HOD ACTION: Council on Medical Education Report 16 adopted and the remainder of the report filed. REPORT OF THE COUNCIL ON MEDICAL EDUCATION

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1 HOD ACTION: Council on Medical Education Report adopted and the remainder of the report filed. REPORT OF THE COUNCIL ON MEDICAL EDUCATION CME Report -A-0 Subject: Presented by: Referred to: US Medical School Expansion Susan Rudd Bailey, MD, Chair Reference Committee (Floyd A. Buras, Jr., MD, Chair) In 00, the Association of American Medical Colleges (AAMC) issued a statement on the physician workforce that called on US MD-granting medical schools to increase enrollment by 0% over 00 levels in the following decade. This would require that the number of new entering medical students be, by 0. The AAMC also recommended that these enrollment increases occur by expanding the class sizes in existing medical schools and by establishing new medical schools. Other groups also called upon the US medical education system to increase its capacity, based on concerns about an existing or impending undersupply of physicians regionally or nationally. For example, the Sixteenth Report of the federal Council on Graduate Medical Education (00) recommended that the total enrollment in US medical schools be increased by % over 00 levels in the next decade. This report summarizes the increases in enrollment in US MD- and DO-granting medical schools as of 00 and describes some of the benefits and challenges associated with the current and anticipated growth. MEDICAL SCHOOL ENROLLMENT TRENDS Table in the Appendix illustrates first-year and total enrollment at US MD- and DO-granting medical schools between and During that period, first-year enrollment in MD-granting schools increased 9.% and in DO-granting schools increased 0.8%. There are plans for future enrollment increases as well. The entering class size at MD-granting medical schools in 0 is projected to be 9,909 (a 0.8% increase from 00). At DO-granting schools, the entering class size in 0 is projected to be,9, a 9% increase over 00. MEDICAL SCHOOL EXPANSION Medical school enrollment may increase by creating new medical schools or by expanding enrollment at existing schools. Table in the Appendix illustrates the number of accredited medical schools since the academic year. Between the and February of the academic year, the number of Liaison Committee on Medical Education (LCME)- accredited MD-granting medical schools increased from to. Five additional schools have formally applied for LCME-accreditation but have not yet been reviewed. The number of Committee on Osteopathic College Accreditation (COCA)-accredited DO-granting medical schools increased from 9 to between and

2 CME Rep. -A-0 -- page Enrollment increases at existing medical schools can be facilitated by starting distributed campuses at a site distant from the main campus. A model of education that distributes medical students to remote campuses for some or all years of the curriculum can provide access to additional resources, such as faculty or patients, or can allow medical schools to expand into different training environments, such as rural locations. A number of both MD- and DO-granting medical schools already use the distributed campus model. For example, the DO-granting medical schools currently offer instruction in locations. There have been branch campuses of medical schools since the 90s. Located at a distance from the main campus, these distributed campuses may include only the preclinical portion of the curriculum, only the clinical years, or all four years of the curriculum. The use of distributed campuses is likely to increase in the future. Responses to the LCME Annual Medical School Questionnaire, which was sent to all MD-granting medical schools with students enrolled and had a 00% response, showed that schools planned to create a new distributed campus during the next three years and 9 planned to expand an existing distributed campus to offer more years of the curriculum. Comprehensive data on the number of schools with distributed campuses is being collected through the LCME Annual Medical School Questionnaire. Some DO-granting medical schools contemplating growth also planned to utilize the distributed campus model as part of their expansion strategies. IMPLICATIONS OF MEDICAL SCHOOL EXPANSION There have been some positive outcomes of US medical school expansion. For example, the creation of new medical schools provides an opportunity to implement new models of medical education and to support enhanced access to care in underserved regions. However, there are challenges that will need to be faced as a result of this period of expansion. Access to Graduate Medical Education Since a period of accredited graduate medical education (GME) is required for licensure in all states, the number of physicians emerging from the educational pipeline will not increase unless the number of accredited first-year GME positions in specialties leading to first certification increases. While the number of US medical school graduates is rising, the number of entry-level graduate medical education positions is not increasing correspondingly. The 00 AAMC Statement on the Physician Workforce recommended that the aggregate number of GME positions should be expanded to accommodate the additional graduates from accredited schools. Our AMA policy supports new funding for increases in the number of medical school and residency training positions, preferably in or to adjacent to physician shortage/underserved areas and in undersupplied specialties (Policy H-0.99, #9 AMA Policy Database). The increase in the number of US graduates from MD- and DO-granting medical schools may, in the near future, impact their access to graduate medical education positions. The National Resident Matching Program (NRMP) noted in its report on the 009 Match that: The real and projected increases in the numbers of U.S. allopathic seniors have raised questions about how this may affect both their performance in the Match and the Match success of other applicant groups. In the past, the number of first-year positions in core specialties leading to first certification was greater than the number of US medical school graduates. The 009 NRMP report also noted that the ratio of first-year (PGY-) positions to total applicants has declined over the past four years

3 CME Rep. -A-0 -- page from 0.8 to (in 00) to 0. to in 009 (see Table in the Appendix). This reflects the fact that the increase in the number of applicants has outpaced the increase in the number of positions. This effect will be exacerbated by the increasing number of graduates from the new medical schools and the expanded class size in existing US medical schools, unless more entry-level GME positions become available. The NRMP Match results for 00 and following years should be closely monitored to determine the effects of US medical school expansion on access to GME for US medical school graduates. Access to Clinical Teaching Sites Data from both MD- and DO-granting medical schools points to concern about access to clinical teaching sites as the number of US medical students increases. In the LCME Annual Medical School Questionnaire, of the 9 schools that reported it was more difficult to find inpatient clinical placements for students in core clerkships, attributed this to an increase in the medical school s class size and to competition for placement sites from other US medical schools (schools could choose more than one reason for the difficulty). A survey of DO-granting schools found that % of responding schools were moderately or very concerned about the overall number of clinical training sites, % were concerned about competition from other osteopathic medical schools, and % were concerned about competition from allopathic medical schools. The Council on Medical Education has addressed the issue of the access to clinical training sites in previous reports and, in general, recommended regional planning to bring new clinical training sites online and enhanced funding to support this expansion as possible solutions to the problem (D-9.0). DISCUSSION AND RECOMMENDATIONS While the number of places in US medical schools is increasing, the number of applicants continues to outnumber the number of available positions. For example, for the 009 entering class in MD-granting medical schools, there were,9 applicants and 8,90 first-year medical students, an applicant to accepted applicant ratio of.. 8 There also is considerable variation across states in the number of enrolled medical students per 00,000 population. In states with medical schools, the ratio ranges from.9 medical students/00,000 population in Oregon to./00,000 in Vermont (the ratio in the District of Columbia is 8/00,000). 9 These data indicate that there may be additional infrastructure capacity for medical school expansion, if resources are made available. However, increasing the number of US medical school graduates will not contribute to the overall number of physicians entering practice unless the number of GME positions is increased. Therefore, the Council on Medical Education recommends that the following be adopted and that the remainder of this report be filed:. That our American Medical Association (AMA) continue to advocate for funding from all payers (public and private sector) to increase the number of graduate medical education positions in specialties leading to first certification. (Directive to Take Action). That our AMA work with other groups to explore additional innovative strategies for funding graduate medical education positions, including positions tied to geographic or specialty need. (Directive to Take Action)

4 CME Rep. -A-0 -- page. That our AMA continue to work with the Association of American Medical Colleges (AAMC) and other relevant groups to monitor the outcomes of the National Resident Matching Program. (Directive to Take Action). That our AMA continue to work with the AAMC and other relevant groups to develop strategies to address the current and potential shortages in clinical training sites for medical students. (Directive to Take Action) Fiscal Note: Less than $00.

5 CME Rep. -A-0 -- page APPENDIX TABLE - MEDICAL SCHOOL ENROLLMENT MD-Granting Medical Schools* DO-Granting Medical Schools** Academic Year First-Year Enrollment Total # of Students First-Year Enrollment Total # of Students 00-00,8 9,90,09, 00-00, 0,,08, ,8,08,, 00-00,00,000,908, ,,,0, ,9,,8, ,0,0,90,89 Sources: * AAMC Data Warehouse: Applicant Matriculant File AAMC Data Warehouse: Student File ** AACOM Annual Osteopathic Medical School Questionnaire TABLE - NUMBER OF ACCREDITED MEDICAL SCHOOLS Academic Year MD-Granting Medical Schools* DO-Granting Medical Schools** As of February 00 Sources: * AAMC 009 Data Book, Table A ** AACOM Annual Statistical Report on Medical Education 00 Osteopathic Medical Education Information Book

6 CME Rep. -A-0 -- page TABLE : NRMP PGY- MATCH RATES FOR VARIOUS GROUPS Year Percent Initially Matched Through the NRMP # of Total Positions Active Applicants US Seniors US IMGs Non-US IMGs 00 0,908, ,9, 9.9.,.8 00,, ,9, ,8, ,0 8, , 9, Source: NRMP, Results and Data, 009 Main Residency Match All Applicants

7 CME Rep. -A-0 -- page REFERENCES. AAMC Statement on the Physician Workforce. AAMC, June 00.. Council on Graduate Medical Education Sixteenth Report. Physician Workforce Policy Guidelines for the United States, COGME, January 00.. AAMC Center for Workforce Studies. Medical School Enrollment Plans: Analysis of the 00 AAMC Survey. AAMC, April Levitan Y. A report on a Survey of Osteopathic Medical School Growth: Analysis of the Fall 009 Survey. AACOM, January 00. Whitcomb M. New and Developing Medical Schools. Josiah Macy, Jr. Foundation, October Salsberg P, Rockey PH, Rivers KL et al. US residency training before and after the 99 Balanced Budget Act. JAMA 008;00(0): NRMP. Results and Data 009 Main Residency Match. Accessed at www. NRMP.org. 8. AAMC Data Warehouse. Applicant Matriculant File as of October, AAMC Center for Workforce Studies. 009 State Physician Workforce data Book. AAMC, November 009.

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