Susan Gasser entered medical school in 1997. During college, she had worked in the laboratory of an anesthesiologist, which made her seriously consider a career in that specialty. During her first year of medical school, the buzz among the fourth-year students was that practice opportunities were drying up fast in anesthesiology. Health maintenance organizations (HMOs) wanted more primary care physicians, not more specialists. Almost none of the fourth-year students applied to anesthesiology residency programs that year. Susan started to think more about becoming a primary care physician. In her third year of school, she had a gratifying experience during her family medicine rotation working in a community health center and started to plan to apply for family medicine residencies.
At the beginning of her fourth year of school, Susan spent a month in the office of a suburban family physician, Dr. Woe. Dr. Woe frequently remarked to Susan about the pressures he felt to see more patients and about how his income had fallen because of low reimbursement and higher practice expenses. He mentioned that the local anesthesiology group was having difficulty finding a new anesthesiologist to join the group to help keep up with all the surgery being performed in the area. The group was guaranteeing a first-year salary that was twice what Dr. Woe earned as an experienced family physician. Susan quickly began to reconsider applying to anesthesiology residency programs.
Approximately 860,000 physicians are professionally active in the United States. One-third are in primary care fields, and two-thirds in nonprimary care fields. Of physicians who have completed residency training, more than 90% have patient care as their principal activity, with the remainder primarily active in teaching, research, or administration (US Department of Health and Human Services, 2008). Licensing of all types of health care professionals, including physicians, is a state jurisdiction. State medical boards require that physicians applying for licensure document a passing grade on national licensing examinations, certification of graduation from medical school, and (in most states) completion of at least 1 year of residency training after medical school.
The University of Pennsylvania opened the first medical school in the colonies in 1765, promoting a curriculum that emphasized the therapeutic powers of bloodletting and intestinal purging. Many other medical sects coexisted in this era, including the botanics, “natural bonesetters,” midwives, and homeopaths, without any one group winning dominance. Few regulations impeded entry into a medical career; physicians were as likely to have completed informal apprenticeships as to have graduated from medical schools. Most medical schools operated as small, proprietary establishments profiting their physician owner rather than as university-centered academic institutions (Starr, 1982).
The modern era of the US medical profession dates to the 1890 to 1910 period. Johns Hopkins University implemented many features that remain the standard of medical education in the United States: a 4-year course of graduate study, competitive selection of students, emphasis on the scientific paradigms of clinical and laboratory science, close linkage between a medical school and a medical center hospital, and cultivation of academically renowned faculty.
A key event in the creation of a 20th-century medical profession was the publication of the Flexner Report in 1910. At the behest of the American Medical Association, the Carnegie Foundation for the Advancement in Teaching commissioned Abraham Flexner to perform an evaluation of medical education in the United States. Flexner’s report indicted conventional medical education as conducted by most proprietary, nonuniversity medical schools. Flexner held up the example of Johns Hopkins as the standard by which the nation’s institutions of medical education should be judged. Flexner’s report was extremely influential. More than 30 medical schools closed in the decades following the Flexner Report, and academic standards at the surviving schools became much more stringent (Starr, 1982). More vigorous regulatory activities in respect to credentialing of medical schools and licensure for medical practice soon enforced the standards promoted in the Flexner Report, and only schools meeting the standards of the Licensing Council on Medical Education (LCME) were allowed to award MD degrees. LCME-accredited schools became known as “allopathic” medical schools to distinguish themselves from homeopathic schools and practitioners. Although homeopaths still practice in the United States (there is now a resurgence of homeopathic practitioners), homeopaths are not officially sanctioned as “physicians” by licensing agencies in the United States. However, one alternative medical tradition has survived in the United States that carries the official imprimatur of the physician rank—osteopathy. Osteopathy originated as a medical practice developed by a Missouri physician, Andrew Still, in the 1890s, emphasizing mechanical manipulation of the body as a therapeutic maneuver (Starr, 1982). Colleges of osteopathy award DO degrees and have their own accrediting organization. Much of the educational content of modern-day osteopathic medical schools has converged with that of allopathic schools. State licensing boards grant physicians with MD and DO degrees equivalent scopes of practice, such as prescriptive authority. By the middle of the 20th century, regulatory restrictions on practice entry, institutionalization of a rigorous standard of academic training, and the rapid growth of medical science and technology solidified the prestige and authority of licensed physicians in the United States.
In 2014, allopathic schools produced 18,078 graduates, and osteopathic colleges 4,806. The annual number of allopathic school graduates changed little between 1980 and 2008, and only started to increase in 2009 in response to a new surge of medical school expansion starting in the first decade of the 21st century. In contrast, the annual number of osteopathic graduates has grown steadily over past decades, increasing threefold between 1980 and 2014.
At least 1 year of formal education after medical school is required for licensure in all states, and most physicians complete additional training to become certified in a particular specialty. Traditionally, the first year of postdoctoral training was referred to as an “internship,” with subsequent years referred to as “residency.” Now, almost all physicians in the United States complete a full residency training experience of at least 3 years.
Although some residency training programs are integrated into the same large academic medical centers that are home to the nation’s allopathic medical schools, many smaller community hospitals sponsor residency-training programs, often in only one or two specialties. The Accreditation Council for Graduate Medical Education (ACGME), a private agency, accredits allopathic residency training programs. Residency training ranges from 3 years for generalist fields, such as family medicine and pediatrics, through 4 to 5 years for specialty training in fields such as surgery and obstetrics–gynecology, to 6 years or longer for physicians pursuing highly subspecialized training. Beginning in 2015, the ACGME also became the accrediting organization for osteopathic residency programs, with the American Osteopathic Association and American Association of Colleges of Osteopathic Medicine participating in the governance structure of the ACGME.
Once physicians have completed residency training, the American Board of Medical Specialties certifies physicians for board certification in their particular specialty field. Criteria for board certification usually consist of completion of training in an ACGME-accredited program and passing of an examination administered by the specific specialty board (e.g., the American Board of Pediatrics). Board certification is not required for state licensure. Physicians may advertise to patients their status as specialty board-certified to promote their expertise and qualifications, and board certification may be a factor considered by hospitals when deciding whether to allow a physician to have “privileges” to care for patients in the hospital or for managed care organizations deciding whether to include a physician in the organization’s physician network. Many specialty boards now require periodic reexamination to maintain certification, with some also requiring physicians to perform and document a quality improvement project in their practice.
In 2014, graduates of US allopathic medical schools constituted only about 70% of the physicians entering ACGME residency programs. Who fills these extra residency positions? Some are filled by graduates of schools of osteopathy; half of DO graduates enter allopathic residencies rather than residency programs sponsored by osteopathic organizations. The remainder are filled by physicians who graduated from medical schools outside the United States. A complex regulatory structure exists to govern which international medical graduates are eligible to enter residency training in the United States, involving state licensing board sanctioning of the graduate’s foreign medical school and graduates completing US medical licensing examinations. There is almost no opportunity for international graduates to become licensed to practice in the United States without first undergoing residency training in the United States, even if the physician has been fully trained abroad and has years of practice experience. Some international medical graduates are US citizens who decided to train abroad, often because they were not admitted to a US medical school. The majority are not US residents, and almost half of these physicians come from India, the Philippines, Mexico and Pakistan. International medical graduates who are not US citizens receive only a temporary educational visa while in residency training, and it is expected that these individuals will return to their nations of origin once they have completed training. However, various visa-waiver programs exist to allow these physicians to remain in the United States, usually linked to a period of service in a US community with a physician shortage. Controversy exists about this reliance on international medical graduates to meet US physician workforce needs, with critics arguing that the United States fosters a “brain drain,” depleting developing nations of vital human resources (Mullan, 2005).
Financing Medical Education
Who pays the cost of medical education in the United States? Unlike the case in most developed nations, where medical schools levy no or only nominal tuition, students pay high amounts of tuition and fees to attend US medical schools. Approximately half of US medical schools are public state institutions, with state tax revenues helping to subsidize medical school education. The Federal Government plays a minor role in financing medical student education, but is a major source of funds to support residency training. Medicare allocates graduate medical education funding to hospitals that sponsor residency programs. These funds are considerable, amounting to $10 billion annually, and include “direct” education payments for resident stipends and faculty salaries plus indirect education payments to defray other costs associated with being a teaching hospital. The joint federal–state Medicaid programs contribute an additional $4 billion annually to residency education (Rieselbach, 2015). Although in 1997, Medicare capped the number of residency program slots it would pay for, Medicare gives hospitals considerable latitude in how to spend their Medicare medical education dollars. Hospitals can decide which specialties, and how many slots in each specialty, they wish to sponsor for residency training, and can qualify for Medicare education payments as long as the positions are accredited. Hospitals may also invest non-Medicare revenues in their residency education programs and are not beholden to a prescriptive national workforce planning policy. Hospitals have tended to add new residency positions in nonprimary care fields, guided more by the value of residents as low-cost labor to staff hospital-based specialty services than by an assessment of regional physician workforce needs and priorities. Between 2002 and 2013, the number of first-year residency positions increased by 7,000 despite the cap on Medicare-funded positions, with virtually all the gains occurring in specialist, rather than primary care, positions (Chen et al., 2013).