The Journal: December 2010



  Five Challenges Facing the US Physician Workforce (And What to Do About Them)

Texas Medicine Logo

The Journal – December 2010


Tex Med. 2010;106(12):e1. 

By T. Samuel Shomaker, MD, JD

Dr Shomaker, The Jean and Thomas McMullin Dean of Medicine and Vice President for Clinical Affairs, Texas A&M Health Science Center. Send correspondence to T. Samuel Shomaker, MD, JD, 3rd Floor, Health Professions Education Building, 8447 Highway 47, Bryan, TX 77807; e-mail: shomaker@medicine.tamhsc.edu.


Abstract

This article outlines 5 major challenges facing the US physician workforce that are especially important in the context of health care reform but have not been featured in the reform debate. Without assuring that sufficient numbers of the right types of physicians are available, reform efforts may not result in increased access to health care. A review of the relevant literature on the physician workforce shows the following findings: 1. The nation faces a physician shortage; 2. We do not have enough primary care physicians; 3. A major physician maldistribution exists, particularly affecting rural and inner-city urban areas; 4. The lack of physician workforce planning means that the United States will not necessarily produce sufficient numbers of the types of physicians needed by the population; 5. The physician workforce being trained does not reflect the diversity of the population it serves. Policy options for addressing the challenges facing the physician workforce are an important national priority in the context of effective reform of the US health care system.


Introduction 

The US health care system has recently been the topic of intense discussion and debate. The United States is paying too much for health care that does not consistently provide acceptable – let alone outstanding – quality, safety, and outcomes. Although the Patient Protection and Affordable Care Act of 2010 PPACA)1 has now become the law of the land and will visit significant changes upon health care in the United States, one important aspect of the health system not addressed comprehensively by the legislation and scarcely discussed during the extensive national debate surrounding PPACA is the size and composition of the physician workforce. The workforce issue is complex; supply and demand models used to make physician workforce forecasts have numerous variables that interact in multiple ways. Despite the challenging nature of the workforce issue, no health care reform solution can work without addressing whether the nation has enough of the right types of physicians to deliver care to patients. This article presents 5 challenges facing the physician workforce and how the nation could address them:  

  1. The nation faces a physician shortage.
  2. We do not have enough primary care physicians.
  3. A major physician maldistribution problem exists, particularly affecting rural and inner-city urban areas.
  4. The lack of physician workforce planning means that the United States will not necessarily produce sufficient numbers of the types of physicians needed by the population.
  5. The physician workforce being trained does not reflect the diversity of the population it serves.  

The History of the Workforce Debate 

The debate on the physician workforce dates back to the Flexner Report of 1910, which decried the existence of proprietary medical schools that were producing poorly trained physicians. The report led to the closing of many of these schools, and by 1930, the physician-to-population ratio in the United States had fallen to 125 per 100,000.2

Following World War II, the growth and prosperity of the United States caused increased demand for health care. In 1959, the Bane report noted a growing shortage of physicians and predicted a shortage of 40,000 physicians by 1975.3 This report helped spur federal legislation subsidizing the expansion of medical education. By 1980, the number of medical schools had increased from 88 to 126, and annual graduates increased from 7,400 to more than 15,000.4

In 1980, the Graduate Medical Education National Advisory Committee (GMENAC) issued a report predicting a US doctor surplus of 145,000 by the year 2000.5 Based on this report, Congress discontinued federal support for medical student education.

The Council on Graduate Medical Education (COGME), created in 1986 to provide Congress advice on workforce issues, issued a series of reports predicting a physician surplus of 80,000 by 2000.6,7 COGME recommended that the number of US graduate medical education (GME) slots be capped at 110% of the number of US medical graduates and that 50% of those positions be in primary care. Congress responded to the growing concerns of a physician surplus by passing the Balanced Budget Act of 1996, capping the number of federally funded residency slots at 1996 levels.8

Between 1980 and 2005, the number of students graduating from US MD medical schools remained flat at around 15,000, and no new MD degree schools were established.9 As the year 2000 arrived, the consensus that the country was facing a physician surplus was questioned. In 2002, Cooper predicted that the United States would face a shortage of 50,000 physicians by 2010 and 200,000 by 2020.10 The notion of an existing and impending physician shortage has been echoed by many recent reports and articles.11-13

Despite the cap on Medicare reimbursement for new GME positions, the number of first-year residency positions has grown slowly to around 22,000.14 The gap between the number of US graduates and first-year residency slots led to growth in the number of international medical graduates (IMGs). By the late 1990s, IMGs occupied around 25% of first-year residency positions,15 and in subsequent years the percentage of IMGs has remained stable.14

In 2005, approximately 817,000 physicians were engaged in active practice or GME training in the United States, representing 714,000 full-time equivalent (FTE) clinicians. Over the past 20 years, the physician-to-population ratio has grown from 202 to 276 per 100,000.13 This begs the question: what is an ideal ratio? The answer depends on how the health care system is organized. Developing countries typically have fewer physicians (Mexico, 110) as do some countries with nationalized health care (United Kingdom, 201; Canada, 210), but other European countries have far more doctors per capita than the United States (Germany, 326; France, 329; Italy, 405).16 Prepaid group practices, such as Kaiser Permanente and Group Health Cooperative, make do with far fewer physicians than does the fee-for-service sector (from 144 to 176).17 In 2006, more than a third of the active physicians in the United States were older than 55 years, and the number of doctors likely to retire each year will increase from 9000 in 2000 to more than 22,000 per year by 2020.9 Women now account for nearly 50% of graduates and 49% of applicants at US medical schools, but still only 26% of practicing physicians.13 Minority groups account for more than 33% of the nation's population, but Asians (5.7%), blacks (3.3%), Latinos (2.8%), and Native Americans (0.3%) combined constitute only 12.1% of the physician workforce.18


Challenge 1. The nation faces a physician shortage. 

The consensus is that the country will experience a growing shortage of physicians over the next 15 years.9,10,13 Physician supply is projected to increase to 970,000 by 2020, but the rate of population growth in the United States will exceed growth in physician supply after 2015. The shortage is projected to be from 60,000 to 200,000 by the year 202010,11,13 (Figure 1).

The response to the impending shortage is taking many forms. Many state and local governments and universities are pushing for the expansion of existing medical schools or the establishment of new ones. Part of this push has been prompted by the Association of American Medical Colleges (AAMC), which in 2006 challenged the medical education community to increase medical school enrollment 30% by 2015.19 One hundred eight of the 130 US MD medical schools have expanded or plan to expand the size of their classes.20 First-year MD enrollment is up 5% from 2002 and now numbers 17,300 students nationally.20 Most of this growth has resulted from expansion of existing schools, but the Liaison Committee on Medical Education (LCME) has accredited 1 new school, granted preliminary accreditation to 7 schools, accorded 1 school candidate status, and received applications for accreditation from 7 others.21 By 2012, AAMC is projecting first-year enrollment will be 19,500 – 18% above that of 200220(Figure 2).

In addition to allopathic medical school expansion, osteopathic medicine is also undergoing rapid growth, with enrollment expected to double between 2002 and 2015 to around 5200.22 The United States now has 25 colleges of osteopathic medicine; 6 new schools have been founded since 2003, and an additional 4 were founded between 1992 and 2003.23

Another sign of a physician shortage is the growth in foreign medical education programs designed to feed into US GME. The number of IMGs entering training programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) has grown 21% over the past decade. The nearly 29,000 IMGs in ACGME programs represent 27.1% of total trainees.24 Commentators have questioned the nation's continued reliance on imported physician labor on ethical as well as economic grounds, but whether this migration will continue is unknown.25

Despite the impressive growth in US medical school capacity, physician supply will not increase without an expansion of GME.8 In the 10 years since the inception of federal GME funding caps, about 1600 first-year ACGME positions have been added, and total positions have grown by 6000 to 105,000.14,15 Thus, ACGME expansion has not kept pace with the ramping up of medical school production. An estimated 10,000 additional first-year slots would be needed to completely address the predicted physician shortage of 200,000 in 2025.8 Lifting the federal GME funding cap would be the most effective way to increase physician supply.8,9 PPACA does not specifically establish new GME training slots but it does appropriate $125M to federally qualified health centers to expand existing or establish new primary care GME slots. PPACA also redistributes unused, existing federally funded GME slots to states with physician shortages.26 Despite the failure of PPACA to squarely deal with GME, states, teaching hospitals, and medical schools will provide funding for some new slots but are unlikely to underwrite large enough numbers to accommodate the demand from additional US graduates.

Unless the GME bottleneck is resolved, chances are doubtful that the country can significantly increase production of physicians to address the coming shortage. Thus, reliance must be placed on improving the utilization and organization of the existing physician workforce and using other health care providers to a greater extent. Studies show that integrated multispecialty groups are more efficient and deliver better coordinated, less fragmented care.27 However, most physicians are still in solo practice or small groups. Financial incentives for physicians to aggregate into larger groups could improve health care organization and efficiency.27 Incentives to develop an interoperable system of electronic health records would allow the creation of virtual provider networks.27,28 These networks could help coordinate care across providers and reduce duplication and waste. Finally, the greater use of physician assistants and nurse practitioners is a proven strategy for delivering effective care, especially in rural and other underserved environments.13,29 The training pipeline for these health professionals is shorter than that for physicians, and production can be ramped up more quickly and less expensively.


Challenge 2. We do not have enough primary care physicians. 

During the period 1997-2004, the percentage of US graduates entering primary care residencies declined from 53.4% to 35.1%.30 The number of US graduates choosing family medicine residencies declined from 14% in 2000 to 8% in 2005.31 In 2007, three-quarters of graduating internal medicine residents planned to pursue careers as hospitalists and subspecialists, and only 25% elected careers as primary care providers, down from 54% in 1998.32

A number of commentators have characterized declining interest in primary care as a crisis. The American College of Physicians has called for immediate and comprehensive reforms, primarily to reimbursement for primary care services, to avoid "higher costs, greater inefficiency, lower quality, more uninsured persons, and growing patient and physician dissatisfaction."33 The AAMC estimates that the shortage of primary care physicians will amount to around 45,000 by 2025, about one-third of the total doctor shortfall.13

Primary care is the backbone of any health care system. Unfortunately, the United States already ranks poorly compared with other developed nations in the strength of its primary care infrastructure, a factor contributing to the suboptimal outcomes and high costs that characterize our system.34 At least one reason commonly advanced for the alarming trend away from primary care careers is the growing income gap between primary care and specialty care.35 In 2004, the median income for family physicians was $156,000, but $428,000 for invasive cardiologists, $350,000 for hematologists/oncologists, and $407,000 for diagnostic radiologists (Table [PDF]). With students graduating with a median debt of $120,000 at public medical schools and $160,000 at private schools, the prospects of a primary care practice with a large panel of patients and extensive after-hours responsibilities is not attractive when one can substitute a specialty practice with more regular hours and a higher income.35

PPACA provides the secretary of Health and Human Services the authority to revise the Medicare payment schedule to correct misvalued physician services. In addition, the legislation provides a 10% increase in primary care payments for 5 years and increases Medicaid payments to Medicare levels for 2 years.36 However, these modest reimbursement changes are unlikely to serve as a powerful inducement to primary care careers.

Finally, PPACA creates a mechanism to pilot delivery system innovations, such as the patient-centered medical home,37 that emphasize primary care. In this paradigm, primary care doctors serve as the focal point for coordinating a patient's medical care, providing primary and preventive services and making and coordinating referrals to specialists.38 This model provides reimbursement for episodic direct patient care services and also an ongoing payment for the coordination of care.


Challenge 3. A major physician maldistribution problem exists, particularly affecting rural and inner-city urban areas. 

Historically, attracting physicians to practices in rural and inner-city areas has proven difficult. While 20% of the US population lives in rural areas, only 9% of physicians practice in those areas.39 This problem is especially acute in states that have an existing shortage of physicians or that are especially remote or rural in character. Across the United States, primary care doctors are less numerous in rural areas, with a distribution of 55 per 100,000 versus 93 per 100,000 in urban areas.13

The trend toward urban concentration of physicians shows no sign of abating. The 2007 AAMC Graduation Questionnaire revealed that only 2.9% of graduating US senior medical students intended to locate their practices in rural areas.39 The federal government currently provides a 10% incentive payment over the Medicare fee schedule for services provided in rural and inner-city health professional shortage areas, but this has not served as a potent spur to physician redistribution.40

Significant research has been conducted on the factors that influence whether physicians practice in rural or underserved areas. Growing up in a rural community is the most important independent predictor of rural practice (29% of individuals in rural practice), while an expressed plan for a family medicine career also plays a positive role. If both characteristics are present, the likelihood of rural practice is 36% versus 7% when neither characteristic is present.41 Another well-known correlation is that students from underrepresented groups are more likely to practice in underserved areas.42,43 Programs to support the medical career aspirations of students from underrepresented backgrounds are an important strategy in caring for our underserved populations, both in urban inner-city and rural areas.43,44

Curricular experiences also have an impact on commitment to serve the underserved.39 The most effective programs provide long-term exposure to rural or inner-city practice sites rather than short rotations or electives.40 The University of California, Los Angeles, Charles R. Drew University program admits a cohort of 24 students, who do 2 years at UCLA but then go to South Central Los Angeles, one of the poorest communities in California, for their clinical training. Drew students are more likely to report an intention to practice in underserved areas before matriculation and to maintain that orientation through their medical education compared with other UCLA students.45 Another model program is the Physician Shortage Area Program of Jefferson Medical College, which admits 15 students per year into a special program designed to encourage selectees to set up practices in rural Pennsylvania. The program has trained 12% of all physicians practicing in rural areas of the state.46

Another successful strategy is scholarship or loan forgiveness in return for service in underserved areas. For example, the National Health Service Corps (NHSC) supplies funding for scholarships or loan forgiveness for primary care providers in exchange for service in underserved communities. Many states also have similar loan forgiveness programs.47 In general, these programs work to temporarily increase providers in shortage areas, but their long-term retention rates are only around 25%.48 PPACA reauthorizes NHSC and increases its funding by $1.5 billion over the next 5 years.49


Challenge 4. The lack of physician workforce planning means that the United States will not necessarily produce sufficient numbers of the types of physicians needed by the population. 

The Flexner Report of 1910 was an early example of de facto workforce planning that had a significant impact on the workforce through its condemnation of proprietary medical education. Since that time, several attempts have been made to move toward national workforce planning, most notably the COGME reports of the mid-80s calling for implementation of the 110% rule that would have restricted the number of GME slots to 110% of US medical school graduates and that sought to mandate a 50/50 distribution between primary and specialty care slots.6

Under the best of conditions, trying to estimate how many physicians will be needed to care for our population in future years is difficult, but many have urged that some efforts to shape the national physician workforce are needed to address the health system's problems, such as the primary care shortage and the uneven distribution of doctors.50 A recent report by the Association of Academic Health Centers criticized the lack of federal workforce planning as a significant public health problem.51

Historically, workforce planning efforts have been decentralized and fragmented.51,52 The Health Resources and Services Administration maintains 4 committees, including COGME, that provide advice to the federal government on workforce issues, but none has a comprehensive, integrated role in recommending policy. However, Congress does indirectly influence how many physicians are being trained through the Medicare GME budget, as well as the budgets of the Veterans Administration and the Department of Defense, both of which are major sponsors of GME.8 However, the specialty mix of physicians ultimately being trained is driven more by the internal priorities of the teaching hospitals sponsoring GME training than by regional or national workforce needs.

In the past, given the lack of federal workforce policy, states have had a primary role in planning workforce. However, in most states, planning is fragmented among different entities, and coordinated efforts are difficult or nonexistent. Furthermore, no planning of workforce occurs across state lines.

The lack of workforce planning was recognized as an issue in PPACA. The legislation creates a grant program for states seeking to improve their workforce planning efforts. In addition, a new National Health Workforce Commission is being created to advise Congress on health care workforce issues, and national and regional workforce centers are also established under the bill.53


Challenge 5. The physician workforce being trained does not reflect the population it serves. 

Creating a physician workforce that reflects the society it serves has long been a goal of AAMC and American medical schools.19,54 This is important for a number of reasons. Studies have shown repeatedly that physicians from underrepresented groups disproportionally practice in underserved areas, taking care of the most vulnerable patient populations.42,43 The AAMC Matriculating Student Questionnaire revealed that 45% of black, 50% of Native American, and 32% of Hispanic matriculating students planned a practice in underserved areas versus only 19% of Caucasian students.18 In addition, minority patients tend to prefer receiving care from physicians of the same ethnic or racial background.55

Furthermore, medical schools with racially, economically, and ethnically diverse classes provide a rich educational environment where students can learn to effectively serve all segments of society.54,56 The notion of cultural competency as a critical component of medical education is now reflected in LCME accreditation standards,57 but it is also critical to a well-functioning health care system as all physicians, regardless of racial or ethnic background, take care of patients from other races.56

The composition of the US population is undergoing rapid and profound change. Minority groups now account for slightly more than 33% of the nation's population. In 2025, the US population will consist of 335 million people, of whom 38%, or 126 million, will be minorities. Despite these major shifts in demography, progress toward physician workforce diversity has been frustratingly slow. The physician workforce remains predominantly white and middle to upper class. During the period 1977-2007, medical school applications from non-Asian minorities increased only from 3400 to 6200; from 1995 to 2007, the number of these graduates increased only by around 500, from 1844 to 2400.18 Despite pursuing an aggressive approach to increasing medical school diversity through the 1990s, the AAMC 3000 by 2000 program fell well short of its target of graduating 3000 underrepresented minorities by the year 2000.18

Minority students combined only represent approximately 14% of matriculants (black, 6.4%; Hispanic, 7.2%; and Native American, 0.3%), and the number of students from these groups has been flat or even declined since 200017(Figure 3). Finally, the economic diversity of medical school classes is, if anything, regressing. Sixty percent of medical students are from families in the upper 20% of income, while only 20% come from the bottom 60%.58 The climbing tuition and average indebtedness at medical schools across the nation give rise to legitimate concern that students from the lower socioeconomic strata are being priced out of careers in medicine.

Why not more progress? Many reasons may be offered for the current state of affairs. Legal challenges to affirmative action programs in the 1990s had a chilling effect on minority admissions. However, the legal climate has improved recently, and the Supreme Court has sanctioned the use of various noncognitive factors in admissions, including race and ethnicity, to create a diverse medical school class.59

However, even with the legal climate more tolerant, the fundamental problem is that not enough minority students are being prepared to take on the challenges of medical school. Minority students are lost to the educational pipeline early due to poor schools in minority communities, challenging social situations, poverty, and the lack of physician role models. The Health Professions Partnership Program (HPPI) was created in 1996 to link US health professions schools with neighboring colleges and secondary school systems with a goal of improving curricula to better prepare underrepresented minority students for careers in health fields. The key findings of HPPI were that effective programs must start early in the educational continuum and persist through all levels of education, that the most effective programs worked with teachers and school districts, not just with individual students, and that improving educational programs requires significant resources, commitment, and time.60

Postbaccalaureate programs that help minority students improve science and study skills and prepare them for medical school have also proven effective.61 Scholarships and financial aid programs are also important in helping underrepresented minority students aspire to careers in medicine.18 Finally, focused curricula that expose students to practice in underserved communities, as described earlier, have been shown to improve the number of students willing to work in these communities long term.45,46

PPACA notes the lack of diversity in the physician workforce and calls for monitoring workforce diversity. The legislation reauthorizes Titles VII and VIII of the Public Health Services Act, which has historically been important in establishing programs to support increasing diversity in the health care workforce. It also provides funding for additional scholarship and loan forgiveness programs in Title VII under a new section entitled "Health Professionals Training for Diversity." However, PPACA stops short of establishing a national strategy for improving diversity in the physician and health care workforce.62


Conclusion 

The recent debate surrounding the passage of PPACA highlights the central role physicians play in the health care system and the important role they will play under health system reform. Health system reform will not be successful without the active engagement of the nation's doctors. The advent of 34 million newly insured patients will stretch the health care system and its doctors to the limit. The nation's medical schools, residency training programs, and physician organizations must accelerate efforts to prepare the physician workforce necessary to the task at hand. The 5 challenges facing that workforce today are difficult, but in each area, progress is being made by committed groups of people and organizations. These efforts provide examples of best practices that are working. As a profession, we must embrace these challenges and overcome them so that medicine can be part of the solution, not part of the problem.


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Dec 10 TM Shomaker Fig 1

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Dec 10 Shomaker Fig 2

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Dec 10 Shomaker Fig 3

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