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A Word from the President: Tackling the Physician Supply Question

Viewpoint: Asking the Teachers to Lead

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Managing Editor Scott Harris sharris@aamc.org Staff Writer Elissa Fuchs efuchs@aamc.org

A Word From the President

Tackling the Physician Supply Question

In this space last month, I offered a brief overview of some of the items that are likely to command much of the association's attention in 2004-and perhaps long thereafter, as well. The first item on my list was the growing concern about whether we are producing an adequate number of physicians to meet future needs.

Although the AAMC has been concerned for years about many aspects of the future physician workforce (e.g., racial and ethnic diversity, gender parity, geographic distribution, specialty mix), we have not felt the need to raise concern about numerical adequacy. Indeed, quite to the contrary, we and many other organizations and individuals have fretted about an impending oversupply of doctors. Until recently, virtually all analyses of physician workforce needs dating back to the mid-1970s have suggested that our country would have an abundant - if not a superabundant - supply of doctors. In 1980, the Graduate Medical Education National Advisory Committee (GMENAC) predicted that the country would have an excess of some 145,000 physicians by the year 2000, and in the early 1990s, several workforce analysts published studies that reached the same conclusion.

Based on these projections, many medical organizations, including the AAMC, called for reducing the number of residency positions to more closely approximate the number of U.S. medical school graduates. Such a reduction was seen as a way, over time, to bring the perceived burgeoning of the physician workforce into line with the country's needs. As everyone is now aware, the dire prediction of a doctor glut by the turn of the millennium did not materialize. As a consequence, we modified our workforce position in 2000, acknowledging that existing data could not be relied upon to forecast either a surplus or a shortage.

Why were the predictions so far off the mark? Clearly, one shouldn't blame the predictors. They did the best they could with the facts at hand. The reason for the false prophecy is to be found in the very nature of workforce predictions. They are only as good as the assumptions upon which they are based. And since assumptions can be made only on the basis of contemporary circumstances, and since circumstances have had a habit lately of changing unpredictably and rapidly, it's not surprising that assumptions made even as recently as a decade ago proved incorrect. Perhaps the most telling (and wrong) assumption that was made in the late 1980s and early 1990s was that the healthcare system would be overtaken quickly by closed-panel HMOs, which utilize physician services at a much lower rate than traditional fee-for-service practice does. The public's unexpected and rapid rejection of that kind of managed care arrangement left the door open for the continued upsurge in the demand for physician services - and for the failed prophecy.

In addition, contemporary musings about the adequacy of the physician supply are giving greater consideration to such factors as the likely increased health care needs of an aging population and the likely reduced lifetime productivity of physicians, the latter due to lifestyle choices, earlier retirement, and family demands (especially among women physicians). These and other considerations account for the recent suggestions by some analysts that the country may now be on the verge of a serious shortage of physicians. An example is the latest study commissioned by the Council on Graduate Medical Education (COGME); the findings of that study led the council to change its long-held prediction of a surfeit of physicians and to acknowledge that the country may well be facing a serious doctor shortage. In response, the council recommended that medical schools increase enrollments by 15 percent over the next decade - a modest recommendation, in keeping with the council's recognition that workforce projections, as I've noted, are hazardous, to say the least. That hazard notwithstanding, the consequences for the public's health of a shortfall in physicians are obviously much more serious than those of an oversupply. Access to equitable health care is already tenuous for many of our countrymen; a paucity of physicians would compound this problem enormously.

Given that medical schools and teaching hospitals are the final common pathway traversed by all future physicians, our community's stake in ensuring an adequate supply is second to none. For this reason, we recently elected, as you may recall, to establish a new AAMC Center for Physician Workforce Studies. The center will be headed by Edward Salsberg, the current executive director of the Center for Health Workforce Studies at SUNY-Albany School of Public Health. Ed will join us full time in April and will lead the association's efforts to analyze the complex and ever-changing issues bearing on the adequacy of the physician supply.

My hope is that the insights gained by these efforts will better position the association to offer credible advice to policymakers and, more important, to our constituents.

Jordan J. Cohen, M.D.
AAMC President

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