Will there be enough doctors in America's future?

The title is provocative enough: Will the Last Physician in America Please Turn Out the Lights? Subtitled A Look at America's Looming Doctor Shortage, the thin, 80-page paperback by the principals of the MHA Group, a physician recruiting and staffing firm, is also a brisk read with a grim conclusion.

America is heading for a perverse version of a Canadian-style healthcare system -- with long waits to see physicians -- but without universal coverage, just higher costs, according to one of the book's three co-authors.

The book lays out in 12 chapters what James Merritt, Joseph Hawkins and Phillip Miller call the "Dirty Dozen" reasons why there aren't enough doctors now and won't be nearly enough in the coming years, particularly specialists.

They conclude there will be a physician shortage of an estimated 90,000 and 200,000 doctors in 15 years because:

1. planners of medical education goofed
2. managed care fizzled
3. training shifted away from specialists
4. the population is getting older and fatter
5. docs are getting older, too
6. the hours limits on residents and fellows has shifted the work load
7. more women are becoming doctors
8. the supply of international medical school graduates is shrinking post-9/11
9. doctors' time is being consumed by increased paperwork
10. many younger physicians won't work the long hours their older colleagues will
11. medical technology is driving demand for care
12. the existing supply of physicians is maldistributed

Miller, the recruiter's vice president of corporate communications, said the target audience for the book includes physician leaders of medical education programs; government leaders who can fund needed increases in medical training, especially residency programs; hospital administrators puzzled at why it is so difficult to recruit physicians, particularly specialists; and physicians themselves, who need to know how their changing practice styles will help create the shortage.

The authors conclude the prospects for alleviation of the shortage are bleak. "I can't really see it happening, because the pain threshold hasn't gotten high enough for most people," Miller said. "Doctors themselves have had a vested interest in keeping the supply limited, and the federal government's direction has been in the whole opposite direction, in decreasing GME funding."

"The place where we see the most repercussions is in the emergency departments," he said. "We're seeing a lot of diversions. It's not from overcrowding; it's from a lack of specialists. That's a harbinger for what we see is coming."

Miller said he does not foresee a crisis in which people will not get treatment. "It will be a matter of inconvenience, sort of what you see in Canada, with the lines getting incrementally longer," he said. "The time and the cost to see a specialist is going to increase dramatically in the coming years."

The analogy to a Canadian system is only partly apt, according to veteran physician workforce watcher Richard Cooper, M.D., because in Canada, at least everyone is covered by government-sponsored insurance.

In America, "It won't be exactly that, because the waiting times are going to be even longer for poor people," said Cooper, director of the Health Policy Institute at the Medical College of Wisconsin in Milwaukee. "Almost no one recognizes this as a national problem."

Not a crisis, says COGME chair

There are several schools of thought about the severity of the problem. On one end of the spectrum is Cooper, who gained notoriety in back 1994 for his controversial projections of an impending shortage. On the other end is Carl Getto, M.D., chairman of the federally funded Council on Graduate Medical Education. COGME tracks physician workforce trends, and Getto is less of an alarmist than the authors.

"I think it is a problem; I don't see it in crisis proportions," Getto said. "They (the authors) have more alarm attached to it because that's their business, and they're hearing more alarm from their clients."

In July, the council issued a report calling for a 15% expansion of the physician workforce in the coming decade, an increase in medical school output of about 3,000 more physicians a year, or fewer than three more graduates a year on average over 10 years from each of the nation's 125 medical schools. The easiest thing will be for the existing schools to expand, Getto said, but several new medical schools probably will come on line, too.

"COGME doesn't think we're looking at a train wreck," said Getto. "We're in the range of where we want to be."

There will be shortages in some areas, even with the recommended increases in medical school output, Getto conceded. "Rural primary care is going to be hurt a lot," he said. "That's the area where you're going to see the biggest shortage.

"The biggest bottleneck is in residency programs," said Getto, who also serves as vice president of medical staff affairs at the University of Wisconsin Hospital & Clinics, Madison. "They aren't going to grow because there is no new money. I think it's the No. 1 question, and I don't have any bright ideas."

Edward Salsberg, a physician-supply expert who authored the COGME report, said he is becoming increasingly troubled about the shortage and is edging toward the Cooper camp. His estimate that there would be a shortage of as many as 90,000 physicians by 2020 would only be mitigated, not alleviated, by the 30,000 additional graduates called for by the COGME increases. Salsberg is the director of the Center for Workforce Studies of the Association of American Medical Colleges, which was created last December and is studying the problem.

"Adding 30,000 would not meet the projected demand," Salsberg said. "There are reasons to be concerned, for sure. I wouldn't classify it as grim yet."

He said better technology and encouraging physicians not to retire could be part of a solution.

"The medical-care field is going to have to evolve," he said, adding the new book is "raising important questions."

Efficiency doesn't mean efficacy

Cooper, however, is grim. He wrote about the problem last month in the article "Weighing the Evidence for Expanding Physician Supply," which appeared in the Annals of Internal Medicine.

"We can get more mileage out of training more advance-practice nurses and physician assistants, but we can't get a lot of mileage. They can do well-baby exams, they can't do surgery. So even if you took away from physicians everything everyone else can do, it wouldn't make much difference." The danger with this tactic, Cooper said, is if it is carried too far, beyond the training and skill level of physician extenders, impacting quality of care and even patient safety. Similarly, efficiency gains through technology, such as electronic medical records, is all well and good, but "it is all counterbalanced by regulations, such as hours of work, HIPAA regulations, managed-care consents. As fast as you become efficient, there is an army of MBAs out there making us more inefficient, and they're winning."

The country could lift the caps on foreign students to U.S. residency programs for a quick fix, he said. "You can get foreign residents in three or four years, but you've drawn these people from where there is a terrible shortage. Already it's a crisis in Africa. They're closing hospitals in the Philippines. That's a real problem.

"So everywhere you turn, you've got the brain-drain problem, or the regulatory problem, or you can't ask PAs and nurses to do much more than they're already doing, and you add that all together and there is no clear solution. COGME created the problem and I wish they'd go away. They've done enough damage.

"I don't have any real short-term solutions for what to do," Cooper said. "In the near term, there is just no way out."