Health Affairs, 22, no. 4 (2003): 85-87 doi: 10.1377/hlthaff.22.4.85 © 2003 by Project HOPE	New Online   Obama's Success & Next Steps   3 Health Policy Options for President Obama   A Hybrid Proposal   Bipartisan Compromise

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Physician Supply

PERSPECTIVE

Toil And Trouble? Growing The Physician Supply

Abstract

 
Richard Cooper outlines several obstacles to increasing the supply of U.S.-trained physicians. His analysis paints a bleak picture, but he may be underselling the possible benefits of technological advances that could increase medical school capacity and of increasing the volume of qualified applicants by broadening eligibility criteria. Another issue that would confront medical educators is that imbalances between supply and demand would not be uniform across states. This development could signal increased involvement from state policymakers, but public and private policymakers should take steps to assure that resources are funneled to where doctors are needed most and to exploit opportunities for innovative curriculum development.

The conclusion of Cooper’s latest work is that if we should need more physicians, they will not materialize at the snap of our fingers. There are major structural impediments to expanding the supply of physicians if we want U.S.-trained doctors with the same grade point averages (GPAs) and test and national board scores as in the past. The importance of this observation depends, of course, on whether one accepts the premise that demand for physicians is outstripping supply. That debate has been joined, and will continue, in other venues. For the moment, let us assume that the premise is correct. The questions then become whether Cooper’s analysis of our ability to produce physicians has it right and whether it could be usefully extended or redirected in certain ways.

Two alternatives.

Top Two alternatives. Obstacles to expansion. Varied imbalances. Implications. Editor's Notes NOTES

 
Before plunging into these issues, I briefly consider the two options for expanding our supply of health professional services that Cooper mentions but does not discuss. The first is to import more physicians from abroad. The second is to substitute nonphysician clinicians (NPCs) for doctors. We are as likely to rely on these options as on expanding the supply of domestically trained physicians if the predicted shortage of physicians occurs.

The major problem with importing physicians is that it deprives other countries, especially in the developing world, of the health professionals they desperately need.³ This strategy is not only ethically suspect but also self-defeating in a world where, as the AIDS and SARS epidemics make clear, our domestic health is dependent on the quality of the health care in other countries. On 27 May 2003 President Bush signed into law a long-overdue commitment of $15 billion to combating AIDS, especially in Africa. It makes no sense to deliver the drugs to treat AIDS victims on the one hand and to hire away the physicians to dispense them on the other.

The option of increasing the supply of NPCs may be more desirable. The numbers of NPCs are growing rapidly, and their ability to provide certain services with efficiency and quality is well documented.⁴ To date, however, they have been used mostly as complements to physicians, not substitutes.⁵ Whether this pattern will or should be modified remains to be determined.

Obstacles to expansion.

Top Two alternatives. Obstacles to expansion. Varied imbalances. Implications. Editor's Notes NOTES

 
Given the problems and uncertainties associated with these other strategies, increasing the supply of U.S.-trained physicians certainly deserves careful study. As in past work on the demand for physicians, Cooper projects forward from historical experience to assess our country’s future ability to train additional physicians. One of the major obstacles he cites is the cost, delay, and difficulty of building new allopathic medical schools or expanding existing ones.

In exploring this obstacle, Cooper assumes that the process of producing new physicians will remain unchanged in the future and, therefore, that the number of physicians trained per school cannot increase greatly. The question here (admittedly unanswered) is whether information technology has the ability to change this production function—in effect, to increase dramatically the capacity of schools to train physicians.⁶ It is now possible to perform all of the major functions of the lecture hall and the library over schools’ intranets. Medical school lectures—text, visuals, voices, references—are available to students in their dorms and apartments. Therefore, the physical structure of schools is no longer the limit it once was to expanding the number of students.

A more difficult issue is that medical schools are increasingly using small-group instruction in addition to lectures as part of the process of teaching students to be independent thinkers.⁷ The major constraint on expanding the number of students in this regard is availability of faculty. Fortunately, the ratio of full-time medical school faculty to students has been increasing steadily, so that there are now 1.5 faculty members for every undergraduate medical student. Admittedly, growth in medical school faculty has occurred primarily among clinical faculty who were hired to expand clinical revenues, not to teach. Thus, their teaching ability is highly variable. The fact remains, however, that important opportunities may exist to reorganize the process of medical education to better use apparently abundant and novel resources that were not available to institutions in the past. Cooper is right, of course, to suggest that it will take substantial external pressure and probably external funding from state and federal governments to capitalize on this opportunity.

If we could make medical schools more efficient, we would still face another obstacle that Cooper cites: insufficient numbers of high-quality applicants. This problem, too, is potentially remediable if medical schools would broaden their eligibility criteria. As Cooper points out, students from the humanities and social sciences make fine clinicians—perhaps better than applicants trained in the life sciences. Some medical schools have actually begun to question whether they should demand a broader premedical preparation from their students.

Varied imbalances.

Top Two alternatives. Obstacles to expansion. Varied imbalances. Implications. Editor's Notes NOTES

 
Another point that Cooper does not explore, perhaps for lack of space, is that imbalances between supply and demand of physicians, should they materialize, will not be uniform across the country. Census data make it clear that growth in the U.S. population is occurring primarily in the South and West.⁸ These regions are already under-supplied with training resources compared with areas of lesser population growth in the North and the East. For example, in 1997 the number of medical students per 100,000 population stood at 26.5 and 15.7 in Texas and California, respectively, compared with 43.9 in New York and 28.5 in the United States as a whole.⁹ One could argue that the market for physicians is national and that physicians trained in Massachusetts can and do settle in San Diego or Tallahassee. But they are much less likely to do so than are physicians trained in the same region of the country. It is very inefficient, therefore, to combat a shortage of physicians in Texas by expanding the class at the University of Vermont Medical School.

Implications.

Top Two alternatives. Obstacles to expansion. Varied imbalances. Implications. Editor's Notes NOTES

 
The implications of these observations are severalfold. First, new medical schools should be preferentially established and classes expanded where doctors are needed most. Promising locations are areas of high population growth, including Texas, Florida, Southern California, and the Mountain states. Second, new or expanding medical schools will have the opportunity to dramatically reengineer the process of medical education, and policymakers should insist that they take advantage of that opportunity. Third, the variability in need across the country suggests that states will have the greatest incentive to fund the expansion of physician supply, and will likely take the initiative to do so, when and if they emerge from their current fiscal calamity. Federal aid for expansion of physician supply is almost certain to fall victim to federal fiscal policy. Thus, workforce policy is likely to be increasingly developed at the state level. This is an apparently inevitable and perhaps appropriate result of secular trends in our national economy and demographics.

In a context of skyrocketing health care costs, growing rates of uninsurance, threats of global pandemics, and debates about how many hundreds of billions to spend on Medicare prescription drugs, the question of whether and how we should increase the supply of health professional services in this country does not seem to be the issue of the moment. However, all of these developments affect and will be affected by the latter issue. A balanced, well-trained health care workforce is one of those things we more or less assume will be there when we need it. One of Cooper’s contributions is to question that complacency.

Editor's Notes

Top Two alternatives. Obstacles to expansion. Varied imbalances. Implications. Editor's Notes NOTES

 
David Blumenthal directs the Institute for Health Policy at Massachusetts General Hospital/Partners HealthCare System and is a professor of medicine and health care policy at Harvard Medical School in Boston. Health Affairs invited his comments on the preceding paper by Richard Cooper.

NOTES

Top Two alternatives. Obstacles to expansion. Varied imbalances. Implications. Editor's Notes NOTES

 

1. U.E.Reinhardt, "Dreaming the American Dream: Once More Around on Physician Workforce Policy," Health Affairs (Sep/Oct 2002): 28–32.
2. K.Grumbach, "The Ramifications of Specialty-Dominated Medicine," Health Affairs (Jan/Feb 2002): 155–157.
3. F.Mullan, "The Case for More U.S. Medical Students," New England Journal of Medicine 343, no. 3 (2002): 213–217.
4. R.A.Cooper, P Laud, and C.L. Dietrich, "Current and Projected Workforce of NonPhysician Clinicians," Journal of the American Medical Association 280, no. 9 (1998): 788–794[Abstract/Free Full Text]; and M.O.Mundinger, "Through a Different Looking Glass," Health Affairs (Jan/Feb 2002): 163–164.
5. B.G.Druss et al., "Trends in Care by Non-physician Clinicians in the United States," New England Journal of Medicine 348, no. 2 (2003): 130–137.[Abstract/Free Full Text]
6. Commonwealth Fund Task Force on Academic Health Centers, Envisioning the Future of the Academic Health Center (New York: Commonwealth Fund, 2003).
7. Commonwealth Fund Task Force on Academic Health Centers, Training Tomorrow’s Doctors (New York: Commonwealth Fund, 2002).
8. U.S. Census Bureau, Population Division, Mapping Census 2000: Geography of Diversity (Washington: U.S. Department of Commerce, 2000), 10.
9. E.S.Salsberg, presentation at Association of American Medical Colleges’ Physician Work-force Colloquium, Washington, D.C., 31 May 2001.

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