politics
The Health Care Crisis
Part One: Are We Facing a Shortage of Qualified Physicians?
Introduction
In the early 1970s, the federal government supported an increase of physicians by almost 30% as Congress approved additional positions and new medical schools.
In spite of this are we facing a shortage of qualified physicians? If we are, what are the causes and potential remedies?
The Nays
In recent years there have been sporadic reports of an anticipated surplus of physicians in coming years. In the 1990s, such predictions were made by the U.S. Bureau of Health Professions, the Council on Graduate Medical Education and the AAMC (Association of American Medical Colleges). These organizations have since revised those optimistic prophesies.
Dr. David Goodman, a professor of pediatrics and community and family medicine at the Center for the Evaluative Clinical Sciences at Dartmouth Medical School, seems to accept the projected numbers, but contends that the quality, rather than the quantity of physicians, is the answer to the dilemma of proposed shortages.
His recent research findings, appearing in the March/April issue of Health Affairs, suggests that regions and states with more medical specialists and general internists have a lower quality of care, as measured by death rates and other performance standards.
He also maintains that since the patients in his study were cared for at academic medical centers, they received high-quality care. (He has apparently never been a patient in a teaching hospital.)
He did acknowledge that the number of physicians needed for this care showed a 4.7-fold variation, from 6-28/1,000 chronically ill patients, between institutions studied in the six months before death.
His conclusion was that, rather than spending more resources on training more physicians, we should be focusing on building more efficient delivery systems, in other words, by improving efficiency.
In response to his assertions, I must insist that the quality of current or future medical care in general can not be assessed by looking only at dying patients in academic medical centers. This perspective completely discounts other important factors such as the quality of future applicants to medical schools, attrition (the numbers of physicians leaving practice), the rise in the number of elderly patients requiring treatment as “Baby Boomers” reach their sixth and seventh decades, as well as economic forces that will shape the numbers and quality of physicians in the future.
The Yeas
These claims seem to be effectively refuted by an accumulation of hard data to the contrary.
Richard Cooper, MD, director of the Medical College of Wisconsin’s Health Policy Institute, projected a shortage of 200,000 physicians by 2020.
Ed Salsberg, for the Council of Graduate Medical Education, estimated that figure to be 85,000.
Regardless of the exact figure, the experts seem to agree.
Several medical specialty groups indicate that they are close to, or are, experiencing shortages.
The Data
The Premedical Advisors Information Service of the AAMC provides data representing the number of applicants to medical schools by State of Legal Residence form 1994-2005. According to this data, the total number of applicants fell from 1994-2005 in 39 states listed. It fell in 14 states from 2004-2005. A trend that seems to be typical for many states was that of a rise in applications until 1996, followed by a decline until 2002.
According to Clemson1 lower numbers in the late 1980s appear to have triggered a rise in the early to mid 1990s that can be explained by:
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Students perceived that their chances of admission to medical school were better when the applicant pool was larger. -
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The pursuit of a career in business was not very promising due to the national economic downturn. The “dot com” boom arrived and some students changed their interests from medicine to business, particularly computer/internet business. In 2003, business once again appeared to be less appealing than medicine.
Other data suggests that these statistics can be reliably generalized to support changes in the numbers of applicants, regardless of their place of residency.
AAMC
The AAMC indicates that medical school applications in general have declined by 29% since 1996 and one of every two applicants is accepted compared to one in three in 1995.
COGME
In 2004, COGME (Council on Graduate Medical Education predicted that if current trends continued, demand for physicians would significantly outweigh supply by 2020. They recommended that medical schools expand the number of graduates by 3,000 per year by 2015. This recommendation was based upon their estimates of how many physicians would continue to practice and approximations of medical school sizes during that time. They did acknowledge the more than 3,000 per year would likely be needed.
CMA
The California Medical Association distributed 19,000 questionnaires to physicians practicing in that state, in February, 2001. They received a 12 % response. These findings were presented in an article, entitled “And Then There Were None” The Coming Physician Supply Problem. The findings were significant and some were disturbing.
Some of the results included:
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Seventy-five percent reported that they had become less satisfied with medical practice in the preceding five years.
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The greatest source of satisfaction was derived from their relationships with patients.
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The greatest sources of dissatisfaction were low reimbursement, managed care hassles and government regulation.
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43% planned to leave medical practice in the next 3 years and another 12% planned to reduce time spent in patient care.
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The time they spent in patient care had declined by 7% in the preceding 5 years and 44% of the physicians spent less time with patients than they did five years before.
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58% reported difficulty attracting other physicians to join their practice.
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Primary care, neurology, orthopedic surgery and neurosurgery showed the greatest shortages.
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More than 25% of physicians stated that they would no longer choose medicine as a career if they were making that decision at the time of the survey.
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More than 1/3 would choose medicine but would not practice in California.
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2/3 advised that their children choose a career other than medicine.
These observations painted a dismal picture. The last three finding say it all.
AMA
In June of 2005, the American Medical Association formally recognized that there was a shortage of physicians in some regions and in some specialties. At that time their House of Delegates requested an investigation of this issue.
In response to this determination, they also proposed "to increase the overall number of physicians and reduce geographic misdistribution by:
working to develop mechanisms, including identification
of funding sources, to create medical school and residency
positions in or adjacent to physician shortage/underserved
areas and in undersupplied specialties"
Conclusions
It appears to be almost universally accepted that we will face some degree of physician shortage in coming decades. Concern about this should be amplified among “Baby Boomers”, who will comprise a sizable portion of the total number of consumers of medical care at that time.
The fact that we know little about relatively new factors that will undoubtedly impact both the quality and number of available physicians should increase our anxiety.
The additional fact that we will likely expect federal and state government to remedy whatever problems do arise, is the most disturbing element of this predicted crisis.
For a discussion of causes and potential remedies, review the articles linked below.
1www.clemson.edu
(Sources: The author’s knowledge base, unless otherwise noted.)
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