http://www.consumerhealthjournal.com/articles/regulated-doctor-shortage.html
Regulated Medical School Admissions
Protects Doctor Shortage and High
Physician Salaries
February 2004
by Alison Stewart
Have you ever waited to see a doctor even though you were on time for
your appointment? Do you feel like doctors are doing you a favor by squeezing
you into their schedules? These may be symptoms of a physician shortage that
some say is regulated by doctors' organizations to maintain physician salaries and
limit competition.
From 1990 to 2000, the number of U.S. medical school graduates increased
2 percent, from about 15,400 to 15,700 graduates, according to the Association of
American Medical Colleges (source), though during the same period the U.S.
population increased 13 percent, according to census data. Although the number of
active doctors has increased due to factors like retirement rates, foreign and
osteopathic medical school graduates, American medical schools are not keeping
up with population growth.
"All we're doing right now is forcing a large number of people who want
to go to medical school to go to foreign medical schools," said Dr. Martin Litwin,
professor of surgery at the Tulane School of Medicine. "We now have a country
full of people who weren't trained in the United States," he said.
And this stagnation of the number of medical students is occurring at a
time of high demand for doctors, high physician salaries and skyrocketing medical
costs.
The median income for U.S. physicians, after expenses, was $160,000 in
1998, according to the Bureau of Labor Statistics. Compare this with other
lucrative professions that require post-college education: According to the Bureau
of Labor Statistics, the 2000 median lawyer salary was $88,000 and doctors of
Electrical Engineering earned a 2000 median of about $90,000, according to a
2001 National Association of Colleges and Employers survey.
These relative high salaries contribute to the ballooning cost of health
care. Average per capita health spending in 2001 was $5,035, according to the
Heartland Institute, while the median household income in 2001 was $42,200,
according to census information.
Economic principles say high prices and long waits can be lowered with
more supply. So why not graduate more physicians? According to census data, the
number of computer science graduate students at doctorate-granting schools
increased 24 percent between 1990 and 1999, to meet the needs of our
increasingly high-tech society. Why not more medical doctors to lower costs and
reduce waits?
One argument is the number of applicants is dropping. In 1992, there were
about 37,500 applicants. In 2001, there were only about 35,000 applicants.
"With our nation facing new health challenges and a possible physician
shortage, the apparent flagging interest in the medical profession, as reflected by
the shrinking applicant pool over the last several years, has been cause for some
concern," said AAMC president Dr. Jordan Cohen in an AAMC, October 30, 2002
press release.
"We are now at risk of reducing the quality of medical school grads if we
simply increase numbers and seek less well qualified applicants," said Dr. Steven
Gambert, professor of medicine at Johns Hopkins University School of Medicine.
"This is another reason to keep numbers smaller but quality higher."
But though there were fewer applicants to choose from, their quality was
higher, based on GPAs and MCAT test scores. In 2001, the mean MCAT scores
were higher than in 1992 (an average of 8.9 for the three sections, vs. a 1992
average of 8.2) and the mean applicant GPA rose from 3.24 to 3.45 from 1992 to
2001, according to data on the AAMC website. Even with the higher applicant
quality, only 47 percent were accepted, compared with 44 percent in 1992.
"Why aren't we building more medical schools and admitting more people
to medical school?" Litwin said.
There are 126 accredited medical schools in the U.S. There have been two
newly accredited schools since 1980: Mercer University School of Medicine in
Georgia, which received full accreditation in 1986, and Florida State University
College of Medicine, which received provisional accreditation in 2002. That’s an
annual increase of less than 0.1 percent, an order of magnitude smaller than the
U.S. population growth rate of about .9 percent, according to the 2002 CIA World
Factbook.
But "It's not as simple as a generalization about the U.S. population size
and lots of students generally wanting to enter the profession," said John Whiton,
manager of enrollment services for the AAMC.
One argument for why there aren't more new schools is that the costs are
prohibitive.
"It costs quite a bit to start a new medical school" said Dr. David Stevens,
vice president of the medical school standards and assessment for the AAMC, and
current secretary of the Liaison Committee on Medical Education, or LCME, the
group in charge of accrediting new medical schools.
Stevens said medical schools are different from other types of schools.
"It's a far more complex part of our society than a number of other disciplines so
it's not special, it just happens to be more complex," he said. "You as a taxpayer
have a much different view. You have a vested interest in that, both as a taxpayer
or a person who wants to attain medical care."
Stevens said there wasn‘t anything to stop someone from starting a new
medical school, but it was thought to be a bad investment. "[The costs are]
perceived to be roughly two-to-three times what tuition pays for, and that
additional income comes from state subsidies [and] from research grants," Stevens
said.
However, despite the costs, foreign schools that aren't regulated by the
LCME operate without U.S. governmental subsidy, though some argue the
schools' standards are not so high as U.S. schools.
Another key piece in explaining why the U.S. doesn't have more schools
or more medical students is that the medical school system is not entirely marketdriven, but is tightly regulated. U.S. medical schools are accredited by the LCME,
recognized by the U.S. department of Education as being qualified to make
judgments on the quality of potential and current medical programs. The LCME is
jointly run by the Association of American Medical Colleges, or AAMC, and the
American Medical Association, or AMA, organizations run by physicians.
When U.S. medical schools begin, they must be accredited by the LCME
and the schools decide, at that point, how many students they are equipped to
admit each year. And after a school is created, it needs to be continually surveyed
by the LCME. If it wants to expand, the expansion must be approved.
"If a school chooses to increase its class size and it doesn't have the
resources, they jeopardize their accreditation," said Dr. Frank Simon, director of
undergraduate and graduate medical education, policy and standards for the
AMA.
However, some drawbacks to this system, in which doctor-run
organizations control the accreditation process, were highlighted during the Ross
University School of Medicine's bid to open a campus in Casper, Wyoming.
Currently, states allow doctors educated in foreign countries to practice
medicine, so long as they pass the licensing exam and test of English. But no
foreign school has been allowed to create a campus in the United States. Ross
University, located on the Caribbean island of Dominica, saw an opportunity in
Wyoming because there is no medical school in the state.
Outside the medical community, there was support for a medical school
that would graduate doctors into the region.
The governor at the time, Jim Geringer, wrote in a 1999 statement of
support for Ross, "The teaching facility proposed by Ross University in Casper
has my continuing support. The efforts by all involved should continue to focus on
the benefits that would come to Wyoming's economy and to the health capacity of
the nation."
And the Casper Area Economic Development Alliance was excited about
a Ross school in Wyoming, said CAEDA Vice President Liz Becher. "Our
economic development group was very much supportive because of the workforce
training [and] jobs that could be created," Becher said.
However, many in the medical community resisted, arguing that schools
not accredited by the LCME were not up to standard.
"The criteria to get into the school is a check that won't bounce," said
Casper surgeon Dr. Jerry Behrens, in Elisabeth A. Wright's 1999 article, "Why
can't Wyoming get its own med school?"
The Natrona County Medical Society, the area medical group, opposed
Ross and played a role in Ross's eventual failure to establish a Wyoming campus.
"The reservations had to do with accreditation," said Lynne Whalen,
executive director of the NCMS. "All American medical schools are accredited.
It's a quality check on the physicians that practice in the country," she said.
Eventually, Ross withdrew its bid and Wyoming still does not have a
medical school. A variety of explanations have been given to why the school
failed to create a campus.
"Ross wasn't accredited in Wyoming because they didn't apply," said
Nicole Buckley, media relations officer to the AAMC.
But George Howley, the 1999 director of CAEDA, saw it differently. In
Wright's article, he said doctors are opposed to the potential competition, not to
the supposed risk of lower-quality care. "To protect the income to the doctors is
what it is," he said.