Physician shortage? Push is on for more medical students

But some question whether there really will be a future shortfall of doctors.

By — Posted March 14, 2005

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The Assn. of American Medical Colleges is calling for the nation's allopathic medical schools to boost their enrollment 15% over the next decade. If every institution answers that challenge, there will be an additional 2,500 medical school graduates annually to offset a projected physician shortage.

AAMC officials said schools need to start planning now to prevent the shortages that at least two studies have predicted. One forecast, by Richard Cooper, MD, director of the Medical College of Wisconsin's Health Policy Institute, expects a shortage of 200,000 physicians by 2020. Another study by Ed Salsberg, for the Council of Graduate Medical Education, projects an 85,000-physician shortfall by 2020.

Numerous medical specialty groups -- including the American College of Cardiology, the American Geriatrics Society and the American Society of Anesthesiologists -- announced that they are in or on the cusp of shortages.

"The AAMC's new position responds to mounting evidence that the demand for physicians will outstrip the supply in future years," said Jordan J. Cohen, MD, AAMC president.

The AAMC, which formed its own Center for Workforce Studies, said the shortage is being driven by population growth, aging baby boomers, physician retirements and younger doctors demanding to work fewer hours. The AAMC's call marks the first time since the 1960s and 1970s that medical schools nationwide have been asked to boost enrollment.

The new proposed enrollment increase translates to a 13.4% total increase in the number of medical school graduates. Today, the nation's medical schools graduate 18,600 students each year -- 16,000 from allopathic medical schools and 2,600 from osteopathic schools.

The AAMC also is asking that the federal cap on graduate medical education spending be lifted, so there could be a parallel increase in the number of medical residents in training. Otherwise, an increase in U.S. graduates will merely mean that fewer international medical graduates will enter the country, and the total supply of medical residents will stay around 98,000 -- a level that the country has been at since 1996.

Dr. Cohen said there is no need for people to fear that expanding the enrollment will sacrifice the quality of new physicians. Each year there are twice as many applicants than enrollment positions at allopathic schools, he said. And the expense of applying means that few unqualified students make the effort.

Also, some of those who don't get into U.S. schools seek options elsewhere, and 1,500 U.S. graduates from international medical schools return each year to vie for medical residency positions.

"There's no question there's more than enough highly qualified applicants," Dr. Cohen said.

But he and others agree that the growth needs to be focused in the right areas.

He said increased enrollment should correspond with areas experiencing rapid population growth, such as the South and the West.

"We already know schools are responding," Dr. Cohen said, citing a new AAMC survey that found that 31% of responding schools were "definitely" or "probably" going to boost first-year enrollment in the next several years.

Mapping a direction

Dr. Cooper, an advocate of medical school expansion, suggested that there should be a national discussion on the issue so that the shape and size of the next generation of physicians won't be determined by individual medical schools but by all members of the health care system.

"This is a very important step that should be taken with a great deal of thought and care," he said. "Strategizing is what's needed right now. We need to identify the problems and propose potential solutions, so state or private institutions don't come in naked. Otherwise growth will be a feature of politics of the moment."

While growth in the 1960s and 1970s created campuses from the ground up, that type of expansion is too costly and time-intensive this time around, Dr. Cooper said.

"We can't afford to build a medical school like the University of Illinois anymore," he said. "Now we're trying to expand just education capacity. We need to expand with a paradigm that doesn't require a parallel expansion of research and tertiary care."

A new approach

That paradigm might look like Florida Atlantic University's, which has joined forces with the University of Miami School of Medicine to act as a branch campus for the established medical school. The Florida Atlantic students enroll at Miami but attend FAU's campus in Boca Raton for their first two years. Its first class of 16 started this fall, and next year the entering class will grow to 32. Students transfer to Miami for their third and fourth years, but FAU is already discussing the possibility of turning the Boca Raton campus into a four-year program.

Such a model is cheaper than starting from the ground up. Officials at FAU said a private donation of $15 million, which was matched by the state, covered the cost of a new building. The donation also was used to create an endowment for the branch campus. Operating costs for faculty and administrative salaries are $4.6 million a year and are paid by the state. In contrast, it would have cost an estimated $450 million to start the program from scratch, FAU officials said.

Reagan Ross is one of the first-year students at the FAU Boca Raton campus. She can't predict where she'll end up, but she's conscious that she's benefiting from the state's push to produce more doctors.

"We know it's one of the reasons the school came about," Ross said.

Will there really be a shortage?

There is a good deal of skepticism among physicians regarding work force projections.

American Medical Association Trustee Rebecca J. Patchin, MD, said that skepticism is well-deserved. "Only 10 or 12 years ago they were forecasting an impending surplus," she said. "Now they are forecasting the opposite, so it shows the lack of precision in forecasting."

While reports of long waits to see a physician could be symptomatic of the maldistribution of physicians, she said, it might not indicate an actual shortage. Consequently, the AMA has been cautious in its approach to the issue.

The Association has taken a neutral stand and is doing its own study. A report from the AMA Council on Medical Education is expected in June.

Jonathan P. Weiner, PhD, professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health, has been a staunch critic of the predictions.

"Training more doctors isn't necessarily the way to bring about better health care for Americans." he said.

But Dr. Weiner said that if the expansion is going to happen, it should be done with some forethought so that areas in need of doctors get them.

For example, he said, turning out more doctors doesn't mean they'll go to areas where they are needed, such as inner cities and rural areas.

"I'd rather there be a surplus than a shortage, but my first choice is a system that provides efficient [care] and equality of care for everybody," he said.

Without a national health care policy, expanding enrollment becomes a piecemeal project controlled by medical school deans, Dr. Weiner said.

"It's not a medical school dean issue. It's a U.S. health policy issue, an insurance company issue, consumer groups -- those are the ones bankrolling it. We need further evidence on this focused on population health and cost versus benefits."

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Expansion plans

The Assn. of American Medical Colleges surveyed allopathic medical schools on their plans to expand enrollment. Of the 118 schools that responded:

31% were "definitely" or "probably" going to boost first-year enrollment in the next several years.

20% were "possibly" going to increase enrollment over the next six years.

Source: Assn. of American Medical Colleges, 2004

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How many doctors does the country need?

Estimating the appropriate number of physicians needed to keep the nation healthy is a complex task. One can count the number of medical school graduates, but not all of those physicians will work full time, and some will retire early. Then there are the nurse practitioners, physician assistants and others who contribute to patient care and need to be factored into the equation.

Figuring demand for physician services is equally complex. Some predictions look at past levels of use to anticipate future demand. Others factor in things such as income increases and the percent of the population that is elderly.

Two work force estimates are commonly referred to in discussions on physician supply.

One study is by Richard Cooper, MD: "Economic and Demographic Trends Signal an Impending Physician Shortage" (Health Affairs, January/February 2002).

The report concludes that the physician supply will stay flat, while the U.S. population grows and the elderly population increases. At the same time, Dr. Cooper predicts, consumer demand for medical services will increase. He projects a deficit of 200,000 physicians by 2020, or 20% of the projected demand.

A second study comes from Ed Salsberg, former executive director of the Center for Health Workforce Studies at the State University of New York. In a 2003 study for the Council of Graduate Medical Education, a congressional advisory group, Salsberg predicted a shortage of 85,000 physicians by 2020.

The key difference in the two reports lies in a projection of how much medical care individuals will seek.

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External links

"Economic and Demographic Trends Signal an Impending Physician Shortage," abstract, Health Affairs, January/February 2002 (link)

"New Steam from an Old Cauldron -- The Physician-Supply Debate," extract, New England Journal of Medicine, April 22, 2004 (link)

"Prepaid Group Practice Staffing and U.S. Physician Supply: Lessons for Workforce Policy," abstract, Health Affairs, online exclusive, Feb. 4, 2004 (link)

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