For decades, medical groups and healthcare experts have warned about an impending overabundance of doctors. One 1994 estimate suggested that the doctor "surplus" would swell to about 216,000 by 2000 and as much as 270,000 by 2020.
Yet, after the number of physicians skyrocketed with the rapid expansion of medical schools about three decades ago, it appears that the U.S. may be faced with the opposite phenomenon-a looming shortage that could cause access problems for years to come if the issue isn't addressed soon, some experts believe.
"The noose is tightening," says Richard Cooper, a physician who is the director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee and a national expert on healthcare workforce issues.
In an oft-quoted study published last year in Health Affairs, Cooper points out that the number of physicians per capita has more than doubled since 1929, increasing from 119 per 100,000 population to 270 per 100,000 in 2000. He estimates the number will peak at 283 per 100,000 population in 2010 before dropping slightly to 280 per 100,000 population in 2020.
In the meantime, while the per-capita supply of physicians remains essentially flat, Cooper says, demand for healthcare services will increase at the same time many physicians-especially the growing number of women-will be adjusting their schedules to work fewer hours.
Cooper projects a shortage of about 50,000 physicians by 2010, with the doctor deficit expected to swell to 200,000 or more by 2020.
If ever there was a true shortage of physicians, Cooper says, it occurred well before the number of medical schools grew by about 25% in a decade-long growth spurt through the mid-1970s, feeding a huge new supply of doctors into the workforce. The number of medical school graduates has almost doubled since 1970.
"Now," Cooper says, "we're getting into a period where the number of doctors produced is the same as the number retiring. Supply is leveling off. Demand is increasing."
Most healthcare observers and medical groups, including the American Medical Association, agree that there are shortages in some geographic areas and specialties. Cooper believes specialties with the most immediate supply concerns include anesthesiology, cardiology, gastroenterology, pulmonary critical care and radiology.
Despite Cooper's detailed analysis, there remains considerable uncertainty about whether the nation will face a physician shortage in the next several years. The Council on Graduate Medical Education, which advises the federal government on physician workforce issues, has operated for years under the assumption that there will be a physician surplus over at least the next two decades, reaching as high as 150,000 by 2020.
In a significant departure, COGME now is reconsidering that position, acknowledging that past projections were based largely on the notion that managed care-with its expected decrease in utilization-would continue to be the predominant model of care for many years to come. The group's revised position is based in large part on a study by Ed Salsberg, director of the Center for Health Workforce Studies in the School of Public Health at the University of Albany (N.Y.), which arrives at the same conclusion as Cooper, forecasting a shortage of about 150,000 physicians by 2020.
"We've recognized-as the entire world has-that managed care isn't exactly the standard any longer," says Carl Getto, a physician who is chairman of COGME and the senior vice president of medical affairs at the University of Wisconsin-Madison.
The report by Salsberg, who was hired by COGME to study workforce trends, indicates the shortage will continue to build with the retreat of the managed-care model. What's more, the demand for healthcare services is expected to increase steadily because of an aging population, a factor that will stretch a thin physician supply even further.
Salsberg, a national authority on healthcare workforce issues, says, "This nation is likely to be facing a major shortage of physicians by about 2015. And if we're going to need significantly more physicians, we need to start planning now."
Getto says COGME will review a final report from Salsberg at a meeting in mid-September that may force the federal government to confront a potentially dangerous shortage of doctors, just a year after it tried to address the far more obvious nursing crisis.
"The issues we have to address are the public policy issues of the distribution of physicians, the support of physician training and graduate medical education, and the dollars that are going into that," Getto says.
Even as COGME revisits the issue, two other high-profile organizations remain on the sidelines-at least for the moment. The Chicago-based AMA, which has maintained for many years that the U.S. has an adequate supply of physicians, directed its Council on Medical Education last year to review the association's current policy on national workforce issues and provide draft recommendations for the future. Those recommendations will be reviewed during the AMA's annual meeting this week in Chicago.
The Association of American Medical Colleges in Washington has taken a hands-off approach, concluding that no effective or accurate way exists to help gauge the future supply of doctors, especially in light of the wildly overblown past estimates of a surplus.
In fact, after years of warnings that the supply of doctors was growing too quickly, the AAMC, which represents all 126 accredited U.S. medical schools, doesn't have a position on whether there's a surplus or a shortage of physicians.
"Our position is one of agnosticism. We don't know," confesses Michael Whitcomb, senior vice president of the AAMC's Division of Medical Education. "And the reason we are agnostic and the reason most people remain agnostic is because all previous projections have been so wrong it's hard to have any confidence in any new projections."
Cooper, who advises opening more medical schools to meet increased demand, faults the AMA and the AAMC for "playing a waiting game" while many specialty societies become increasingly concerned about the threat of shortages in their ranks. The nation needs 25 new medical schools in the next decade just to alleviate one-third of the expected shortages, he believes.
"Why isn't the AAMC doing something?" he asks. "Why isn't the AMA doing something? Specialty societies are having fits. There's a sense of complacency, on one hand, and a sense of urgency-I would call it panic-among specialty groups. No one seems to know what to do."