The Medical Education Futures Study Blog

In 1954, Darrell Huff wrote a book entitled, “How to Lie with Statistics” which suggests the way statistical analyses are chosen and presented can bend the truth.  This month’s Health Affairs web exclusive suggests we could all use a review of this lesson.

On Dec. 4, Health Affairs released a package of web exclusives - a sort of point-counterpoint examining the relationship between physician supply, workforce composition and health care quality.  Buz Cooper’s article: States with More Physicians Have Better Quality of Health.  Baiker and Chandra’s response: Cooper’s Analysis is Incorrect.

For the non-statistician, Baiker and Chandra’s arguments are at times confusing and Cooper’s graphics appear compelling.  Cooper finds that states with more physicians per capita generally rank higher in state health care quality rankings.  He also finds that states with more specialists are associated with higher state incomes per capita. 

But, does this mean that more specialists result in better quality (Figure A) or does it mean that higher income results in better quality and incidentally more specialists (Figure B)?  Where is the true causal relationship?  Are more specialists only a representation of higher income and otherwise unrelated to quality?

In this case, income might be considered a “confounding factor” – in other words, income is related to both quality and the number of specialists, and the failure to control for income in the analysis may lead to an inaccurate conclusion that more specialists equals better quality.  These are hypothetical arguments.  I have not done the analysis either to support or negate Cooper’s arguments.  However, Baiker and Chandra find that when they compare areas with the same number of total physicians, areas with higher generalist to specialist ratios have better quality and lower costs.

On Nov. 10, the Wisconsin Council on Medical Education and Workforce released an update to its 2004 report Who Will Care for Our Patients?  The report is well researched and well thought out.  It concludes Wisconsin has a current maldistribution of physicians within the state and a current shortfall of 374 primary care physicians.  However, one of the report recommendations particularly struck me.  The recommendation -

     Attract physicians to Wisconsin and keep them here.

In fact, the physician workforce issue is a national issue.  In Oct. 2008, the AAMC reported on 22 state reports on physician shortages and 5 national studies on the physician workforce.  Simply pulling physicians to our own state of choice will not solve the problem.

Wisconsin is at the head of the class on the physician workforce issue.  The very existence of the Council on Medical Education and Workforce, a result of the 2004 report, is an indicator of the level of collaboration of both private and public organizations within the state to address this critical issue.  And it is appropriate to have state level organizations examining this issue, as physician workforce needs will vary depending on current state and local workforce compositions and needs for healthcare.  But the question is - if Wisconsin is successful, what happens to the workforce needs and the health status of the states they recruit from?

The Wisconsin recommendation points to the need for a national level “council” to develop a US physician workforce that meets the needs of all states and communities.  It is quickly becoming clear that a well thought out physician workforce will be a critical component to any kind of health care reform.  It’s time to make this issue a priority and develop a national level health care workforce institute with the funding and political will needed to provide the research, analysis and guidance to create this workforce.

In the past I’ve written about what government and the presidential candidates are doing in terms of developing a health care workforce to meet the needs of the nation.  This week the Macy Foundation convened a working group to look at medical education’s role in this critical health care issue during this period of medical school expansion.  Participants included medical school deans and leaders from the Association of American Medical Colleges, the American Association of Colleges of Osteopathic Medicine and the Association of Academic Health Centers.

I sat in on this meeting as an observer and I was reassured to know that medical education leadership is taking on this issue seriously, recognizing the opportunity to shape America’s future physician workforce.  I was also impressed at the level of consensus on the responsibility of medical education to produce not only quality physicians, but physicians that meet the social mission of medical education - that is the production of a diverse workforce equitably distributed both geographically and across medical specialties.

The working group’s recommendations included:

1. Re-evaluating increasingly arcane admission policies in order to align those policies with factors that truly correlate with the desired characteristics of future physicians (another issue recently discussed on the MEFS blog).
2. Evaluating the full effect of student debt on medical education’s mission and working to substantially reduce debt as a barrier to the mission.
3. Promoting educational innovations such as moving away from traditional 2+2 year models, increasing longitudinal clinical training, evaluating new sites for clinical education, and promoting inter-professional team models.
4. Calling on foundations and government to support innovation and the social mission both at the education level and at the national workforce level, specifically calling on the federal government to expand the Title VII and the National Health Service Corps and to develop a national institute for health workforce research and policy.

Yesterday the House passed HR 2583 which would provide loans to hospitals to establish residency training programs with a preference for family medicine, internal medicine, emergency medicine, OB-gyn, and general surgery programs.  The loans would also favor hospitals in rural areas or small cities.

I applaud this action.  Developing a thoughtful physician workforce will be a critical component to a cost-effective quality health care system for all Americans.  However, this new piece of legislation adds urgency to the need to also address the other factors that contribute to how the physician workforce develops - namely, physician payment systems and medical school policies and programs.

The trend is for medical students to increasingly choose specialties over primary care.  Adding more primary care residency positions to the current system of graduate medical education (GME) without addressing the market forces and medical school factors that influence student choices, at best, will not fix the problem.  At worst, it will exacerbate the problem.

GME is largely funded by the federal government through Medicare payments to teaching hospitals.  However, teaching hospitals currently determine their residency compliments with no guidelines.  The last major legislation affecting Medicare GME came with the 1997 Balanced Budget Act which capped the total number of residents that existing teaching hospitals could receive Medicare payments for.  Again, no requirements were set for the types of residents trained and increasingly those limited residency program positions have been converted from primary care to specialty positions.

Some of this shift is due to hospitals choosing the more lucrative specialties over the primary care specialties.  But medical students are making the same choices and when there aren’t enough students to fill the primary care residency positions available, hospitals will eventually cut those positions.  Without addressing the factors that are influencing student choices, adding more primary care positions in the current GME system will only shift the few students choosing primary care into different residency programs while the positions they vacate are slowly converted into specialty positions paid for by Medicare.

HR 2583 is a step in the right direction.  But it’s only step 1 and to build the physician workforce needed by Americans, the market forces pulling physicians to specialty practices need to be fixed and medical school programs to promote primary care need to be expanded.

In the past week, both the House Ways and Means Subcommittee on Health and the Senate Finance Committee have held hearings to examine the Medicare physician payment system. Both hearings quickly evolved to discuss:

Source: JAMA Annual Graduate Medical Education data

1. The pending primary care crisis – medical students are increasingly choosing medical subspecialties over primary care.

2. Primary care’s role in developing a more cost-effective quality health care system – analysis of Medicare claims indicates regional differences in Medicare spending.  Higher spending regions are largely explained by more specialty-oriented practice but have no increase in quality or access to care (Goodman, 2003).

But what about the presidential candidates? In her Sept. 16 Good Morning America interview, former candidate Hillary Clinton encourages Americans to re-focus on the issues and she tells us from her experiences traveling America, “concerns about healthcare, that’s what’s on the minds of Americans.”  But if primary care is a key leg to cost-effective quality health care for all Americans, what do Barack Obama and John McCain’s health plans say about primary care?

The answer is – not much. Barack Obama at least recognizes the problem and the need to address it.

WORKFORCE. Primary care providers and public health practitioners have and will continue to lead efforts to protect and promote the nation’s health. Yet, the numbers of both are dwindling, and the existing workforce is further challenged by inadequate training about new health threats such as bioterrorism and avian flu, antiquated funding and reimbursement mechanisms, and limited access to real-time information and technical support. Barack Obama and Joe Biden will expand funding—including loan repayment, adequate reimbursement, grants for training curricula, and infrastructure support to improve working conditions— to ensure a strong workforce that will champion prevention and public health activities (excerpt from Obama/Biden Health Plan).

John McCain’s plan never mentions it.

A new study released in JAMA today shows racial and ethnic diversity within medical schools produces physicians who are better prepared to care for minority populations.  Affirmative action in schools is a long and ongoing battle.  In the 1978 Bakke case, the U.S. Supreme Court declared that while admission preferences based solely on race constitute discrimination and are therefore illegal, colleges were legally justified in taking race into account for the purpose of improving the delivery of health services to underserved communities and for the attainment of a diverse student body.  In 2003, the Supreme Court upheld the Bakke decision in a challenge of the University of Michigan’s admission policies.

Diversity within medical schools is critical for 2 practical reasons –

1.  Underrepresented Minority (URM) physicians are more likely to enter primary care and care for underserved and minority populations.  The same JAMA article showed “URM students are substantially more likely than white or nonwhite/non-URM students to plan to serve the underserved (48/7% vs 18.8% vs 16.2%).”  Another article released in today’s JAMA looking at medical student career choices, shows that although URMs made up only 11% of those surveyed (consistent with general URM numbers in medical schools), 18% of those planning to enter Family Medicine were URM students.

2.  Diversity in medical schools better prepares all of tomorrow’s physicians to care for minority populations.  This desired outcome is critical as the general minority population grows in the U.S.  The U.S. Census Bureau estimates that by 2010, 29% of the U.S. will be underrepresented minorities (Black, Hispanic or American Indian).

The question at this point is not whether diversity is important, but how do we increase diversity in American medical schools.  Step 1 is to uphold the Bakke decision.  In 1996 California passed Proposition 209 which barred public institutions from considering race and ethnicity in their admission processes.  By 2006, UCLA saw its lowest representation (just 2%) of black students in its incoming freshman class.  That same year, UCLA, amidst concerns over the lack of student diversity, changed their admission policies to a more “holistic” approach, in which applicant GPAs and test scores would be considered in the context of the personal experience.  By the fall of 2007, the number of black freshman had doubled.  However, the American Civil Rights Institute is indicating they will likely file suit against the university for violating Proposition 209.  If they do, it will be the first major test of the Bakke case in California since Proposition 209.

Step 2 is to not only to defeat challenges to increasing medical school diversity, but to propagate policies and programs to increase diversity.  Medical school admission policies should be re-evaluated to increase the national “holistic” approach.  Medical schools serve a primary goal – to train the physicians needed to care for the American people.  It’s time for admission policies to reflect the needs of the nation, rather than a desire to score well on the U.S. News and World Report rankings.  It’s also time to re-invest in this goal on a national level.  Title VII of the Public Health Service Act has supported diversity programs since the 1970s.  However, funding for these programs has been continually slashed in recent years.  The President’s FY08 budget all but eliminates the program.  The need here is clear.  The minority population in the U.S. is growing and a diverse, culturally sensitive workforce will be needed to care for this population.  It’s time to stop cutting Title VII and start re-investing in a physician workforce that meets the needs of the nation.

A timely new article by Rittenhouse et al. in the Annals of Family Medicine finds a significant positive association between exposure to Title VII training programs and subsequent physician work in Community Health Centers (CHCs). 

These findings are particularly noteworthy as just four weeks ago, the National Association of Community Health Centers (NACHC) released their report – Access Transformed: Building a Primary Care Workforce for the 21st Century – in which they estimate a current deficit of 1,843 primary care providers in CHCs and a need for an additional 15,585 primary care providers if they are to reach their goal of 30 million patients by 2015.

Since the 1970s, Title VII has supported programs aimed at increasing primary care, underserved areas and minority physicians.  However, funding for these programs has been severely slashed in recent years.  The program was cut in half in 2006.  This year, as in previous years, the President’s FY08 budget all but eliminates the program.  On July 18, the House approved $228 million for Title VII programs – a 24% increase from FY07, but the Senate approved only $188 million for the program on June 21 (AAMC)

As the need for primary care physicians, particularly in underserved areas, grows, it is time to invest in the programs that produce these needed physicians.  And the Rittenhouse article shows us that Title VII programs clearly work.