To the Editor: In his Health Policy Report on physician supply,Iglehart (April 17 issue)1 focuses on a result of the MedicarePayment Advisory Commission (MedPAC) 2006 survey of Medicarebeneficiaries: among a small percentage of beneficiaries whowere seeking a new specialist, more of them had a problem findingone in 2006 than in 2004. This finding must be considered incontext. Each year, beneficiaries who respond to our surveyreport having better access to specialists than to primary carephysicians. That was the result again in 2007, when 85% of thoseseeking a new specialist reported having had no problem, ascompared with 70% of those seeking a new primary care physician.2Moreover, MedPAC is concerned that primary care services areundervalued in Medicare's physician fee schedule and are atrisk of being underprovided relative to procedurally based services.In response, MedPAC recently recommended increases in fee-schedulepayments for primary care services that are "furnished by practitionersfocused on delivering primary care" and a medical home pilotprogram in Medicare.3 These recommendations are in additionto reforms MedPAC recommended previously to better address overvaluedservices in the fee schedule.4
Glenn M. Hackbarth, J.D. Medicare Payment Advisory Commission Washington, DC 20001
References
Iglehart JK. Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med 2008;358:1741-1749. [Free Full Text]
To the Editor: Iglehart leaves out one factor that impingeson physician supply: the number of applicants to medical school.The number relative to positions has gradually fallen over theyears. When I applied to medical school in 1942, some schoolsreceived as many as 10 applications for every position. Thecurrent ratio of applicants to acceptances is approximately2:1.1,2 If this trend continues, quality will eventually decrease,and it is possible that later there won't be enough qualifiedapplicants to fill available positions. Why do we have so fewapplicants? Medicine is no longer attractive to our youngsters,and the best ones are training in other fields. The reasonsfor this are multiple and need to be addressed by necessarymeasures, including proper health care reform.
Francis J. Haddy, M.D., Ph.D. Mayo Clinic College of Medicine Rochester, MN 55901 tbhaddy{at}aol.com
References
Blumenthal D. New steam from an old cauldron -- the physician-supply debate. N Engl J Med 2004;350:1780-1787. [Free Full Text]
Mullan F. The case for more U.S. medical students. N Engl J Med 2000;343:213-217. [Free Full Text]
To the Editor: Although Iglehart's article captures the medicalcommunity's collective pursuit of an expanded physician supply,it should be noted that the expansion of medical schools doesmore than heal a town's lackluster economy. It provides somecommunities that are faced with limited access to physiciansmuch-needed health care.
The osteopathic medical profession has a tradition of producingprimary care physicians who will practice in rural and othermedically underserved communities. Many colleges of osteopathicmedicine have focused on meeting the needs of underserved ruraland urban populations.1
Since physicians are likely to practice within the area wherethey received their training, new colleges of osteopathic medicineare being established in some of the nation's most medicallyunderserved regions, including New York City's Harlem community,which welcomed its inaugural class of osteopathic medical studentslast fall. As the osteopathic medical community looks towardfuture growth, it will continue to honor its tradition of producingprimary care physicians to ensure that all people have accessto health care.
Peter B. Ajluni, D.O. American Osteopathic Association Chicago, IL 60611
References
Levitan T. AACOM projections for growth through 2012: results of a 2007 survey of US colleges of osteopathic medicine. J Am Osteopath Assoc 2008;108:116-120. [Free Full Text]
The author replies: Hackbarth has a valid point with which Ido not quibble. I would note that MedPAC, which he chairs, haspledged to examine physician-workforce issues more closely,"especially with respect to the supply of primary care providers"and "the choices medical students and residents make about theircareer specialty."1 I favor a more thorough examination of thesubject or, as Brennan called for recently, a federally supported"comprehensive study of the adequacy of the current physicianworkforce and projected future needs."2
The number of applicants to medical schools has fluctuated widelyover the years, as Haddy points out. However, 2007 marked thefifth straight year of growth in the number of applicants toallopathic schools, increasing from 33,625 in 2002 to 42,315in 2007. In the same 5-year period, applications to collegesof osteopathic medicine increased from 6324 to 11,459. Perhapsthe most relevant question is whether there will be an adequatenumber of applicants to medical schools and colleges of osteopathyto treat the health care needs of a U.S. population that increasesby about 25 million people every decade. The Association ofAmerican Medical Colleges (AAMC), which has recommended thatallopathic schools increase their class sizes by 30% to accommodatethis growing population, believes so. The AAMC concluded recently,"We believe future applicant pools should be large enough tosustain a national first-year medical school enrollment of 21,434students, equal to a 30% increase over the matriculating classof 2002."3
Ajluni is correct in saying that doctors of osteopathic medicinehave established practices in medically undeserved communitiesmore frequently than have their colleagues in allopathic medicine.However, new graduates of schools of osteopathic medicine areattracted to these locales and careers in primary care lessfrequently than in the past and are turning increasingly tospecialization. According to annual surveys of graduating seniorsthat were conducted by the American Association of Collegesof Osteopathic Medicine, the number of students planning topursue careers in primary care dropped from 43.8% in 1999 to28.3% in 2007. Many medical students are turning to non–primarycare specialties because of both higher pay and more lifestyle-friendlyworking conditions. In 1999, students of osteopathic medicinereported having a mean educational debt of $116,700; by 2007,that number had reached $168,031. By comparison, on the basisof responses to AAMC questionnaires, students of allopathicmedicine reported having a mean educational debt of $76,141in 1999 and $139,500 in 2007.
Iglehart JK. Grassroots activism and the pursuit of an expanded physician supply. N Engl J Med 2008;358:1741-1749. [Free Full Text]
Garrison G, Matthew D, Jones RF. Analysis in brief: future medical school applicants. 1. Overall trends. Analysis in brief. Vol. 7. No. 3. Washington, DC: Association of American Medical Colleges, May 2007:1-2.
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