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Physician workforce shortage: Yes, no, or maybe?

In the March 2005 issue of the GME E-letter, we wrote, "It appears we are facing a national shortage of doctors. This shortage is currently confined to some regions and specialties, but the bulge of aging baby boomers threatens to widen the gap.

"The Association of American Medical Colleges (AAMC) has called for a 15 percent increase in the number of medical school graduates by 2015--but that won't solve the whole problem. We will need more GME positions as well.

"To be feasible, this expansion will require removing the current caps on the number of federally funded residency positions as well as finding additional funding sources for GME. But how should these residency slots be distributed geographically and among the specialties? And how should we develop national policy on medical workforce issues such as these?"

Following are edited versions of the comments received, with identifying information removed.

It is quite simple to say that the aging of the baby boomers will increase demand and should be balanced by an increase in supply, ie, an increase in the output of physicians from our medical schools.

Unfortunately, the problem is far more complex. The solution implies that it would be desirable to continuing the practice of medicine as it exists and training enough additional physicians to meet the demand.

I would like to point out some weaknesses in this approach.

High quality medical care will likely incorporate advances in technology that will so increase the efficiency of medical care delivery that fewer physicians will be required.
Many specialized procedures can be carried out by technologists. I am certain that with adequate training, an intelligent technologist could do lense implants, insert hip prostheses, and perform a large number of other uncomplicated procedures without full blown medical training. In the Air Force, medical techs at remote sites dealt with trauma, etc. Do psychiatrists really need to complete medical school?
I think we are a mecca for IMGs. In fact, I was born in the US and studied medicine in Europe immediately after WWII when there was still a quota on admission of Jews to medical schools in this country. There were 95 Americans in my class of which only a handful were not Jewish. We import computer engineers from India. Why do we assume that importing MDs is any different? We have recruiters in South Africa bringing nurses into this country. Ditto in the Phillipines and Ireland.
If we believe that our training is superior, why aren't we recruiting foreign pre-med and med students, bringing them here for their medical instruction and then sending them home? We could exchange training for oil with Nigeria. They would make fine, motivated house officers and we would be paid to train them. Some of the best would find a way to stay here.
Where is it written that the public will be willing to pay for the kind of medical care they now enjoy? I was in Ireland and spoke with a patient who was on a 3-year waiting list for a hip prosthesis. He thought that was normal and okay. The Canadians think we deliver "boutique" medicine. There are more MRIs in Manhasset,New York than in many Canadian provinces. They would say that if a patient has a back sprain and has to wait a month for an MRI, he will have an 80 percent chance of getting better before the test is done.
The cost of medical care is now between 15 and 20 percent of the GDP. How much more are the taxpayers willing to devote to health care? Medicare is in more trouble than Social Security.
I told a patient that of the possibility of a cure for vascular disease (a recent New York Times article covered a new Pfizer pill that will combine Lipitor and a drug to raise the level of HDL) and predicted that, with better understanding of oncogenes, more cancers would be curable. He asked, "What will you do with all the old people?"

I guess, for me, the face of medicine has changed several times. I opened my first office in 1963, paid $104 for malpractice insurance, and saw the introduction of Medicare and Medicaid. Death certificates used to list the cause of death as "old age," a euphemism for those too poor to have had medical care and victims of an unknown disease.

What about the coming shortage of academic faculty and program directors? Program director turnover is an important issue for me (I have been a PD since 1992). I think the public and Congress need to recognize the value of full-time and voluntary faculty and program directors, as well as department chairs and deans. There needs to be a way to assign a metric to being a program director in an era where the major metric is RO-1 funding. This issue is especially acute for new faculty. I hope there can be some good solutions to this continuing problem.

The new slots should not be geographically distributed at all. The emphasis should be to allocate them based on the better programs' ability to expand existing programs rather than starting many new programs. Also, the process to receive an increase should be streamlined to avoid discouraging expansion. Finally, new sources of funding must be found--industry is probably the best initial candidate.

The other consideration is that expanding research requirements for program faculty may disqualify training programs with lesser scholarly output that still produce very good doctors who can care for patients. After all, more doctors are required to care for the public than are required to expand the frontier of science.

Could you possibly forward some of the data that brought us to this "new consensus." With all due respect, the AAMC position statement sounds more like an opinion paper, with terms such as "anecdotal evidence suggests" and "mounting analytical work suggests." As physicians, we certainly know the potential misinformation that can be associated with anecdotal evidence. What is it that makes us think that we are not 180 degrees off the mark, as we were in the 1980s and 1990s? What did we learn from those erroneous predictions, and how can we be sure that we are not making equally as erroneous predications in the opposite direction now?

Based on a recent study ("The Physician Workforce of the United States: A Family Medicine Perspective"), I believe this shortage prediction risks the same humble-pie as previous predictions. It really begs the question of what the physician workforce will do over the next 20 years. It clearly won't be doing the same things it is now.

The need for more US grads has been obvious for 20 years, nice to see he powers that be are aware. There are many more HO1 positions than US grads, so more GME positions are not needed unless we plan to continue the same number of IMGs. Of course there is a distribution issue, which is currently accommodated by IMGs taking less desirable specialties and residencies.

It's interesting that the establishment assumes that "there will have to be more Medicare-funded residency positions." This assumes that the federal government "should" fund GME. As soon as an astute politician discovers that is not in the constitution, federal funding will disappear and hospitals will be responsible for resident salaries (again). Of course hospitals can appoint as many residents as the RRC will allow, as long as they come up with funding. This is not a "cap" issue, just a hospital economics issue.

The undergraduate BS in Wellness and Alternative Medicine program, at Johnson State College in Johnson, Vermont, is among the first of its kind in the nation.

The program is interdisciplinary and multicutural: it teaches students standard pre-medical courses in biology and chemistry, in addition to courses in wellness and mind/body psychoneuroimmunology and courses in the sociocultural history of and science supporting allopathic medicine, wellness, alternatives, and integrative medicine.

Many JSC WAM students plan to become doctors and nurses . . . but want to practice integrative medicine. Recall Eisenberg's 1998 study: 50 percent of physicians would not recommend it to their children, 33 percent were not satisfied with their profession. What is wrong? Clearly HMOs have some role. But, given the entering students at JSC, what is also wrong is the medical education--allopathic medicine is not enough.

Our entering students want to be able to use the very best from all systems of medicine--not only allopathic.These students are bright and passionate about healing. They love science. And they love helping people be well and heal from disease.

If you want more doctors, support medical education changes that will encourage public trust: Changes that will address expanded multicultural diagnostics options for chronic disease, antibiotic resistance with infectious disease, and the spiritual aspects of disease.

The students are there. Build it... and they will come.

The experts that track these things have been so wrong so many times before that I would not be too concerned. Do not trust the experts or the Crusader Rabbits--they have blown it over and over again. We expanded medical school enrollments a number of years ago in order to create competition and market forces to drive down the cost of doctor bills. Medical schools were even given US government money for each additional medical student slot as an incentive. It clearly did not work. More doctors just created more doctor bills and more national money consumed on health care.

About 7 years ago, the Experts/Crusader Rabbits said the answer was for medical centers to merge and join forces. UCSF and Stanford did this and lost about $400 million in a year and that merger was soon deconstructed. The merger between NYU and Mount Sinai likewise went sour, as did others. The bottom line:

Do Not Trust the Experts.

Training positions should be allocated based on need. Underserved areas should get more slots than those that are not.
Similarly, underserved specialties and those anticipated to have the greatest future needs with an aging population should be favored.
Better parity in compensation should be provided for the nonprocedural specialties that will be needed.
Some of the shortfall could be mitigated by turning out more physician extenders.
Better compensation or more subsidies should be provided to those in training to reduce their debt load. That would help to obviate their need to make so much money once they enter practice, and possibly could translate to less greed later. One could even consider subsidizing each learner's training and requiring a preliminary service commitment in an underserved area, possibly at a stage during their training.
We need enough doctors so that the current trends towards fewer hours and less stress can be developed even further and carried into practice, so that doctors will not feel that they need so much money to make up for the sacrifice of everything dear to them in their personal lives, so that they can be better balanced, healthier persons themselves, and so they will not burn out at such a young age.
The requirements for and provision of really relevant, meaningful CME should be increased to prevent skills from deteriorating so rapidly.

It is nice to increase the number of medical schools. It would, however, be much better to increase the number of seats at existing medical schools, and have the state support education more directly and adequately. The state seems to function under a notion that it has no obligation towards state schools once a school has become operational. Education must a higher priority of the state.

Also undergraduate college years should be reduced to 2 years from current 4 years. Our students would not suffer on that account because IMGs don't fare any worse than US graduates even though IMGs have less than 2 years of college-level instruction. It would leave our students with less debt burden as well, and not place them at a disadvantage when it comes time to start earning wages.

Residency slots should be filled according to regional needs, but it should take into account needs of existing programs in order to sustain quality of education as well as expand opportunities for meaningful research at these institutions.

Increase awareness of the problem generally. Since many first-time and repeat patient contacts are with nonphysicians, consumers/patients may not be aware or even believe there is a need.
Nonphysicians may present their facts showing there is no real shortage for economic/political reasons. The value of nonphysician work should be underscored while clearly stating the facts of doctor shortages.
Make it interesting for semiretired physicians to spend some time in underserved areas as an interim measure while long-lasting solutions are found.

As a program director and the former chief of staff at a major hospital, I am concerned about the upcoming shortage of physicians. It is not only a problem with the demand side (baby boomers) but there are several other very important reasons why this shortage will occur.

Approximately one-half of our current medical students are women. What portion of these trained professionals will be practicing even 40 hours per week in 5 years is speculative. The desire to have and raise a family and the requirements for practice are on a collision course. If we lose even one-half of these women the impact on available physicians will be profound.

Additionally, declining reimbursement, increasing problems in dealing with insurance companies, managed care, and the absurdity of the current legal climate will drive physicians into group practice, where these issues do not so readily impact the physician's day-to-day life. The result is likely to be more of a 9 to 5 mentality, with the 5 to 9 patients sent to overcrowed emergency rooms. This is already a fact in our community.

Add to this the "Schiavo" factor (the family is asking the Florida legislature to pass a law requiring physicians to keep patients without a "living will" alive as long medically possible). If this occurs it will demoralize and bankrupt the health care system.

As to the distribution of GME positions: Our university had 500 applicants for four dermatology slots (majority AOA) and 180 applications for two plastic surgery slots. How many do you think that geriatics had?

What is needed is an overhaul of our health care system. The current system is not sustainable! Fixing the doctor shortage is only a part of the answer.

Note: Please don't misinterpret my concerns about women graduates. My comments regarding them should not be in any way taken as mean spirited. My daughter received an MBA and is now home raising my two beautiful grandchildren. I am very cognizant of the imperative of women doing the critically important work of motherhood, I just think that we need to factor this into our workforce projections.

Last updated: Jan 23, 2008
Content provided by: Graduate Medical Education