support the expansion of home grown doctors.9 However, without a comprehensive overhaul of medical and general immigration policy, more US trainees would not necessarily decrease the brain drain from developing nations. Moreover, if the larger number of US medical school graduates is to translate into more practising clinicians down the road, the number of postgraduate residency positions must increase concomitantly. Otherwise the expanded pool of US graduates will displace the large cohort of international graduates now in these positions and there would be no net gain of doctors.