Federal advisory group predicts physician shortage looming

Council on Graduate Medical Education reverses stance, calls for 15% increase in medical school graduates.

By Myrle Croasdale, amednews staff. Nov. 3, 2003.

In a dramatic change in policy recommendations, the Council on Graduate Medical Education has cast aside a forecast of a surplus of physicians that it has held since the mid-1980s and now backs a prediction of a shortage.

Carl Getto, MD, chair of COGME and senior vice president for medical affairs for the University of Wisconsin Hospitals and Clinics, said the council's change in perspective was in response to mounting evidence from physician work-force experts and physician recruitment firms.

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"Where we are now is a result of two years of analyzing changes," Dr. Getto said. "[Health policy expert] Buz Cooper and others have been talking of work-force shortage. The AAMC [Assn. of American Medical Colleges] has been asking the same work-force questions. This is not a surprise."

Among the trends: younger physicians wanting to work fewer hours; an aging population that requires more care; and an increased demand for specialists' services combined with less-restrictive managed care models. COGME commissioned Ed Salsberg, executive director of the Center for Health Workforce Studies at the State University of New York in Albany, to analyze the changing physician work-force environment.

COGME is adopting Salsberg's report, which calls for an increase of 3,000 U.S. medical graduates by 2015, a corresponding expansion in the number of resident positions and a change in the distribution of residency positions to more closely mirror market demand. Salsberg anticipates a shortage of 85,000 physicians by 2020.

This is in contrast to COGME's current guidelines limiting resident positions to 110% of U.S. medical graduates as of 1993 and dividing resident positions evenly between primary care and specialties, Salsberg said.

The Center for Health Workforce Studies sees a shortage of 85,000 physicians by 2020.

"After 15 years of tooting the horn that there are physician surpluses, in a single day COGME completely changed," said Richard "Buz" Cooper, MD, director of the Institute for Health Policy at the Medical College of Wisconsin in Milwaukee. "This means we can stop arguing about whether there will be a shortage or not and turn our energy to what is really important, which is how to solve this problem."

COGME has yet to formally release the new recommendations. The council was authorized by Congress to assess physician work-force trends, but that mandate expired shortly after COGME's September meeting and the ending of the fiscal year. Dr. Getto said he expected COGME's authorization to be renewed when Congress approves the 2004 federal budget. The report will then be made official.

Dr. Cooper, who has made similar recommendations of his own, said COGME's increases were modest given that the U.S. Census Bureau anticipates the U.S. population will grow 18%, from 274 million in 2000 to 324 million by 2020, while medical school slots will have expanded 7% under current limitations. A 15% increase is the lowest needed to keep accessibility stable, Dr. Cooper said.

Michael Whitcomb, MD, senior vice president for the AAMC Division on Medical Education, said the association would reconsider its physician work-force policy in light of COGME's position change.

"A couple of years ago, we changed the policy that had been adopted in mid-1990s, that we'd have too many doctors," Dr. Whitcomb said. "Now our perspective is one of agnosticism. We aren't exactly sure. We've paid careful attention to the reports suggesting that we'll have too few physicians, and we feel some responsibility to take those concerns seriously. [The COGME recommendations] will stimulate a lot more thinking on the options for increasing the supply of physicians in this country."

Some disagreement

Not everyone agrees that a physician shortage is imminent. Jonathan Weiner, PhD, professor of health policy and management at Johns Hopkins Bloomberg School of Public Health, is skeptical that increasing the number of medical students and residents will improve access to health care.

"Simply turning up the heat in the house without fixing the broken windows doesn't work," said Dr. Weiner, who presented his views at a recent COGME meeting.

Producing more physicians without creating more incentives to work in underserved areas is likely to pump more doctors into regions already well served, he said. He would like to see the $500,000 to $1 million that states and the federal government pay to subsidize each physician's training linked more directly to service in underserved areas.

Another critic of physician shortage models is Fitzhugh Mullan, MD, a professor of pediatrics and health care sciences at George Washington University School of Medicine and Health Sciences, Washington, D.C., and a contributing editor of the journal Health Affairs. "What we need are targeted programs for primary care in underserved areas," he said, instead of giving more services to those who already have access to care.

Dr. Mullan doesn't anticipate a physician shortage, but he does support expanding U.S. medical education so that fewer international medical graduates would be needed to fill resident positions.

"I say we don't need more doctors, but we do need more medical students," he said. "How is that? Currently one-quarter of the physicians in practice and in training are graduates of schools abroad."

But according to those who agree with COGME that a shortage is imminent if more doctors aren't trained, 10 years from now physicians will find their workweeks scheduled to overflowing, and recruiting young physicians will be difficult at best. Patients will be waiting longer to see doctors, and those already having a hard time accessing the system will face even bigger hurdles.