A good place to start considering the history of medical education in the United States (and Canada) is with the Flexner report. In 1910 Abraham Flexner, an educator and member of the research staff of the Carnegie Foundation, published a comprehensive report of the state of medical education in the United States and Canada. The release of this study was the culmination of a two year study during which Flexner surveyed all 155 medical and osteopathic educational institutions in the United States and Canada that granted M. D. or D. O. degrees at the time. You can read the full report here.
Flexner concluded that the education offered by these institutions was substandard, there were too many of them, and that free-standing educational institutions were hard-pressed to produce the funding necessary to maintain a quality level of education. He made several suggestions:
- the schools should have minimum admission standards: a high school education and at least two years of college level or university science.
- medical schools should be 4 years in duration: two years of basic sciences and two years clinical.
- “proprietary” schools should be closed or incorporated into universities.
It’s hard to overestimate the effect of the Flexner Report. From the year of its publication to 1935 89 medical institutions closed their doors. Particularly hard hit were the osteopathic institutions. Some have said that this was part of the assault on competing disciplines launched by the American Medical Association that has continued to this day.
The number of physicians fell from 173 per 100,000 to 125 per 100,000 and it stayed at roughly that level until 1960 as population increased due to a modest expansion in the number of institutions and number of graduates per class. The guiding philosophy was to produce fewer but better doctors and that philosophy has endured to the present day.
In 1959 the Surgeon General Consultant Group on Medical Education produced a report known as the Bane Report which concluded that there was an impending physician shortage of some 40,000 physicians. As a result of this report and intense efforts by the Kennedy and Johnson administration from 1965 to 1980 the number of physicians graduation rose from 7,849 to 16,935, where it’s stayed ever since.
One of the key factors in this increase was the program of Graduate Medical Education subsidies which are provided through the Medicare system. Under this system roughly $80,000 is paid by Medicare for each and every medical resident in the country.
Although the number of physicians trained per year in the United States has remained fairly constant over the last 25 years the number of physicians has managed to keep pace with the natural increase in population over the period by the increasing numbers of International Medical Graduates (IMG’s). In other words we’ve imported enough doctors trained elsewhere to make up for the inadequate supply of medical graduates produced here. Today IMG’s constitute roughly 23% of the total number of physicians (and comprise a substantially higher proportion of doctors in major cities).
In recent weeks there’s been a lively discussion going on in the blogosphere on the subject of reforming the health care system in the United States. The comments to this post at Dean’s World are particularly interesting. Gary Becker and Richard Posner have posted their thoughts on the subject. And economists Mark Thoma and Andrew Samwick have conducted an interesting debate on the subject at WSJ Econoblog.
One thing that many commenters have missed is that in order for market forces to have any real influence on the availability and cost of health care in the United States there must be a functioning market in health care. Some have mentioned the problems of asymmetrical information in this regard.
But it’s clear from the history of medical education in the United States that the supply of physicians has been very carefully regulated and has only been increased as a result of enormous government subsidies. Medical training has not responded either to the increased population in the country or to the larger expenditures on health care per capita and as a percentage of GDP over the period. There are many possible conclusions that could be drawn from this but I see no way to draw the conclusion that medical education responds to anything resembling a market. We aren’t producing more doctors even though we’re spending a lot more money on health care.
In my view we should be producing many, many more physicians—possibly an order of magnitude more—for practical, economic, and moral reasons. We should be training physicians here and exporting them to the world rather than draining the developing world of medical professionals. The application of modern training technology to medicine can more than satisfy the concerns raised by Abraham Flexner nearly a century ago.
The Flexner Report
SciencePolicy: On the physician-supply debate
Economic and Demographic Trends Signal an Impending Physician Shortage, Cooper et al.
Making the Case for More U. S. Medical Students
Re-thinking physician supply: moving beyond the MD, DO, IMG dance
National Issues for the International Medical Graduates (PowerPoint presentation)