In this country we have an odd way of doing workforce planning for physicians. Many years ago medical schools in this country were optional, set up to supplement the apprenticeship system that functioned in the seventeenth and eighteenth centuries. As described by Abraham Flexner in 1910 “The likely youth of that period, destined to a medical career, was at an early age indentured to some reputable practitioner, to whom his service was successively menial, pharmaceutical, and professional; he ran his master’s errands, washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew toward its close, actually took part in the daily practice of his preceptor,—bleeding his patients, pulling their teeth, and obeying a hurried summons in the night.” Students who desired to learn a more rigorous practice could supplement this apprenticeship with medical study in the larger towns in America. Mobile had medical schools early in its history and a very good one (Medical College of Alabama in Mobile) was established in 1859 to “supply physicians to rural Alabama, to reverse the economic and cultural drain among Alabamians that out-of-state education implied, and to educate medical students regarding the unique health care requirements of a predominantly rural Alabama populace.” Medical schools were commonly established near hospitals to expose students to people with various ailments with the Hospital Physician charged with oversight of these students.

The additional training of doctors freshly out of medical school in hospitals became popular in the 1870s and the City Hospital of Mobile had such a training program prior to 1895. The emphasis was on personalized instruction, use of laboratory to make diagnoses, and (after antisepsis became widespread) the use of surgery to cure illnesses such as appendicitis. Beginning in the late 1800’s but accelerating after WWII, physician specialization required additional training in a hospital after medical school. Where such training took place often dictated where one could practice following training (and still does to some extent) so there were not as many coveted positions as there were medical students. Medical students would go on interviews and were lucky enough to receive an offer would be given as little as several hours to think it over. This was not conducive to good medical student mental hygiene.

In 1952 a group of medical students got together and determined a method that internships (and further training  called residencies) could be announced using a computer to match the medical student choices with the hospital choices. That process is now known as  the match. In 1952, when the match was created, the money to pay for internships and residencies was put up by the hospitals. There were no work restrictions and the job became an apprenticeship type experience with some education provided. The book “House of God” is a good description of the training from that era.

Over the ensuing 50 years, much has changed regarding residency training. beginning in 1965 the federal government began paying for medical education through the Medicare program. Hospitals took advantage of this opportunity to add a number of training programs. These programs benefitted the hospitals by allowing them to provide more extensive care but did not necessarily lead to good training and the programs offered had no relationship to the needs of the community. In addition, physicians from other countries were encouraged to train here (and ultimately the system came to depend on these 5,000 physicians brought over every year) but were offered training that they could not use in their country for the most part because of a lack of available technology. Beginning in the 1980s efforts were made to control both the quality of the training programs and the importation of physicians from other countries, with mixed results.

What does this have to do with workforce? Graduating medical students select a specialty based on what they think they might like to do, where they might want to live, and (some more than others) how much money they anticipate making. Hospitals, who have little skin in the game when it comes to training residents and actually make money for having residents, want to be successful in attracting residents so they tend to offer training programs that are desirable to prospective residents. In an odd coincidence, those programs that graduates think will allow them to make a lot of money tend to fill first, before those that are needed to provide care for the poor and underserved (primary care). In the annual ritual, we offer more specialty care positions than we need as a country to provide optimum care, celebrate all of our bright students getting into these programs, and then bemoan the waste that comes from doing too many cardiac catheterizations. After all, a cardiologist has to eat.

After all was said and done, this years match actually ended on an optimistic note for my specialty. Although only reflecting an improvement of about 100 students, there were more US graduates going into Family Medicine than in previous years. Doctors in our specialty may not make as much as some of our limited specialty colleagues but I hope that one of the results of tomorrow’s vote will be to eliminate some of the stresses that contribute to professional dissatisfaction. It appears that at least some US students are anticipating this. Maybe next year will continue the trend…

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