Too few physicians, or too many?

Does the United States need to be training more physicians? One might think not, given that we currently have more physicians--both in absolute terms and as a percentage of the population--than at any other time in the last fifty years. (1) It may, therefore, be a surprise to discover that the Association of American Medical Colleges has been predicting a serious physician shortage over the upcoming decades. (2) It is calling for a 30 percent increase in U.S. medical school enrollment, an expansion of graduate medical education positions to accommodate the new enrollees, and increased federal funding for GME. It is joined in its prediction by the Council on Graduate Medical Education, (3) which forecasts a 10 percent shortfall of physicians by 2020, and by a veritable flotilla of state and specialty medical society workforce reports and papers. (4) How can the physician-rich United States be facing a shortage? The AAMC's Center for Workforce Studies offers a number of reasons. (5) First, using data from the American Medical Association's Physician Masterfile, the AAMC estimates that nearly a quarter of practicing physicians (24.7 percent) are over age sixty. (6) This large percentage means that in the next decade, retirement will take a large bite out of physician supply. Next, the U.S. Census Bureau predicts a population increase of upward of 50 million between 2006 and 2025; this growth will naturally increase demand for physicians. That expanding population is also aging, and older people demand more medical services than younger ones. Finally, if health reform really does result in more insurance coverage, then that, too, will increase demand for physician services. AAMC estimates that universal health coverage would increase demand by 4 percent. What would a physician shortage mean for the average American? The AAMC predicts a number of negative effects. Patients might have to wait longer to see physicians or specialists. They might have to travel farther for appointments and spend less time with their overburdened physicians. Because they'll experience more difficulty accessing physicians in their offices, some patients will turn to the emergency room for primary care; this will cause crowding and high-cost, inefficient use of ER resources. Other patients, not wanting to face the logistical problems caused by the physician shortage, will delay or curtail their medical visits, sometimes with terrible results. The AAMC also predicts that a shortage could result in the increased use of foreign medical graduates, osteopaths, and clinicians who are not physicians (like nurse practitioners), especially in primary care. Finally, though the AAMC does not particularly emphasize the point, any economist will tell you that when demand for physician services outstrips supply, physicians will raise their prices. Of course, as the AAMC recognizes, these effects would not occur uniformly. Shortages will be worse and demand will change more in some parts of the country than in others, and more serious shortfalls will occur within certain medical specialties. The AAMC cites data predicting shortages in family medicine, general surgery, and emergency medicine, and in specialties that primarily serve the elderly, such as cardiology, oncology, and geriatrics. Here, then, in sum, is the AAMC's case: A serious physician shortage is in the offing because of demographic changes that will dramatically increase demand as it curtails supply through physician retirement. This will decrease quality of care, raise prices, and cause massive dislocation and inconvenience across the United States. We therefore need to quickly increase the supply of U.S.-trained physicians in multiple specialties. Increasing the productivity of individual physicians can help, as can the greater use of nurse practitioners and physician assistants, but the bottom line is more MDs, and soon. It's a compelling argument. But is it right? …