WHO KNOWS
Physician Supply in the United States: Do We Face a National Shortage or a Surplus?
An interview with David Sundwall, M.D., president of the American Clinical Laboratory Association and former chair of COGME (Council on Graduate Medical Education) and Richard Cooper, M.D., director of the Health Policy Institute at the Medical College of Wisconsin. Drs. Sundwall and Cooper comment on the current supply of primary care and specialty physicians and discuss previous COGME recommendations to increase the supply of new physicians who choose primary care specialties in an effort to alleviate a developing surplus of specialists.
Is physician supply in the United States sufficient to meet current demand?
Cooper: The word "demand" is an important one. Whose demand? At the moment, physician supply is marginally sufficient to meet consumer demand, which is high. [But] there's vast excess to meet the demand that COGME said existed. If you look broadly, you won't find many places that have surpluses. And the places that claim they have surpluses appear to be behaving more like they don't have surpluses.
Sundwall: We currently have too many physicians in many areas of the country and too few in others. Our supply of physicians really does depend on where you are. There is no pat answer, it just depends on [regional factors].
What is the status of the supply of specialists in relation to primary care physicians?
Cooper: Specialists are in short supply now and it's going to get worse very soon, for two reasons. First, many specialty training programs have been severely curtailed. Second, [specialty care is] where the demand is. This notion that you had to have a certain percentage of primary care physicians was just fallacious. As you increase demand for health services, you're not increasing demand for primary care. We don't need any more primary care physicians today than when I was a child, because they don't do anything fundamentally different. The increasing demand is for specialists who can perform highly specialized procedures such as cosmetic surgery and treat more of the complex illnesses that currently face our society.
You will also find recruitment requests have shifted from primary care physicians to specialists. Recruiting firms say there are shortages in most specialties, as evidenced by the number of recruitments they've been asked to do.
Sundwall: The COGME report is very enlightening, yet it's also very humbling because most of the specialty societies that have invested significant resources into measuring their own numbers do it very differently. Because there's no common yardstick, you have to be somewhat skeptical. The government traditionally had a very simplistic approach, looking just at population-to-physician ratios. That didn't work [because] we've learned that this measure doesn't take into consideration either new diseases or new demographics.
How might the growing prominence and availability of certain non-physician clinicians (i.e., nurse practitioners, physician assistants, nurse-midwives) affect future supply and demand of primary care physicians?
Cooper: The impact of non-physician clinicians-those who work with specialists as well as those who work with primary care physicians-is principally in primary care. In specialty practices, nurse practitioners and physician assistants often provide primary care services. Non-physician clinicians who work with specialists by and large supplement what specialists do and make them more efficient; they don't tend to replace specialists. Primary care non-physicians do the same things physicians do, to a large extent. In many cases, primary care physicians have included nurse practitioners in their practices to complement the work that they do and to increase overall efficiency. As a result, both groups of non-physician clinicians really add directly to the workforce.
Sundwall: [The increase of non-physician clinicians] will change the role of the primary care physician. There's no question that non-physician clinicians provide a lot of primary care, but they are going to have less of an impact than some projections might suggest. I don't think they're going to replace the primary care physicians but in some respects they will force the general internist, pediatrician or family doctor into more of a managerial or administrative role.
In the mid-1990s, COGME recommended that 50 percent of new physicians choose primary care specialties. Has this greater attention to primary care increased the number of generalists and thus ameliorated concerns about future shortages?
Cooper: [The recommendation to increase the number of generalist physicians] was ridiculous. There was no epidemiologic or factual basis for doing that. The notion was that primary care physicians would encompass a greater spectrum of patient care needs. Well, primary care physicians don't want to do that. They don't want to venture beyond their level of competence. You shouldn't want them to do that. This notion was a philosophic view that was utterly disconnected from the reality of clinical practice. And lo and behold, it didn't happen...Nobody wants half of the doctors to be primary care doctors today. Even COGME is rethinking it.
Sundwall: COGME has been influential, but changing academic medicine is like turning the Titantic; it moves very, very slowly. None of COGME's recommendations were embraced wholeheartedly. However, they did influence the growth of family medicine residencies and the encouragement of generalists in pediatrics and in internal medicine. The change was not as great as we had hoped for but it was in the right direction. Now, we need to revisit some of those assumptions. I don't know where COGME is going, but I would be surprised if it changed its position on the 50 percent primary care 50 percent specialty split. That still makes sense to me. What COGME might change its mind on is the overall number of physicians that are needed.
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