This position paper highlights the need for a national policy for the health work force in general and supports the creation of a national commission to better coordinate the supply and distribution of health care workers to meet the nation's health care needs. It acknowledges that although there are no definitive data on the optimal mix of physicians, the nation should at least set a preliminary goal of achieving a 50/50 balance between specialists and generalists. Previous efforts to reverse the trend of decreasing numbers of medical students choosing careers in primary care have failed. A combination of legislative, regulatory, and voluntary incentives is now required.
A national commission should be established to help develop and coordinate federal work force policies for the health professions. It would set targets for the aggregate numbers of physicians by specialty and would allocate residency and fellowship training positions to match future physician supply with requirements. The American College of Physicians emphasizes that the commission should be structured to include members, including physicians, who are knowledgable about graduate medical education and that it should be insulated from political considerations as much as possible. Controlling the number of residency and fellowship training positions among specialties and linking total postgraduate year-1 positions to the output of U.S. medical schools would substantially affect redirecting the future supply of physicians.
The College offers eight principles for allocating postgraduate training positions. Quality should be the strongest determinant. Local needs and minority representation must also be considered. Service needs should not dictate the number of training positions, but special arrangements are necessary to allow public hospitals in major urban centers to reduce their dependence on housestaff for meeting patient service needs. The roles and number of nonphysician health care providers must be considered. Private sector accreditation bodies such as the Accreditation Council for Graduate Medical Education should recommend allocations of training positions based on the quality of training programs. Allocation decisions should be made in advance so that disruptions for programs and residents are minimized. The allocation process, including the national work force commission, should be subject to external review.