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Squeeze Looms for Doctors

More Med Students In the Pipeline, but Too Few Residencies Await Them

 U.S. medical schools are expanding to meet an expected need for more doctors due to the federal health law. With at least 12 new schools opening and existing ones growing, enrollment is on track to produce 5,000 more graduates a year by 2019.

But medical educators are cautioning that those efforts won't do anything to alleviate a doctor shortage unless the number of medical residency positions rises as well. The number of federally funded residencies has been frozen since 1997.

Residencies are the three to seven years of on-the-job training in the U.S. that medical-school graduates must complete before they can practice independently in this country. Medicare funds most of the residencies, paying $9.5 billion a year to subsidize 94,000 positions at teaching hospitals. Medicaid and other sources such as hospitals fund about 10,000 more.
Medicare-funded spots were frozen under the Balanced Budget Act of 1997, and numerous bills to lift the cap have stagnated in Congress amid budget-cutting concerns, including proposals to slash Medicare funding for doctor training.

On Thursday, Reps. Allyson Schwartz (D., Pa.) and Aaron Schock (R., Ill.) plan to reintroduce a bill seeking 15,000 more U.S.-funded residencies over the next five years, at a cost of about $1 billion a year—a measure likely to face an uphill climb. "This has to be part of the conversation," Ms. Schwartz said.
The American Medical Association and other physician groups arguing for the increase say health-care needs have changed markedly since 1997. For one thing, the U.S. population has grown by 50 million people.
The population also is aging: Every eight seconds, another Baby Boomer turns 65, an age when health problems typically increase. And starting next year, 30 million more Americans will have access to health insurance under the Affordable Care Act.
All told, the Association of American Medical Colleges predicts the U.S. will face a shortage of 62,900 doctors by 2015 and as many as 140,000 by 2025.
"We thought we were being responsible by having our medical schools expand to address the doctor shortage, but the federal government has to do its share, too," said Atul Grover, the chief public policy officer of the medical-college group.
As of now, there are more residency openings than doctors graduating from U.S. medical schools, as has been the case for many years. The gap traditionally has been filled by graduates of U.S. osteopathic schools (which stress holistic and preventive medicine) and foreign medical schools, including doctors hoping to immigrate to the U.S. and Americans who attend medical programs abroad.
At the current expansion rate, graduates from U.S. medical and osteopathic schools alone will exceed the number of expected residencies by the end of the decade, the Association of American Medical Colleges predicts.
Residency applicants from foreign schools are likely to be squeezed out, medical educators say, which could make it more difficult to fill the nation's growing needs in primary care, which includes internal medicine, family medicine and pediatrics.
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Graduates of foreign medical schools now make up more than 25% of all U.S. practicing physicians—and about half of primary-care doctors—because U.S. graduates tend to prefer more lucrative specialties.
Foreign doctors also make up a disproportionate share of those in rural communities, in part because such work can qualify them for certain visa waivers.
"If we don't add more residencies, we are just replacing the international graduates with U.S. graduates, not creating any more doctors," said Patrick Dowling, the chairman of family medicine at the University of California, Los Angeles.
Noting that 38% of Californians are Hispanic, but only 5% of its physicians are, Dr. Dowling co-founded a UCLA program to help Spanish-speaking immigrants who had been doctors back home qualify for U.S. residencies. One participant, Marcos Uribe, is among those hoping for a residency in the annual residency "match" on Friday. The 31-year-old earned his medical degree in Mexico, before moving to the Los Angeles area in 2007.
Dr. Uribe laid bricks and poured concrete by day while studying for the required U.S. licensing exams at night. Now he hopes to land a residency in family medicine in Riverside, Calif., where Spanish-speaking doctors are in short supply.
"It's very competitive—there are people from all over the world trying to be doctors here," Dr. Uribe said.
Some experts argue that rather than fund additional residencies, Medicare should find ways to channel more U.S. medical students away from specialty fields and into primary-care medicine in rural areas.
How severe the need is for more doctors also is a matter of debate. Skeptics say doctors should be able to care for many more patients in the future with more efficient group practices, greater reliance on physician assistants and nurse practitioners, and "telemedicine" done via the phone and online.
But even today, 1 in 5 Americans lives in areas without adequate access to primary care, government reports say.
The Affordable Care Act calls for creating 600 additional primary-care residencies in community health centers, outside of Medicare's funding for teaching hospitals. The first 44 such residents started training in 2011. But the funding is guaranteed only through 2015.

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