Solutions for the high US maternal mortality rate: Part 1 Improvements in physician workforce
Summary: Need for a well-trained and diverse physician workforce
An essential solution for the reduction of the high maternal mortality rate is to promote an increase in physicians with obstetrical training, especially as the US population is projected to grow by 34.8 million by 2034. The newly educated physicians need to be culturally, economically, racially, and geographically diverse. Many studies or physician workforce needs clearly show that when physicians are themselves members of the communities they serve, health outcomes are much better than when the physician is not a part of the community,
Complete solution to reducing maternal morality is complex and requires multiple approaches
Solutions for the reduction of the high maternal mortality in the United States are by necessity multiple. The Campion Fund will be posting a series of blogs outlining the solutions in all their complexity. All the solutions outlined are necessary to accomplish the goals of enhancing maternity care and avoiding maternal death. In the past we have highlighted this serious public health problem and discussed some of the reasons why it exists. We have pointed out that our maternal mortality rate among black is extremely high, the rate for other demographic groups is also unacceptably high.
Blog focus: physician shortages and current training
In this blog we focus on the physician workforce in terms of numbers and financing of the education of physicians who practice obstetrics. An understanding of what our health care system provides now in 2023 for the education of physicians is necessary before we suggest ways to improve the future pipeline. Our next blog will discuss the need for training of certified nurse-midwives, certified midwives, and other advanced practice nurses as well as doulas and community health workers as essential members of maternal health teams. Coordinated health systems with a team of highly trained professionals that are well financed and distributed geographical in a rational manner is critical for eliminating maternal mortality. These teams must be racially, economically, and culturally diverse to truly meet the needs of the US population At least 2.2 million women of childbearing age current live in geographic areas of the United States without hospitals or birth centers providing maternity care and lack a provider capable of caring for their needs. 4.7 million live in US counties with limited access to such essential care. Many of these counties are in rural remote areas and are essentially “maternity care deserts”. Many of these counties also have large numbers of minority populations. Surprisingly, a large portion of these counties are in the Midwest. More than one half of all US counties have no obstetrician gynecologist. Recent data released from the American College of Obstetricians and Gynecologists demonstrates that the number of applications for residence positions in Obstetrics and Gynecology has declined. Newspaper articles from many states report that board certified obstetrician-gynecologists are reluctantly leaving states and territories that now have pre-viability bans on induced abortions. The reason for this is that the laws are confusing and vague regarding many pregnancy complications that end in fetal or maternal demise. Care for individuals with an incomplete abortion (miscarriage) and ectopic pregnancy is poorly defined, often misunderstood by non-professionally trained persons as “abortion” leading to provider fears of legal entanglement. Many physicians leave because they disagree with the legal bans. This fact must be discussed and understood by US citizens. As a result, without this dialog and changes in the legal environment, there will undoubtedly be more US counties without obstetrician-gynecologists.
We are faced with a shortage of future obstetrician-gynecologists. In 2019 the US population was 328.2 million. By 2034 the estimates are that the US will have 363 million people. While 22.9 will be over 65 years old, 11.9 million of this estimated increased population will be under 65. While the number of persons in the childbearing age of 18 to 44 ( CDC definition) is unknown and while it is possible to become pregnant at earlier and later ages, is it safe to surmise that this percentage of the population in 2034 will be higher than it is today. Therefore, the number of physicians needed to provide maternity care will increase as well. The United States cannot provide safe and satisfying maternal care without an increase in physicians trained in obstetrics and gynecology as well as others professionals trained in maternity care. Overall, it is projected that there will be a physician shortage in all medical specialties of 37,800 to 124,000 physicians in 2034. The American College of Obstetricians and Gynecologists states that the projected shortage of physicians in the specialty will be 22,000 by 2050. Many the current physicians will reach retirement age in the next decade and a number will leave the profession due to burnout. They will need to be replaced. The increased population growth will also increase the need for more physicians in the future. Furthermore, as scientific, and medical knowledge increases, the demands on individual practitioners increases, meaning that larger health care teams will be needed.
Current physician education
Prior to presenting solutions to the problem of education future physicians is it useful to understand the education of physicians and how this is funded currently. Physician education in the United States is long and expensive requiring eight years of college and medical school after secondary education followed by 3-9 years of residency and in some fields a fellowship. The average medical school graduate has a student debt of $240,000.00. Despite future earning potential this is not easy to repay. Most physicians will be in the early thirties before they are licensed to practice in their field. While US medical schools have increased the number of students and new schools have opened in the past several decades, they are limited by the necessity of providing enough appropriate clinical experience for students. Each school exists in a particular geographic area with a finite population. This limits the number of student physicians the school can enroll if it is to meet educational requirements of safe practice. This involves numbers, such as how many patients with a particular disease should a student examine and evaluate before graduation? I doubt that anyone would want to go to a doctor who has not actually examined real people before starting to practice. Even in centuries past physicians were required to be apprenticed to a medical practitioner before seeing patients on their own. Thus, the decision to increase the number of students in existing schools and in starting new schools must take into consideration the number of people served who will provide clinical experience. Experience counts.
In the United States, there are two types of medical schools. Medical schools in the allopathic tradition award MD degrees while schools in the osteopathic tradition award the DO degree. At the present time the curriculum of these schools is similar, offering basic science and clinical experience. Both are four years in length. Following graduation, an individual with an MD or DO degree must enter a residency program prior to obtaining state licensure. MD students must pass the US Medical Licensing Examination (USMLE) sponsored by the Federation of State Medical Boards and the National Board of Medical Examiners (NBME) consisting of three steps. The first two are taken in medical school and the third which assesses the application of medical knowledge to patient management is taken after the first year of residency. In 2022 the examination was given as a pass/fail and will continue to be pass/fail. The 2024 costs are $670 for Step one, $670 for Step two and $945 for step three. The student must pass all three steps. The results are used by state medical boards in their licensing procedures. The DO graduate must take Part I, II, III of the COMPLEX examination and they may take the USMLE.
Graduate Medical Education
Residency and fellowship education is provided by formal programs offered by teaching hospitals and medical centers. They are accredited by the Accreditation Council of Graduate Medical Education (ACGME). Residency Review Committees (RRC) which are composed of selected physicians oversee each medical specialty’s resident education programs. Residencies are funded by the federal government with about 70% from Medicare, 30% from Medicaid and some funds from the Department of Defense. Residents as well as fellows are paid a yearly stipend. Programs that are not ACGME accredited do NOT receive federal money. Salaries vary according to specialty and geographical location but on the average is $59,000 to $70,000 for first year residents. As of 2023 there are 37,425 positions for residents in ACGME accredited programs.
Graduation from medical school and the entry into a residency program is a major pinch point on the way to becoming a practicing physician. Each year the National Residency Match Program (NRMP) of the ACGME sorts the applications of those applying for the match to the lists of those accepted by each residency and fellowship program via a computer algorithm. On the day the positions are filled those who did not match or programs that did not fill are able to communicate with each other in a process in order to fill as the empty slots. There are applicants who do not match at all and decide to work as research fellows or in other jobs in the health care field until they apply again. The numbers of the positions available are controlled by the government as they fund the programs. In 1997 the Balanced Budget Act put a cap on the number of positions offered which essentially froze the number of physicians trained each year. The Consolidated Appropriations Act of 2021 increased the number of residency positions by 1000 over a five- year period. In 2023 the number of positions offered increased by 3 percent while the first-year positions increased by 3.2 percent. This is a good first step. Currently, the largest number of resident positions are in programs located in the Northeast. Very few residency programs are in rural areas or located in areas in cities or towns where accessibility for minority populations is difficult. This is important to our understanding of the current state of the medical education pipeline for two reasons. First graduates of residencies and fellowships in most situations decide to practice in the same geographic area where they trained. Second in our current structure of education it is teaching hospitals that treat most persons insured by Medicaid and those without insurance. It is true that some physicians in private practice do Medicaid patients but not do so. These two facts lead to serious accessibility problems for individuals and help create “maternity care deserts”.
Obstetrics and Gynecology Residency Education
In 2023 a total of 1503 positions were offered in the Obstetrics/Gynecology match held in March. 1499 of these positions were filled. The number of applicants in the 2023 matching program for obstetrics and gynecology is not yet available. However, in 2022 there were a total of 2044 applicants for 1503 positions. Thus 541 individuals who wished to be obstetrician/gynecologists did not enter a residency. No data is available regarding their future education. Many presumably went into other specialties and some reapplied to obstetrics and gynecology residencies. There were 1102 MD students and 46 MD graduates from previous match years for a total of 1148 that filled these positions. 249 DO students and 15 DO graduates filled additional places for a total of 264. 49 US citizens who had received their education in other countries (called US IMGs) were placed in 49 positions and 38 non-citizens who trained in other countries received positions. Individuals who complete their residencies either enter general obstetrical and gynecology practice or continue their training in a fellowship. The Maternal-Fetal Medicine Fellowship prepares obstetrics and gynecology specialists in high-risk and complicated obstetrics. These physicians practice in large regional hospitals and major teaching hospitals and are important members of the maternity health care team. In addition to direct care, they conduct clinical studies and basic research on pregnancy and birth. Obstetrics and Gynecology residencies are four years in length. Board certification is given following a comprehensive written and oral examination. Maternal-fetal medicine fellowship is three years post residency and to be certified the physician must pass both a written qualifying examination and an oral examination as well as write a research thesis.
Family Medicine Residency Education
Family Medicine physicians also receive education in obstetrical care. The residency program is three years in length. Currently only 6.7 percent of Family Medicine practitioners perform obstetrical care and many practice in rural and underserved areas. To be credentialed in obstetrics care they need to have performed at least 60 deliveries. To be credentialed in obstetrics with surgical qualifications allowing for the performance of cesarean sections they must have at least 60 deliveries and at least 50 cesarean sections as primary surgeon verified by a mentor. These qualifications can be obtained in a residency and in practice in order to obtained certification by the Board of Family Medicine. In 2023 Family Medicine programs offered 5088 positions. 4460 positions were filled. 1484 were filled by medical students soon to graduate and 90 positions were filled by MD graduates. Thus 1514 MDs were matched to Family Medicine. 1511 positions were filled by DO students soon to graduate while 70 DO graduates where matched for a total of 1581. 743 places were filled by US IMGs and 562 by non-US citizen IMGs.
Since there are physician graduates who enter the match and do not obtain a residency position, the concern is what do they finally do. Most individuals reapply and within a year or so are matched to a residency. In the meantime, they are not able to use their medical skills in most states. They either elect to work in medical or basic science research or work in areas of health care In nine states they can obtain an associate physician license and work as a physician under the supervision of a licensed physician. This is type of licensing provides the associate physician with the ability to maintain their medical skills and to provide help to physicians in practice. Physicians who work with associate physicians as well as advanced practice nurses, midwives, and physician assistants and who respect the scope of practice of all providers express the opinion that the associate physician is a welcome and useful addition to their team.
Solution in detail
Given this extensive review of physician education and funding of residency education what are the solutions can be suggested. First, the federal funding system should be evaluated in order to fund positions that are more geographically distributed. Because federal funds are involved in graduate medical education it is necessary to make very certain in an era of debate about national budgets that both the public and their elected representatives in Washington, DC understand the needs of residency education. They need to understand the cost to our economy when all persons in the country do not have access to and obtain adequate medical care. There are published studies which present the costs to our society when diseases are neglected and when preventive care and wellness is not provided and especially when maternity care is not adequate. Maternal mortality costs the United States a great deal of money. In 2020 the cost of maternal mortality to our society was $27 billion! The public in general and our leaders need to know this cost. A serious effort by professional societies should be made to get this important message and facts to US citizens. When the Medicare and Medicaid reimbursement plan was initiated, the funds were allocated to hospitals as internships and residencies were functioning as service to hospitals and were not necessarily considered to be educational. The graduate medical educational programs In associated with medical schools and their affiliated hospitals as well as the ACGME Residency Review Committees have worked diligently to ensure that the educational mission of residency programs is advanced rather than service by a resident. The funding does go to hospitals by complex mechanisms. These mechanisms should be simplified and thought should be given to mechanisms that encourage education. For instance, the number of positions should depend on workforce needs and not necessarily on the needs of individual hospitals and their corporations. The funding mechanism should be evaluated to ensure an equal geographic distribution according to actual health care needs of populations. Residency programs should be encouraged to provide experience to trainees in underserved areas as part of their leaning. Since sufficient clinical experience is essential for the education of all health care providers and that a team approach to care will promote optimal care to all areas of the United States a national program to integrate side by side education of physicians with advanced practice nurses, physician associates and midwives will ensure that all health care professional student receive the necessary clinical experiences need to provide safe care of all our population. If this is not done by professional consensus at a national level there will continue to be competition for adequate clinical experience of all practitioners. Patient simulations have assisted in teaching mandated clinical skills and is encouraged for beginning skills but students need supervised experience in clinical situations. Workforce projections should become more generally known. Without adequate numbers of physicians in obstetrics we will not reduce our high maternal mortality. Medial educators must continue their efforts to increase the needed cultural, socioeconomic, racial, and geographical diversity of the physician workforce to ensure excellent outcomes low maternal mortality. We cannot afford to do any less.
References:
https://amc.org/data-reports/workforce/data/complexities-physician-supply-and-demand-projections-2019-2034
Campion Fund Blog April 30, 2023. US maternal mortality costs our economy. https://campionfund.org/blog-and-education/blog
Campion Fund Blog April 5, 2023. Increases maternal mortality: we need to act. https://campionfund.org/blog-and-education/blog
Campion Fund Blog October 3, 2022. US maternal mortality rate is still high. https://campionfund.org/blog-and-education/blog
Campion Fund Blog August 3, 2022. The United States maternal mortality rate is the worst rate among developing countries. This is a scandal. https://campionfund.org/blog-and-education/blog
Campion Fund Blog November 19, 2019. Maternal mortality is too high in the UDS. https://campionfund.org/blog-and-education/blog
https://www.healthgrades.com/pro/8-things-to-know-about-the-ob-gyn-shortage
Leppert, PC, Partner, SF, Thompson, A. Commentary: Learning from the Community about Barriers to Health Care, Obstetrics and Gynecology. Obstetrics and Gynecology 87: 140-141, 1996.
https://www.nationalreview.com/2021/10/america-cant-fix-its-doctor-shortage-without-fixing-federal-financing/
https://www.niskanencenter.org/unmatched-repairing-the-u-s-medical-residency-pipeline/
https://www.nrmp.org/wp-content/uploads/2023/04/Advance-Data-Tables-2023_FINAL-2.pdf
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Tipton M. Unmatched medical graduates help address physician shortage in Utah. Utah Physician: June/July 2023: 6-11