M.D. Graduates: From Glut to Shortage

Dan Greenberg
http://chronicle.com

doctorHow many physicians are needed to care for the population of the United States?

There’s no sure answer. Nonetheless, given the long lead times required for expanding doctor training, the medical-education establishment is on a track aimed at increasing output 30 percent by 2020. Five new allopathic schools are in the works, which will bring the national total to 134, and many schools are expanding class sizes. Expansions are also under way in osteopathic training, which now numbers 25 schools.

In the economics of higher education, there is nothing like a medical school for gobbling up money. Class sizes are tiny — often around 100 — and faculty members far outnumber students. Labs are necessary for the pre-clinical years, and hospital affiliation is a must. Little wonder, then, that groundbreaking for a new medical school is a rare event.

Great uncertainties about expansion are acknowledged even by advocates, including the allopathic Association of American Medical Colleges. Warning of the “many unknowns that make forecasting future supply and demand very difficult,� the AAMC states that “an increase at this time, with continuing monitoring of developments and trends in supply and demand, is the most prudent approach.�

Until just a few years ago, the medical establishment and federal health authorities frequently warned of an M.D. glut, with attendant implications of idle doctors needlessly drumming up business and accelerating runaway costs of medical care. Reflecting the glut fears, limits on training slots held the number of M.D. graduates in the U.S. at about 15,700 per year from 1980 to 2005; the number of allopathic medical schools remained at about 125. Given the population growth of some 70 million in that 25-year span, the standstill in domestic graduates was remarkable, even allowing for foreign-trained physicians making up 25 percent of the medical workforce.

The turnabout in forecasting of needs comes from a convergence of factors that seem to point toward a coming shortage. A growing and aging population requires more medical service. Doctors are opting for fewer work hours and are retiring younger. Female doctors — an increasing portion of the medical workforce — tend to work fewer hours. Managed care, which aimed to reduce utilization of medical services, is out of favor. New medical technologies are a puzzler. Imaging devices, for example, can improve diagnostic methods, saving time and money; and they can also provide opportunities for uselessly running up the tab.

Foreign comparisons of physicians per capita cast no light on the American medical landscape. The U.S. numbered 264 M.D.‘s per 100,000 of the population in 2000, according to the Organization for Economic Cooperation and Development. The ratio was over 300 per 100,000 in Sweden, Germany, Spain, France, Denmark, Switzerland, Austria, Italy, and Belgium. Other medically advanced countries had fewer doctors per 100,000: Australia, 244: New Zealand, 223; Canada, 210; Britain, 201, and Japan, 193.

If the expansion leads to the feared glut, a tempting solution would be a reduction in the admission of international medical graduates to U.S. residency training. A good-deed rationale can be attached to such restrictions: Many of these physicians are from developing countries that need their services. But U.S. domestic politics also gets involved. Many of the foreign graduates take inner-city and rural jobs that homegrown doctors generally shun, as members of Congress from those less-favored areas point out when cutbacks on the foreigners are proposed. The physician shortage in such areas would be far worse without foreign graduates.

Other factors are coming along to further complicate medical-workforce planning.
The outsourcing of some M.D. services, once deemed impractical, has arrived, via the Internet. X-rays can be expertly read in low-wage countries. So-called medical tourism, in quest of skilled medical services in low-cost countries, is catching on. A national health-insurance scheme, or a broadening of existing insurance coverage, is likely to follow the presidential election. The impact on medical-workforce needs is another uncertainty, but if cost constraint is a goal, the surest means is through restraints on utilization, which means reduced medical service.

At lower cost, it’s argued, nurse practitioners and other non-M.D. health-care workers can provide many medical services now restricted to physicians. But attempts at jurisdictional changes set off turf battles.

It’s tempting to berate the medical establishment for its stumbling about in uncertainty about medical workforce needs. The sudden turnabout on glut and shortage is puzzling, given that population growth and aging, and many of the other factors now cited, were evident many years ago.

Nonetheless, the available evidence seems to point to shortage. And, as the AAMC suggests, an expanded output in coming years is a prudent approach.

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