No Cause for Concern Over GME Squeeze for Med School Graduates in Coming Years

The number of medical school graduates in the United States has been increasing over the past decade, leading some to stress over a potential shortage of graduate medical education (GME) positions available for incoming trainees. But a new analysis predicts a very small likelihood of any “GME squeeze” in the near future, and instead suggests that any inability to secure a residency position may be the fault of the student.

Authors said they have not yet looked at fellowship positions, or at future GME position/graduate gaps by medical specialty.

The “anxiety has been stoked by press releases, videos, and news articles, and I daresay by student and faculty advisers because everybody had been believing that we are going to run out of residency slots,” said co-author of the perspective Fitzhugh Mullan, MD, of the George Washington University Health Workforce Institute (Washington, DC), in an interview with TCTMD.

In 1997, Medicare placed a funding cap on an estimated 91,000 GME residency positions. Since the, hospitals and institutions wanting to add more slots have had to find funding elsewhere.

In a perspective published online November 4, 2015, ahead of print in the New England Journal of Medicine, Mullan and colleagues explain that the number of filled entry-level GME positions grew by 1.66% between 2004 and 2014 (from 24,982 to 28,962). Over the same period, the number of MD and DO graduates grew by 2.4% from 18,542 to 22,960.

Over the next decade, their model predicts, the gap between graduates and open positions will narrow from 21.7% today to 13.5% in 2023-2024. “The gap will close a bit, but not much over the next 10 years,” Mullan said. “The anxiety among medical students about them not getting a training position, especially in their specialty, is much [overstated].”

Smaller Margin, Healthy Competition

Traditionally, he said, US medical school graduates have filled about three-quarters of all open entry-level GME positions, with international graduates—including US citizens—filling the remainder. “There are way more [international graduates] than are positions open, and generally they go where US physicians are in shorter supply or in specialties that US medical students choose less frequently,” Mullan said, adding that primary care is the current specialty with the biggest gaps in coverage.

And US medical graduates have fared quite well. Mullan estimated that US graduates each apply to an average of 47 residency programs, and “virtually all of them match.” However, international graduates average 100 applications and only “match about half the time,” he said.

“Greater competition for residency opportunities may challenge US medical students’ traditional assumptions about specialty selection and give new importance to the advice about appropriate specialties provided by medical school faculty and advisors,” they write in the perspective. Rather, the “enduring gap” suggests that “failure of US graduates to obtain residency positions is not attributable to a lack of positions.”

The truth is that through alternative funding from the Veterans Health Administration, the Affordable Care Act Primary Care Residency Expansion Program, and the Teaching Health Center GME program, new residency positions are being created, some under new models of training, Mullan said, adding that even states themselves, in some cases, are finding ways to pay for additional GME positions.

With regard to calls from current medical students to increase Medicare funding for GME positions, Mullan and colleagues note that “the primary goal of public GME support… is to produce trained physicians to meet the country’s health care needs and not to fulfill the personal preferences of individual graduates for the specialties of their choice.”

Moreover, they continue, “It would seem difficult to argue that Congress should fund more GME positions in order to create a larger margin for US graduates.”

How Fellows Fit In

Although his group did not look at positions other than residencies, Mullan said hospitals are reimbursed slightly less for fellowship slots. “Something that’s never been calculated until recently,… is what residents [and fellows] make for hospitals,” he said. “The current system presumes that a resident is ‘dead weight’—that he or she is not performing any useful or billable activities so they have to be totally supported for all their years.”

He calls this assumption “absurd.” While “your intern is unquestionably on the negative side of the ledger in terms of requiring supervision and teaching and training in large quantities,” experienced fellows and chief residents are “undoubtedly enormous assets for the hospital because the value of the work they are doing on an hourly basis in terms of what’s billable is huge.”

Mullan said he currently cannot speak to the future availability of GME positions in specific fields like cardiology, but his team plans to continue to examine this going forward.

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Source: 
Mullan F, Salsberg E, Weider K. Why a GME squeeze is unlikely [perspective]. N Engl J Med.2015; Epub ahead of print.

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