New Paradigms for 

Physician Training for 

Improving Access to 

Health Care

S E P T E M B E R 2007

COUNCIL ON GRADUATE MEDICAL EDUCATION

Eighteenth Report

COUNCIL ON GRADUATE MEDICAL EDUCATION

Eighteenth Report

New Paradigms for 

Physician Training for 

Improving Access to 

Health Care

S E P T E M B E R 2007
ii EIGHTEENTH REPORT OF COGME

The views expressed in this document are soley those of 

the Council on Graduate Medical Education and do not 

necessarily represent the views of the U.S. Government.
EIGHTEENTH REPORT OF COGME iii

Table of Contents

The Council on Graduate Medical Education ................................................................................................v

Members of the Council ................................................................................................................................. vii

Executive Summary ...........................................................................................................................................1

Background ........................................................................................................................................................3

The Access Quagmire ....................................................................................................................................3

Mandatory Service for the U.S. Military .......................................................................................................3

The Global Experience ..................................................................................................................................3

Mandatory Service Considerations ................................................................................................................4

Recommendations

RECOMMENDATION 1: Increase Access to Health Care Using Incentive-based Models ................................5

RECOMMENDATION 2: Increase Federal and State Loan Repayment Programs ............................................5

RECOMMENDATION 3: Increase Admission of Students from Underserved Areas in 

 Medical Schools .........................................................................................................................................6

RECOMMENDATION 4: Create a National Medical School .............................................................................8

RECOMMENDATION 5: Expand Strategic Access (e.g., Title VII) Funding Cap ...........................................10

Appendix A: Two Models of Successful Recruitment in Underserved Areas .............................................11

Appendix B: Proposal for the Operation of a United States Public Health National 

 Medical School .............................................................................................................................................13

References .........................................................................................................................................................15
iv EIGHTEENTH REPORT OF COGME
EIGHTEENTH REPORT OF COGME v

The Council on Graduate Medical Education

The Council on Graduate Medical Education (COGME) was authorized by Congress in 1986 to provide 

an ongoing assessment of physician workforce 

trends, training issues, and fi nancing policies and to recommend appropriate Federal and private-sector efforts to 

address identifi ed needs. The legislation calls for COGME 

to advise and make recommendations to the Secretary of 

the Department of Health and Human Services (DHHS); 

the Senate Committee on Health, Education, Labor, and 

Pensions; and the House of Representatives Committee 

on Commerce. Since 2002, COGME has been extended 

through annual appropriations.

The legislation specifi es 17 members for the Council. 

Appointed individuals are to include representatives of 

practicing primary care physicians, national and specialty 

physician organizations, international medical graduates, 

medical student and house staff associations, schools of 

medicine and osteopathy, public and private teaching 

hospitals, health insurers, business, and labor. Federal 

representation includes the Assistant Secretary for Health, 

DHHS; the Administrator of the Centers for Medicare and 

Medicaid Services, DHHS; and the Chief Medical Director 

of the Veterans Administration.

CHARGE TO THE COUNCIL

The charge to COGME is broader than the name 

implies. Title VII of the Public Health Service Act, as 

amended, requires COGME to provide advice and recommendations to the Secretary and Congress on the following 

issues:

1. The supply and distribution of physicians in the United 

States;

2. Current and future shortages or excesses of physicians in 

medical and surgical specialties and subspecialties;

3. Issues relating to international medical school 

 graduates;

4. Appropriate Federal policies with respect to the 

matters specifi ed in items 1–3, including policies 

concerning changes in the fi nancing of undergraduate 

and graduate medical education (GME) programs and 

changes in the types of medical education training in 

GME programs.

5. Appropriate efforts to be carried out by hospitals, 

schools of medicine, schools of osteopathy, and accrediting bodies with respect to the matters specifi ed 

in items 1–3, including efforts for changes in undergraduate and GME programs; and

6. Defi ciencies and needs for improvements in databases concerning the supply and distribution of, and 

postgraduate training programs for, physicians in 

the United States and steps that should be taken to 

eliminate those defi ciencies.

In addition, the Council is to encourage entities providing GME to conduct activities to voluntarily achieve the 

recommendations of the Council specifi ed in item 5.

COGME PUBLICATIONS

Reports

Since its establishment, COGME has submitted the 

following reports to the DHHS Secretary and Congress:

• First Report of the Council (1988);

• Second Report: The Financial Status of Teaching 

Hospitals and the Underrepresentation of Minorities 

in Medicine (1990);

• Third Report: Improving Access to Health Care 

Through Physician Workforce Reform: Directions 

for the 21st Century (1992);

• Fourth Report: Recommendations to Improve Access 

to Health Care Through Physician Workforce Reform 

(1994);

• Fifth Report: Women and Medicine (1995);

• Sixth Report: Managed Health Care: Implications 

for the Physician Workforce and Medical Education 

(1995);

• Seventh Report: Physician Workforce Funding Recommendations for Department of Health and Human 

Services’s Programs (1995);

• Eighth Report: Patient Care Physician Supply and 

Requirements: Testing COGME Recommendations 

(1996);

• Ninth Report: Graduate Medical Education Consortia: Changing the Governance of Graduate Medical 

Education to Achieve Physician Workforce Objectives 

(1997);

• Tenth Report: Physician Distribution and Health Care 

Challenges in Rural and Inner City Areas (1998);

• Eleventh Report: International Medical Graduates, 

The Physician Workforce and GME Payment Reform 

(1998);

• Twelfth Report: Minorities in Medicine (1998);
vi EIGHTEENTH REPORT OF COGME

• Thirteenth Report: Physician Education for a Changing Health Care Environment (1999);

• Fourteenth Report: COGME Physician Workforce 

Policies: Recent Developments and Remaining Challenges in Meeting National Goals (1999);

• Fifteenth Report: Financing Graduate Medical 

Education in a Changing Health Care Environment 

(2000);

• Sixteenth Report: Physician Workforce Policy Guidelines for the United States, 2000–2020 (2005); and

• Seventeenth Report: Minorities in Medicine: An Ethnic and Cultural Challenge for Physician Training, an 

Update (2006).

OTHER COGME PUBLICATIONS

• Scholar in Residence Report: Reform in Medical 

Education and Medical Education in the Ambulatory 

Setting (1991);

• Process by which International Medical Graduates are 

Licensed to Practice in the United States (September 

1995);

• Proceeding of the GME Financing Stakeholders Meeting (April 11, 2001) Bethesda, Maryland;

• Public Response to COGME’s Fifteenth Report (September 2001);

• Council on Graduate Medical Education and National 

Advisory Council on Nurse Education and Practice: 

Collaborative Education to Ensure Patient Safety 

(February 2001);

• Council on Graduate Medical Education: What Is It? 

What Has It Done? Where Is It Going? 2nd edition 

(2001);

• 2002 Summary Report (2002).

COGME RESOURCE PAPERS

• Preparing Learners for Practice in a Managed Care 

Environment (1997);

• International Medical Graduates: Immigration 

Law and Policy and the U.S. Physician Workforce 

(1998);

• The Effects of the Balanced Budget Act of 1997 on 

Graduate Medical Education (2000);

• Update on the Physician Workforce (2000);

• Evaluation of Specialty Physician Workforce Methodologies (2000); and

• State and Managed Care Support for Graduate Medical Education: Innovations and Implications for Federal Policy (2004).

For more information on COGME, visit the Council’s 

Web site at:

http://www.cogme.gov or contact:

Council on Graduate Medical Education

5600 Fishers Lane, Room 9A-21

Rockville, MD 20857

Voice: (301) 443-6326

Fax: (301) 443-8890
EIGHTEENTH REPORT OF COGME vii

Members of the Council on Graduate 

Medical Education

Kendall Reed, D.O., F.A.C.O.S., F.A.C.S.

Dean and Professor of Surgery

Des Moines University

College of Osteopathic Medicine

Des Moines, Iowa

Earl J. Reisdorff, M.D.

Director of Medical Education

Department of Medical Education

Ingham Regional Medical Center

Lansing, Michigan

Vicki L. Seltzer, M.D.

Professor and Chairman

Department of Obstetrics and Gynecology

Long Island Jewish Medical Center

New Hyde Park, New York

Jason C. Shu, M.D.

OB / GYN, Pennsylvania State University

Montoursville, Pennsylvania

William L. Thomas, M.D., F.A.C.P.

Executive Vice President for Medical Affairs

MedStar Health

Columbia, Maryland

Leana S. Wen, M.D., M.A.

Merton College

University of Oxford

Oxford, United Kingdom

Statutory Members

Assistant Secretary for Health

Department of Health and Human Services

Washington, D.C.

Administrator

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Washington, D.C.

Undersecretary for Health

Veterans Health Administration

Department of Veterans Affairs

Washington, D.C.

Chair

Russell G. Robertson, M.D.

Professor and Chair, Department of Family Medicine

Feinburg School of Medicine

Northwestern University

Chicago, Illinois

Vice Chair

Robert L. Phillips, Jr., M.D., M.S.P.H.

Director

The Robert Graham Center: Policy Studies in Family 

Medicine and Primary Care

Washington, D.C.

Denice Cora-Bramble, M.D., M.B.A.

Executive Director

Goldberg Center for Community Pediatric Health, 

Children’s National Medical Center

Washington, D.C.

Joseph Hobbs, M.D.

Professor and Chair, Department of Family Medicine, 

and Vice Dean for Primary Care and Community 

Affairs

School of Medicine

Medical College of Georgia

Augusta, Georgia

Mark A. Kelley, M.D.

Executive Vice President

Henry Ford Health System

Detroit, Michigan

Rebecca M. Minter, M.D.

Assistant Professor, Department of Surgery

University of Michigan

Ann Arbor, Michigan

Thomas J. Nasca, M.D., M.A.C.P.

Senior Vice President and Dean

Thomas Jefferson University

Jefferson Medical College

Philadelphia, Pennsylvania

Angela D. Nossett, M.D.

Edward R. Robal Comprehensive Health Center

Los Angeles, California
viii EIGHTEENTH REPORT OF COGME

Designee of the Assistant Secretary for Health

Anand Parekh, M.D., M.P.H.

Senior Medical Advisor

Offi ce of Public Health and Science

Offi ce of the Assistant Secretary for Health

Washington, D.C.

Designee of the Centers for Medicare and 

Medicaid Services

Tzvi M. Hefter

Director

Division of Acute Care

Centers for Medicare and Medicaid Services

Baltimore, Maryland

Designee of the Department of Veterans Affairs

Barbara K. Chang, M.D., M.A.

Director of Medical and Dental Education

Offi ce of Academic Affi liations

VHA Central Offi ce (141),

Washington, DC and

Albuquerque, New Mexico

Staff, Division of Medicine and Dentistry, Bureau of 

Health Professions, HRSA, Department of Health and 

Human Services, Rockville, Maryland

Marilyn Biviano, Ph.D

Director, Division of Medicine and Dentistry

Lou Coccodrilli, MPH

Deputy Director, Division of Medicine and Dentistry

Jerald M. Katzoff

Executive Secretary and Designated Federal Offi cial 

for COGME

Eva M. Stone

Program Analyst and Committee Management Specialist 

for COGME

Anne Patterson

Secretary

Report Writing Group

Earl J. Reisdorff, M.D., Chair

Angela D. Nossett, M.D.

Russell G. Robertson, M.D.

Anand K. Parekh, M.D.

Jason C. Shu, M.D.

William L. Thomas, M.D.

Leana S. Wen, M.D.

Contractor for Resource Paper Preparation

Insight Policy Research, Inc.
EIGHTEENTH REPORT OF COGME 1

Executive Summary

The United States invests signifi cant resources in the 

education and training of physicians while at the 

same time it faces signifi cant medical access problems both in rural areas and among the urban uninsured. 

Physicians, who in part benefi t from society’s investment in 

their training, may have an obligation to repay society for 

some of the benefi ts they received during their training. A 

system of mandatory physician national health care service 

directed toward improved access and reducing disparities 

could provide a vehicle by which physicians would recompense society while addressing an urgent national need. 

Though such a system may be attractive to some, its success 

would not be guaranteed, as both its cost and impact on 

the practice of medicine are uncertain, and such mandatory 

service is antithetical to American values. Therefore, in the 

absence of a mandatory service requirement, how can the 

American medical profession provide greater incentives 

to physicians to engage in public service directed toward 

enhanced access to medical services for those who have 

historically experienced access problems?

At the September 2005 meeting, the Council on Graduate Medical Education (COGME) decided to review the 

topic of a mandatory national health care service requirement for physicians. The discussion was guided by two 

beliefs: First, the development of an adequate physician 

workforce is necessary to deliver health care to all Americans. An adequate workforce is one that is both suffi cient 

in size and appropriately geographically dispersed such 

that most Americans do not experience an access problem. 

The group concluded that even if a perfect system for 

distributing a medical workforce could be developed, an 

insuffi cient number of physicians would, de facto, create 

medical access problems. Therefore, fi rst and foremost, a 

suffi cient cadre of physicians must be trained.

Second, given the role physicians play in society and 

the tremendous amount of public resources that are devoted 

to the training of doctors, physicians have some public 

obligation to society at large. The group felt that this social obligation should be embraced by the profession and 

remembered by physicians.

The group explored the problems caused by limited access to health care by many members of the public and the 

potential nature of the social obligation physician’s bear as 

a result of the graduate medical education (GME) support 

they received during their training. As it was generally felt 

that mandatory service is not a viable consideration, the 

group focused on alternative strategies that could improve 

access to health care in rural and urban areas.

At the September 2006 meeting of the COGME, three 

commissioned papers that were presented discussed a 

mandatory physician national service requirement. Those 

presentations were as follows:

• Doug Campos-Outcalt, M.D., M.P.A., “Mandatory 

Social Service for Physicians: A Discussion of 

 Issues” [1]

• Robert Graham, M.D., “Mandatory Service for Physicians: Issues and Approaches” [2]

• Roger A. Rosenblatt, M.D., “Is Mandatory National 

Service for Physicians Desirable and Feasible?” 

(presented by Robert Graham, M.D.) [3]

Though these papers raised a range of poignant issues, 

the most troubling was whether a national service program 

could adequately address physician geographic or specialty 

maldistribution. The authors agreed that while physicians 

have a social obligation to provide medical care to all persons, regardless of their social-income status, mandatory 

service was neither the desirable nor feasible mechanism 

for achieving this goal. These papers, and the group’s 

discussions, form the basis for this report.

Briefl y, the fi ve recommendations discussed in this 

report are as follows:

1. Existing programs should be expanded and new models of training developed that focus on delivering care 

in areas of high medical need. This should include an 

incentive-based, non-mandatory structure that encourages medical school and residency graduates to serve 

in such practice settings.

2. Federal loan programs through the National Health 

Service Corps (NHSC), the Department of Defense, 

the Department of Veterans Affairs, and State-based 

loan repayment programs should be enlarged to 

increase the number of physicians serving in underserved areas.

3. Incentives should be created that encourage medical 

schools to recruit and prepare physicians for clinical 

practice in underserved areas.

4. A National Medical School (or system of medical 

schools)—the “United States Public Health Medical 

College” (USPHMC)—should be established. The 

USPHMC would be unique in its emphasis on service, 

public health issues, epidemiology, and emergency 

preparedness and response.

5. Funding targeted for physician training that creates 

a clinical physician workforce to serve populations 

in areas of limited access to medical care should be 

increased. For example, reinvigoration of Title VII 

funding should be considered.
2 EIGHTEENTH REPORT OF COGME
EIGHTEENTH REPORT OF COGME 3

BACKGROUND

THE ACCESS QUAGMIRE

Problems with access to health care are manifold. The 

problem is most glaring when there is no physician, of any 

kind, in a geographic area, such as in rural areas of low 

population density. A similar situation can be found in inner-city urban areas, even though there is a much higher 

physician-to-patient ratio, where other obstacles create 

impediments for many needing health care. For instance, 

in both rural and urban areas, the poor, even when covered 

by such public insurance as Medicare or Medicaid, may 

face considerable out-of-pocket costs for transportation to 

the hospital or doctor. Others, such as those with cognitive 

disorders, mental health problems, or chemical dependencies, also face access problems. In addition, the near poor, 

particularly those who are uninsured, may lack the fi nancial 

means to access services.

Access to health care involves multiple forms and 

responses. Health maintenance is important to the vitality 

of the United States. Nonetheless, medicine must also be 

able to respond effectively to patients who are acutely ill 

and injured. This range of demands requires that a mix of 

primary care physicians, surgeons, and specialists in medically and surgically based disciplines exists. A health care 

system that consists of only specialists or only primary care 

physicians would not be effective. Effective access to health 

care requires access to both generalists and specialists.

In February 1998, the COGME released its Tenth Report focused on physician distribution and medical care 

access in rural and inner-city areas in the United States. 

Eight years later, the concerns articulated in that report 

persist. A lack of health insurance and the exigencies of 

geographic location result in limited access to health care 

for large numbers of people. The two dominant barriers 

to access (inadequate insurance coverage and geographic 

location) are clearly separate problems. However, given 

the aggregate effect of these issues on health care access, 

they are joined in our discussion.

One option for solving the nation’s access problem may 

be mandatory national service for physicians. One justifi cation for mandatory service would be the public’s return on 

the public’s investment in the training of physicians. Below, 

we examine the United States’ prior experience with mandatory physician service in the military and the experience of 

other countries with mandatory service requirements.

MANDATORY SERVICE FOR THE U.S. 

MILITARY

Mandatory physician service has a historical precedent 

in the United States. During the Korean War, there was an 

increased need for physicians to support the military. An 

initial plan to meet the military’s need was established by 

Congress in 1950 (Public Law 779) and was labeled the 

“Doctor Draft Law” [4]. Under the subsequent “Berry 

Plan,” established in 1954, physicians received deferments while acquiring specialized training, after which 

they fulfi lled their military obligations. The Berry Plan, 

implemented despite the opposition of the American 

Medical Association, the Association of American Medical Colleges, and the American Hospital Association, was 

discontinued in 1974 after the Vietnam War.

In total, from 1950 to 1973, there were more than 

23,000 physicians enlisted into military service through 

the Berry Plan and its predecessor [4–7]. It is likely that 

mandatory military service prompted some physicians to 

participate in alternative, civilian voluntary service plans 

akin to the NHSC. However, the impact of a military 

service requirement on public access to care and other 

competing public health service programs is unclear.

Eventually the armed services were able to adequately 

meet their physician workforce requirements without mandatory military service. One of the ways in which this is 

accomplished today is through the successful Uniformed 

Services University of Health Sciences, service-linked 

scholarship programs, physicians voluntarily participating 

the National Guard and Military Reserve programs, and 

voluntary enlistees [6,8].

THE GLOBAL EXPERIENCE

The problem of access to medical care is a common 

concern throughout the world: “Practically all countries 

have problems bringing about an equitable distribution of 

health manpower” [9]. Some national attempts to address 

the issue are instructive. Some nations attempt to solve 

this through the establishment of mandatory service programs. Australia, for instance, has sought to meet its access 

needs (in lieu of a mandatory service program) through 

the active recruitment of international medical graduates 

(IMGs) [10]. While IMGs have placed physicians in remote areas, such efforts have also created challenges with 

language skills and verifi cation of credentials. Spike [10] 

concludes that the result of the Australian effort “is that 

the most under-serviced regions of the country continue 

to be under-serviced by less qualifi ed doctors for reasons 

of political expediency.”

Other countries address the issue of inadequate 

medical access in remote areas by requiring physicians 

to participate in mandatory service programs. One of the 

earliest programs was instituted in the Soviet Union in 
4 EIGHTEENTH REPORT OF COGME

1920. This program required a three-year commitment to 

rural areas.

In 1936, Mexico was the fi rst Latin American country 

to use a mandatory service program. The pasantia system 

initiated a one-year service requirement for medical school 

graduation [11]. Cuba followed with a compulsory rural 

service program for medical graduates in 1960, and the 

Dominican Republic adopted a pasantia system in the 

1960s [12,13]. Ecuador and Bolivia have also adopted 

mandatory service models that attempt to minimize health 

care maldistribution, especially in rural areas [14].

The system in Ecuador (established in 1970) has been 

carefully studied [15,16]. A close examination of the 

Ecuadorian system illustrates the challenges confronting 

mandatory service programs. All graduates from medical, 

dental, and nursing schools must perform one year of rural 

service as a condition to obtaining a medical license. Physicians participating in the program have expressed several 

concerns, including the appropriateness of their training for 

placement in rural areas and the importance of public health 

initiatives, such as clean water, waste disposal, and quality 

housing in addition to traditional medical services.

Another example is Puerto Rico [17]. In 1978 (despite 

opposition by students, hospitals, and organized medicine), 

Puerto Rico began requiring all persons entering the health 

professions to provide one year of service in a regionalized health care system. This system served 60% of the 

population, and the requirement involved many different 

types of health care professionals (e.g., nurses, medical 

technologists) [17]. In essence, this system acted as a de 

facto compulsory health care draft that deployed physicians to rural areas.

The success of international programs to remedy defi -

ciencies in health care access has not been systematically 

studied. The ultimate impact of physician supply in Central 

and South America regarding the provision of health care 

to underserved areas remains undetermined. Several of the 

countries, including Argentina, Bolivia, Chile, Columbia, 

Dominican Republic, Ecuador, and Mexico actually report a physician surplus. This surplus could theoretically, 

through market force diffusion, further drive physicians 

into rural areas and, at least in part, improve medical access 

in their rural areas.

The ultimate translation of these programs into a 

U.S. model (as well as the limitations they experience) is 

uncertain. After reviewing these programs, Rosenblatt’s 

commissioned paper for the COGME concluded:

“The impact of these programs had been diffi cult to 

assess, and there is a dearth of rigorous studies of their 

effectiveness and viability. It is clear from existing information that it is possible to create and sustain such programs 

over a period of decades, although not necessarily with enthusiastic support of those required to serve. Whether these 

models can be adapted to the U.S. context is more diffi cult 

to appraise. Perhaps more problematic is the fact that these 

programs have not been proved to be effective in improving 

the problems they were designed to address” [3].

MANDATORY SERVICE 

CONSIDERATIONS

Overall, mandatory service may not be a favorable approach to addressing the medical access issue. Currently, 

GME already supports and improves health care access to 

marginalized persons. Teaching hospitals and their training programs provide a substantial amount of service to 

lower socioeconomic groups. Nonetheless, the absolute 

value of this service is poorly quantifi ed. Undoubtedly, in 

the absence of teaching programs, the impact of indigent 

care on private physician practices and for-profi t hospitals 

would be substantial.

The barriers to establishing a mandatory service program are manifold. Key hurdles include:

• Loss of autonomy: The discipline of medicine requires a tremendous degree of intellectual autonomy, 

and physicians tend to be independent [18]. Requiring 

a physician to set aside his or her career at the behest 

of a mandatory service program is antithetical to the 

notion of independence.

• Cost: Currently, the Centers for Medicare and Medicaid Services (CMS) provides more than $8 billion 

in Indirect Medical Education and Direct Graduate 

Medical Education funding for residency and fellowship training. A mandatory program involving all residency graduates that paid a stipend of $75,000/year 

would amount to an additional $1.8 billion of annual 

spending. In addition to the stipend costs, there would 

be additional administrative costs.

• Creating an aversion: A mandatory service program 

would dissuade some talented people from a career 

in medicine. The degree to which this would occur 

is speculative. Nonetheless, a mandatory service 

program might be profoundly discouraging when one 

considers the effect of yet further deferring income 

in the presence of a large debt burden caused by 

student loans.

• Enforcement: The most likely manner by which 

participants would be successfully captured would be 

through the State licensing process. There would need 

to be a newfound level of cooperation between State 

and Federal agencies. Individual State agencies would 

be responsible for reporting and tracking physicians 

participating in a Federal program. In the absence of a 

funded, collaborative effort, this would be diffi cult.
EIGHTEENTH REPORT OF COGME 5

Recommendations

medical school or residency graduates. There were 

15,925 graduates from U.S. allopathic medical school 

in 2006 [21] and an additional 2,829 from osteopathic 

schools of medicine (2006) [22]. There is a brisk rate 

of increase projected for osteopathic class sizes [23]. 

Approximately 4,800 IMGs also enter clinical practice 

each year. Taken as a whole, about 23,500 new graduates would provide a pool from which service program 

participants could be selected. For the foreseeable future, 

this number should be fairly constant if Federal GME 

funding remains fi xed.

RECOMMENDATION 2: Increase funding 

of Federal and State loan repayment 

programs.

Federal loan programs through the NHSC, the Department of Defense, the Department of Veterans Affairs, and 

State-based loan repayment programs should be enlarged 

to increase the number of physicians serving in underserved areas.

Currently, NHSC positions are being adequately fi lled 

while Department of Defense positions recently are less 

consistently fi lled. The Department of Veterans Affairs 

repayment program is inconsistently used. These Federal 

programs could, and should, be expanded. Many States 

also have loan repayment programs.

In general, physicians tend to practice in metropolitan 

areas, thus neglecting rural America. The recently projected 

physician shortage will worsen already existing access 

problems and drain resources away from underserved 

areas. As the physician shortage has a local and regional 

dimension, individual States may consider expanding their 

physician placement programs to solve their specifi c needs. 

Moreover, given the expanding magnitude of medical 

student indebtedness, debt forgiveness and loan repayment 

programs may have enhanced appeal.

The Federal government has recognized geographic 

and specialty maldistribution and has largely responded 

through funding decisions. From 1991 to 2001, the funding 

for the NHSC and the Loan Repayment Program increased 

from $48 million to $78 million. Likewise, Title VII funding (largely supporting primary care initiatives) increased 

from $176 million to $266 million over the same period. 

This represents a less than 16% real increase in spending over the decade beginning 1991. This effort to craft 

a remedy to the disparity in health care access has been 

further compromised with recent funding cuts, especially 

in Title VII funding.

RECOMMENDATION 1: Increase access 

to health care using incentive-based 

models.

Existing programs should be expanded and new models of training developed that focus on delivering care in 

areas of high medical need. These should incorporate an 

incentive-based, non-mandatory structure that encourages 

medical school and residency graduates to serve in such 

practice settings.

There are existing programs that could improve access 

to health care without the imposition of a mandatory service 

requirement. Redesign and expansion of existing programs 

would be a more favorable solution than the imposition of 

mandatory service both in terms of cost and the support that 

such an initiative would garner from the profession.

Working or training in an area of high medical need 

validates the altruism that initially prompts many physicians to enter the medical profession. Clinical experience 

in a medically underserved venue provides a substantial 

understanding of the complex health issues and health care 

delivery concerns confronting the economically marginalized. Examples of such areas might include (1) rural areas 

with limited access to medical services; (2) urban centers 

with limited access to medical services largely owing to 

socioeconomic barriers; (3) areas of elevated need due to 

natural or man-made disasters, such as large-scale fl ooding or hurricanes, severe epidemics involving infectious 

disease, and mass-casualty incidents; and (4) areas that 

address military needs. This could involve fi lling medical 

service needs at domestic military bases as well as medical 

support to the families of deployed troops.

There is a considerable need for primary care physicians. It is estimated that for primary care alone, there are 

4,742 primary care shortage areas. It would take an additional 8,248 primary care physicians to fi ll these areas, 

one-third of which are in large urban locales [19].

Despite the notion that primary care physicians are 

sorely needed in most areas, there are situations wherein 

specialists are required to solve regional access issues. 

In rural areas, there is a clear need for specialty care. 

For example, the ratio of primary care physicians to 

population is 100:100,000 in urban areas and 46:100,000 

in rural areas. More dramatic is the ratio of specialist 

physicians: 181:100,000 in urban areas and 18:100,000 

in rural areas [20].

The greatest opportunity for fi lling the aforementioned positions would be through attracting recent 
6 EIGHTEENTH REPORT OF COGME

National Health Service Corps

In 1970, the NHSC was created to encourage Federal, 

State, and local collaboration to improve access to health 

care in Health Professional Shortage Areas (HPSA). Over 

time, the NHSC has become an integral part of the medical 

safety net in underserved areas. Initially, the NHSC focused 

on geographic disparities in health care access by sending 

physicians into rural areas with low physician-to-population ratios. The NHSC has since expanded the criteria for 

designation as a HPSA in an attempt to provide greater 

access for the uninsured populations in urban areas. Today, 

approximately 20% of all Americans live in a designated 

HPSA area.

The NHSC provides fi nancial incentives to health care 

providers interested in working in underserved areas. The 

fi nancial incentives are in the form of scholarships for 

medical students and loan repayment for providers who 

have completed training and are ready to practice medicine 

independently. Numerous communities across the country 

depend on NHSC participants as a key source of health care. 

In fi scal year 2005, 340 scholarship recipients and 1,223 

loan repayment physicians entered the fi eld in HPSAs of 

greatest need. Moreover, an additional 164 scholarships 

were awarded, and 86 scholarships were continued. Over 

the last 36 years, the program has placed approximately 

27,000 health care providers in service to underserved 

populations. In 2003, the NHSC boasted 78.4% retention 

of NHSC clinicians in HPSA sites.

Department of Veterans Affairs

The Department of Veterans Affairs’ Education Debt 

Reduction Program allows physicians to be reimbursed 

for medical school costs. The annual amount for reimbursement, adjusted periodically for infl ation, is between 

$6,000 and $10,000 per year, depending on the year of participation, with a cumulative maximum award of $48,000. 

Several challenges exist for this program. First, few people 

are aware of its existence, even within the Department of 

Veterans Affairs system. Second, staff must fi rst be hired 

prior to applying for debt reduction. Thus, the program 

acts more as a retention incentive, as compared to a recruitment opportunity. Specifi c procedures for applying to this 

program are outlined in the VHA Handbook 1021.1 (issue 

date: ed. May 3, 2002).

State-Sponsored Programs

Following the example of the NHSC, State agencies 

throughout the United States have created programs to 

mimic the success of the NHSC in reducing physician 

shortage areas. These State-sponsored loan repayment 

programs (SSLRPs) create partnerships with local communities, the NHSC, and other agencies within the Federal 

government or “go it alone” to offer physicians fi nancial 

incentives to practice in underserved sites. These diverse 

programs most commonly recruit primary care physicians 

still in residency with stipends. Other strategies offer 

student loan repayment to physicians who are fi nishing 

residency training.

Participation in an SSLRP generally requires a commitment of two years of full-time service in an HPSA-designated site. The amount of loan repayment varies widely 

among States. Rhode Island offers physicians a $35,000 

loan repayment per year. In North Dakota, physicians are 

paid $5,000 per year as loan repayment. Oregon’s SSLRP 

offers participants 20% of their loan per year, allowing 

physicians to be debt free in fi ve years. Given the enormity 

of this problem, the NHSC and other State loan repayment 

and scholarship programs must be more substantially 

funded in order to serve people who are “medically disenfranchised.”

Barriers to Participation

Finally, most programs are infl exible in allowing parttime participation, job-sharing, or other nontraditional 

practice options. These aforementioned programs have 

made signifi cant advances in the provision of health care 

to specifi c populations. The NHSC model is often praised 

for its success in recruiting and retaining providers in 

medically underserved areas that often offer lower provider 

salaries than that can be earned elsewhere.

Unfortunately, working at an HPSA site does not 

always guarantee loan repayment. Providers interested in 

working with the underserved must accept employment 

and apply for loan repayment with the NHSC. Providers at 

facilities with higher HPSA scores receive the greatest consideration [24]. Providers at sites with lower scores must 

wait for remaining funds after a specifi ed date. Because 

funding is not guaranteed, many needy HPSA sites have 

several position unfi lled because applicants are unwilling 

to risk this fi nancial uncertainty.

RECOMMENDATION 3: Increase 

admission of students from 

underserved areas in medical 

schools.

Incentives should be created that encourage medical 

schools to recruit and prepare physicians for clinical practice in underserved areas.

There must be an incentive for medical schools to admit 

minority students as well as students from underserved 

urban and rural areas. This would increase the likelihood 

that graduates return home to practice medicine. The 

admissions practices of many medical schools raise the 

thorny question of whether admissions committees cause 

and perpetuate the physician maldistribution problem. 
EIGHTEENTH REPORT OF COGME 7

Medical school class diversity might be enhanced if 

public or governmental representatives participated in 

the selection process. Medical school selection processes 

and admissions committees are unlikely to change in any 

signifi cant way in the absence of an incentive. To that end, 

one meaningful enticement would be to alter ranking systems’ scoring schemes to favor colleges of medicine whose 

graduates practice in areas of high medical need.

The creation of incentives for medical schools to 

produce physicians who will practice in underserved communities complements three other recommendations in this 

report: (1) increasing Federal and State loan repayment programs; (2) expanding Title VII funding; and (3) the creation 

of USPHMCs. The fi rst two recommendations address 

the issue of maldistribution of physicians by specifi cally 

reducing the economic barriers for students and trainees. 

The third recommendation, creating a Federal medical 

college, addresses targeted recruitment and subsequent 

training of students who are more committed to staying in 

underserved urban and rural communities. However, even if 

our other recommendations are successfully implemented, 

the outcome will be insuffi cient to solve the complex issues 

enfolding the physician manpower maldistribution issue. 

Both allopathic and osteopathic medical schools need to 

be partners with the communities that they serve to better 

address this problem.

Contrary to public perception, there is no explicit 

“public” policy regarding the supply and distribution of 

physicians in this country. Accordingly, the supply and 

distribution of physicians crudely follows normal economic rules of supply and demand, largely based on the 

existing reimbursement system for physician services. One 

major reason for the misalignment of physician manpower 

with public need is the nature of the selection process 

of entering medical school classes. Factors that predict 

acceptance to medical school strongly favor those with 

lifelong socioeconomic and educational advantages. The 

vast majority of students accepted into medical school 

come from urban or suburban communities and typically 

do not migrate to underserved rural or urban areas after 

training. Even students with initial intentions to practice 

in needy communities often change career paths given the 

debt they incur in obtaining their education.

While most public medical schools have a publicly 

stated mission that includes a commitment to caring for 

their communities, there is little accountability for medical 

schools, public or private, to measure outcomes, successes 

or failures, in meeting the self-proclaimed goals of community service. Instead, medical schools are largely driven 

by two major factors in the manner in which they operate: 

prestige and funding.

Prestige is fundamentally desired by all academic institutions, including medical schools. Organizations that 

rank U.S. medical schools provide a strong incentive for 

colleges of medicine to select students who enhance the 

perception of the rating agencies. Ranking organizations 

do not assess the degree to which medical schools meet 

public policy needs. Total Federal research funding, degree 

of diffi culty in gaining acceptance to the school, and the 

faculty-student ratio are three factors that are commonly 

used but do not directly address physician shortage and 

maldistribution. One example of a ranking process is that 

used by the U.S. News & World Report. The U.S. News & 

World Report rates medical schools using the following 

weighted criteria: 40% of the overall ranking is based on 

“reputation,” as determined by a survey of medical school 

deans and senior faculty; 30% is based on the total National 

Institutes of Health research funding secured by the medical school and its affi liated hospitals; and 20% is based on 

student selectivity or the “degree of diffi culty” in gaining 

acceptance. Within this ranking system, no credit is given 

to the selection of under-represented minorities or students 

originating from rural or urban underserved communities. 

Likewise, no rating points are granted for schools whose 

graduates ultimately provide care to medically underserved 

populations. In fact, most schools do not even measure 

this outcome.

Fundamental questions begged by the foregoing are 

what are the necessary qualifi cations for entering medical 

students who have a reasonable chance to succeed throughout their medical education; what is the impact of the 

current medical school admission practices on the supply 

and distribution of the physician workforce; can schools 

reasonably modify qualifi cations for the greater societal 

good of a more equitable distribution of physicians in the 

future; can societal and medical school interests reasonably 

be aligned; and are there successful models?

States can and should provide incentives to schools 

to develop special admission tracks focused on students 

from disadvantaged backgrounds, given that the community origin is a strong predictor of physicians returning to 

these communities. With the current recommendations to 

increase medical school class sizes, there exists a timely 

opportunity to create programs that are supported by State 

governments to recruit non-traditional students into these 

additional slots. If the government were to subsidize tuition 

for a predetermined number of students hailing from specifi c backgrounds, could the rating agencies perhaps agree 

to exclude these students from the traditional “prestige” 

factors so as not to deter the school from embracing this 

change? Ultimately, communities, legislatures, and rating 

organizations must align interests to create genuine incentives for change.

Funding is a strong incentive for all endeavors, especially in the academic realm. Both public and private 

universities rely heavily on funding from multiple sources 

to achieve their goals. Medical schools have traditionally 

counted on Federal funding to further their clinical and 
8 EIGHTEENTH REPORT OF COGME

basic science research enterprise. More robust research 

funding enhances the pursuit of prized faculty and the 

acquisition of cutting-edge technology. However, the allocation of funds is not aligned with efforts to admit and 

train students hailing from underserved communities.

This report is not the fi rst to make recommendations 

germane to the selection and distribution of physicians. 

In 1971, the Millis Report [25] concluded that medical 

schools should

• “Change admission policies to encourage a more 

heterogeneous student population (and hence diverse 

practitioners),

• Increase the number of students, and

• Develop local educational opportunities that 

would “interdigitate with evolving regional health 

 systems.”

In 1970, the Carnegie Commission [26] also evaluated 

medical education in the United States. The Commission 

emphasized the need to explore new regional approaches 

to medical education, such as the Area Health Education 

Center (AHEC) concept. This proposal also correctly predicted that a regional approach to education could be more 

closely integrated with regional health services planning.

Finally, there is non-alignment between the supply 

and distribution of physicians and health policy with any 

measurable outcomes for the health status of a community. 

Physician supply is aligned with the demand created for 

reimbursable services, not the maintenance of healthy 

communities. Moreover, there is mounting evidence that 

the delivery of medical services and the performance of 

procedures correlates poorly to the health status of a community. Given this evidence, there is emerging recognition 

that, at a minimum, part of the future physician workforce 

will need to be far more engaged in improving the overall 

health status of the communities they serve.

There are a number of prerequisites that need to be in 

place for this recommendation to be widely accepted and 

ultimately successful.

• The medical school ranking system needs to be 

modifi ed. The current ranking systems should be 

revised to give greater emphasis to schools that place 

practitioners in medically underserved communities. 

Ranking systems should reward schools for selecting 

students who advance the goal of a diverse cadre of 

medical practitioners serving in medically underserved areas. As schools change their student mix or 

expand their class size to create greater opportunities 

for students from underserved areas, these students 

should be excluded from the calculation of rankings. 

The exemption should apply only to a specifi c percent 

of the student class (e.g., 10%).

• Demonstration projects should be Federally 

funded. Federal and State funds should be provided 

to subsidize tuition costs for these students from underserved areas. Research initiatives for community 

collaboration programs should be funded. Research 

centers that measure outcomes addressing physician 

maldistribution as well as other barriers to access 

should be fi nancially supported.

• Funding should be provided for programs that 

create longitudinal education partnerships. There 

should be fi nancial incentives for medical schools that 

work cooperatively with public primary and secondary 

education leadership to develop programs to mentor 

and recruit underserved students into medical careers 

in medicine.

• Current incentive programs should be maximized. 

Programs that have a record of success should be 

better promoted and expanded, such as the Medicare 

“bonus” payment available for those physicians working in designated HPSAs.

Ultimately, medical schools must look critically at the 

structure and effectiveness of their selection processes, not 

only in light of their own stated missions but in the context 

of the continuing dilemma of physician maldistribution. 

The medical education community must candidly acknowledge its contribution to the existing problem of physician 

maldistribution. Medicals schools need to consider how 

to incorporate community needs into the school’s mission and strategy. One option that should be considered 

is community representation on admissions committees, 

in clinical practice strategies, and in other forms of local 

public representation that would complement existing 

structures.

RECOMMENDATION 4: Create a national 

medical school.

A national medical school (or system of medical 

schools)—the USPHMC—should be established. The USPHMC would be unique in its emphasis on service, public 

health issues, epidemiology, and emergency preparedness 

and response.

One way to address the impending physician shortage 

is to increase medical school class sizes. The COGME 

Report No. 16 recommended a 15% increase. The Association of American Medical Colleges (AAMC) has 

subsequently recommended a 30% increase. Though these 

increases would decrease the magnitude of the projected 

defi cit, beyond relying on “market forces” they do little to 

attenuate the regional and economic disparities in health 

care access.

The COGME therefore joins the American Medical Student Association (AMSA) in proposing the 
EIGHTEENTH REPORT OF COGME 9

 establishment of a new type of Federally funded medical 

school (the USPHMC) originally detailed in an AMSA 

monograph [27]. The USPHMC would specifi cally address 

the shortage, maldistribution, and lack of diversity in the 

physician workforce by targeting the societal concerns 

of health disparities, public health issues, and emergency 

preparedness. Tuition for medical school will be waived 

in lieu of subsequent service.

There are number of factors that make the creation 

of a Federal medical school appealing at this time. The 

amalgam of these factors drives the need to enhance access 

to medical care while maintaining a robust and diverse 

medical workforce.

• The COGME Report No. 16 (2005) projected a shortage of approximately 90,000 full-time physicians by 

the year 2020. Pursuant to this concern, the COGME 

Report No. 16 recommended that medical school sizes 

be enlarged by 15%. The AAMC has since suggested 

a 30% increase in the number of U.S. medical school 

enrollees. Existing medical schools are currently expected to expand by less than 15%. In the absence of a 

robust and sustained increase in medical school class 

sizes, the needed cadre of medical school graduates 

must come from newly created medical colleges.

• There are substantial health disparities in the United 

States that are projected to worsen. These critical challenges are borne of racial and ethnic health disparities, 

a paucity of physicians practicing in rural and urban 

underserved areas, and too few physicians projected to 

practice in primary care. Given the schools’ focus on 

training physicians to serve underserved communities, 

the schools will seek students from these communities as they have a greater likelihood of establishing 

their medical practices in their home communities 

on completing medical training and thus are more 

likely to work within underserved communities and 

for minority populations.

• The prospect of graduating from medical school 

without signifi cant debt will encourage qualifi ed 

under-represented college students to enter medicine and ultimately to serve underserved areas and 

 populations.

• High debt on graduation also discourages physicians 

from entering primary care practice or practicing in 

underserved high-need areas. Medical student tuition 

and debt are at an all-time high. Tuition schedules have 

been increasing annually; the average annual public 

medical school tuition for an allopathic school in 2005 

was $18,000 and averaged $34,700 per year at private 

schools [23,28,29]. In 2003, public osteopathic medical school graduates’ debt averaged $117,000, while 

that for private school graduates averaged $141,700. 

In 2005, public allopathic medical school graduates’ 

debt averaged $110,500, while that for private school 

graduates averaged $138,000. Nine percent of graduates borrowed more than $200,000, and only 15% 

graduated without debt. A student who borrowed 

$120,000 could pay as much as $1,800 a month for 

10 years after completing residency [28]. Graduates 

from a USPHMC would have less debt and therefore 

be more likely to take positions serving underserved 

areas and populations.

• The Institute of Medicine has recommended that traditional medical education and public health issues 

should be more closely aligned. This is particularly 

relevant when one considers threats to public health, 

such as large-scale natural disasters (e.g., hurricanes, 

fl oods), global pandemics (e.g., avian fl u), and the risk 

of bioterrorism. A new cadre of physicians needs to be 

trained to serve as experts for these health problems 

facing the United States.

• Medical education efforts must be aligned with 

workforce needs. Traditional medical education in 

the United States has been unsuccessful in reversing 

geographic physician maldistribution and barriers 

to health care access. Additional problems include a 

growing lack of primary care physicians and a limited 

degree of cultural diversity in medicine. Moreover, 

the current process of education inadequately fosters 

and sustains public service values among medical 

students. Physician attitudes are shaped throughout 

medical school and residency training and, too often, 

the altruism embraced by medical students is eroded 

while progressing through the continuum of medical 

education.

Proposal for a United States Public Health 

Medical College

The USPHMC would serve to develop a sustained supply of physicians committed to public service and social 

responsibility. It is expected that the USPHMC would serve 

American public interests in a manner parallel to that of 

the United States Public Health Service (USPHS). The 

USPHMC would intentionally target cultural competency 

and rural and urban medical issues as part of its integrated 

curriculum. Moreover, the admissions process would select people based on the necessary attitudes, knowledge, 

skills, and experiences to excel in this model. Diversity, 

career interest, and motivation would be keen criteria in 

the selection process and would ideally lead to a group 

that was properly trained and committed to the mission 

and goals of the USPHS.

We appreciate that the ultimate design of the School 

would be the product of additional planning and review. 

However, the initiative should embrace the following 

features:
10 EIGHTEENTH REPORT OF COGME

• First and foremost, the USPHMC will be committed 

to serving those most in need of health care.

• The USPHMC system will be dedicated to improving the health of the public, with a clinical emphasis 

in chronically undeserved areas across racial, ethnic, 

socioeconomic, and educational boundaries.

• The USPHMC will create physicians who will work 

in underserved areas with the intention of eliminating 

health disparities. In addition, these physicians will 

serve as public health experts.

We recognize that despite the potential benefi t of a 

single new medical school, it would be inadequate by itself 

to address the magnitude of the physician workforce and 

health care access challenges. To more adequately address 

this problem, a network of six to ten schools would be required. The AMSA white paper more completely discusses 

the formation of a network of USPHMCs [27].

RECOMMENDATION 5: Expand the 

strategic access (e.g. Title VII) 

funding cap.

Funding targeted for physician training that creates a 

clinical physician workforce to serve populations in areas 

of limited access to medical care should be increased. For 

example, reinvigoration of Title VII funding should be 

considered.

Federal funding should support programs that provide a 

solution to restricted health care access. Such funding could 

support existing programs and assist in the creation of new 

programs. One example of an existing funding stream is 

Title VII funding [30]: “Title VII of the Health Professions 

Education Assistance Act was designed to increase the 

production of primary care physicians who serve medically vulnerable populations. Title VII grants supported the 

development of curricula in community-oriented primary 

care and provided clinical training sites where physicians 

learned to serve vulnerable populations. These grants 

instilled an understanding of the importance of personal 

medical homes and a sense of obligation to serve communities and populations.” This funding was associated with 

“higher rates of entry into family practice and practice in 

HPSAs, and pre-doctoral training and departmental development funding were strongly related to achievement of 

the Title VII, section 747 objectives” [31].

The impact of recent cutbacks in Title VII are not immediately obvious, but the consequences of the cutbacks 

can be seen in the broader health care system. Title VII 

funding has historically been a primary mechanism for 

attracting physicians to areas of need. Title VII funding 

encouraged graduate medical students to select specialties 

and locations that have experienced physician shortages in 

primary care and specialties needed to serve in Community 

Health Centers (CHCs).

Beginning in 2001, the Administration increased funding for CHCs. Under the current Administration, the number of CHCs and people served has grown impressively. 

The Washington Post (June 19, 2007) found that, since 

2001, the 500 new or expanded CHCs served an additional 

4.5 million individuals. The reductions in Title VII funding, 

however, have skewed physicians away from CHCs and, 

as a result, CHCs are now experiencing chronic shortages 

that are likely to limit the further expansion of the CHC 

system. For instance, “[I]n Ohio, the number of health 

centers rose from 107 to 122 between 2002 and 2005—a 

14% increase—and the number of patients seen increased 

by 26 percent, but the number of physicians increased by 

only 9 percent” (Washington Post, June 19, 2007). In fact, 

the average health center had a family physician vacancy 

rate of more than 13%. For the CHC system to be a sustainable success, it needs to be coupled with increased Title 

VII funding to ensure that CHCs are adequately staffed to 

care for the needy and uninsured.

Though Title VII is renewed through a yearly appropriations process, recent funding reductions have jeopardized 

the ability of U.S. medical training programs to produce 

a suffi cient and numerically stable cohort of generalist 

providers. Given the important goals of Title VII, Section 

747 funding to primary care and the complementary relationship between Title VII support and the recent initiatives to meet the needs of the underserved through CHCs, 

reinvigoration of the funding of these programs should be 

given serious consideration. In the absence of reinvigorated 

Title VII funding, other forms of fi nancial support to meet 

the needs of people in critical access settings will need to 

be more robust.
EIGHTEENTH REPORT OF COGME 11

Appendix A: Two Models of Successful 

Recruitment in Underserved Areas

(2) Integrated longitudinal plan for medical education 

across the continuum. Medical school, postgraduate 

medical education, and continuing medical education 

are treated as a continuum to accomplish long-term 

recruitment and retention.

(3) Signifi cant support of community practices to 

further the goals of the program.

(4) Genuine sense of ownership by the participating physicians, institutions, legislatures and 

 associations.

(5) Educational equivalency among training sites.

As the program developed and evolved, there has 

been increased participation in clinical practices. For 

example, in 1985, the University of Washington assumed 

sponsorship of the AHEC program. The regional AHEC 

network contains six clinical centers. The Programs for 

Health Communities (PHC) was established in 1989 as a 

collaboration between UWSM and the AHEC. PHC has 

worked with 60 towns in the WWAMI States to strengthen 

health care delivery.

The WWAMI Center for Health Workforce Studies 

was established in 1998 to conduct applied research on the 

distribution and supply of health care providers, with an 

emphasis on State workforce issues in underserved urban 

and rural regions in the WWAMI consortium.

The WWAMI Rural Health Research Center was 

established in 1998 within the UWSM Department of 

Family Medicine to study issues surrounding rural and 

underserved health care delivery. It is one of only fi ve 

Federally funded rural health care research centers.

The largest published study describing training and 

practices of family physicians was conducted by researchers from the WWAMI Rural Health Research Center in 

2003. This longitudinal study reviewed the 26 years of 

family practice training under this model [33]. Since 1972, 

the Family Practice Residency Network has trained more 

than 2,000 family physicians. Approximately 37% of 

the program graduates practice in communities of fewer 

than 25,000 people; 23% are practicing in communities 

of between 25,000 and 100,000 residents; and 37% are 

practicing in communities of more than 100,000 people. 

Table 1 highlights WWAMI’s success in educating residents from the fi ve-State area who then return to their 

home State and in attracting nonresidents to remain in 

the region.

The University of Washington School of Medicine 

(UWSM) and the Urban Health Program at the University of Illinois (UIC) are examples of two schools 

that have successfully used their admissions process to 

expand access to medical care in their communities. The 

UWSM seeks to increase the number of physicians in their 

priority fi ve-State, primarily rural service area, whereas the 

UIC seeks to improve service in the Chicago area. Below, 

we highlight these two programs.

One of the oldest and most studied regional center 

programs is based at the UWSM. In 1971, the medical 

school established a program to meet the unique needs 

of a four-State region that included Washington, Alaska, 

Montana, and Idaho; hence the title: the WAMI program. 

Wyoming has since been added and the acronym changed 

to WWAMI. This large rural territory includes about onefi fth of the nation’s land mass but only 3.3% of the population [32]. When the program originally was designed, the 

States of Alaska, Montana, and Idaho were among only 

seven States in the country lacking GME training programs. 

The WWAMI program met dual needs: It offered medical 

education for States that could not fund their own medical 

schools, and it encouraged physicians trained in the region 

to remain in the region. [32]

When the WWAMI program was established, it had 

fi ve goals. Measurable outcomes have been attained for 

each of these goals:

• Admit more WWAMI States students to medical 

school.

• Train more primary care physicians.

• Place physicians in the areas of greatest need.

• Make medical school resources available to the communities.

• Accomplish programmatic goals without major 

costs.

By 1973, the number of applicants from the partnerStates increased by 155% as compared to ten years earlier. 

Research fi ndings suggest at least fi ve factors that explain 

the breadth and depth of the WWAMI’s success.

(1) Focus on primary and secondary education. The 

program fosters success in disadvantaged K-12 

students, in particular the middle-school students. 

There are specifi c efforts to recruit youths residing 

on Native American reservations.
12 EIGHTEENTH REPORT OF COGME

Medical school programs that are focused on addressing 

the specifi c needs of the urban medically underserved are less 

prevalent than rural programs. The Urban Health Program 

(UHP) at UIC was created in 1978 to recruit, retain, and 

graduate students from groups of underrepresented minorities in the health professions. The ultimate goal is “to train a 

cadre of underrepresented health professionals” [34].

UIC, the largest medical school in the United States, 

boasts a 25% minority enrollment and graduates one in 

every six Illinois physicians. The medical school has a 

special curriculum track for urban health called the UMed 

Program. Its mission is “[t]o admit, prepare and graduate 

physicians who will—after completing residency training—practice in urban communities in any specialty 

deemed as needed for those communities.” The four-year 

curriculum aims to prepare physician leaders for practice 

in urban communities.

The UHP is designed to reach students early in the 

educational process—as early as kindergarten—with the 

intention of preparing young students for a career in the 

health professions. Similar to the WWAMI model, there 

is a partnership involving the local community, physician 

practices, the local AHEC, and legislative leadership. A 

Community Advisory Council was created to serve as a 

forum for community leaders, educators, health professionals, and others to assist UIC in its efforts to increase 

the number of underrepresented health professionals and to 

improve health care services in underserved urban areas.

The UHP reports that approximately 70% of AfricanAmerican and Latino physicians who practice in Chicago 

are UIC graduates. Further, UIC graduates the third greatest 

number of African-American students from its medical 

school. It is eclipsed only by the Howard University College of Medicine and the Meharry Medical College. The 

UIC Medical Center and Clinics serve approximately 50% 

African-American and 25% Latino patients.

Other medical schools have initiatives that provide 

outreach to underserved communities, both urban and rural. Only a few have been as successful as the UHP or the 

WWAMI. Successful programs, demonstrating a long-term 

commitment coupled with measurable outcomes, tend to 

share certain characteristics.

• Vision. The medical school must articulate a core 

value that includes a commitment to clinical practice 

in underserved communities.

• Partnership. A medical school cannot, by itself, 

address all the needs of underserved communities, 

regardless of the size and complexity. To achieve 

success, a true partnership must be created with the 

community, local government and legislature, and the 

existing community medical practices.

• Inclusiveness. All stakeholders in the continuum of education must collaborate to bring scientifi c education into 

primary and secondary education to prepare pre-medical 

students for medical school. Additional resources must 

be given to schools in underprivileged communities.

• Investment. Investment in educational research that 

is dedicated to measuring community health outcomes must be aligned with service-based objectives. 

 Research and measurement are imperative in understanding how goals are being met.

TABLE 1.

Statistics about Graduates from the University of Washington 

School of Medicine Who Practice in WWAMI States, 1973–1998

Idaho Montana Alaska

No. State WWAMI graduates in practice ..................................... 243 292 149

No. State WWAMI graduates who returned to practice

in home State .............................................................................. 107 119 76

State WWAMI graduate return rate ............................................. 44% 41% 51%

No. non-State UW graduates who practice in the State ............... 66 31 30

Total return rate .......................................................................... 71% 51% 71%

* Return rates for Washington and Wyoming are not included. Statistics concerning return rates have been 

maintained only for States with contracts for medical education through the WWAMI program. Because the 

fi rst Wyoming class graduated in 2001, return rates are not yet available for that State. From the annual 

AAMC senior survey, 85% or more of UWSM graduating seniors have consistently expressed the intention 

to practice within the fi ve State region after completion of training.

Source: Ramsey PG, et. al., Acad Med 2001;76:765–775
EIGHTEENTH REPORT OF COGME 13

Appendix B: Proposal for the Operation of a United 

States Public Health National Medical College

that are located in areas of medical need. Traditional medical training with a focus on chronic medical conditions 

will be integrated with clinical experiences in underserved 

areas. Additional training would pinpoint public health 

areas, epidemiology, disease surveillance, occupational 

and environmental health, the business of medicine, legislative and public policy processes, health education and 

health promotion, emergency preparedness and response, 

and biostatistics. Students would receive an MPH (master 

in public health) degree combined with an M.D. or D.O. 

(doctor of osteopathy) degree.

Clinical rotations would occur in geographic areas, 

both urban and rural, that have limited access to medical care. Areas targeted for enhanced health care access 

would consider maldistribution across racial, ethnic, socioeconomic, and educational parameters. The USPHMC 

would further train physicians in the importance of public 

health issues and emergency preparedness. Graduates of 

this program would be commissioned into a public health 

service organization or department (e.g., NHSC). in an 

HPSA (as defi ned by the Health Resources and Service 

Administration), Indian Health Bureau, Community Health 

Center, or other site deemed appropriate. Graduates will 

select their preferred assignment, in a manner similar to 

the process used by the NHSC.

The medical school faculty would focus primarily on 

teaching clinical medicine. The instructors should not be 

encumbered by grant requirements or heavy clinical service 

requirements. Additionally, there must be an intentional 

balance between primary care and specialty disciplines. 

Though primary care would be an essential area of medical 

service and training, subspecialty and surgical disciplines 

are also sorely needed in underserved areas.

Graduates would be encouraged to enter residency 

training in primary care fi elds, especially in programs that 

have an emphasis on community-oriented care. Selected 

residency programs would be credited against service 

requirements on a year-for-year basis. For example, an 

eight-year commitment would be decreased to fi ve years 

if a preferred three year primary care residency were chosen. Another way in which to encourage an emphasis on 

primary care training would be to fi nance these positions 

more favorably. For example, an elevated per-resident 

amount payment from CMS for qualifi ed primary care 

programs could lead to greater payment to house staff 

in needed disciplines and, thus, increased enrollment in 

these programs.

The School would follow the existing model of the 

Federal military medical school, the Uniformed 

Services University of the Health Sciences. The 

USPHMC would operate under the ultimate authority of 

the Surgeon General of the United States, and oversight 

would be under the auspices of the DHHS or its Health 

Resources and Service Administration.

The USPHMC would enroll 600 students annually, thus 

graduating and placing 150 physicians in high-medicalneed areas each year. Students would be selected to generate a medical workforce that refl ects the ethnic, cultural, 

and societal values of a diverse population and to select 

a socially sensitive cadre of medical students. Thus, students from underserved communities will be given strong 

consideration. Valued characteristics for applicants will be 

(consistent with the Sullivan Commission report Missing 

Minorities in Health Professions) leadership, community 

service, cultural competency, multilingual skills, and broad 

overall experience.

In exchange for four years of free medical education, 

a student would be obligated to practice in an underserved 

area after graduation—generally two years of service for 

each year of education. After the initial service commitment, there would be an additional ten-year commitment 

in a Reserve Corps. These physicians would be under the 

direction of the Commissioned Corps of the USPHS, and 

these physicians would also be fi rst responders for situations requiring public health emergency responses.

The location of any medical school and the sites for 

clinical rotations would be strategically determined to serve 

communities most in need and promote a sense of social 

responsibility through service to others. The service repayment requirement would not necessary be applied only to 

the time after residency training. The service repayment 

could be considered “in effect” if a medical school graduate trained in an approved residency. For example, if a 

physician entered an approved family medicine residency, 

the repayment program would start taking effect during 

the residency. At the completion of a three-year program, 

such a physician would then owe fi ve additional years in 

a service repayment program.

The USPHMC would train students during the entire 

four-year medical curriculum. The fi rst two years of preclinical education (emphasizing basic sciences) will be at 

one of the regional medical school campuses. The fi nal 

two clinical years would occur in existing area regional 

hospitals, community clinics, and other health care centers 
14 EIGHTEENTH REPORT OF COGME

Federal-State partnerships would be a natural derivative 

of the USPHMC. Currently, there are at least 69 State and 

local programs that provide support for a medical education 

in exchange for service. States could easily use USPHMC 

facilities for training physicians who are currently in loanrepayment programs. Through this exchange, States would 

fund a portion of the operating costs of the USPHMC.

The full operating budget of the USPHMC is undetermined. The major cost burden for capital expenses would 

derive from creating a teaching facility for the fi rst two 

years of basic sciences, rather than building an entirely 

new academic medical center [34]. Moreover, any individual State-sponsored medical school or school receiving a Federal subsidy (including CMS funds for graduate 

medical education) would be approached to participate in 

this system. Few new allopathic medical schools have been 

recently established. Nonetheless, the recent information 

from the Florida State University College of Medicine 

that opened in 2002 could serve as a template for fi scal 

estimates.[34] The annual operating costs of USPHMC 

would be approximately $33 million.
EIGHTEENTH REPORT OF COGME 15

References

16. Robertson RL, Castro CE, Gomez LC, et al. Primary 

health services in Ecuador: Comparative costs, quality, 

and equity of care in Ministry of Health and rural social 

security facilities. Soc Sci Med 1991;32:1327–1336.

17. Ramirez de Arellano AB. A health “draft”: Compulsory 

health service in Puerto Rico. J Public Health Policy

1981;2:70–74.

18. Blakeney P, Schottstaedt MF, Sekula S. Personality 

characteristics of women entering medical school over 

a 10-year period. J Med Educ 1982;57:42–47.

19. Bureau of Health Professions, Shortage Designation 

Branch. Selected Statistics on Health Professional 

Shortage Areas. December 31, 2005.

20. Government Accounting Offi ce. Physician Workforce: 

Physician Supply Increased in Metropolitan Areas but 

Geographic Disparities Persisted. GAO-04-124 [available at www.gao.gov/cgi-bin/getrpt?] GAO-04-124, 

accessed 2/16/2006.

21. http://www.acgme.org/adspublic/reports/accredited_

programs.asp, accessed 2/12/07.

22. Griffi n A-VO, Miskowicz-Retz, KC. Undergraduate 

osteopathic medical education. JAOA 2007;107:109–

116.

23. American Association of Colleges of Osteopathic 

Medicine. 2004 Annual Report on Osteopathic Medical Education. http://www.aacom.org/data/annualreport/AROME2004.pdf, accessed 2/18/2006.

24. HPSA Scores are developed for use by the National 

Health Service Corps in determining priorities for 

assignment of clinicians. Scores range from 1 to 25 

for primary care and mental health and 1 to 26 for 

dental. The higher the score, the greater the priority. 

For specifi c scoring methodology, see http://bhpr.hrsa.

gov/shortage/autoscore.htm#criteria

25. Millis JS. A Rational Public Policy for Medical Education and Its Financing. New York: The National Fund 

for Medical Education, 1971.

26. Carnegie Commission on Higher Education. Higher 

Education and the Nation’s Health. New York: McGraw-Hill, 1970.

27. Wen LS, McCoy C, Hedgecock J, Garrison S, Wright, 

PR (eds). Enhancing national security, public health preparedness, and the U.S. physician workforce establishment of the United States Public Health Medical College 

(USPHMC) Act [unpublished report]. The American 

Medical Student Association, March 14, 2006.

 1. Campos-Outcalt D. Mandatory social service for 

physicians: A discussion of issues. Presentation at the 

September 6, 2006 meeting of the Council on Graduate 

Medical Education, Rockville, MD [available upon 

request].

 2. Graham R. Mandatory service for physicians: Issues 

and approaches. Presentation at the September 6, 2006 

meeting of the Council on Graduate Medical Education, Rockville, MD [available upon request].

 3. Rosenblatt RA. Is mandatory national service for 

physicians desirable and feasible? Presentation at the 

September 6, 2006 meeting of the Council on Graduate 

Medical Education, Rockville, MD [available upon 

request].

 4. Barton FW. Berry Plan history. JAMA 1961;175:57–

59.

 5. Petersdorf R. Financing medical education—a universal Berry Plan for medical students. N Engl J Med

1993;328:651–654.

 6. Lalich RA. Health care personnel delivery system: 

Another doctor draft? Wisc Med J 2004;103:21–24.

 7. Putnoi M. The Berry Plan and its modifi cation. The 

New Physician 1964;June:173–175.

 8. AMA Council on Medical Education Report 2-I-04. 

The Implications of the Health Care Personnel Delivery System.

 9. Roemer MI, Roemer R. Health Manpower Policies 

under Five National Health Care Systems. Washington, 

D.C.:U.S. Government Printing Offi ce, 1978.

10. Spike NA. International medical graduates: The Australian perspective. Acad Med 2006;81:842–846.

11. Rubel, 1990, 138, cited in Cavender A, Albán M. Compulsory medical service in Ecuador: The physician’s 

perspective. Soc Sci Med 1998;47:1937–1946.

12. Ugalde, 1984, cited in Cavender A, Albán M. Compulsory medical service in Ecuador: The physician’s 

perspective. Soc Sci Med 1998;47:1937–1946.

13. Danielson, 1979, 133, cited in Cavender A, Albán M. 

Compulsory medical service in Ecuador: The physician’s perspective. Soc Sci Med 1998;47:1937–1946.

14. Asturizaga R, 1995, 10, cited in Cavender et. al.

15. Cavender A, Albán M. Compulsory medical service 

in Ecuador: The physician’s perspective. Soc Sci Med

1998;47:1937–1946.
16 EIGHTEENTH REPORT OF COGME

28. Association of American Medical Colleges Facts—

applicants, maculates and graduates. http://www.

aamc.org/data/facts/2005/2005school.htm, accessed 

2/18/2006.

29. Association of American Medical Colleges Facts—applicants, matriculates and graduates 2001–2005. 

http://www.aamc.org/data/facts/2005/factsgrads1.htm, 

accessed 2/18/2006.

30. Freeman J, Kruse J. Title VII: Our loss, their pain. Ann 

Fam Med 2006;4:465–466.

31. Evaluating the Impact of Title VII, Section 747 Program, 5th Annual Report to the Secretary of the U.S. 

Department of Health and Human Services and to Congress, November 2005, http://bhpr.hrsa.gov/medicine-

 dentistry/actpcmd/reports/fi fthreport/5.htm, accessed 

4/6/07.

32. Ramsey PG, Coombs JB, Hunt DD, et al. From concept to culture: The WWAMI program at the University of Washington School of Medicine. Acad Med 

2001;76:765–775.

33. Kim S, Phillips WR, Stevens NG. Family practice 

training over the fi rst 26 years: A cross-sectional 

survey of graduates of the University of Washington Family Practice Residency Network. Acad Med

2003;78:918–925.

34. University of Illinois at Chicago, Urban Health Program, http.www.uic.edu/depts/uhealth/program.html, 

accessed 4/6/2007.

35. Plan for a Four-Year Allopathic School of Medicine 

at Florida State University. MGT of America, Inc. 

November 1999, http://med.fsu.edu/pdf/10 four year 

allopathic.pdf, accessed 3/14/2006.