Back to Front PageVOLUME 6, NUMBER 4

Addressing the Question of Physician Supply in America

By Jennifer Proctor

In May, the AAMC hosted a colloquium on the physician supply in America. AAMC President Jordan Cohen, M.D. (far left), served as the mediator for the event, which also featured Richard "Buz" Cooper, M.D. (second from right).

Ask experts whether the physician supply will be sufficient to meet America's future health care needs, and you'll get as many answers as people asked. Since predictions must take into consideration myriad factors including everything from the growing nonphysician work force to the future population of the United States, it's an educated guessing game. And the lack of consensus on long-term predictions may prove problematic for medical educators: Given the minimum of seven years that it takes to produce a fully trained physician, it's impossible to quickly adjust the number of doctors to meet changes in demand.

"There are significant implications when we consider physician supply in the United States. In order to adjust the number of physicians we produce, we must examine the size of medical schools, the number of medical schools, and the number of residency positions," says Michael Whitcomb, M.D., senior vice president of the AAMC's Division of Medical Education.

The potential consequences for miscalculations are serious. Dr. Whitcomb says if the community produces too few physicians, access to medical care can be severely limited. "This isn't just a medical school problem," he says. "If we don't have enough doctors, there could be a dire impact on the delivery of medical care services in this country." History demonstrates the difficulty of accurately predicting the number of physicians needed. In the early to mid-1990s, many experts agreed that the United States would experience an oversupply of physicians by 2000 - with some prophesying a surplus of more than 160,000 - and yet these predictions clearly did not materialize. Acting on similar estimates, Canada reduced its medical school slots by 10 percent only to find itself scrambling today to increase enrollment and remedy a growing physician shortage. Now some experts are forecasting a dearth of physicians in the United States as well.

Too Few or Too Many?

One of the most outspoken voices on this topic is Richard "Buz" Cooper, M.D., director of the Health Policy Institute at the Medical College of Wisconsin. Dr. Cooper says his 20-year estimates show that, unless dramatically increased from its current level, the United States physician supply will not be able to meet health care demand, and he recommends that medical school output be increased 35 percent by 2020.

"The number of physicians per capita is plateauing, while the population is expanding," Dr. Cooper says. "We have an upward trend in the number of nonphysicians who are performing advanced clinical services, but when you add it together, the economy and the population are growing more rapidly than the combination of physician and nonphysician clinicians."

Dr. Cooper reaches his conclusions about the physician work force by studying the economy; population growth, age, and ethnic mix; the demand for health care; and the growing role of nonphysician health care providers. He particularly emphasizes the role of the economy, because, he explains, as disposable income increases so does the proportion of dollars spent on health care by both individuals and the government, including the Medicare and Medicaid programs. In fact, Dr. Cooper says that for every 1 percent rise in the gross domestic product per capita, health care spending increases 1.6 percent. Thus, as the economy expands, he predicts the country will experience an unprecedented demand for health care.

The AAMC colloquium on physician supply highlighted diverse issues and viewpoints on the issue. Jonathan Weiner, Ph.D., (on the left) shared his beliefs that there currently is a surplus of physicians.

If physicians are unable to satisfy this demand, nonphysician providers stand poised to meet the challenge, Dr. Cooper predicts. "The public will get what it wants," he says. "The question is from whom they will get their health care." He suggests that physicians may find themselves treating only complex cases as people discover they can receive more routine care from nonphysician providers, including physician assistants, nurse anesthetists, and optometrists.

"Doctors need to either expand their numbers to meet demand or specialize what they do to appeal to a lesser portion of the demand," Dr. Cooper says. "You can't do both."

Jonathan Weiner, Ph.D., stands in sharp contrast to Dr. Cooper. "We have and will continue to have a surplus of physicians, particularly in some specialties and geographic areas," says Dr. Weiner, a professor of health policy and management at the Johns Hopkins University School of Public Health.

Dr. Weiner estimates that there are more than 500 patients for each doctor who provides care - a number that he says will decrease to 375 by 2020. He explains that the United States academic medicine community responded to a clear shortage of physicians in the 1960s by increasing medical school class size and allowing more international medical graduates (IMGs) to fill United States residency positions. Since that time, he says, medical educators have continued to expand the ranks of physicians in training at a rate greater than that of the population increase.

A surplus could have serious effects on the health care system, Dr. Weiner warns. He cautions that a physician oversupply could result in lower physician salaries, fewer patients per physician, increased tension between doctors and nonphysician providers, and greater dissatisfaction with the medical profession.

Making Adjustments

Fitzhugh Mullan, M.D., argues that medical educators don't need to look any further than the number of first-year residency positions for an impetus to increase the number of United States medical students. While the number of U.S. medical school graduates has remained constant at about 16,000 per year for the past two decades, first-year residency positions have grown to about 20,000, requiring hospitals to fill slots annually with thousands of foreign medical school graduates.

Dr. Mullan, contributing editor for Health Affairs and former director of the Health Resources and Services Administration's Bureau of Health Professions, stresses that rather than relying on foreign medical school graduates to complete residency classes, United States schools should increase their output to fill the gap. "The position of medical education ought to be: The product that they train - physicians - is the standard for health care delivery, and they should without apology produce physicians to meet needs that are both historical and current," he says.

Dr. Mullan notes that United States medical schools turn away qualified applicants every year because of the strict class size limits, and he reasons that schools should offer admissions to a larger group of talented candidates. He adds that by accepting more students into medical schools in the United States, the community develops a work force that more closely resembles the population. Additionally, foreign doctors, many from nations with staggering health care needs, will be less likely to leave their native countries to train and practice in the United States.

Since a disproportionate number of IMGs work in underserved rural and urban areas both in residency and afterward, Dr. Mullan acknowledges that steps would need to be taken to ensure that increasing U.S. medical school output doesn't negatively impact these communities. One of these steps, he says, should be additional loan repayment programs that would help make such service financially feasible for more U.S. medical school graduates.

For now, Dr. Mullan recommends that U.S. medical schools aim to fill one-half of the residency gap with their own graduates. "The principal goal should be self-sufficiency."

Ah, Just Right
"The number of physicians being trained now is about right," says Carl Getto, M.D., chair of the Council on Graduate Medical Education (COGME), which has congressional authorization to provide an ongoing assessment of physician work force trends, training issues, and financing policies.

COGME is standing by its recommendation to provide graduate medical education to 110 percent of the number of United States medical school graduates, a point made in COGME's eighth report, released in the mid-90s. The report also recommends a 50-50 split between generalist and specialist providers.

To reach its conclusions, COGME examined physician supply and distribution, both by specialty and geographic area, in conjunction with the quality of data used in physician supply analysis and policy determinations. Two recent reports highlight the council's work. In a 1998 report, COGME described the need for continued support of federal and state programs that encourage physicians to choose generalist careers and practice in medically underserved areas. A 1999 COGME report emphasized the need for federal and state governments as well as medical educators to "expand the collection and dissemination of data on supply, need, and demand for physicians by specialty and region."

Dr. Getto notes that the physician work force is now determined more by the number of residents trained in the country than by the number of students who graduate from U.S. medical schools. However, despite the discrepancy between the numbers of U.S. medical school graduates and first-year residency positions, COGME does not detect a strain in the work force that would be severe enough to cause a shift in federal policy.

Dr. Getto also emphasizes that the council does recognize the geographic and specialty areas where there are shortages, including many rural and inner-city communities. COGME is weighing the possibilities for equalizing the distribution of both generalist and specialist physicians that will best serve these areas.

"Predicting physician supply is a bit of a game," Dr. Getto says. "Organizations such as COGME and the AAMC have to serve as a bellwether and regularly get as much information as possible out to the community in order to gauge whether the system needs a tweak or a major change."

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19 July 2001