Back in the 1960s and '70s, there was a lot of talk about an oncoming glut of physicians in the U.S. Those predictions took on the air of certainty in 1980 with a national report foreseeing a horrific situation by the end of the century, with hordes of specialists all competing for the same patients. It seems that many people, particularly those in government, still think this way.
The problem with this outlook is that the surplus never happened and now we are looking at a shortage of doctors.
This magazine was among the first to report on this situation ("The vanishing doctor surplus," June 16, 2003, p. 28). Now there is a new book that postulates that the doctor shortage is already well-established and will soon get worse. Will the Last Physician in America Please Turn Off the Lights? is authored by three executives of MHA Group, an organization of six affiliated healthcare staffing firms. Their names are well-known to readers-James Merritt, Joseph Hawkins and Phillip Miller. All of them have been in the business for many years and know firsthand the critical problems this country will face finding and recruiting physicians. As a matter of fact, some parts of this nation are already facing very serious physician shortages. Those who set healthcare policy don't seem too concerned about this, but they should be.
Perhaps the lack of awareness of the shortage isn't so surprising. For years the industry has been inundated with alarming statistics about a physician surplus. The Graduate Medical Education National Advisory Committee told us in 1980 that by the year 2000 we would have 150,000 too many physicians. That prediction was backed up by a 1994 report by the successor organization, the Council on Graduate Medical Education, which said we would have as many as 165,000 too many specialists. This became the accepted wisdom in the field.
Experts also said the overabundance of doctors would cause a sharp increase in healthcare costs because these specialists would be out there ordering enough tests to keep their incomes high. So moves were made to limit physician supply. The number of residency slots for training specialists such as anesthesiologists and radiologists were reduced. The number of U.S. medical school graduates was kept static at about 16,000 per year. Then, with the Balanced Budget Act of 1997, federal financial support for specialty physician training was cut.
Now, it's no secret that the American Medical Association and many other medical societies felt they had a vested interest in keeping the physician supply lower, which meant less competition for existing AMA members and therefore higher incomes. The education council-which, in another sign of the prevalence of the oversupply viewpoint, was forced to shut down last year for lack of federal funding-eventually reversed itself and predicted a shortage of up to 96,000 doctors by the year 2020. Richard Cooper of the Wisconsin Medical College believes that estimate is way too low. He foresees a shortage of some 200,000 doctors by 2020.
The authors posit 12 reasons why this is happening-what they call the "dirty dozen."
In the heyday of managed care, we were told that primary-care physicians would be the gatekeepers to specialty care, a formula that was seen as the best way to run healthcare cost-effectively. But it didn't work out because the American consumer rebelled. Patients want to see the specialist of their choosing when they want to. It was too late to avert the trend in medicine toward generalists. As a consequence we have too few specialists, particularly in fields such as anesthesiology.
Then there's the fact that we as a nation are getting older. Those 65 and older visit doctors twice as often as the population as a whole and spend far more time as inpatients than younger people. Physicians are getting older along with their patients and are leaving the practice of medicine.
Younger generations of doctors are working less. They want a "lifestyle" that isn't medicine 24/7. They don't plan on practicing until they are 80. A rule was put into effect in 2002 limiting residents' work hours to 80 per week, or some 20% less than before, the equivalent of taking 15,000 to 20,000 physicians away from America's busiest hospitals. We have many more women physicians, but they work 18% fewer hours than their male counterparts because of family demands.
The international pipeline is being pinched. Today almost 25% of all physicians involved in active patient care in the U.S. are foreign medical school graduates, but a relatively new and tougher clinical skills assessment test and the immigration changes issued after Sept. 11, 2001, have severely affected recruitment.
There aren't any easy answers to the physician shortage. American people want the best healthcare they can get, but it's getting harder and harder to see a specialist on short notice. Rural areas are having trouble finding any doctors willing to live there and make less money.
For consumers it is time to get educated. The answer to the physician shortage may be giving people a better idea of when they really need to see a physician and when a lower level of care is called for. We may have to ration the physician hours we have to make the best use of them. The Internet may play a key role in this education, but providers and other institutions need to ensure that this information is accurate and easily understood by laymen.
For those who are concerned about access to quality healthcare for ourselves and future generations, Will the Last Physician in America Please Turn Off the Lights? is an important warning that we need to heed.
Let's hope the lights stay on,
Lauer is the author of two books, Reach for the Stars and Soar with the Eagles, and is an experienced guest lecturer available for public speaking engagements. For more information, go to chucklauer.com.