It’s Time to Address the Problem of Physician Shortages

It is now widely accepted that the United States is on the cusp of deepening shortages of physicians.1,2 This article will briefly review how these shortages could have been anticipated, how they are being manifested, and how policy-makers were drawn to the contrary conclusion, and it will discuss the challenges that now exist as the nation undertakes to expand undergraduate and graduate medical education in an attempt to meet the projected future demand. SETTING THE STAGE FOR FUTURE SHORTAGES Anticipating the Demand for Physicians As physicians, it is natural to think about the future demand for physicians in terms of needs, such as the aging population and the obesity epidemic, or new technologies, such as implantable defibrillators and targeted therapeutics. During the 1990s, many thought that payment systems would drive the need for more primary care physicians. But none of these has proven to be decisive. Rather, the dominant factor that my colleagues and I have observed is growth in the economy overall, because ultimately it is the capacity of a society to purchase health care that determines how many services will be used.3 From 1929 to 2000, the growth in physician supply followed the trend of economic growth rather closely, except in the period after World War II, when the economy grew briskly but the production of physicians lagged behind. In response, medical school capacity doubled, and so did the capacity of residency programs (Fig. 1). By 1980, physician supply had increased to the level that could be predicted from per capita gross domestic product, and it roughly paralleled gross domestic product growth over the next 2 decades. Figure 2 displays this trend and extrapolates the demand for physicians to the year 2025.FIGURE 1.: Medical graduates and PGY-1 residents without previous residency. 1950–2005.FIGURE 2.: Physician supply and demand projections. Extrapolated to 2025.Downward Pressure on Supply—Medical Schools As the supply of physicians began to build in the 1970s, and as health care spending increased, policy-makers feared that too much spending on health care would harm the economy, and many reasoned that it was physicians who drove spending. Therefore, freezing their numbers would be beneficial. Others were alarmed by the fact that, in per capita terms, the growth in physician supply was entirely due to additional specialists, while primary care held constant, thereby tipping the ratio, a process that must be rectified. These 2 philosophies found quantitative support in a series of workforce projections that, in retrospect, were badly designed but that gave strength to the idea that the nation would soon have too many physicians and the medical education pipeline must shut down. Federal support for medical schools abruptly ceased in 1976, and the expansion of both allopathic (MD) and osteopathic (DO) schools ground to a halt (Fig. 1). While DO schools began to grow soon thereafter, MD schools remained at 1980 levels for more than 2 decades. In per capita terms, the output of medical students declined. Downward Pressure on Supply—Graduate Medical Education Graduate medical education (GME) followed a different course (Fig. 1). After growing in parallel with medical school enrollment in the 1960s and 1970s, it paused briefly in the 1980s but then continued its upward path in the 1990s. However, this latter period was not associated with additional US medical graduates but with more international medical graduates (IMGs), some of whom were US citizens but most of whom were foreign nationals. Indeed, by the late 1990s, IMGs accounted for approximately 25% of first year (PGY-1) residents. Looking back over the 35 years from 1960 through the mid-1990s, one can discern an overall upward trend of 350 to 400 additional PGY-1 positions annually. This trend did not escape the notice of planners, most of whom held to the notion that there were too many specialists being trained, and in 1996 a “Consensus Statement” was developed by a coalition of the American Medical Association (AMA), Association of American Medical colleges (AAMC), Association of Academic Health Centers (AAHC), American Osteopathic Association (AOA), American Association of Colleges of Osteopathic Medicine (AACOM), and National Medical Association (NMA).4 It proposed to “reduce the number of GME positions funded by the federal government to a number closer to that of the graduates of US allopathic medical schools,” a proposal that found expression in the Balanced Budget Act of 1997, which froze federal funding for GME at its 1996 levels. This single action fully accounts for the leveling off of physician supply in 2005 and the projected decline thereafter. Indeed, had a cap not been placed on GME, the physician shortages that are developing today would not exist (Fig. 2). Downward Trend of Physician Work Effort A second factor affecting physician supply has to do with the decreasing work effort of physicians. One reason for this relates to aging of the workforce, as the youthful cohorts of the 1970s and 1980s mature. Another is the increased participation of women, and a third is generational—the desire of younger physicians of both genders for more family time, less time on-call and fewer hours overall. Added to this is the 80-hour rule for residents. Finally, increasing numbers of physicians are finding opportunities in health care organizations, pharmaceutical companies and other venues outside of clinical practice. It is the combination of increasing demand for physicians and a decline in their actual and effective supply that is leading to a projected short-fall of more than 200,000 physicians by 2025 (Fig. 2). Evidence of Shortages Although the nation is headed toward very large shortages in the future, evidence of physician shortages exists already. One example is longer waiting times for patients, even when referred by another physician. Hospitals and group practices report increasing difficulty in recruiting physicians, not only in specialties such as urology, radiology, cardiology, gastroenterology, and oncology, which have been experiencing shortages for a number of years, but also in primary care, which is now the most frequent specialty sought by search firms. Young physicians are receiving more jobs offers, higher starting salaries, and larger signing bonuses, particularly in procedural specialties. Some group practices have found recruitment of new physicians too time consuming and expensive and have simply decided to get smaller. Night and weekend coverage is difficult to assure in many areas of the country, and hospitals find that they must compensate specialists for being available to cover emergency rooms. The quest for physicians now provides employment for 8000 recruiters. Surveys of medical school deans confirm the tight physician labor market.5 Similarly, in a recent survey of hospital CEOs conducted by the Council on Physician and Nurse Supply, 45% of respondents reported that recruiting physicians is very challenging and 51% that it is more challenging that 1 year ago. Medical societies and hospital associations in 15 states, which represent more than half of the US population, have issued reports that project shortages of physicians, and 15 specialty organizations have published reports projecting national shortages in their disciplines. Most organizations that had participated in the “Consensus Statement” concerning physician surpluses a decade ago have issued statements that the nation is facing physician shortages, instead. Even the Council on Graduate Medical Education (COGME), which promulgated the notion of physician surpluses throughout the 1990s, has recanted and, based on the approach to planning that my colleagues and I described,3 has projected large shortages of physicians in the coming years.2 CHALLENGE #1: EXPANDING GRADUATE MEDICAL EDUCATION What is needed to fill the gap? Indeed, can it be filled? With the to in the United States is through residency programs by the Council on Graduate Medical Education or the approximately residents PGY-1 positions for the first time this physicians will be in the period from to as is approximately 200,000 too the number of PGY-1 positions had continued to grow after at about more than had been the the previous and such growth were to the number of PGY-1 positions would in more than in and a of new physicians would be over the years from to which is the number of physicians that projected will be (Fig. 1). had the natural of GME been to the United States would not now be facing a physician (Fig. 2). I that it is that the number of PGY-1 positions be increased to a level that is more than at additional PGY-1 positions for years to a of by the of residency is more than years, this for an of residents overall. on this path a number of and a number of residency capacity will new or programs with the of of patients, and of The and the in new residency programs or the expansion of Even programs have had difficulty in for and new programs can be to an even more difficult and Therefore, the of expansion is to be than new PGY-1 positions annually. for Most are are roughly hospitals in the United of which have or fewer the with half are but half are that, at in terms of there be for the needed Even more could exist hospitals with in which and more would exist organizations other than hospitals to the of During the the of residency increased, as of the need for to the of with increasing specialties by the are some of the in and be and be to One of would be to and and to do so the Even With the As the natural expansion of PGY-1 positions been to the United States would not now be facing a physician The can the and projected shortages be in the years to Figure displays the of increasing the number of PGY-1 positions by over the years from to the to PGY-1 residents in a this to be a the of was and However, even it were to this large number of new residency the by a of growth in the years could not be The the supply of physicians and the projected demand would but it would not This not that residency programs not be Rather, it the in while also the of programs for and who will be needed to fill the PGY-1 positions Extrapolated to GRADUATE MEDICAL EDUCATION Medical Education its in has been the of funding for The that the of care in an and it is the undertakes to such education in some other that a of the of such of as as of and other be to an by the hospital were in these medical education were to After they were by from for clinical The this latter that that this approach will for continued Federal support of medical education through the while that support as from grew as the number of residents from approximately in to years and as per at in 1996 and to approximately of federal health care 1). this approximately is to the associated for Medical Education In the and Act additional to hospitals for the increased of care in The this the that this was of about the of the to fully for such as of and the for services and the of In the of funding levels were to the ratio, and only to this payment was Medical Education which are are through an to clinical During the 1990s, grew more than to in a number of have this to less than have increased to cover a of in the of is to be by support for hospitals in and the that in this payment could the of hospitals to their for evidence that hospitals that of The approximately residency positions and has a to this number to and the of additional The for these positions are approximately 1). also GME, its to hospitals are not to a number of residents. from states, as its but more than these with funding of approximately for for a of approximately in In hospitals residency through the higher that many are to based on the and of services in that these to this would for an additional It is that as much as more is from clinical and other the support for residency to of which approximately can be thought of as and as the GME of the GME hospitals are to more but without In hospitals that had a residency are to with support at the of residents that exist after years, a very time to build a of residency hospitals also an that to their by an additional The of outside of the and the additional positions that it will support are they represent fewer than of the that are these hospitals have approximately PGY-1 residents and residents overall the evidence that growth is but that, in the of on growth is very States in which new medical schools are developing the challenges of too residency programs in their areas for the clinical of their medical students and too residency positions in their areas for their expansion of GME, Physician Act of which would the cap in have fewer residents per capita than the national Some other in which medical schools are being such as and would also of and about funding of GME, there have been a number of to the of One such proposal would from the and it of federal Another would the GME funding but the of payment for and with to to hospitals and to the organizations that are for medical schools or of schools A on this latter proposal would to residents as that can be to Another off would the of GME to such as primary care or the of physicians for and that these exist GME, and many have for primary care to their Most have also for However, such these have not been and it be to such through rather that through Finally, a number of organizations have that the to GME be more and thereby the of the federal One such proposal from the would a Medical Education to which would this could support the of by the or this approach in its in and as as the its support for an Although on the and in and, to a in and for many years, such a proposal at the national level is with would both and be it would a single national over the of both and by In an it is also to that 1). and do so as do the and the through the higher on by many health and there is for the to Indeed, as to the of the through and they to The federal government would that from the fact that the from are the approach to health care in the United that it is not that a for GME has not to is that a continued on an the from the of in GME, which is in federal and, contrary to the of that has been by of an in GME not be fully or not fully but this is the GME and be that the that to years ago. CHALLENGE GME and in GME It is difficult to support for GME when there is such about both and Although there are for some of the for much of it is that GME funding 2 and and a The is the latter is A in is that their has been by in a number of different As the of was to that hospitals with of services and the of residents. The Budget has continued to to these but have to the of and the of care, both of which are of The of is by the fact that hospitals in and and in the of and there are approximately of which are of which are Although these hospitals of the residents and, in the have the and the of they widely in these In a recent by only of the hospitals were also the of hospitals for and only were in the with to hospitals were in the of both and The had than the but there was in This of is a of in the and it for some other for society to assure that are A second in the relates to the fact that GME is to to for many a fact that has to in for to be In the 1990s, for and as much as In 1997, these were for by the of to of the national and this was to in because GME is in to the of who are by hospitals of GME is most to because its is most and have that hospitals have or more care, be Similarly, the care that they is of higher that, be through an to a process that is to through Finally, the of is for of and and there is reason that these be for through an rather than the and have a for that residents for their education by and that there is reason to their in a that from the of other hospital which are through the which as have The of residents has been by the National which their to and by the which from the of students and, to to Even residents are students and the to are for such as from that federal spending for medical education be through the process rather than an I have that residents are students but a that is not by labor and that the that they through for the of and education that is in because years, to the of or even rather than to a has the to the process and a national Another reason for the of about in GME relates to the number of specialists who have been trained, a that can be back to the gave to these in for published in In GME support was to for specialty residents who had their specialty residents continued to and in the which would have the number of PGY-1 residents to of the number of US medical graduates and that half be in primary The of this proposal is in statements by the then of the of Health who it as not a one that was to production of specialists by hospitals that were to their programs to the of the Although by most health care and organizations, this was However, a in its by the payment for specialty residents while for primary care residents. the time, the a proposal that of medical school graduates primary these and toward specialty continued to leading ultimately to the 1996 “Consensus Statement” by the and and in the Balanced Budget Act of 1997, which the number of residents that hospitals could for at their 1996 levels and the hospital for to the has been an action affecting medical education that has had as a it was this single now by many of its that fully accounts for the physician shortages that are now being Federal Budget from and attempt to the through action will the that now at a time when the on to GME from A which is through a is from which is by and that only a years ago there was a for a in the number of residency This is with a large of from the and to that with more physicians with in or However, these simply is in the as the a that from the of to in health care which specialists, and also to as a for the health care are but are this is is not as a of the but as a of the of surpluses and through the of The of and the that is not only in to but in on from its One is a rule proposed by for and that would the time that residents in from the of GME After a of this was back to only that an A second proposed rule would have support for GME from the federal of through of the American the of this rule was for 1 These 2 the for and toward GME a that in with a for in funding the of residents. the now to GME are to the and that have the of a that has been in medical education at a of approximately of the health care but that, by its on is an to the supply of physicians for the are simply too many of and they are from too many systems of these is the that the nation is too many specialists and too Added to this is the that, contrary to of for GME, physicians are not a and, even they medical education not be with these is the held that, the of their have and to support in medical and or to compensate hospitals for and over these about GME is the more than from and to which are both and Even for hospitals that less than the national the be than some GME funding to more hospitals or with numbers of residents to grow a of even additional are It is that there is so much in GME while many specialty organizations have the desire to expand GME in their the by most have been through a of residency with more effective recruitment of residents from the other than the American Association and the American of have the that the of GME must be Even organizations that have increasing GME have so with the of has the to action to GME the has not been in this and while the has also for the on GME, that is not its particularly the health care that were so in the quest to physician simply many that organizations and must the and there is none of to the than a and physician. CHALLENGE MEDICAL Although residency is the single to the physician workforce, the of residents is It US medical both MD and US citizens who were and foreign who were in other From the to the of residents were graduates of MD schools in the United However, with the of the report of the Graduate Medical Education National in 1980 and reports to large surpluses of physicians, a on medical school was accepted by MD schools (Fig. 1). as GME continued to with an of more in the 1990s, additional DO graduates in the and more by the have MD to the fact that the of residents who are MD graduates of US medical schools has to while the of and IMGs have medical school output will not be Although medical schools is the most to do most MD schools grew in the 1960s and 1970s, for Surveys of MD medical school deans that the overall expansion capacity is about or about new schools is a and As of MD schools are in of from a that will students in to first not be for years or are they are to more than graduates by this MD enrollment in will be only more than in 1980, an of only a period in which the population grew by DO schools have been more in After a in the the 15 schools then and another schools the to from in 1980 to in With additional schools being enrollment is projected to in the number that in an of the growth of MD and DO schools that their enrollment of in 1980 MD and could in MD and Although this is more than in 1980, it is only more than the of 2000, of the needed of that from projections of demand. CHALLENGE MEDICAL The US students to MD and DO schools in the United States and to From is more than of DO to an MD school and more than of students who an school to an MD or DO school in the United the large to the expansion of medical on of in MD medical a of to of is the to is to the ratio, which that there is very This not that there are not who do not Rather, the of who did not as the of who are on in population and participation in have projected that there will be approximately more to medical schools in than in 2000, an that is for the in medical school enrollment but not for the by MD by which is the of the and DO to as it is projected to and in enrollment of US students in schools from the level of approximately to there would be a of medical However, the first time of MD schools would to less than and the overall of would to than a of who do not now medical education there will be too in and the years to as it is now it is accepted that the for medical students and the that are not of as a and is being on the need to a that is more and must be to the process and the and to the that A FUTURE It is to that is there are too there is need for more medical students or medical or for more residents or residency or for more for it is to that there are and that they are the most in none of this is have a a number of residency a need for expansion of medical schools and a in the medical students are and in in the time of the expansion of the 1960s and there been a need for from and and has there been so much do not to meet the future will was was by a to and they and their must without to a and physician. But that need not the American Association and the American of are on that GME must be and that on GME must be It is time for colleagues in other specialties to on to these so that a national can be The medical has accepted the for an supply of physicians. that is an must now