Richard A. Cooper, MD
Acknowledgment: The author acknowledges the many contributions of Thomas E. Getzen, PhD, whose ideas flow through this review and whose collegial relationship has been deeply appreciated.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Richard A. Cooper, MD, Health Policy Institute, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226; e-mail, email@example.com.
For 2 decades, health planners have forecasted impending physician surpluses, and policy decisions related to medical schools and residency programs have been based on such expectations. However, these much-heralded surpluses never materialized, and a growing body of data and opinion now point in the other direction. The question at the forefront is whether the United States is instead headed for a physician shortage. What is the evidence? This paper reviews the trends that link economic growth to health care spending and to the demand for physicians. It assesses the current environment by examining trends in the characteristics of clinical practice, signals from the medical market, and recent experiences of physician shortages in other English-speaking countries; it also discusses why past forecasting approaches may have failed. Taken together, this body of information indicates that physician shortages are emerging and that they will probably worsen over the next 2 decades. By 2020 or 2025, the deficit could be as great as 200 000 physicians—20% of the needed workforce. If remedies are to be found, the nature of the problem must be appreciated, and a consensus to solve it must be reached.
Annual percentage changes in private health expenditures and in gross domestic product (GDP) 4 years previously.
Physician supply and demand projections.COGMEBLSGMENACBHPr
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Vincent M. Pedre III
Mount Sinai Medical Center
November 3, 2004
Projected physician Undersupply is not a surprise!
In contrast to what the article suggests, the root of the problem of physician undersupply in the coming years is not only the limitation in allopathic medical school admissions following the 70's, but also the drastic changes that have occurred in the healthcare world that have made becoming a doctor a nightmare ridden with headaches when dealing with a changing healthcare climate, where insurance carriers dictate how much they can make and how they practice medicine. Look at the recent report in Medical Economics detailing how physician salaries, especially much needed PCP's, trail way behind rising inflation costs and the costs of running a practice in this age of added regulations, HIPPA, etc...
I know of numerous medical school and residency friends who have left the medical service field of caring for patients because of the increasing unattractiveness of efforts made versed rewards received. This is not only a problem of limited spaces in medical school admissions, this is a problem of an overworked healthcare force that is telling their youth to find another career that is more attractive in terms of hours and rewards. Who wants to be on the phone all day getting precertification for this and that, or being told when and how a CT or MRI may be ordered?
I'm sorry. The solution is far more complex than merely creating more "spaces" in allopathic medical schools across the country. We need to fix the root of the problem -- an insurance system devoid of the necessary checks and balances from the proper authorities. We need to give medicine BACK to us PHYSICIANS and the PATIENTS. And take it away from these poorly run bureaucracies (the insurance companies) that are endlessly skimping on payments to providers and services to enrollees.
How is it that medicine became subject to the authority of lawyers and politicians? The AMA needs to become more proactive in protecting the rapidly deteriorating rights of physicians and patients.
Fix this, and we will produce the healthcare force that this population needs.
Vincent M. Pedre III, M.D. Board-Certified Internal Medicine, Clinical Instructor - Mt. Sinai Medical Center, 1049 Park Avenue, Suite 1C, New York, NY 10028
W. Bruce Fye
Mayo Clinic College of Medicine
November 5, 2004
Cardiology's workforce shortage
Richard Cooper, in his thoughtful and well-referenced article on physician supply, cites cardiology as a specialty confronting a mismatch in the supply of and demand for doctors. Several scientific, technological, social, and demographic factors are driving demand for cardiologists. Meanwhile, the output of cardiology training programs decreased significantly in the 1990s (1). The American College of Cardiology recently published a detailed report of a two-year study of cardiology workforce (2). Entitled "Cardiology's workforce crisis: A pragmatic approach," the ACC report includes sections devoted to 1) the origins and implications of a growing shortage of cardiologists, 2) ways to increase the supply of cardiologists, 3) how to encourage more women and underrepresented minorities to choose a career in cardiology, 4) the growing number of international medical graduates in cardiology, 5) how cardiologist-led teams of non-physician clinicians can enhance cardiovascular care, 6) the role of technology in enhancing efficiency, 7) methods to improve the job-matching process, and 8) how to encourage more cardiology trainees to choose a career in general clinical cardiology. The report includes several specific recommendations to help address the growing shortage of cardiovascular specialists. Hopefully, Cooper's paper and studies such as the ACC-sponsored workforce report will catalyze academic medical centers, regulatory organizations, federal policy-makers, professional societies, and others that influence the output of cardiologists to address this problem. As the national burden of cardiovascular disease continues to grow, we must increase the output of cardiologists who will devote their careers to the prevention, early and accurate diagnosis, and cost-effective treatment of cardiovascular disease.
1. Fye WB. Cardiology's workforce shortage: Implications for patient care and research. Circulation 2004;109:813-6.
2.Fye WB, Hirshfeld JW, et al. Cardiology's workforce crisis: a pragmatic approach. J Am Coll Cardiol 2004;44:215-75.
William A. Curry
University of Alabama School of Medicine, Birmingham AL
November 29, 2004
The U.S. Physician Supply: What is it now?
TO THE EDITOR: Dr. Cooper (November 2 issue) notes that projections of physician workforce needs suffer from a lack of information about physician work effort, particularly from women and older physicians. This is a critical observation. While Dr. Cooper's model for projecting future needs is impressive, its usefulness - and that of any model - will be severely limited if baseline data are faulty. The lack of full time equivalent data may be a major reason that so many projections of workforce needs have been contradictory (1,2,3). As noted by the article, recent reports suggest either a shortage of primary care physicians or a surplus (4,5).
The inadequacy goes even deeper than the lack of work effort data: current systems used to identify and classify physician practice specialties are seriously flawed. This includes data used to designate physician shortage areas by state and federal governmental agencies. Most of these databases are derived from licensure or professional society information. The specialty, practice site, and effort data from these systems appear likely to overstate the number of primary care physicians and to understate the number of subspecialists. A recent pilot study in rural Alabama demonstrated this by comparing onsite surveys to existing databases (Coleman, W., unpublished data, 2004).
If Congress does not renew the charter of the Council on Graduate Medical Education, other bodies will have to address this confusion. Otherwise, we are doomed to more erratic projections, flawed decisions, and greater problems for populations at risk, both rural and urban.
William A. Curry, MD, FACP University of Alabama School of Medicine, Birmingham AL 35294 firstname.lastname@example.org
Clyde Barganier, Dr.PH Office of Primary Care and Rural Health, Alabama Department of Public Health, Montgomery AL 36130
1. Rosenblatt, R. A View from the periphery - health care in rural America. N Eng J Med 2004;351:1049-1051.
2. Council on Graduate Medical Education. Improving access to health care through physician workforce reform: directions for the 21st century: 3rd report to Congress and the Health and Human Services Secretary. Rockville, Md.: Health Resources and Services Administration, 1992.
3. Croasdale, M. Federal advisory group predicts physician shortage looming. AMNews, Nov. 3, 2003.
4. Rivo, ML and Kindig, DA. A report card on the physician work force in the United States. N Eng J Med 1996; 334:892-896.
5. Fryer, GE, Consoli, R, Miyoshi, RJ, Dovey, SM, Phillips, RL, and Green, LA. Specialist physicians providing primary care services in Colorado. J Am Board Fam Prac 2004; 17:81-90.
Richard A Cooper
Medical College of Wisconsin
December 29, 2004
Response to letters and editorial
TO THE EDITORS:
Dr. Fye and his colleagues are to be congratulated for calling attention to the plight of cardiology, or, more correctly, the plight of patients who will need cardiologists but who, because of shortages, will lack the opportunity. It's a sad day when Americans cannot access the advanced cardiac care that our nation has invested so heavily in creating, while it squanders billions on regulation, litigation and other administrative intrusions, which not only add cost but, as noted by Dr. Pedre, create bureaucratic burdens that force physicians to leave practice altogether. It also is sad that, while physician shortages were evolving, the Council on Graduate Medical Education (COGME) was steadfast in forecasting impending physician surpluses, not because, as Drs. Curry and Bargainer suggest, the AMA Masterfile is wrong (although it is far from perfect) but, rather, because COGME's methodology was wrong. Indeed, COGME used the same AMA data in its more recent model, fashioned after our own, which caused it to reverse course and acknowledge that the problem was one of shortages rather than surpluses (1).
In their accompanying editorial, Drs. Garber and Sox (2) seek comfort in the notion that the nation may not need more physicians because older folks are healthier these days and don't require as much care, but, of course, they're healthier because of their stents, artificial hips and cataract operations, and, despite these aids, they're certain to encounter disease and its costly therapy still later in life. But such care will surely be unnecessary, at least if these commentators are correct in conjuring up the old "supplier-induced demand" argument, noting that a correlation exists between the number of surgeons and the amount of surgery, but, then, a similar one exists between the number of obstetricians and the number of babies (3), so where does the demand originate? And, lest anyone think that the advances of the last three decades are worth anything, their editorial dutifully recites the "more is worse" catechism (4), a statistical artifact of population clustering. Most terrifying is their notion that price will control demand, a disastrous scenario in which shortages of physicians will lead to such steep increases in cost that utilization will fall because most people won't be able to afford care, so why produce more physicians anyway. One can only hope that reason prevails.
Richard A. Cooper, MD Medical College of Wisconsin Milwaukee, Wisconsin
1. Council on Graduate Medical Education. Reassessing Physician Workforce Policy Guidelines for the U.S. 2000-2020. Washington, DC: U.S. Department of Health and Human Services; 2003. 2. Garber AM,. Sox HC. The U.S. Physician workforce: serious questions raised, answers needed. Ann Intern Med. 2004;141:732-34. 3. Dranove D, Wehner P. Physician-induced demand for childbirths. J Health Economics. 1994;13:61-73. 4. 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;138:273- 87.
Richard A. Cooper. Weighing the Evidence for Expanding Physician Supply. Ann Intern Med. 2004;141:705–714. doi: 10.7326/0003-4819-141-9-200411020-00012
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Published: Ann Intern Med. 2004;141(9):705-714.
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