At the Intersection of Health, Health Care and Policy Cite this article as: Atul Grover and Lidia M. Niecko-Najjum Building A Health Care Workforce For The Future: More Physicians, Professional Reforms, And Technological Advances Health Affairs, 32, no.11 (2013):1922-1927 doi: 10.1377/hlthaff.2013.0557
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Graduate Medical Education By Atul Grover and Lidia M. Niecko-Najjum 10.1377/hlthaff.2013.0557 HEALTH AFFAIRS 32, NO. 11 (2013): 1922–1927 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Atul Grover (agrover@aamc .org) is chief public policy officer at the Association of American Medical Colleges, in Washington, D.C. Lidia M. Niecko-Najjum is a senior research and policy analyst at the Association of American Medical Colleges.
A N A LYSI S
&
C O M M E N TARY
Building A Health Care Workforce For The Future: More Physicians, Professional Reforms, And Technological Advances Traditionally, projections of US health care demand have been based upon a combination of existing trends in usage and idealized or expected delivery system changes. For example, 1990s health care demand projections were based upon an expectation that delivery models would move toward closed, tightly managed care networks and would greatly decrease the demand for subspecialty care. Today, however, a different equation is needed on which to base such projections. Realistic workforce planning must take into account the fact that expanded access to health care, a growing and aging population, increased comorbidity, and longer life expectancy will all increase the use of health care services per capita over the next few decades—at a time when the number of physicians per capita will begin to drop. New technologies and more aggressive screening may also change the equation. Strategies to address these increasing demands on the health system must include expanded physician training. ABSTRACT
H
ealth care workforce projections have been notoriously unreliable because they are often based upon idealized future delivery systems rather than current utilization trends. Recent data suggest that advances in care—such as a 50 percent reduction in mortality for cardiovascular disease—will only expand the need for more physicians.1 Current utilization patterns suggest that by 2020 there will be a shortage of 91,500 physicians—45,400 primary care physicians and 46,100 subspecialists.2 These shortages are driven by the demographic characteristics of the US population, which is growing and aging and whose disease burden is increasing. The shortages are also driven by the demographic characteristics of physicians: One in three practicing physicians are older than fifty-five and are expected to retire in the next ten to fifteen years.3 1922
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Physician supply projections are also likely to overestimate physician full-time-equivalents because younger physicians seek to work fewer hours than their predecessors did.4 Physician training is inextricably tied to patient care. Since its inception in 1965, Medicare has been the largest single explicit supporter of graduate medical education (GME) programs and has paid for its share of training costs. However, the Balanced Budget Act of 1997 imposed a cap on Medicare-funded GME at 1996 levels, at a time when tightly managed care seemed to be the future of the health care system. The system of tightly managed care networks failed to take hold, and the demand for physicians is growing. Nonetheless, the cap is still in place, limiting teaching hospitals’ efforts to expand or create new programs. Medicare now pays for less than 25 percent of direct training costs for residents and fellows.5
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Incrementally Increasing The Physician Workforce Training an additional 4,000 physicians a year would allow the United States to increase its expected supply of doctors by not quite 30,000 by the end of the decade—meeting roughly onethird of the expected shortage. This would represent an expansion of approximately 15 percent over current training levels. According to the Census Bureau, the US population has already increased by almost fifty million (15 percent) since 1997.6,7 The Congressional Budget Office estimates that under the Affordable Care Act, up to eleven million previously uninsured nonelderly Americans may gain health insurance by 2014, and that number may reach twenty-six million or more by 2022—with many of the newly insured having long-unmet needs for care, especially specialty care and surgical treatments.8 In addition, the number of older Americans will double between 2000 and 2030. Every day for the next nineteen years, 10,000 Americans will turn sixty-five.9 This age group uses more than twice as many health care services as younger adults, as shown in Exhibit 1. The aging of the population will lead to higher prevalence of cancer and cardiovascular disease.10 The incidence of cancer more than quadruples in the twenty years after an individual turns forty-five.11 As a result of scientific advances, the number of cancer survivors will increase, from fourteen million today to eighteen million by 2022.12 These patients will require recurrent care by primary care physicians, oncologists, surgeons, other subspecialists, nurses, and myriad other health professionals. In the case of heart disease, one could argue that advances in clinical interventions, coupled with public health initiatives, have increased at breakneck speed and yet have been outpaced by the US obesity epidemic. As heart disease mortality has decreased, longevity has increased. So has the rate of obesity in people ages sixty-five to seventy-four, 42 percent of whom are now obese.13 Unfortunately, obesity—and all of its associated comorbidities, such as diabetes—is likely to continue to be a major risk factor for many Americans into the foreseeable future.1 The nation’s lower age-adjusted mortality is likely to lead to another wave of age-related illness in the coming decades: neurologic disease. A recent study from the RAND Corporation suggests that almost 15 percent of Americans ages seventy-one and older have dementia and that by 2040 more than nine million are likely to have the diagnosis.14 The prevalence of Parkinson’s disease is expected to double between 2010 and 2040.15
Medical advances have also improved the care for illnesses from rheumatologic disease to congenital cardiac disorders for children and young adults. Children suffering from previously fatal diseases will survive into adulthood but require decades of follow-up by primary care providers, pediatric subspecialists, and adult subspecialists. These advances in treatment have increased the need for pediatric subspecialists beyond the nation’s current capacity16 and are likely to cause further pressure on the health system. Absent necessary increases in Medicare-supported residency positions, per capita numbers of physicians will continue to fall as the population grows and ages, with increasing per capita needs.
Lower Mortality, Longer Lives, And Greater Lifetime Utilization There is little doubt that the current US health care delivery system is less than ideal, and there are opportunities to reduce demand for services without harming patients. However, even if it is fully implemented, the ongoing health care system transformation under the Affordable Care Act—intended to reduce unnecessary health care costs through improved prevention, coordination, and integration of care—offers little evidence of decreased physician demand to date. Roughly 15 percent of all US primary care practices are now recognized by the National Committee for Quality Assurance as “medical homes.”17 These medical homes are intended to provide high-quality care consistent with
Exhibit 1 Estimated Requirements For Patient Care Physicians Per 100,000 Population, By Patient Age And Physician Specialty, 2000 Specialty Age group
Primary carea
Medicalb
Surgicalc
Otherd
Total
0–17 years 18–24 years
95 43
10 15
16 54
29 48
149 159
25–44 years 45–64 years
59 89
23 41
52 59
62 81
196 270
65–74 years 75+ years
175 270
97 130
125 161
145 220
543 781
95
33
55
70
253
Total
SOURCE Bureau of Health Professions. The physician workforce: projections and research into current issues affecting supply and demand [Internet]. Rockville (MD): BHPr; 2008 Dec [cited 2013 Oct 8]. Exhibit 29. Available from: http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. a Includes general and family practice, general internal medicine, and pediatrics. bIncludes cardiology and other internal medicine subspecialties. cIncludes general surgery, obstetrics/ gynecology, ophthalmology, orthopedic surgery, otolaryngology, urology, and other surgical specialties. dIncludes anesthesiology, emergency medicine, pathology, psychiatry, radiology, and other specialties.
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Graduate Medical Education the principles set forth at the Alma-Ata conference thirty-five years ago, which declared the need “for urgent action” to provide primary care to protect and promote the health of all people.18 Adding around-the-clock, culturally competent access to the traditional primary care model in the other 85 percent of practices in the United States is likely to improve the nation’s return on investment. However, no marked reductions in health care use or physician demand have yet been demonstrated.19 In 2004 Bruce Fireman and colleagues examined the experience of the Permanente Medical Group in Northern California and found that disease management did not substantially reduce utilization or costs, even when deployed across a tightly managed care network.20 One recent study of imaging utilization at an integrated, closed system with no financial incentives for imaging showed that rates of use have gone up and that they remain highest among the elderly.21 The reasons for increased utilization included improvements in scanning technologies and their applicability.21 Another study, in Ontario, supported these results, finding that the increased use of imaging studies and specialists was directly correlated with better outcomes for patients with complex needs.22 Some researchers have rightly characterized screenings as potentially overused in some populations; however, screenings are likely underused in other populations—for reasons related to geography23 or lack of insurance coverage.24 For example, guidelines would suggest that colonoscopies performed in patients older than seventyfive are unnecessary, but colorectal cancer screening is underused in many patients, particularly those with no insurance or with Medicaid coverage.24 Reducing colorectal screenings in one population but increasing it in others where recommended would not result in an overall reduction in services. Even if reductions in the unnecessary use of screenings or diagnostics are achieved, the expansion of access to health care in the Affordable Care Act and advances in screening and new treatments are likely to increase the long-term demand for appropriate interventions. Personalized medicine and genomics may also contribute to improved health but may simultaneously increase long-term needs for health care. The sequencing of the genome opened a number of possibilities for patients who previously had little hope for survival. New treatments and protocols such as targeted treatment for colorectal, breast, and lung cancer and personalized pharmacologic regimens;25 prophylactic surgery such as mastectomies for patients who are genetically at high risk for breast cancer; and 1924
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It would be unwise to prescribe a static specialty composition that would not respond to the dynamic health care environment.
stem cell therapy are all under intense investigation and development.26 The promise of such new technologies and therapies does not lie in their potential to reduce the lifelong consumption of medical care. Rather, the hope is that these approaches will lead to cures for disease or better treatment, both of which lead to longer and better lifespans. Longer life spans result in more use of medical care over the course of a lifetime for ailments that have become treatable diseases rather than causes of death. Some have argued that unexplained local variation in the use of health care is evidence of waste or inefficiency and that the use of health care can be greatly reduced. For example, in 2006 the per capita rate of knee replacements in Sioux Falls, South Dakota (14.3 replacements per 1,000 Medicare enrollees), was more than three times the rate of knee replacements in the Bronx, New York (4.1 replacements per 1,000 Medicare enrollees).27 However, recent studies suggest that variation in medical care is not driven largely by providers’ preferences, as has been suggested by researchers with the Dartmouth Atlas Project.28 Instead, differing health status and other individual patient factors continue to contribute to the necessary (if not ideal) variation in utilization.29–32
A Balanced Approach Population health care needs change over time, and it would be unwise to prescribe a static specialty composition of the health care workforce that would not respond to the dynamic health care environment. Equally, given the long medical training period and the likely modest rate of change in delivery and payment systems, it would be unwise to rely on any expected radical transformation of the health care system to meet
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Even if health reform is successful, the growing and aging US population certainly will need a larger health care workforce.
the projected increase in physician demand. Instead, it would be prudent to incrementally expand the number of federally supported residency positions based on current health care utilization rates and to commit to ongoing analysis of changing demand to inform future workforce planning. Several pending bills in Congress (S. 577, H.R. 1180, and H.R. 1201) to expand GME funding take into account the notion that primary care is the foundation of a high-performing health system, but they also note that it is of equal importance to address shortages of subspecialists in many areas. In fact, specialists such as general surgeons, neurosurgeons, and pathologists are facing decreases in their absolute numbers, not just in per capita ratios.33–35 These pending GME bills allocate the specialty composition of residency positions in accordance with physician shortages identified by federal analyses and direct that future specialty allocation be driven by workforce data that are constantly updated and analyzed to reflect trends—for example, analyses of shortages by the Government Accountability Office or the yet-to-be-funded National Health Care Workforce Commission. This approach would allow policy makers to adjust the future numbers of residents in line with population needs. In 2010 the median ratio of active patient care physicians to the US population was 215.1:100,000.36 Approximately 37 percent of those physicians were primary care practitioners—a designation that includes providers in the three fields of general internal medicine, family medicine or general practice, and general pediatrics.3,36 These three primary care specialties combined accounted for the largest number of active physicians in any single discipline. The remaining 63 percent of active patient care physicians were spread over 155 specialties and subspecialties.3,37 In the 2011–12 academic year approximately
43 percent of all core residents—that is, residents in postgraduate year 1 positions available immediately following medical school—entered primary care specialties, although many of them will choose to subspecialize. Approximately 20 percent of all GME slots are fellowship (or subspecialty) training positions. In comparison to larger specialties such as family medicine (which has approximately 3,400 positions per year) or internal medicine (approximately 7,300 positions), the number of subspecialty positions in any given specialty is relatively small. For example, roughly 500 oncologists are trained annually. Eliminating these fellowship opportunities would not only have a limited impact on growing the primary care workforce, but it would also exacerbate physician shortages for patients with complex and high-acuity health care needs. Improved access to primary and preventive care should be one focus of workforce expansion. However, improved access will not prevent all patients from ever developing diabetes, cancer, or neurologic disease. The expansion of the specialty workforce should be coupled with more efficient provision of subspecialty care. For example, chronic conditions currently managed by specialists could be treated by primary care physicians. Likewise, providers such as physician assistants and nurse practitioners could care for patients with lower-acuity conditions who are now treated by physicians. This approach could help address barriers to access for patients in communities that consistently struggle to recruit physicians. Some of these improved efficiencies could be achieved through reimbursement policies that recognized and rewarded cognitive services, such as patient counseling; service in geographically or economically underserved communities; or both. However, these changes likely will take time to implement and are unlikely to alleviate the full burden of physician shortages in the interim.
Conclusion The Association of American Medical Colleges and the Council on Graduate Medical Education, among others, recommend training additional physicians annually (4,000 and 3,000 more physicians, respectively), while improving the use of existing resources and continually reassessing workforce requirements.38,39 Even if current health care delivery reforms are implemented and successful, the growing and aging US population certainly will need a larger health care workforce, including more physicians. The United States already has fewer November 2013
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37
◀ %
Primary care physicians
In 2010, approximately 37 percent of active patient care physicians were primary care practitioners. The remaining 63 percent were spread over 155 specialties and subspecialties.
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Graduate Medical Education physicians per capita than most of the other countries in the Organization for Economic Cooperation and Development—not only fewer generalists, but in some cases fewer specialists as well.40 For example, the United States has fewer specialists (65 per 1,000 population, including all specialties of internal medicine) than the United Kingdom (66.1), Luxembourg (68.4), Slovenia (71.1), Italy (75.7), the Czech Republic (76.9), Poland (77.1), and the Slovak Republic (85.4).40 The aging of the US population has implications for the metrics used to benchmark the health care workforce, such as the number of physicians per capita. Whereas the numerator (number of physicians) in the United States has increased, the changing nature of the denominator (the number of patients, who collectively are growing older and more diverse and have increasingly complex comorbidities) suggests that an even higher ratio will be needed.41 With looming changes in health care treatments, technology, finance, and delivery, researchers and policy makers must understand that an adequate supply of physicians will have to be achieved both through more efficient health care delivery models and through an increased number of GME training positions. States and schools have responded already by
increasing the number of medical students, but that independently will not increase the supply. The unwillingness of Congress to fund additional Medicare GME positions may lead to US medical school graduates who lack opportunities to complete their residencies. Just last March, 528 qualified 2013 US medical school graduates were not matched to a residency training position; 758 qualified US medical doctors who had graduated prior to 2013 also failed to be matched.42 Current attempts at payment and delivery system reform must be complemented with an adequate supply of physicians and other health professionals in primary care and in medical and surgical specialties. The United States will need to take full advantage of every health professional and every type of technology available to address the needs of an aging, growing population. The exact model of interprofessional collaboration to achieve this goal has yet to be determined. However, ongoing efforts toward a common classification of competencies for the health professions will help improve teamwork across providers and improve access, care, and care coordination for patients.43 In the meantime, to avoid impediments to access, it would be prudent to increase the number of resident positions that Medicare partially supports. ▪
NOTES 1 Goldman DP, Cutler D, Rowe JW, Michaud PC, Sullivan J, Peneva D, et al. Substantial health and economic returns from delayed aging may warrant a new focus for medical research. Health Aff (Millwood). 2013;32(10):1698–705. 2 Association of American Medical Colleges. Physician shortages to worsen without increases in residency training [Internet]. Washington (DC): AAMC; 2010 Jun [cited 2013 Oct 8]. Available from: https://www.aamc.org/download/ 286592/data/ 3 Association of American Medical Colleges. 2008 physician specialty data [Internet]. Washington (DC): AAMC; 2008 Nov [cited 2013 Oct 8]. Available from: https://www.aamc .org/download/47352/data 4 Health Resources and Services Administration. The physician workforce: projections and research into current issues affecting supply and demand [Internet]. Rockville (MD): HRSA; 2008 Dec [cited 2013 Oct 11]. Available from: http:// bhpr.hrsa.gov/healthworkforce/ reports/physwfissues.pdf 5 ResDAC. Healthcare Cost Report Information System [home page on the Internet]. Baltimore (MD): Centers for Medicare and Medicaid
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Services, Research Data Assistance Center; 2012 Sep 30 [cited 2013 Oct 11]. Available from: http://www .resdac.org/cms-data/files/hcris Census Bureau. State and County QuickFacts. Washington (DC): Census Bureau; 2012. Census Bureau. Population profile of the United States. Washington (DC): Census Bureau; 1997. Hanchate AD, Lasser KE, Kapoor A, Rosen J, McCormick D, D’Amore MM, et al. Massachusetts reform and disparities in inpatient care utilization. Med Care. 2012;50(7): 569–77. Passel JS, Cohn D. U.S. population projections: 2005–2050 [Internet]. Washington (DC): Pew Research Center; 2008 Feb 11 [cited 2013 Oct 10]. Available from: http:// www.pewhispanic.org/files/ reports/85.pdf Centers for Medicare and Medicaid Services. CMS Chronic Condition Data Warehouse (CCW): Medicare beneficiary prevalence for chronic conditions for 2000 through 2011 [Internet]. Baltimore (MD): CMS; [cited 2013 Oct 8]. Table B.2. Available from: http://www .ccwdata.org/cs/groups/public/ documents/document/wls_ucm1000774.pdf
11 Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, et al. SEER Cancer Statistics Review, 1975–2010. Bethesda (MD): National Cancer Institute; 2013 Apr [cited 2013 Oct 8]. Available from: http://seer.cancer.gov/csr/1975_ 2010 12 De Moor JS, Mariotto AB, Parry C, Alfano CM, Padgett L, Kent EE, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomarkers Prev. 2013;22(4): 561–70. 13 Fakhouri THI, Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity among older adults in the United States, 2007–2010 [Internet]. Hyattsville (MD): National Center for Health Statistics; 2012 Sep [cited 2013 Oct 11]. (NCHS Data Brief No. 106). Available from: http://www.cdc.gov/nchs/data/ databriefs/db106.htm 14 Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med. 2013;368: 1326–34. 15 Kowal SL, Dall TM, Chakrabarti R, Storm MV, Jain A. The current and projected economic burden of
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Parkinson’s disease in the United States. Mov Disord. 2013;28(3): 311–8. Basco WT, Rimsza ME, Committee on Pediatric Workforce, American Academy of Pediatrics. Pediatrician workforce policy statement. Pediatrics. 2013;132(2):390–7. National Committee for Quality Assurance. Letter to the Hon. Fred Upton and the Hon. Henry Waxman [Internet]. Washington (DC): 2013 Jun 10 [cited 2013 Oct 11]. Available from: http://www.ncqa.org/Portals/ 0/Programs/Recognition/PCMH/ NCQA%20Energy%20&%20 Commerce%20SGR%20Comments %206-10-13.pdf World Health Organization. Declaration of Alma-Ata: International Conference on Primary Health Care, Alma-Ata, USSR, 6–12, September 1978 [Internet]. Geneva: WHO; [cited 2013 Oct 8]. Available from: http://www.who.int/ publications/almaata_declaration_ en.pdf Erikson CE. Will new care delivery solve the primary care physician shortage? A call for more rigorous evaluation. Healthcare. 2013;1(1–2): 8–11. Fireman B, Bartlett J, Selby J. Can disease management reduce health care costs by improving quality? Health Aff (Millwood). 2004;23(6): 63–75. Smith-Bindman R, Miglioretti DL, Johnson E, Lee C, Feigelson HS, Flynn M, et al. Use of diagnostic imaging studies and associated radiation exposure for patients enrolled in large integrated health care systems, 1996–2010. JAMA. 2012; 307(22):2400–9. Stukel TA, Fisher ES, Alter DA, Guttmann A, Ko DT, Fung K, et al. Association of hospital spending intensity with mortality and readmission rates in Ontario hospitals. JAMA. 2012;307(10):1037–45. Makarov DV, Desai R, Yu JB, Sharma R, Abraham N, Albertsen PC, et al. Appropriate and inappropriate imaging rates for prostate cancer go hand in hand by region, as if set by thermostat. Health Aff (Millwood). 2012;31(4):730–40.
24 Rosenthal E. Paying till it hurts: the $2.7 trillion medical bill. New York Times. 2013 Jun 1. 25 Laberge AM, Burke W. Personalized medicine and genomics. In: Crowley M, editor. From birth to death and bench to clinic: the Hastings Center bioethics briefing book for journalists, policymakers, and campaigns. Garrison (NY): Hastings Center; 2008. p. 133–6. 26 Hamburg MA, Collins FS. The path to personalized medicine. N Engl J Med. 2010;363:301–4. 27 Fisher ES, Bell JE, Tomek IM, Esty AR, Goodman DC. Trends and regional variation in hip, knee, and shoulder replacement [Internet]. Lebanon (NH): Dartmouth Institute for Health Policy and Clinical Practice; 2010 Apr 6 [cited 2013 Oct 11]. (Dartmouth Atlas Surgery Report). Available from: http:// www.dartmouthatlas.org/ downloads/reports/Joint_ Replacement_0410.pdf 28 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4): 273–87. 29 Reschovsky JD, Hadley J, Romano PS. Geographic variation in fee-forservice Medicare beneficiaries’ medical costs is largely explained by disease burden. Med Care Res Rev. 2013;70(5):542–63. 30 Zhang Y, Baicker K, Newhouse JP. Geographic variation in Medicare drug spending. N Engl J Med. 2010;363:405–9. 31 Reschovsky JD, Hadley J, SaiontzMartinez CB, Boukus ER. Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries. Health Serv Res. 2011;46:997–1021. 32 Institute of Medicine. Variation in health care spending: target decision making, not geography. Washington (DC): National Academies Press; 2013. 33 Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model. Ann Surg. 2013;257(5):
867–72. 34 Gottfried ON, Rovit RL, Popp AJ, Kraus KL, Simon AS, Couldwell WT. Neurosurgical workforce trends in the United States. J Neurosurg. 2005;102(2):202–8. 35 Robboy SJ, Weintraub S, Horvath AE, Jensen BW, Alexander CB, Fody EP, et al. Pathologist workforce in the United States. Arch Pathol Lab Med. 2013 Jun 5. [Epub ahead of print]. 36 Association of American Medical Colleges. 2011 state physician workforce data book [Internet]. Washington (DC): AAMC; 2011 Nov [cited 2013 Oct 8]. Available from: https://www.aamc.org/download/ 263512/data/statedata2011.pdf 37 American Board of Medical Specialties. ABMS 2010 certification statistics. Chicago (IL): ABMS; 2010. 38 Association of American Medical Colleges. AAMC physician workforce policy recommendations [Internet]. Washington (DC): AAMC; 2012 Sep [cited 2013 Oct 11]. Available from: https://www.aamc.org/download/ 304026/data/2012aamcworkforce policyrecommendations.pdf 39 Council on Graduate Medical Education. Twenty-first report: improving value in graduate medical education [Internet]. Rockville (MD): COGME; 2013 Aug [cited 2013 Oct 11]. Available from: http:// www.hrsa.gov/advisorycommittees/ bhpradvisory/cogme/Reports/ twentyfirstreport.pdf 40 Organization for Economic Cooperation and Development. Factbook 2011–2012: economic, environmental, and social statistics. Paris: OECD; 2011 Dec 7. 41 Blumenthal D. New steam from an old cauldron—the physician-supply debate. N Engl J Med. 2004;350(17): 1780–7. 42 National Resident Matching Program. Results and data: 2013 Main Residency Match. Washington (DC): NRMP; 2013. 43 Englander R. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88(8):1088–94.
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The online version of this article, along with updated information and services, is available at: http://content.healthaffairs.org/content/32/11/1922.full.html
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Health Affairs is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600, Bethesda, MD 20814-6133. Copyright © 2013 by Project HOPE - The People-to-People Health Foundation. As provided by United States copyright law (Title 17, U.S. Code), no part of Health Affairs may be reproduced, displayed, or transmitted in any form or by any means, electronic or mechanical, including photocopying or by information storage or retrieval systems, without prior written permission from the Publisher. All rights reserved.
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Graduate Medical Education By Atul Grover and Lidia M. Niecko-Najjum 10.1377/hlthaff.2013.0557 HEALTH AFFAIRS 32, NO. 11 (2013): 1922–1927 ©2013 Project HOPE— The People-to-People Health Foundation, Inc.
doi:
Atul Grover (agrover@aamc .org) is chief public policy officer at the Association of American Medical Colleges, in Washington, D.C. Lidia M. Niecko-Najjum is a senior research and policy analyst at the Association of American Medical Colleges.
A N A LYSI S
&
C O M M E N TARY
Building A Health Care Workforce For The Future: More Physicians, Professional Reforms, And Technological Advances Traditionally, projections of US health care demand have been based upon a combination of existing trends in usage and idealized or expected delivery system changes. For example, 1990s health care demand projections were based upon an expectation that delivery models would move toward closed, tightly managed care networks and would greatly decrease the demand for subspecialty care. Today, however, a different equation is needed on which to base such projections. Realistic workforce planning must take into account the fact that expanded access to health care, a growing and aging population, increased comorbidity, and longer life expectancy will all increase the use of health care services per capita over the next few decades—at a time when the number of physicians per capita will begin to drop. New technologies and more aggressive screening may also change the equation. Strategies to address these increasing demands on the health system must include expanded physician training. ABSTRACT
H
ealth care workforce projections have been notoriously unreliable because they are often based upon idealized future delivery systems rather than current utilization trends. Recent data suggest that advances in care—such as a 50 percent reduction in mortality for cardiovascular disease—will only expand the need for more physicians.1 Current utilization patterns suggest that by 2020 there will be a shortage of 91,500 physicians—45,400 primary care physicians and 46,100 subspecialists.2 These shortages are driven by the demographic characteristics of the US population, which is growing and aging and whose disease burden is increasing. The shortages are also driven by the demographic characteristics of physicians: One in three practicing physicians are older than fifty-five and are expected to retire in the next ten to fifteen years.3 1922
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Physician supply projections are also likely to overestimate physician full-time-equivalents because younger physicians seek to work fewer hours than their predecessors did.4 Physician training is inextricably tied to patient care. Since its inception in 1965, Medicare has been the largest single explicit supporter of graduate medical education (GME) programs and has paid for its share of training costs. However, the Balanced Budget Act of 1997 imposed a cap on Medicare-funded GME at 1996 levels, at a time when tightly managed care seemed to be the future of the health care system. The system of tightly managed care networks failed to take hold, and the demand for physicians is growing. Nonetheless, the cap is still in place, limiting teaching hospitals’ efforts to expand or create new programs. Medicare now pays for less than 25 percent of direct training costs for residents and fellows.5
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Incrementally Increasing The Physician Workforce Training an additional 4,000 physicians a year would allow the United States to increase its expected supply of doctors by not quite 30,000 by the end of the decade—meeting roughly onethird of the expected shortage. This would represent an expansion of approximately 15 percent over current training levels. According to the Census Bureau, the US population has already increased by almost fifty million (15 percent) since 1997.6,7 The Congressional Budget Office estimates that under the Affordable Care Act, up to eleven million previously uninsured nonelderly Americans may gain health insurance by 2014, and that number may reach twenty-six million or more by 2022—with many of the newly insured having long-unmet needs for care, especially specialty care and surgical treatments.8 In addition, the number of older Americans will double between 2000 and 2030. Every day for the next nineteen years, 10,000 Americans will turn sixty-five.9 This age group uses more than twice as many health care services as younger adults, as shown in Exhibit 1. The aging of the population will lead to higher prevalence of cancer and cardiovascular disease.10 The incidence of cancer more than quadruples in the twenty years after an individual turns forty-five.11 As a result of scientific advances, the number of cancer survivors will increase, from fourteen million today to eighteen million by 2022.12 These patients will require recurrent care by primary care physicians, oncologists, surgeons, other subspecialists, nurses, and myriad other health professionals. In the case of heart disease, one could argue that advances in clinical interventions, coupled with public health initiatives, have increased at breakneck speed and yet have been outpaced by the US obesity epidemic. As heart disease mortality has decreased, longevity has increased. So has the rate of obesity in people ages sixty-five to seventy-four, 42 percent of whom are now obese.13 Unfortunately, obesity—and all of its associated comorbidities, such as diabetes—is likely to continue to be a major risk factor for many Americans into the foreseeable future.1 The nation’s lower age-adjusted mortality is likely to lead to another wave of age-related illness in the coming decades: neurologic disease. A recent study from the RAND Corporation suggests that almost 15 percent of Americans ages seventy-one and older have dementia and that by 2040 more than nine million are likely to have the diagnosis.14 The prevalence of Parkinson’s disease is expected to double between 2010 and 2040.15
Medical advances have also improved the care for illnesses from rheumatologic disease to congenital cardiac disorders for children and young adults. Children suffering from previously fatal diseases will survive into adulthood but require decades of follow-up by primary care providers, pediatric subspecialists, and adult subspecialists. These advances in treatment have increased the need for pediatric subspecialists beyond the nation’s current capacity16 and are likely to cause further pressure on the health system. Absent necessary increases in Medicare-supported residency positions, per capita numbers of physicians will continue to fall as the population grows and ages, with increasing per capita needs.
Lower Mortality, Longer Lives, And Greater Lifetime Utilization There is little doubt that the current US health care delivery system is less than ideal, and there are opportunities to reduce demand for services without harming patients. However, even if it is fully implemented, the ongoing health care system transformation under the Affordable Care Act—intended to reduce unnecessary health care costs through improved prevention, coordination, and integration of care—offers little evidence of decreased physician demand to date. Roughly 15 percent of all US primary care practices are now recognized by the National Committee for Quality Assurance as “medical homes.”17 These medical homes are intended to provide high-quality care consistent with
Exhibit 1 Estimated Requirements For Patient Care Physicians Per 100,000 Population, By Patient Age And Physician Specialty, 2000 Specialty Age group
Primary carea
Medicalb
Surgicalc
Otherd
Total
0–17 years 18–24 years
95 43
10 15
16 54
29 48
149 159
25–44 years 45–64 years
59 89
23 41
52 59
62 81
196 270
65–74 years 75+ years
175 270
97 130
125 161
145 220
543 781
95
33
55
70
253
Total
SOURCE Bureau of Health Professions. The physician workforce: projections and research into current issues affecting supply and demand [Internet]. Rockville (MD): BHPr; 2008 Dec [cited 2013 Oct 8]. Exhibit 29. Available from: http://bhpr.hrsa.gov/healthworkforce/reports/physwfissues.pdf. a Includes general and family practice, general internal medicine, and pediatrics. bIncludes cardiology and other internal medicine subspecialties. cIncludes general surgery, obstetrics/ gynecology, ophthalmology, orthopedic surgery, otolaryngology, urology, and other surgical specialties. dIncludes anesthesiology, emergency medicine, pathology, psychiatry, radiology, and other specialties.
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Graduate Medical Education the principles set forth at the Alma-Ata conference thirty-five years ago, which declared the need “for urgent action” to provide primary care to protect and promote the health of all people.18 Adding around-the-clock, culturally competent access to the traditional primary care model in the other 85 percent of practices in the United States is likely to improve the nation’s return on investment. However, no marked reductions in health care use or physician demand have yet been demonstrated.19 In 2004 Bruce Fireman and colleagues examined the experience of the Permanente Medical Group in Northern California and found that disease management did not substantially reduce utilization or costs, even when deployed across a tightly managed care network.20 One recent study of imaging utilization at an integrated, closed system with no financial incentives for imaging showed that rates of use have gone up and that they remain highest among the elderly.21 The reasons for increased utilization included improvements in scanning technologies and their applicability.21 Another study, in Ontario, supported these results, finding that the increased use of imaging studies and specialists was directly correlated with better outcomes for patients with complex needs.22 Some researchers have rightly characterized screenings as potentially overused in some populations; however, screenings are likely underused in other populations—for reasons related to geography23 or lack of insurance coverage.24 For example, guidelines would suggest that colonoscopies performed in patients older than seventyfive are unnecessary, but colorectal cancer screening is underused in many patients, particularly those with no insurance or with Medicaid coverage.24 Reducing colorectal screenings in one population but increasing it in others where recommended would not result in an overall reduction in services. Even if reductions in the unnecessary use of screenings or diagnostics are achieved, the expansion of access to health care in the Affordable Care Act and advances in screening and new treatments are likely to increase the long-term demand for appropriate interventions. Personalized medicine and genomics may also contribute to improved health but may simultaneously increase long-term needs for health care. The sequencing of the genome opened a number of possibilities for patients who previously had little hope for survival. New treatments and protocols such as targeted treatment for colorectal, breast, and lung cancer and personalized pharmacologic regimens;25 prophylactic surgery such as mastectomies for patients who are genetically at high risk for breast cancer; and 1924
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It would be unwise to prescribe a static specialty composition that would not respond to the dynamic health care environment.
stem cell therapy are all under intense investigation and development.26 The promise of such new technologies and therapies does not lie in their potential to reduce the lifelong consumption of medical care. Rather, the hope is that these approaches will lead to cures for disease or better treatment, both of which lead to longer and better lifespans. Longer life spans result in more use of medical care over the course of a lifetime for ailments that have become treatable diseases rather than causes of death. Some have argued that unexplained local variation in the use of health care is evidence of waste or inefficiency and that the use of health care can be greatly reduced. For example, in 2006 the per capita rate of knee replacements in Sioux Falls, South Dakota (14.3 replacements per 1,000 Medicare enrollees), was more than three times the rate of knee replacements in the Bronx, New York (4.1 replacements per 1,000 Medicare enrollees).27 However, recent studies suggest that variation in medical care is not driven largely by providers’ preferences, as has been suggested by researchers with the Dartmouth Atlas Project.28 Instead, differing health status and other individual patient factors continue to contribute to the necessary (if not ideal) variation in utilization.29–32
A Balanced Approach Population health care needs change over time, and it would be unwise to prescribe a static specialty composition of the health care workforce that would not respond to the dynamic health care environment. Equally, given the long medical training period and the likely modest rate of change in delivery and payment systems, it would be unwise to rely on any expected radical transformation of the health care system to meet
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Even if health reform is successful, the growing and aging US population certainly will need a larger health care workforce.
the projected increase in physician demand. Instead, it would be prudent to incrementally expand the number of federally supported residency positions based on current health care utilization rates and to commit to ongoing analysis of changing demand to inform future workforce planning. Several pending bills in Congress (S. 577, H.R. 1180, and H.R. 1201) to expand GME funding take into account the notion that primary care is the foundation of a high-performing health system, but they also note that it is of equal importance to address shortages of subspecialists in many areas. In fact, specialists such as general surgeons, neurosurgeons, and pathologists are facing decreases in their absolute numbers, not just in per capita ratios.33–35 These pending GME bills allocate the specialty composition of residency positions in accordance with physician shortages identified by federal analyses and direct that future specialty allocation be driven by workforce data that are constantly updated and analyzed to reflect trends—for example, analyses of shortages by the Government Accountability Office or the yet-to-be-funded National Health Care Workforce Commission. This approach would allow policy makers to adjust the future numbers of residents in line with population needs. In 2010 the median ratio of active patient care physicians to the US population was 215.1:100,000.36 Approximately 37 percent of those physicians were primary care practitioners—a designation that includes providers in the three fields of general internal medicine, family medicine or general practice, and general pediatrics.3,36 These three primary care specialties combined accounted for the largest number of active physicians in any single discipline. The remaining 63 percent of active patient care physicians were spread over 155 specialties and subspecialties.3,37 In the 2011–12 academic year approximately
43 percent of all core residents—that is, residents in postgraduate year 1 positions available immediately following medical school—entered primary care specialties, although many of them will choose to subspecialize. Approximately 20 percent of all GME slots are fellowship (or subspecialty) training positions. In comparison to larger specialties such as family medicine (which has approximately 3,400 positions per year) or internal medicine (approximately 7,300 positions), the number of subspecialty positions in any given specialty is relatively small. For example, roughly 500 oncologists are trained annually. Eliminating these fellowship opportunities would not only have a limited impact on growing the primary care workforce, but it would also exacerbate physician shortages for patients with complex and high-acuity health care needs. Improved access to primary and preventive care should be one focus of workforce expansion. However, improved access will not prevent all patients from ever developing diabetes, cancer, or neurologic disease. The expansion of the specialty workforce should be coupled with more efficient provision of subspecialty care. For example, chronic conditions currently managed by specialists could be treated by primary care physicians. Likewise, providers such as physician assistants and nurse practitioners could care for patients with lower-acuity conditions who are now treated by physicians. This approach could help address barriers to access for patients in communities that consistently struggle to recruit physicians. Some of these improved efficiencies could be achieved through reimbursement policies that recognized and rewarded cognitive services, such as patient counseling; service in geographically or economically underserved communities; or both. However, these changes likely will take time to implement and are unlikely to alleviate the full burden of physician shortages in the interim.
Conclusion The Association of American Medical Colleges and the Council on Graduate Medical Education, among others, recommend training additional physicians annually (4,000 and 3,000 more physicians, respectively), while improving the use of existing resources and continually reassessing workforce requirements.38,39 Even if current health care delivery reforms are implemented and successful, the growing and aging US population certainly will need a larger health care workforce, including more physicians. The United States already has fewer November 2013
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37
◀ %
Primary care physicians
In 2010, approximately 37 percent of active patient care physicians were primary care practitioners. The remaining 63 percent were spread over 155 specialties and subspecialties.
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Graduate Medical Education physicians per capita than most of the other countries in the Organization for Economic Cooperation and Development—not only fewer generalists, but in some cases fewer specialists as well.40 For example, the United States has fewer specialists (65 per 1,000 population, including all specialties of internal medicine) than the United Kingdom (66.1), Luxembourg (68.4), Slovenia (71.1), Italy (75.7), the Czech Republic (76.9), Poland (77.1), and the Slovak Republic (85.4).40 The aging of the US population has implications for the metrics used to benchmark the health care workforce, such as the number of physicians per capita. Whereas the numerator (number of physicians) in the United States has increased, the changing nature of the denominator (the number of patients, who collectively are growing older and more diverse and have increasingly complex comorbidities) suggests that an even higher ratio will be needed.41 With looming changes in health care treatments, technology, finance, and delivery, researchers and policy makers must understand that an adequate supply of physicians will have to be achieved both through more efficient health care delivery models and through an increased number of GME training positions. States and schools have responded already by
increasing the number of medical students, but that independently will not increase the supply. The unwillingness of Congress to fund additional Medicare GME positions may lead to US medical school graduates who lack opportunities to complete their residencies. Just last March, 528 qualified 2013 US medical school graduates were not matched to a residency training position; 758 qualified US medical doctors who had graduated prior to 2013 also failed to be matched.42 Current attempts at payment and delivery system reform must be complemented with an adequate supply of physicians and other health professionals in primary care and in medical and surgical specialties. The United States will need to take full advantage of every health professional and every type of technology available to address the needs of an aging, growing population. The exact model of interprofessional collaboration to achieve this goal has yet to be determined. However, ongoing efforts toward a common classification of competencies for the health professions will help improve teamwork across providers and improve access, care, and care coordination for patients.43 In the meantime, to avoid impediments to access, it would be prudent to increase the number of resident positions that Medicare partially supports. ▪
NOTES 1 Goldman DP, Cutler D, Rowe JW, Michaud PC, Sullivan J, Peneva D, et al. Substantial health and economic returns from delayed aging may warrant a new focus for medical research. Health Aff (Millwood). 2013;32(10):1698–705. 2 Association of American Medical Colleges. Physician shortages to worsen without increases in residency training [Internet]. Washington (DC): AAMC; 2010 Jun [cited 2013 Oct 8]. Available from: https://www.aamc.org/download/ 286592/data/ 3 Association of American Medical Colleges. 2008 physician specialty data [Internet]. Washington (DC): AAMC; 2008 Nov [cited 2013 Oct 8]. Available from: https://www.aamc .org/download/47352/data 4 Health Resources and Services Administration. The physician workforce: projections and research into current issues affecting supply and demand [Internet]. Rockville (MD): HRSA; 2008 Dec [cited 2013 Oct 11]. Available from: http:// bhpr.hrsa.gov/healthworkforce/ reports/physwfissues.pdf 5 ResDAC. Healthcare Cost Report Information System [home page on the Internet]. Baltimore (MD): Centers for Medicare and Medicaid
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11 Howlader N, Noone AM, Krapcho M, Garshell J, Neyman N, Altekruse SF, et al. SEER Cancer Statistics Review, 1975–2010. Bethesda (MD): National Cancer Institute; 2013 Apr [cited 2013 Oct 8]. Available from: http://seer.cancer.gov/csr/1975_ 2010 12 De Moor JS, Mariotto AB, Parry C, Alfano CM, Padgett L, Kent EE, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomarkers Prev. 2013;22(4): 561–70. 13 Fakhouri THI, Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity among older adults in the United States, 2007–2010 [Internet]. Hyattsville (MD): National Center for Health Statistics; 2012 Sep [cited 2013 Oct 11]. (NCHS Data Brief No. 106). Available from: http://www.cdc.gov/nchs/data/ databriefs/db106.htm 14 Hurd MD, Martorell P, Delavande A, Mullen KJ, Langa KM. Monetary costs of dementia in the United States. N Engl J Med. 2013;368: 1326–34. 15 Kowal SL, Dall TM, Chakrabarti R, Storm MV, Jain A. The current and projected economic burden of
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24 Rosenthal E. Paying till it hurts: the $2.7 trillion medical bill. New York Times. 2013 Jun 1. 25 Laberge AM, Burke W. Personalized medicine and genomics. In: Crowley M, editor. From birth to death and bench to clinic: the Hastings Center bioethics briefing book for journalists, policymakers, and campaigns. Garrison (NY): Hastings Center; 2008. p. 133–6. 26 Hamburg MA, Collins FS. The path to personalized medicine. N Engl J Med. 2010;363:301–4. 27 Fisher ES, Bell JE, Tomek IM, Esty AR, Goodman DC. Trends and regional variation in hip, knee, and shoulder replacement [Internet]. Lebanon (NH): Dartmouth Institute for Health Policy and Clinical Practice; 2010 Apr 6 [cited 2013 Oct 11]. (Dartmouth Atlas Surgery Report). Available from: http:// www.dartmouthatlas.org/ downloads/reports/Joint_ Replacement_0410.pdf 28 Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending. Part 1: the content, quality, and accessibility of care. Ann Intern Med. 2003;138(4): 273–87. 29 Reschovsky JD, Hadley J, Romano PS. Geographic variation in fee-forservice Medicare beneficiaries’ medical costs is largely explained by disease burden. Med Care Res Rev. 2013;70(5):542–63. 30 Zhang Y, Baicker K, Newhouse JP. Geographic variation in Medicare drug spending. N Engl J Med. 2010;363:405–9. 31 Reschovsky JD, Hadley J, SaiontzMartinez CB, Boukus ER. Following the money: factors associated with the cost of treating high-cost Medicare beneficiaries. Health Serv Res. 2011;46:997–1021. 32 Institute of Medicine. Variation in health care spending: target decision making, not geography. Washington (DC): National Academies Press; 2013. 33 Fraher EP, Knapton A, Sheldon GF, Meyer A, Ricketts TC. Projecting surgeon supply using a dynamic model. Ann Surg. 2013;257(5):
867–72. 34 Gottfried ON, Rovit RL, Popp AJ, Kraus KL, Simon AS, Couldwell WT. Neurosurgical workforce trends in the United States. J Neurosurg. 2005;102(2):202–8. 35 Robboy SJ, Weintraub S, Horvath AE, Jensen BW, Alexander CB, Fody EP, et al. Pathologist workforce in the United States. Arch Pathol Lab Med. 2013 Jun 5. [Epub ahead of print]. 36 Association of American Medical Colleges. 2011 state physician workforce data book [Internet]. Washington (DC): AAMC; 2011 Nov [cited 2013 Oct 8]. Available from: https://www.aamc.org/download/ 263512/data/statedata2011.pdf 37 American Board of Medical Specialties. ABMS 2010 certification statistics. Chicago (IL): ABMS; 2010. 38 Association of American Medical Colleges. AAMC physician workforce policy recommendations [Internet]. Washington (DC): AAMC; 2012 Sep [cited 2013 Oct 11]. Available from: https://www.aamc.org/download/ 304026/data/2012aamcworkforce policyrecommendations.pdf 39 Council on Graduate Medical Education. Twenty-first report: improving value in graduate medical education [Internet]. Rockville (MD): COGME; 2013 Aug [cited 2013 Oct 11]. Available from: http:// www.hrsa.gov/advisorycommittees/ bhpradvisory/cogme/Reports/ twentyfirstreport.pdf 40 Organization for Economic Cooperation and Development. Factbook 2011–2012: economic, environmental, and social statistics. Paris: OECD; 2011 Dec 7. 41 Blumenthal D. New steam from an old cauldron—the physician-supply debate. N Engl J Med. 2004;350(17): 1780–7. 42 National Resident Matching Program. Results and data: 2013 Main Residency Match. Washington (DC): NRMP; 2013. 43 Englander R. Toward a common taxonomy of competency domains for the health professions and competencies for physicians. Acad Med. 2013;88(8):1088–94.
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