HOW WILL GRADUATE MEDICAL-EDUCATION REFORM AFFECT SPECIALTIES AND GEOGRAPHIC AREAS

Objectives.-To project specialty and geographic impacts of workforce r eform proposals on the practice output of graduate medical education ( GME). Design.-A demographic life-table model to predict GME output was developed using 1987 cohort data from the Association of American Med ical Colleges Annual GME Census. The 1992 GME cohort was used as a bas eline to compare the simulated impact of alternate specialty and regio nal policies. Setting.-Allopathic and osteopathic GME programs in the United States. Main Outcome Measure.-Projected number of physicians (M Ds and DOs) entering nine categories of practice specialty at the conc lusion of GME. Results.-lf GME input is reduced to 110% of US medical graduates with 55% entering practice as generalists (including obstetr ics and gynecology), then the total number of first-year positions wil l decline from 24 433 to 18 783, and the total number of residents in GME would decline from 103 858 to 80 699 at equilibrium. Even with a 1 10% restriction on GME input, the overall physician-to-population rati o will continue to grow, albeit at a much slower rate. The number of g eneralists leaving GME annually would increase by 742 (9%) and the num ber of specialists would decline by 6517 (44%). At the regional level, allocating GME positions by prorating to the current distribution res ults in less change than would prorating positions to regional populat ions. Conclusion.-Achieving national goals of reduced aggregate physic ian production, reduced specialist supply, and generalist increases wi ll require significant alterations in the GME pool. Adequate time and funding for resident substitution will be required for hospitals to de velop alternate models of providing service to allow national workforc e goals to be met.