Graduate Medical Education Must Extend Beyond the Coasts

Too many young physicians today are shunning the so-called “fly over” states as they launch their careers, leaving millions of Americans between Pennsylvania and California with inadequate access to physician care.

Later this month, the Institute of Medicine (IOM) is expected to release a study and set of recommendations on the health care workforce and graduate medical education. This study is the result of a letter sent by seven U.S. Senators to the IOM in December 2011 encouraging the Institute “to conduct an independent review of the governance and financing of our system of graduate medical education (GME).”

The Senators’ letter outlines a weighty set of recommendations and it is doubtful that the IOM report will make meaningful and definitive policy recommendations on all of them.  However, it is critical for the IOM to address two items raised in the letter – “…the use of GME to assure a future workforce possessing the skill set to effectively address current and future health care needs…” and “…the uneven distribution of GME funding across states…”

Coincidentally, just three percent of physicians in this country are trained in the five states (NM, AZ, CO, IA, ID) represented by the Senators on the letter. There is nothing inherently wrong with these five states in particular. In fact, 65% of physicians are trained in just 12 states according to the Association of American Medical Colleges (AAMC) Center for Workforce Studies.

The AAMC’s 2013 State Physician Workforce Data Book reveals several concerning trends in our nation’s physician workforce and graduate medical education system.  In 2011, there were 114,000 residents and fellows training in accredited programs in the 50 states, District of Columbia, and Puerto Rico.  It is important to note that this figure does not include those physicians in residency or fellowship programs accredited by the American Osteopathic Association.

The geographic distribution of these 114,000 physicians demonstrates why the Senators raised concerns about the maldistribution of GME positions in their request. Thirty-eight percent are trained in a state that touches the Atlantic Ocean (or gets really close – DC) and a mere 22% are trained in a state west of the Mississippi River.

These numbers reflect a very concerning clustering of GME programs – primarily along the Atlantic and Pacific seaboards.  Digging a little deeper, you also see that a disproportionate number of residents and fellows in those top 12 states are trained in Academic Health Centers (AHCs) – large institutions with multi-pronged missions.  Don’t get me wrong, these institutions are pillars of the American health care system that have led the world in the advancement of science and medicine.  What they haven’t done is lead the world in the production of a physician workforce that meets the needs of American citizens that pay the very taxes that finance their GME programs.

I am going to go out on a limb and suggest that AHCs, while excelling at many things, are falling embarrassingly short of training what the Senators’ letter describes as “a future workforce possessing the skill set to effectively address current and future health care needs.”

These two narratives – composition and distribution of the physician workforce – alone should prompt the IOM to act in a meaningful way.  Our nation’s investment in GME must result in a physician workforce better trained to meet “current and future” needs through a greater emphasis on training primary care physicians (family medicine, general internal medicine, pediatrics) and ensuring that there is geographic balance.

Please note that I did not say a singular emphasis on primary care, but rather a greater emphasis on primary care.  There needs to be a greater level of accountability in the GME system so that those receiving financing have some obligation to produce physicians that serve the health care needs of the population, not the financial needs of the host institution.

The simple fact that so many physicians are trained along the Atlantic should concern each of us due to a simple understanding in medical education circles that physicians will practice in close proximity to where they train.  A 2013 study conducted by the Robert Graham Center found that 56% of all family physicians practice within 100 miles of where they train.  39% will locate within 25 miles of their residency program and 19% will locate within 5 miles.  5 miles!

In other words, those cities and states that train a significant number of our nation’s physicians aren’t exporting them – they are keeping their talent close to home.

Let’s hope the IOM makes recommendations to better align our financial investment in GME with producing a physician workforce that is positioned to serve the health care needs of our population, shifts more physicians training into community hospitals, community health centers and other non-AHC sites and most importantly distributes more training positions into those pesky “fly-over” states.


Shawn Martin is the Vice President of Practice Advancement & Advocacy.

Morning Consult