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SCIENCE POLICY: ON THE PHYSICIAN-SUPPLY DEBATE

The following points are made by David Blumenthal (New Engl. J. Med. 2004 350:1780):

1) Just yesterday, it seems, the conventional wisdom was a confident prediction that we faced a worrisome surplus of physicians.(1-3) But today a swelling chorus of experts contends that we may face an equally worrisome shortage of physicians.(4,5) The shift has occurred suddenly enough to inflict cognitive whiplash on policymakers and physicians who have not been schooled in the arcane science of projecting the supply of and demand for physicians. Indeed, some observers may be tempted to conclude that assessing workforce needs is a fool's errand, one that is too technically difficult and too mired in controversy to be useful.

2) In some ways, the history of the physician-supply debate begins, like so much else in modern medicine, with the Flexner report, which was published in 1910. Implicit in this document was the conclusion that the US at the time had an oversupply of poorly trained physicians that had been produced by an unregulated, largely proprietary system of medical education. One effect of the revolution that resulted from the Flexner report was a decrease in the supply of physicians owing to the closing of medical schools that were considered educationally deficient. Between 1900 and 1930, the ratio of physicians to the population in the US fell from 173 per 100,000 to 125 per 100,000 as the medical establishment sought to produce "fewer but better doctors."

3) During the Depression and World War II, no major reassessment of the supply of physicians was conducted. A 1932 report by a commission on medical education concluded that the supply of physicians in the US was more than ample as compared with ratios of physicians to populations in Europe. There was some modest expansion in the number of physicians as medical schools were built in areas with growing populations. The number of medical school graduates had increased to levels that obtained before the Flexner report by the early 1930s and grew in parallel to the growth of the US population in the years from 1930 to 1960. However, after a long period of "professional birth control" in the early 20th century, these graduation rates were not sufficient to raise substantially the physician-to-population ratio, which totaled 140 per 100,000 in 1960.

4) The conventional wisdom with regard to the physician supply gradually changed after World War II. The change reflected a number of forces, including the expectations of a more affluent public, the growing demand for places in medical schools as the number of college graduates increased, and pressure from underserved rural and inner-city areas. In comparison with current ratios of applicants to acceptances of approximately 2:1 in 1950, acceptance to medical school was a herculean task. Only 1 of every 3.4 applicants was accepted. The American Medical Association (AMA), and even some medical school deans, stoutly resisted proposals to expand the number of medical school slots.

5) The tide turned, however, with the publication in 1959 of the report of the Surgeon General's Consultant Group on Medical Education (the Bane report), which predicted a shortage of approximately 40,000 physicians in the US by 1975. In Ludmerer's opinion, "The Bane report became the most influential and effectual report on medical education" since the Flexner report. The Kennedy and Johnson administrations responded in the 1960s by successfully championing legislation that subsidized medical schools to grow in number and size. Between 1965 and 1980, the number of medical schools increased from 88 to 126, and the annual number of graduates grew from 7409 to 15,135.

References (abridged):

1. Summary of third report: improving access to health care through physician workforce reform: directions for the 21st century. Washington, D.C.: Council on Graduate Medical Education, 1992.

2. Cooper RA. Perspectives on the physician workforce to the year 2020. JAMA 1995;274:1534-1543

3. Weiner JP. Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA 1994;272:222-230

4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21:140-154

5. Salsberg E. Physician workforce policy guidelines for the U.S. 2000-2020. Presented to the Council on Graduate Medical Education Meeting, Bethesda, Md., September 17-18, 2003

New Engl. J. Med. http://www.nejm.org

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ALARM OVER DECLINE IN NUMBER OF US PHYSICIAN-SCIENTISTS

Notes by ScienceWeek:

In general, the term "physician-scientist" refers to MDs who devote all or a majority of their professional effort to research concerning health and disease. The designation thus includes basic, disease-oriented, patient-oriented, population-oriented, and prevention-oriented investigators. In the US, there is apparently a current great concern about an evident "dangerous" decline in the number of physician-scientists.

The following points are made by Leon E. Rosenberg (Science 1999 283:331):

1) The decline is not a new problem, and was already discussed 20 years ago. The problem has been repeatedly discussed during the past 2 decades, particularly with respect to patient-oriented research.

2) The author suggests the problem must be addressed now for a number of reasons: a) The entire species of physician-scientist is apparently at risk, not only those doing patient-oriented research. b) Endangering physician-scientists endangers everyone concerned with medical research. c) The actions taken to date cannot solve the problem. d) The threat can be averted only by bold, concerted action on the part of all the participants in the US medical research enterprise.

3) The number of first-time MD applicants for National Institutes of Health (NIH) research project grants decreased 31 percent from 1994 to 1997. If this progression continues linearly, there will be zero applicants by 2003. (The drop in first-time MD applicants was not compensated by an increase in applications from MD/PhD applicants.)... The data indicate that progressively fewer young MDs are interested in (or perhaps prepared for) careers as independent NIH-supported investigators.

4) Since 1992, there has been a 51 percent decrease in the total number of MD postdoctoral trainees supported by NIH through individual fellowships and training grants. If this trend continues, there will be no MDs in this pool by 2006.

5) Recent data from the Howard Hughes Medical Institute (HHMI) indicate that in the past 2 years there has been a 57 percent decrease in the number of MDs applying for the prestigious HHMI postdoctoral fellowships.

6) In 1989, 14 percent of graduating medical students expressed a strong interest in research as a career; in 1996, the number was 10 percent. Concerning disincentives, the author points out that the debt burden for US medical school graduates now averages US$80,000, a debt difficult to manage via the modest stipends paid to postdoctoral trainees. The author concludes: "We must act now to create a national environment conducive to creating a new generation of physician-scientists who have been trained rigorously and are confident in their ability to compete and succeed. Above all, these young investigators must be imbued with the belief that their efforts are essential."

Science http://www.sciencemag.org

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ON THE EVOLUTION OF MEDICAL SCHOOL ADMISSIONS TESTING

The following points are made by William C. McGaghie (J. Am. Med. Assoc. 2002 288:1085):

1) The origins of the Medical College Admission Test (MCAT) coincide with the rise of scientific psychology and quantitative approaches to mental measurement in the late 19th and early 20th centuries. The intellectual foundation of this work has been traced to ideas of Charles Darwin (1809-1882) expressed in his _On the Origin of Species_ (first published in 1859) concerning individual variation and natural selection. Sir Francis Galton (1822-1911), Darwin's cousin, subsequently attempted to measure human variation in intellectual abilities using a variety of laboratory tests. At the turn of the 20th century Alfred Binet (1857-1911) and Theodore Simon created early versions of intelligence tests, while E. L. Thorndike (1874-1949) developed several achievement tests and interpreted their results, in part, using the Karl Pearson (1857-1936) newly developed correlation coefficient. Early individual tests of intelligence and school achievement were quickly adapted for group administration in service of efficiency and extensive use.(1)

2) The technology of intelligence and achievement testing of school children was soon applied to other educational and social measurement problems. Psychological historian Murray Levine(1) observes:

"It is likely that the experience in group testing in the schools before World War I prepared the way for the group intelligence tests developed by Army psychologists for the selection of officers and for screening out those who were intellectually inadequate for service. It was after the war that group tests came into wide use and became firmly entrenched in the schools and in our culture."

3) Scholastic aptitude has been defined as a fixed trait. Furthermore, there are individual differences in knowledge or skills that contribute to educational achievement. Scholastic aptitude emphasizes verbal, quantitative, and frequently subject-centered (eg, biology, chemistry, physics) knowledge and skill that enhance educational success. Operationally, academic aptitude is similar, if not identical, to common conceptions of intelligence. From their inception, intelligence, achievement, and aptitude tests have been judged by the extent to which, when given to a group, they yield a normal distribution of scores that clearly separates high, medium, and low performers. Reliable score differences allow for objective (scientific) norm-referenced selection, classification, or placement decisions about individuals.

4) In summary: The attrition rate of 5% to 50% from US medical schools in the 1920s propelled the development of a test that would measure aptitude for medical studies. Since its development in 1928, the Medical College Admission Test (MCAT) has undergone 5 revisions. The first version was divided into 6 to 8 subtests that focused on memory, knowledge of scientific terminology, reading and comprehension, and logic. The second, which appeared in 1946, was reduced to 4 categories: verbal and quantitative skills, science knowledge, and added a category called understanding modern society. The major difference in the third version, launched in 1962, expanded the test's understanding modern society section to a broader test of general information. In 1977, the MCAT underwent its fourth change: its science section, reading and quantitative skill assessment sections were expanded; its general liberal arts knowledge section was eliminated; its scoring report structure and scoring range were altered; and its cultural and social bias was minimized. The current version, beginning in 1991, has undergone another significant change. Although it does not contain independent measures of either liberal arts or numeracy as separate categories, quantitative skills are needed to solve some of the problems in biological and physical sciences. However, its principal innovation is the writing sample section. Through its 74-year history, the various renditions of the MCAT demonstrate that the definition of aptitude for medical education reflects the professional and social mores and values of the time.

References (abridged):

1. Monroe WS. An Introduction to the Theory of Educational Measurements. Boston, Mass: Houghton Mifflin; 1923. Cited by: Levine M. The academic achievement test. Am Psychol. 1976;31:228-238.

2. Barzansky B, Etzel SI. Educational programs in US medical schools. JAMA. 2001;286:1049-1055.

3. Flexner A. Medical Education in the United States and Canada. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910. Bulletin No. 4.

4. Ludmerer KM. Learning to Heal. Baltimore, Md: Johns Hopkins University Press; 1985.

5. Scholastic Aptitude Test for Medical Schools, Form 15, First Edition. 1941; Hollinger Box No. 1; IM Box No. 501982734. Located at: Association of American Medical Colleges.

J. Am. Med. Assoc. http://www.jama.com

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