Medicine as a Career

A new major debate is developing over the issue of physician surplus. It was fueled by a report by a commission of health care policy experts funded by the Pew Foundation. The commission recommended that 20% of the nation's medical schools be closed by the year 2005. It warned of a surplus of 100,000 to 150,000 physicians in the next century, and urged closing some schools as the best way to solve the problem, although it did not identify which schools should be shut down.

The conclusion by the Pew commission that there will be a surplus of physicians is consistent with the earlier findings of other organizations and the GEMENAC report discussed above. Not surprisingly, there has been a cool reaction by those in academic medicine to the recommendation that schools be closed. They advocate two other courses of possible action, namely downsizing schools and limiting access to graduate training by foreign graduates. Currently, U.S. schools graduate about 17,000 physicians a year, but there are 24,000 first-year graduate positions available. The 7,000 extra spaces are filled by foreign medical graduates. The commission did recommend that graduate medical training be capped at 110% of U.S. medical graduates. Some educators believe that solving the foreign graduate problem by itself will resolve the issue and downsizing will be unnecessary. This is because they feel that once this number is down, the marketplace will in a natural way readjust the specialist-to-generalist ratio and uneven geographic distribution of physicians, this eliminating surplus physicians.

One major element strongly impacts upon the issue of physician surplus, namely managed care. Since the number of specialists will be reduced under managed care, more physicians will enter primary care, altering our health care system's infrastructure more rapidly than expected.

More recently a total contradictory view on physician supply has emerged, suggesting that there may be a physician shortage by the beginning of the next decade. The rationale behind this suggestion is that (1) the current population of physicians is aging; (2) the workload for residents is diminishing, generating a need for more of them; (3) there is a markedly increased number of female physicians with a prospective decrease in lifetime work; and (4) the professional activity work schedule of physicians is dminishing, but the need for medical services is increasing. While these considerations are resonable, a physician shortage may nevertheless fail to materialize. This would be comparable to the surplus that did not take place toward the end of the twentieth century as originally predicted.

The current serious difficulty in assessing the future need for physicians is clearly evident by the highly conflicting reports published in recent times. On one hand, the Council on Graduate Medical Education (CGME) called for more medical schools to help stem what it believes is a looming physician shortage. This is a reversal of its prior policy. The CGME has called for a 15% increase in the number of medical school graduates. The impetus for this decision was a report by the Center for Health Workforce Studies at the State University of New York at Albany. The council predicted an 85,000 physician shortfall by 2020 at current rates.

On the other hand, the General Accounting Office (GAO) has come to a completely opposite conclusion. In the study of the nation's physicians' work force, the GAO found that physician numbers grew at twice the rate of the general population in the decade between 1991 and 2001. Comparing data from the AMA and the AOA against the U.S. Census Bureau figures, the GAO determined that all of the nation's statewide and ruralareas and all but 17 metropolitan areas gained physicians per 100,000 people. Moreover, of those 17 cities, only two saw a decline in the total number of physicians, while the large remainder gained physicians, albeit below the general rate of increase. In addition, it was found that the ratio of generalist to specialist remained about one-third to two-thirds during this ten-year interlude. Also, the disparity in the distribution of physicians between urban and rural areas, while narrowed, still exists.

It is clear that the present decade is an era of change and uncertainty; it will take time till this situation becomes clarified. The current debate reinforces the conclusion noted above that prospective physicians must be strongly committed, need to show flexibility and openmindedness, and above all stay informed.