Health policy

Expanding GME, rather than expanding scope of practice, can alleviate looming physician shortage, DO writes

Harris Ahmed, DO, MPH, emphasizes the importance of strategic GME expansion and physician involvement in advocacy efforts.

Though ophthalmology resident Harris Ahmed, DO, MPH, initially frames the growing physician shortage as an issue highlighted by COVID-19 in a review article he cowrote and recently published in Cureus, he has been interested in physician workforce issues for years.

Dr. Ahmed has spent much of his life in government-designated Health Professional Shortage Areas (HPSA), having grown up in California’s Inland Empire region, graduated from The Burrell College of Osteopathic Medicine at New Mexico State University, and returned to the Inland Empire for residency at Loma Linda University Medical Center. The physician shortage hits close to home for him, and he says the osteopathic profession is uniquely positioned to help address it.

“So much of what I’ve seen in legislative discussions addressing the shortage over the last five years is related to filling gaps with non-physician providers,” Dr. Ahmed said. “That was always puzzling to me; why would we look towards non-physicians to fix a physician shortage? I felt that the issue is better characterized as a distribution issue, which is what led to writing this paper with [J. Bryan Carmody, MD, MPH].”

In this edited Q&A, Dr. Ahmed explains how the strategic expansion of graduate medical education (GME) could help solve the shortage and get more specialists in areas that need them and what DOs can do to make sure their voices are heard.

What’s the best legislative route for addressing the physician shortage?

The biggest issue, as I alluded to in the paper, is that the Centers for Medicare and Medicaid Services account for the majority of GME funding. But since the 1997 Balanced Budget Act passed, there’s been a cap on the number of residents who could receive direct GME funding from CMS.

A lot of people are not giving sophisticated solutions to the cap issue; they’re just saying “lift the cap.” That’s not going to help because in the last 23 years, new residency positions that were created in spite of the cap have been disproportionately located in already physician-dense areas. That likely wouldn’t change without a cap unless there are additional strategic incentives to drive growth towards high-need areas.

It’s really important that we talk about strategic GME expansion. The paper discusses multiple GME expansion bills that were introduced in the last few years that are very targeted. They expand funding for residency spots in high-need areas in specialties that are most needed. That’s the future we need to move toward.

Other programs that could help are Public Service Loan Forgiveness programs or any similar program that provides loan forgiveness in exchange for service in high-need areas.

What are some concerns you have about the way the shortage is currently being addressed?

What frustrates me, coming from the Inland Empire, is: Why do legislators think that my family and friends don’t deserve funding to have physicians in their communities, and instead just send non-physician clinicians to be the caretakers of our communities?

That’s troubling to me because it lends itself to a two-tiered health care system, where those in areas that are saturated with physicians maintain their full access to physician-led care, while those in underserved areas don’t. That’s why it’s important to focus on targeted strategies.

Everyone on a health care team is uniquely trained and valuable, but the training between different members of the health care team is different. Non-physician providers such as nurse practitioners and physician assistants are critical members of those teams, but not substitutes for physicians.

Why is osteopathic medicine so well-suited to address the urgent need for physicians in underserved areas?

DO schools tend to be in these high-need areas to a greater extent than allopathic schools are. DO schools also tend to recruit students from high-need communities, and after those students graduate, they are more likely to practice in high-need areas. A study I co-authored that was published recently in The Journal of the American Osteopathic Association found that DO ophthalmologists in Michigan are more likely to practice in smaller rural communities than their MD counterparts.

I actively sought out a residency position in a high-need area. That’s the kind of practice environment that, for me, is the most rewarding.

How can DOs get involved and make sure their opinions are heard and understood by legislators?

If physicians are not at the table, other people make decisions for us. One of the ways other lobbies and groups have been so effective is by sticking together as a group. So we have to be active in our national and state associations, because that’s how you get strength in numbers.

Physicians are the best possible advocate for patients, so it’s critically important for us to be involved in advocacy.

Related reading:

A case for a paradigm shift in rural health care

Physician shortages have states offering perks to new doctors. Is it working?


  1. Hailey Dempster

    Interesting read. It is clear that solutions to the physician shortage need to be strategic. We need to think about the future and what will happen 10 or 15 years down the line. Filling This gap by a blanket lifting of the cap or expanding scope of work for non physician providers puts a band aid on a hemorrhage.

  2. kB

    This is a thoughtful article that speaks to some cureent issues in Healthcare. And with funds being diverted from physician education to Non physician education the physician shortage will be worse because of poor planning.

  3. DO

    Interesting concept.

    However, I believe the majority of DO’s don’t want to practice in rural or such isolated areas.

    Many tend to gravitate towards the cities and more populous areas.

    The use of Non-Physician providers in rural areas makes sense unfortunately

    1. OMSIV

      The data suggests the opposite of your experience.

      From PCPs to Surgical sub specialists, DOs tend to gravitate to smaller cities and communities. I invite you to check out the citations in the Cureus article cited here

      1. DO

        You can move to small cities, away from the major population centers.

        I will stick to being in the suburbs of these major population centers

  4. Proud DO

    DOs do a better job of serving the underserved – as compared even to midlevels. The answer is not midlevel expansion of scope and/or giving up supervision of midlevels. As a physician with public health graduate training as well as experience in both physician demography and public health in addition to medicine – I wholeheartedly agree with the main line of this article: physicians need to get off the sidelines and chart our own legislative course rather than have others do it for us.

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