The Tragedy of the Medical Education Commons.

‘‘N ip. Tuck. Or Else. ’’ jumped out at me from the cover of a Time magazine issue this past summer. Subtitled ‘‘Why You’ll Be Getting Cosmetic Procedures Even if You Don’t Really Want To,’’ the article described the huge increase in US physicians who provide cosmetic treatments. Those of us who forego the wide variety of available procedures are now termed natural agers, a term that was news to this geriatrician. According to Time, in 2014, US doctors performed more than 15 million cosmetic procedures and treatments at patient costs of $13 billion. I learned that the most common procedure in the United States is breast augmentation, but there are many popular interventions, including the ‘‘Cinderella’’ procedure (to shorten a toe to better fit into highheeled shoes) and Botox injections, now provided by 83% of dermatologists. Dermatology and plastic surgery are among the most competitive specialties in terms of the ratio of applicants to positions, with the average annual earnings approximately double that of the average family medicine physician. This surprising information prompted me to consider our graduate medical education (GME) training pipelines in the context of Professor Garrett Hardin’s 1968 essay, ‘‘The Tragedy of the Commons. ’’ In writing about the population explosion, Hardin used the metaphor of the commons, which is overgrazed because of individual self-interest, to the detriment of the larger group. Although largely inaccurate in terms of actual history, this powerful metaphor of individual pursuits eroding a resource shared by all resonates with workforce issues facing GME today. Hardin’s enduring contribution has been the tenet that future generations must have a moral ‘‘voice’’ in decisions made today. That is, the welfare of future generations should be considered in decisions about resources held in common. In 2015, the National Resident Matching Program (NRMP) reported the largest main residency match in history with more than 27 000 postgraduate year (PGY) 1 positions, an increase of approximately 600 first-year positions from 2014. In fact, despite warnings of imminent shortages of residency positions, the overall number of residency positions has been increasing, and the number of first-year positions continues to be greater than the number of US graduating medical student applicants. The number of positions in specialty matches outside the NRMP also appears to be increasing. However, in what fields are new training slots found? Despite the 1997 caps for Medicare-funded GME positions, since 2001, resident and fellow positions have increased each year (TABLE). Most of these new positions were funded through Medicaid (the secondlargest payer for GME) and nongovernment sources, such as hospitals or departments, sponsoring individual programs. Until recently, most of the increase was in non–primary care subspecialties. In the past 5 years, this trend has altered, with increases in core residency positions in internal medicine and family medicine. In 2015, about half of the new first-year positions offered in the Match were in primary care specialties: family medicine, internal medicine, and pediatrics. While usually 95% of family medicine graduates enter primary care, only about 22% of internal medicine and 45% of pediatrics graduates remain in primary care after training. Examining trends in family medicine, medicine-primary, pediatrics-primary, and medicine-pediatrics residencies may provide a more accurate approach to predicting the future supply of primary care physicians: these numbers remain flat (TABLE). The cost of training future physicians through residency and fellowship has grown exponentially since the days when residents lived in the hospital and rode in ambulances. Many groups have presented thoughtful proposals for expanding GME funding and positions through increasing the pool of payers for GME and linking payment to training quality, among other approaches. None of these proposals consider a reduction in total funding. Although not an expert in health care politics or policy, I do not perceive a national appetite for increasing funding for GME. Traditionally, GME-conferring institutions have focused on educational quality and adherence to accrediting body requirements for ongoing and new GME programs. They have less often, or not at all, considered the needs of the region or state in ‘‘right-sizing’’ programs for an optimal distribution of specialties. As long as funding was available and stable, it did not DOI: http://dx.doi. org/10.4300/JGME-D-15-00552.1