Physician shortage predicted to spread

The AMA becomes the latest of many expressing concern that there might not be enough physicians to go around, now or in the future.

By Victoria Stagg Elliott — Posted Jan. 5, 2004

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Honolulu -- The American Medical Association acknowledged a physician shortage in some areas of the country and some specialties, according to policy adopted at its Interim Meeting last month.

"We don't know what the correct mix is, and what we need is data to determine what the best policy is," said AMA president-elect John C. Nelson, MD, MPH. "The bottom line is we want to make sure that patients have access to physicians that they need."

The AMA is the latest organization to shift official policy from recognizing a surplus of physicians to realizing that numerous factors may be contributing to an imminent physician shortfall.

Several specialty societies are considering the issue, and the government-appointed Council on Graduate Medical Education reversed its position in November 2003 and called for an expansion of medical school spaces and residency slots. U.S. medical schools have been churning out 15,000 to 16,000 doctors a year since 1980, according to the Dept. of Health and Human Services, but census data show the population has increased 24%, from more than 226 million to more than 281 million people.

Trends pointing to undersupply

Experts say a growing population that is older and needs more medical care is one of many factors converging to create a potential crisis. Also, a greater desire to balance work and family life means that many doctors are opting to work part-time or on a temporary basis.

"It's not limited to our physicians who are female," said Gibbe Parsons, MD, an American Thoracic Society delegate. "We're seeing a real shift toward physicians wanting to work very controlled hours."

International medical graduates also are having problems getting visas or are being denied them completely, creating particular problems for underserved areas that rely on these doctors. The AMA intends to work with the relevant governmental agencies in an attempt to streamline this process, according to policy also adopted at the meeting.

"IMGs play a vital role in areas with shortages," said Ahmed Faheem, MD, a West Virginia delegate. "If you don't ease off the visa requirements, then it's going to get worse."

The liability crisis that many states are experiencing may also be influencing where some doctors choose to set up shop, creating shortages in some areas.

In addition, there are suggestions that staggering medical student debt may influence which specialties students are choosing to enter. The AMA intends to look for ways to alleviate this burden.

"As student debt continues to climb, students are driven from the lower-paying specialties and practice situations, endangering access to care for minorities, indigent and the underserved," said Adam Levine, a medical student and California delegate.

No easy answers

Identifying the problem, however, may be far easier than solving it. Most people agree that the shortages are less an issue of not enough doctors in the country and more an issue of not enough doctors in certain areas.

"Even if we do increase the number of physicians who are in the country, the problem of physician maldistribution will exist unless we address that," said Rajam Ramamurthy, MD, a pediatrician in San Antonio and a delegate from the International Medical Graduates Section. "We can have 5,000 more doctors, and they would all be crowded in the metropolitan areas."

Some regions of the country may be less appealing, and there are some communities that may not be able to economically support certain specialties.

"An interventional radiologist may not be able to survive in a small rural area even though he or she may wish to live there," said Dr. Nelson. "There's a hodgepodge of reasons why the distribution may be inappropriate."

Part of the problem may also be a lack of physicians who are members of a racial or ethnic minority and who can provide culturally relevant care in a patient's first language. The AMA also resolved to increase minority presence in medical schools and medical practice.

"The care of Latinos will be in the hands of non-Latinos, probably for most of this century," said Rodrigo Munoz, MD, an American Psychiatric Assn. delegate from San Diego. "We don't have enough Latino doctors, and Latinos do not have proper care, particularly in the poorer communities where there are no doctors."

Delegates preach caution

Even as they acknowledged the shortage, delegates expressed concern that any action taken to address it should be well thought out. In the past, they said, shortages have, over time, turned into surpluses.

"Be very cautious," said Richard Pan, MD, an American Academy of Pediatrics delegate. "In 10 years, we could be talking about policies dealing with oversupply."

And there is always the concern that this prediction, like many others before it, may not be that accurate.

"Predictions have been wrong," said David Wilson, MD, a member of the AMA Council on Medical Education.

"And even though many of us feel that there needs to be more primary care physicians, there's an equal group that feels there are many specialties that are going to be in short supply in the future."

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Doctors wanted

To offset a shortfall by 2020, the Council on Graduate Medical Education has recommended an increase of 3,000 U.S. medical graduates by 2015, a corresponding expansion in residency positions and a change in the distribution of residency slots.

781,000 Physicians in 2002

972,000 Physicians projected by 2020

1.06 million Physicians needed by 2020

Source: Ed Salsberg, executive director of the Center for Health Workforce Studies at the State University of New York, Albany

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Increasing the ranks

In recognition of an impending physician shortage, the AMA announced at its 2003 Interim Meeting that it will:

  • Work to minimize visa delays for international medical graduates.
  • Support continued funding of the Public Health Service Act, Title VII, Section 747, to increase the number primary care physicians working with medically underserved populations.
  • Work to ease medical student debt.
  • Encourage and conduct national and regional research on physician supply and distribution.
  • Collaborate with public and private sectors to ensure adequate physician supply in all specialties and to develop strategies to mitigate geographic maldistribution.
  • Develop recommendations for adequate reimbursement of primary care physicians and improved recruitment into primary care.
  • Publicize the need to enhance underrepresented minority representation in medical schools and in the physician work force.
  • Develop a national consensus on physician work force policy, in conjunction with state and specialty societies.

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Medical schools, states report specialty shortages

A majority of medical school deans and state medical society executives say physician shortages are having a negative impact on medical education and patient care, according to a survey by Richard Cooper, MD, published in the Dec. 10, 2003, Journal of the American Medical Association.

More than 80% of the medical school deans who responded said shortages were causing problems with faculty recruitment and retention and with clinical education. Some said a lack of faculty was putting some clerkship and fellowship programs at risk.

Dr. Cooper, director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee, has predicted an impending physician shortfall.

But he said he didn't expect the medical school deans to respond with such energy to his questions.

"The deans were passionate in their answers about shortages, and that took me by surprise," he said. "I guess it shouldn't have, since [at the Medical College of Wisconsin] we're having serious problems recruiting faculty and losing them to community practices."

A total of 73 of the 126 deans from allopathic medical schools responded to the survey, as did 44 state medical society executives, including the District of Columbia's.

Of the respondents, 89% of medical school deans and 82% of medical society executives reported shortages of physicians in at least one specialty, with many reporting shortages in multiple disciplines.

Several deans told him that faculty shortages were hampering teaching. One had to close a fellowship program because the school couldn't hire needed faculty. Others said the competitive recruitment process was wreaking havoc on their salary structures, and the threat of losing physicians to community practices was constant, a situation that was uncommon several years ago.

Shortages were most striking in radiology and anesthesiology.

Shortfalls also were seen in cardiology, dermatology, gastroenterology, general surgery and the surgical subspecialties, among others.

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External links

"Perceptions of Medical School Deans and State Medical Society Executives About Physician Supply," Journal of the American Medical Association, Dec. 10, 2003 (link)

Proposed revisions to AMA Policy on the Physician Workforce, Report of the AMA's Council on Medical Education (link)

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