[Volume 69 No. 3 March 2010]

In the February JABSOM Hotline (Medical School Hotline), we reviewed initial findings of a JABSOM study commissioned by Hawai‘i State Legislature in 2007 to assess trends in physician workforce in our state. Initial results provided to the legislature demonstrate that when compared to national averages, Hawai‘i is currently underserved by at least 500 physicians. Of the approximately 2660 FTE practicing, more than 1000 will be reaching common retirement age of 65 in the next 10 years. Those who reach that milestone currently have a greater than 50% probability of retiring from clinical practice in each of the following decades. Growth in both the general and aging populations will add a need for 1000 physicians by 2030. This will adversely affect public access to a physician.

The Council on Graduate Medical Education, authorized by Congress in 1986 to provide an ongoing assessment of physician workforce trends, reported in January of 2005 that there would be significant shortages of physicians by 2020.¹ The Health Resources and Services Administration (HRSA) confirmed this prediction later that same year.² In response to growing evidence of this shortage, the American Association of Medical Colleges (AAMC) convened a Physician Workforce Task Force to assess and recommend actions to be taken to respond to the potential for serious shortages. The AAMC Position Statement on Physician Workforce, approved by the AAMC Executive Council on June 15, 2006, contained twelve recommendations intended to “better assure an appropriate supply of physicians while increasing medical education opportunities for Americans.”

The status of seven of these recommendations as they relate to medical education in Hawai‘i follows.

Recommendation: Enrollment in LCME-accredited medical schools should be increased by 30% from the 2002 levels over the next decade. (2015)

Last year, the Liaison Committee for Medical Education (LCME) awarded JABSOM full accreditation for 8 years. With this platform, attention can now be given to systematically expand the class size to meet the demand for physicians. JABSOM enrollment has remained unchanged at 62 students per year. This will be expanded to 64 in the incoming class this fall. To achieve the AAMC recommendation above, class size will need to expand to a total of 75 to 80 entering students per year.

The challenges to expand the class size are substantial. Tight state budgets mean that additional financial support will be difficult to find. Problem based learning (PBL) is faculty intensive. Expanding the class will require the recruitment and training of additional preceptors. Clerkships in major specialties will need to be expanded by initiating rotations on neighbor islands. Despite these challenges, the initial stages of planning for a class of 75 students per year have begun.

Recommendation: The aggregate number of graduate medical educations (GME) positions should be expanded to accommodate the additional graduates from medical schools.

Currently, there are 15 residency and fellowship programs in graduate medical education in Hawai‘i managed by the Hawai‘i Residency Programs, Inc. JABSOM is the Sponsoring Institution. There are 230 to 240 residents and fellows in the JABSOM/HRP residency and fellowship training. About 20 residents are in transitional or preliminary programs (1 year) and will transfer to the mainland for residency. JABSOM/HRP offers programs in the primary specialties of medicine, surgery, psychiatry, pediatrics, pathology, family medicine, geriatrics and obstetrics/ gynecology. However there are major specialties for which there is no GME training in Hawai‘i. For example, there are no residencies in anesthesia, emergency medicine, radiology, or dermatology. Medical and surgical subspecialty fellowship programs are quite limited. There are fellowships in surgical ICU, neonatology, maternal fetal medicine, child & adolescent psychiatry, addiction psychiatry, geriatric medicine and geriatric psychiatry. Just this past month, a cardiology fellowship was approved to start in July of 2010.

While the population and medical community of Hawai‘i may never be large enough to support residencies and fellowships in a ll areas, the best chance of keeping JABSOM graduates in Hawai‘i is to have them complete their GME training in Hawai‘i. Eighty percent of physicians who attend JABSOM and then a JABSOM/HRP residency will end up practicing in this state.

We note that of all residency programs sponsored by JABSOM, the average accreditation length is 4.2 years out of a possible 6. Several of our programs have enjoyed back-to back- 5 year accreditation, which places them in the top percentiles nationally. Internal Medicine was just awarded an additional 6th year, which is unprecedented.

Even so, there are many barriers to expanding GME. GME funding by the Centers for Medicare & Medicaid Services (CMS) has been frozen since 1996, although a slight adjustment to the CMS GME position cap occurred in 2004. Significant new CMS positions are not expected. All HRP hospitals are functioning at or above current cap levels. Although the JABSOM/HRP GME cap level this year is about 170 residents, there are 233 residents and fellows. Although Hawai‘i lacks GME programs in several key specialty areas, there are opportunities. The recent success of the cardiology program application suggests that with proper planning our capacity in GME can grow. This should be done strategically by identifying those programs that will have the greatest impact on anticipated patient care access and outcomes.

Recommendation: Medical Schools expand enrollment in a cost effective manner; assuring appropriate medical education for traditional and non-traditional students; and increasing the number and preparedness of applicants.

Recommendation: Medical Schools should increase the enrollment and graduation of racial and ethnic minorities; and promote the education and training of leaders in medical education and health care from racial and ethnic minorities.

These two recommendations are particularly important in the culturally diverse state of Hawai‘i. Fortunately, JABSOM has done well in these areas. Much has been written about the Imi Ho’ola program in previous articles. In brief, JABSOM has been on the forefront of preparing local candidates for success in medical school through its post-baccalaureate program (Imi Ho’ola) that provides a year of medical school preparation in study skills, basic science, and cultural knowledge to promising applicants with disadvantaged backgrounds. The “Imi” program is overseen by the school’s Department of Native Hawai‘ian Health and is funded in part through a grant from the Queens Medical Center. Each year, up to 10 disadvantaged students per year complete the “Imi” program and begin medical school at JABSOM.

While JABSOM routinely receives 1600+ applications each year, only 230 to 240 come from Hawai‘i. If we are to grow the class with successful in-state students, we may need to consider growing Imi Ho‘ola as well. JABSOM is also working to address the pipeline of future applicants through leadership on the Hawai‘i/Pacific Basin Area Health Education Center (AHEC).

Recommendation: The J-1 visa is the most appropriate visa for non- U.S. citizen graduates of foreign (international) medical schools entering GME programs in the U.S. and should be encouraged.

There are many residents in Hawai‘i programs who are international medical graduates (IMGs) on J-1 visas. Unfortunately, the J-1 visa requires that they leave the country for 2 years after their training, before they can apply to return. The workforce implications are concerning. It is unclear whether resident positions in short supply should be used to train physicians from abroad.

A few IMGs stay each year on a Conrad 30 waiver, a program that allows IMGs to serve in areas designated as under served for 3 to 5 years in return for a working visa. However, if there is a substantial increase in LCME accredited US graduates, competition for residency positions will become severe. In the short term, Hawai‘i has the ability to provide 30 such waivers each year. Currently only a few of these are used. JABSOM is working to identify locations that qualify for such waivers and will be exploring recruitment options.

Recommendation: Ongoing and stable funding should be provided to track the physician workforce, including monitoring the supply of and the demand for, and the distribution of physicians (including IMGs).

The 2007 Hawai‘i state legislature funded, through a medical licensing fee, a study of physician supply, demand and distribution. This funding will need to be continued if we are to address shortages systematically.

Recommendation: The AAMC should undertake a study of the geographic distribution of physicians and develop recommendations to address mal-distribution in the US.

Funds appropriated above are being used by faculty at JABSOM to assess supply and to develop models that can identify Hawai‘ian island-specific needs. Much more must be done on local and regional shortage estimates. Kelley Withy MD, Director of the AHEC program at JABSOM is currently working on these models.

Conclusion
The AAMC recommendations remain good guidelines. In Hawai‘i, we have been proactive in some areas and have been slow to respond in others. The key thing to remember is that it takes several years to educate a physician. Reports are that we will fall further behind over the next 10 years as a result of demographic shifts and physician retirements. Expansion and improvement of the pipeline to practice must start now.

Thoughtful growth now even in these difficult economic times will require the recruitment of key faculty, development of new departments and divisions, expansion of the medical school and our GME programs. It will take decades but our efforts today must be redoubled.

References
1. Physician Workforce Policy Guidelines for the United States, 2000-2020, Council on Graduate Medical Education Sixteenth Report, U.S. Department of Health and Human Services, Health Resources and Services Administration. January 2005.

2. Health Resources and Services Administration: Bureau of Health Professionals. Physician Supply and Demand. October 2006.

3. Association of American Medical Colleges: AAMC Statement on the Physician Workforce. June 2006.