Physician shortages pose a risk to the nation's health

A message to all physicians from the president of the American Medical Association, J. Edward Hill, MD

By J. Edward Hill, MDis a family physician from Tupelo, Miss., was AMA board chair during 2002-03 and served as AMA president during 2005-06. Posted Feb. 20, 2006.

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For the last couple of months, it's been hard to pick up a news magazine or newspaper without reading about influenza and the threat of a pandemic. Nobody knows when such a pandemic might emerge, or what population it might hit first. All we know is that it will someday strike, and that we in medicine and public health had better be prepared.

The same might be said of a less well known, but no less ominous public health threat: The coming shortage of physicians in our country. We don't know exactly when this shortage will reach crisis levels, or which patients it will affect most. But we are fairly certain a shortage of physicians is coming, and we need to get ready for it.

More and more medical organizations, including the AMA, are coming around to this point of view. In fact, at the AMA's 2005 Annual Meeting, the House of Delegates passed policy stating that a physician shortage is already here, at least in some regions and for some specialties.

What's more, based on the current evidence, we believe the problem is likely to get worse.

Here's why.

In the late 1970s and early 1980s researchers neither accounted for nor predicted some important social, economic and demographic trends for the 21st century. Yet these trends are having a huge impact on the demand for physician services, as well as our ability to meet that demand.

First and foremost is simple population growth. The United States population is now projected to expand 18% between 2000 and 2020. More people means more patients -- and a greater need for physicians.

Second, our nation is graying at a rapid pace. Between 2000 and 2020, the number of people older than 65 will increase from 35 million to 54 million. These are the patients who use the most physician services.

Third, more and more physicians want a better balance between work and home. This means a significant number of doctors are working fewer hours than in years past.

It also means that some specialties have become more attractive because they require less demanding schedules. At the same time, new physicians are less likely to choose more time-intensive specialties, such as primary care.

Fourth, half of physicians ages 50 to 65 plan to leave or reduce their clinical practice in the next three years, at least according to one large survey. If it happens, this exodus will have a serious impact, again, especially in primary care.

Finally, research suggests that macroeconomic forces, such as gross domestic product and personal income, strongly influence demand for physician services. During the past two decades, we have seen incredible economic growth. At the same time, the supply of physicians from U.S. medical schools has not grown. Some experts believe that this growing demand, coupled with limited physician production, is inevitably leading us to serious physician shortages.

I have to agree. In fact, were it not for growing numbers of international medical graduates and osteopathic physicians, as well as various physician "extenders" such as physician assistants and advanced-practice nurses, we would be witnessing even more severe patient access problems, not just in underserved areas and specialties, but across the board.

How can I be so sure? Each year, the United States graduates approximately 17,000 physicians. However, it actually has about 22,000 medical residency positions to fill. That's a gap of 5,000 physicians per year.

Right now, this gap is largely filled by IMG physicians. Yet we cannot continue to rely so heavily on IMGs, nor can we depend solely on osteopathic educational institutions to increase the number of practicing physicians. Finally, while we depend on physician extenders to be our partners and colleagues, there are simply too many cases where what the patient truly needs is a doctor.

So where do we go from here?

First, we need to start helping those who are feeling the pain of physician shortages right now, particularly patients in rural and inner-city areas. At present, 35 million Americans live in such underserved areas. That's a little bit more than the combined populations of the 22 least populous states -- including my own state, Mississippi.

What can we do to improve access? To simplify a complex issue, I suggest that we start with the following:

  • Recruit men and women to our profession who actively want to care for the underserved -- especially minority physicians, who are more likely to work with these populations. This means we need to graduate more medical students and create more graduate medical education positions to accommodate them.
  • Support the training of these future doctors not just with new funding, but also with careful mentoring and special curricula.
  • Re-emphasize the importance of primary care. Primary care physicians play a particularly critical role in caring for underserved Americans.

But what about future shortages, you ask?

There the waters become a bit murkier. As we have already seen, physician work force projections can be a tricky business, whether we're analyzing the various data points or deciding on appropriate action. The bottom line is that physicians and physician organizations must help lead this complicated endeavor, wherever and whenever it takes place, whether in the public or the private sectors, regionally or nationally.

For that reason, we at the AMA continue to work with Federation members, as well as national and regional policy-makers, to help address existing and anticipated physician shortages. We will closely monitor the work force situation, particularly in terms of geography and specialty. We will do all we can to ensure that our nation uses its current GME resources wisely, and we will do our best to get more resources on the table.

The threat to our physician work force is a critical public health issue that touches every American. We at the AMA can't -- and won't -- ignore it. Neither should you.

To learn more about this critical issue, look at the materials collected on the Council on Graduate Medical Education's Web site (link). I also urge you to get involved with this issue at the state and specialty level, as appropriate, to help organized medicine ensure that we train enough physicians today to care for the patients of tomorrow.

J. Edward Hill, MD is a family physician from Tupelo, Miss., was AMA board chair during 2002-03 and served as AMA president during 2005-06.

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