Physician
Workforce Policy Guidelines for the United States, 2000-2020
Sixteenth Report
January 2005
Table of Contents
(for
on-line viewing only) Entire Report in Adobe .pdf
The
Council on Graduate Medical Education
Members
of the Council on Graduate Medical Education
Preface
Summary
and Recommendations
Key Findings
Recommendations
Related Issues of Concern
Background
Supply
of Physicians, 2000-2020
Overview of
Methodology: Baseline Model and Factors Affecting Future Supply
New Entrants
Women in Medicine
Aging of the Physician Workforce
Separation From the the Physician Workforce
Specialty Distribution and Choices
Activity Rates
Alternative
Supply Scenarios and Assumptions
Alternative
Scenario One: Lifestyle Changes
Sensitivity
Analysis: Alternative Scenario One
Alternative
Scenario Two: Productivity Changes
Sensitivity
Analysis: Alternative Scenario Two
Alternative
Scenario Three: Hybrid Lifestyle/Productivity Changes
Sensitivity
Analysis: Alternative Scenario Three
Conclusions:
Supply of Physicians in the U.S., 2000-2020
Future
Demand for Physicians, 2000-2020
Overview of
Methodology: Baseline Model and Factors Affecting Future Demand
Alternative Demand
Scenarios and Assumptions
Alternative
Scenario One: Economic Factor
Sensitivity
Analysis: Alternative Scenario One
Alternative
Scenario Two: Changes in Age-Specific Utilization Rates
Sensitivity
Analysis: Alternative Scenario Two
Alternative
Scenario Three: Elimination of Unnecessary Services/Increased
Utilization Review
Sensitivity
Analysis: Alternative Scenario Three
Alternative
Scenarios Four and Five: Hybrid Models—Economic Expansion
and Unnecessary Services/Increased Utilization Review; Changes
in Age-Specific Utilization Rates and Unnecessary Services/Increased
Utilization Review
Conclusions:
Demand for Physicians in the U.S., 2000-2020
Future
Need for Physicians, 2000-2020
Overview of
Methodology: Baseline Model and Factors Affecting Future Need
Alternative Need
Scenarios and Assumptions
Alternative
Scenario One: Changes in Age-Specific Utilization Rates
Sensitivity
Analysis: Alternative Scenario One
Alternative
Scenario Two: Elimination of Unnecessary Services/Increased Utilization
Review
Sensitivity
Analysis: Alternative Scenario Two
Alternative
Scenario Three: Changes in Age-Specific Utilization Rates; Unnecessary
Services/Increased Utilization Review Hybrid
Sensitivity
Analysis: Alternative Scenario Three
Conclusions:
Need for Physicians in the U.S., 2000-2020
Physician
Supply, Demand, and Need, 2000-2020: Specialty Mix Issues
Supply of Generalist
and Non-Generalist Physicians: Baseline Projections
Supply Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Mix
Supply Specialty
Mix Alternative Scenario Two: Generalist-Weighted Mix
Demand for Generalist
and Non-Generalist Physicians: Baseline Projections
Demand Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Demand Mix
Demand Specialty Mix Alternative Scenario Two: Generalist-Weighted
Mix
Need for Generalist
and Non-Generalist Physicians
Need Specialty
Mix Alternative Scenario One: Non-Generalist Dominant Need Mix
Need Specialty Mix Alternative Scenario Two: Generalist-Weighted
Mix
Issues
Beyond the Models
Resident and
Fellow Work-Hour Restrictions
Non-Physician Clinicians (NPCs)
Boutique Medicine
Conclusions:
Physician Supply, Demand, and Need in the U.S., 2000-2020
Supply
Demand
Need
Summary
References
Tables
and Figures
Table
1. Supply of Physicians in the U.S., 2000-2020: Baseline Projections
Table
2. Projected Number of New Entrants Into the Physician Supply, 2000-2020
Table
3. FTE-to-Physician Ratio, 2000-2020
Table
4. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections: Physician Lifestyle Changes
Table
5. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections of Physician Lifestyle Changes: Sensitivity Analysis
Table
6. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Physician Productivity Increases
Table
7. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections of Physician Productivity Increases: Sensitivity Analysis
Table
8. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Hybrid Lifestyle/Productivity Changes
Table
9. Supply of Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections of Hybrid Lifestyle/Productivity Changes: Sensitivity
Analysis
Table
10. Demand for Physicians in the U.S., 2000-2020: Baseline Projections
Table
11. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections: Economic Factor
Table
12. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections of Economic Factor: Sensitivity Analysis
Table
13. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Changes in Utilization Rates
Table
14. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections of Changes in Utilization Rates: Sensitivity Analysis
Table
15. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Reduction of Unnecessary Services
Table
16. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections of Reduction of Unnecessary Services: Sensitivity
Analysis
Table
17. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Four Projections: Economic Factor/Increased Utilization Review
Table
18. Demand for Physicians in the U.S., 2000-2020, Alternative Scenario
Five Projections: Changes in Utilization Rates/Increased Utilization
Review
Table
19. Need for Physicians in the U.S., 2000-2020: Baseline Projections
Table
20. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections: Changes in Utilization Rates
Table
21. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
One Projections of Changes in Utilization Rates: Sensitivity Analysis
Table
22. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Reduction of Unnecessary Services
Table
23. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Two Projections: Sensitivity Analysis
Table
24. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Changes in Utilization Rates/Increased Utilization
Review
Table
25. Need for Physicians in the U.S., 2000-2020, Alternative Scenario
Three Projections: Sensitivity Analysis
Table
26. Supply of Physicians in the U.S., 2000-2020: Baseline Specialty
Projections
Table
27. Supply of Physicians in the U.S., 2000-2020, Specialty Projections:
30% Generalist/70% Non-Generalist Scenario
Table
28. Supply of Physicians in the U.S., 2000-2020, Specialty Projections:
45% Generalist/55% Non-Generalist Scenario
Table
29. Demand for Physicians in the U.S., 2000-2020, Baseline Specialty
Projections
Table
30. Demand for Physicians in the U.S., 2000-2020, Specialty Projections:
30% Generalist/70% Non-Generalist Scenario
Table
31. Demand for Physicians in the U.S., 2000-2020, Specialty Projections:
45% Generalist/55% Non-Generalist Scenario
Table
32. Need for Physicians in the U.S., 2000-2020: Baseline Specialty
Projections
Table
33. Need for Physicians in the U.S., 2000-2020, Specialty Projections:
30% Generalist/70% Non-Generalist Scenario
Table
34. Need for Physicians in the U.S., 2000-2020, Specialty Projections:
45% Generalist/55% Non-Generalist Scenario
Figure
1. Total Number of Allopathic and Osteopathic Graduates, 1980-2020
Figure
2. Change in Medical Students, Population, and Students per Population,
1980-2020
Figure
3. Age Distribution of Active Allopathic Physicians in the U.S., 1982
and 2001
Figure
4. PDM Population/Delivery Setting Matrix (Simplified)
Figure
5. Relationship Between Active Physician Supply and GDP, 1929-2000
Figure
6. Number of Americans 65 and Over and 85 and Over, 2000-2030
Figure
7. Days of Care in Short-Stay Hospitals, 1999
Figure
8. Estimates of Ambulatory Care Visits to Physician Offices and Clinics
1980, 1990, and 2000
Figure
9. Physician Supply, Demand, and Need in the U.S., 2020
The
Council on Graduate Medical Education
The Council on
Graduate Medical Education (COGME) was first authorized by Congress
in 1986 to provide an ongoing assessment of physician workforce trends,
training issues, and financing policies and to recommend appropriate
Federal and private-sector efforts to address identified needs. The
legislation calls for COGME to advise and make recommendations to
the Secretary of the Department of Health and Human Services (DHHS);
the Senate Committee on Health, Education, Labor, and Pensions; and
the House of Representatives Committee on Commerce. Section 219 of
the Department of Labor, Health and Human Services, and Education
and Related Agencies’ Appropriations Act, 2004, Public Law 102-394,
106 Stat. 1825, resulted in the Secretary of DHHS extending COGME
through the end of the fiscal year.
The legislation
specifies 17 members for the Council. Appointed individuals are to
include representatives of practicing primary care physicians, national
and specialty physician organizations, international medical graduates,
medical student and house staff associations, schools of medicine
and osteopathy, public and private teaching hospitals, health insurers,
business, and labor. Federal representation includes the Assistant
Secretary for Health, DHHS; the Administrator of the Centers for Medicare
and Medicaid Services, DHHS; and the Chief Medical Director of the
Veterans Administration.
CHARGE
TO THE COUNCIL
The charge to
COGME is broader than the name would imply. Title VII of the Public
Health Service Act, as amended, requires COGME to provide advice and
recommendations to the Secretary of DHHS and Congress on the following
issues:
- The supply
and distribution of physicians in the United States;
- Current and
future shortages or excesses of physicians in medical and surgical
specialties and subspecialties;
- Issues relating
to international medical school graduates;
- Appropriate
Federal policies with respect to the matters specified in items
1-3, including policies concerning changes in the financing of undergraduate
and graduate medical education (GME) programs and changes in the
types of medical education training in GME programs;
- Appropriate
efforts to be carried out by hospitals, schools of medicine, schools
of osteopathy, and accrediting bodies with respect to the matters
specified in items 1-3, including efforts for changes in undergraduate
and GME programs; and
- Deficiencies
and needs for improvement in databases concerning the supply and
distribution of, and postgraduate training programs for, physicians
in the United States and steps that should be taken to eliminate
those deficiencies.
In addition, the
Council is to encourage entities providing GME to conduct activities
to achieve voluntarily the recommendations of the Council specified
in item 5.
COGME
PUBLICATIONS
Since its establishment,
COGME has submitted the following reports to the Secretary of DHHS
and Congress:
Reports
- First Report
of the Council (1988);
- Second Report:
The Financial Status of Teaching Hospitals and the Underrepresentation
of Minorities in Medicine (1990);
- Third Report:
Improving Access to Health Care Through Physician Workforce Reform:
Directions for the 21st Century (1992);
- Fourth Report:
Recommendations to Improve Access to Health Care Through Physician
Workforce Reform (1994);
- Fifth Report:
Women and Medicine (1995);
- Sixth Report:
Managed Health Care: Implications for the Physician Workforce and
Medical Education (1995);
- Seventh Report:
Physician Workforce Funding Recommendations for Department of Health
and Human Services’ Programs (1995);
- Eighth Report:
Patient Care Physician Supply and Requirements: Testing COGME Recommendations
(1996);
- Ninth Report:
Graduate Medical Education Consortia: Changing the Governance of
Graduate Medical Education to Achieve Physician Workforce Objectives
(1997);
- Tenth Report:
Physician Distribution and Health Care Challenges in Rural and InnerCity
Areas (1998);
- Eleventh Report:
International Medical Graduates, The Physician Workforce and GME
Payment Reform (1998);
- Twelfth Report:
Minorities in Medicine (1998);
- Thirteenth
Report: Physician Education for a Changing Health Care Environment
(1999);
- Fourteenth
Report: COGME Physician Workforce Policies: Recent Developments
and Remaining Challenges in Meeting National Goals (1999); and
- Fifteenth Report:
Financing Graduate Medical Education in a Changing Health Care Environment
(2000).
OTHER
COGME PUBLICATIONS
- Scholar in
Residence Report: Reform in Medical Education and Medical Education
in the Ambulatory Setting (1991);
- Process by
which International Medical Graduates are Licensed to Practice in
the United States (September 1995);
- Proceeding
of the GME Financing Stakeholders Meeting (April 11, 2001) Bethesda,
Maryland;
- Public Response
to COGME’s Fifteenth Report (September 2001);
- Council on
Graduate Medical Education & National Advisory Council on Nurse
Education and Practice: Collaborative Education to Ensure Patient
Safety (February 2001);
- Council on
Graduate Medical Education: What is it? What has it done? Where
is it going? 2nd Edition (2001); and
- 2002 Summary
Report (2002).
COGME
RESOURCE PAPERS
- Preparing Learners
for Practice in a Managed Care Environment (1997);
- International
Medical Graduates: Immigration Law and Policy and the U.S. Physician
Workforce (1998);
- The Effects
of the Balanced Budget Act of 1997 on Graduate Medical Education
(2000);
- Update on the
Physician Workforce (2000);
- Evaluation
of Specialty Physician Workforce Methodologies (2000); and
- State and Managed
Care Support for Graduate Medical Education: Innovations and Implications
for Federal Policy (2004).
For more information
on COGME, visit the Council’s Web site at:
http://www.cogme.gov or contact:
Council on Graduate
Medical Education
5600 Fishers Lane, Room 9A-21
Rockville, MD 20857
Voice: (301) 443-6785
Fax: (301) 443-8890
Members
of the Council on Graduate Medical Education
Members
Chair
Carl J. Getto,
M.D.
Senior Vice President Medical Staff Affairs/Associate
Dean Hospital Affairs
University of Wisconsin Hospital & Clinics
Madison, Wisconsin
Vice
Chair
Robert L. Johnson,
M.D., Professor of Pediatrics and
Vice Chair, Department of Pediatrics
New Jersey Medical School
Division of Adolescent and Young Adult Medicine
Newark, New Jersey
Ms. Laurinda L.
Calongne
President
Robert Rose Consulting
Baton Rouge, Louisiana
William Ching,
Medical Student
New York University School of Medicine
New York, New York
Allen Irwin Hyman,
M.D., FCCM
Executive Vice President and Chief of Staff
Columbia-Presbyterian Medical Center
New York, New York
Rebecca M. Minter,
M.D.
VAMC Ann Arbor Healthcare System
Surgery Service
Ann Arbor, Michigan
Lucy Montalvo,
M.D., M.P.H.
San Diego, California
Angela D. Nossett,
M.D.
Executive Vice President
Committee of Interns and Residents (CIR)
Wilmington Family Health Center
Wilmington, California
Earl J. Reisdorff,
M.D.
Director of Medical Education
Ingham Regional Medical Center
Department of Medical Education
Lansing, Michigan
Russell G. Robertson,
M.D.
Department of Family and Community Medicine
Medical College of Wisconsin
Milwaukee, Wisconsin
Jerry Alan Royer,
M.D., M.B.A.
229 Cascade Falls Drive
Folsom, California
Susan Schooley,
M.D.
Chair, Department of Family Practice
Henry Ford Health System
Detroit, Michigan
Humphrey Taylor,
Chairman
The Harris Poll, Harris Interactive
New York, New York
Douglas L. Wood,
D.O., Ph.D., President
American Association of Colleges
of Osteopathic Medicine
Chevy Chase, Maryland
Statutory Members
Cristina Beato,
M.D.
Acting Assistant Secretary for Health
and Surgeon General
Washington, D.C.
Mark B. McClellan,
M.D., Ph.D.
Administrator, Centers for Medicare and
Medicaid Services
Department of Health and Human Services
Washington, D.C.
Robert H. Roswell,
M.D.
Undersecretary for Health
Veterans Health Administration
Department of Veterans Affairs
Washington, D.C.
Designee of
the Acting Assistant Secretary for Health
Howard Zucker,
M.D., Deputy Assistant
Secretary for Health
Department of Health and Human Services
Washington, D.C.
Designee of
the Centers for Medicare and Medicaid Services
Tzvi M. Hefter,
Director
Division of Acute Care
Centers for Medicare and Medicaid Services
Baltimore, Maryland
Designee of
the Department of Veterans Affairs
Stephanie H. Pincus,
M.D., M.B.A.
Chief Academic Affiliations Officer
Department of Veterans Affairs
Washington, D.C.
Staff, Division
of Medicine and Dentistry,
Bureau of Health Professions, HRSA
Department of Health and Human Services
Rockville, Maryland
Tanya Pagán
Raggio, M.D., M.P.H.
Executive Secretary and
Director, Division of Medicine and Dentistry (DMD)
O’Neal Walker,
Ph.D.
Chief, Dental and Special Projects Branch/DMD
Jerald M. Katzoff
Deputy Executive Secretary
C. Howard Davis,
Ph.D.
Staff Liaison
Jaime Nguyen,
M.D., M.P.H.
Staff Liaison
Eva M. Stone
Program Analyst and Committee Management Specialist
Anne Patterson
Secretary
Contractor for
Report Preparation: Edward Salsberg and Gaetano Forte
The Center for Health Workforce Studies
State University of New York at Albany
Preface
A central charge
of the Council on Graduate Medical Education (COGME) is to make policy
recommendations to the Nation with respect to the adequacy of the
supply and distribution of physicians in the United States (U.S.).
This mandate includes recommendations on current and future shortages
or excesses of physicians in the medical and surgical specialties
and subspecialties. Beginning in 1992, with its Third Report,
COGME issued a series of reports expressing concern with potential
surpluses of physicians and recommending an increase in the percent
of physicians trained and practicing as generalists. These concerns
led the Council to develop a recommendation that 110 percent of the
number of U.S. medical graduates in 1993 should enter residency training
each year (or about 19,750 physicians) and that half of these physicians
should be generalists. This recommendation became known as the “110/50-50”
goal for the physician workforce in the U.S.
In response to
changes in the health care delivery system, demographic changes in
the Nation’s population, changes in the practice of medicine,
and other developments, the Council concluded in 2002 that it was
appropriate and timely to re-assess the current and future supply,
demand, and need for physician services in America. The following
report is the result of this most recent re-assessment. In light of
limited resources, this study primarily used existing models to forecast
physician supply and demand, but also used more current data unavailable
for prior assessments.
The Nation’s
physician workforce is critical to the delivery of health care to
Americans. In consideration of this role and the high cost of educating
and training the physician workforce, ongoing tracking of workforce
needs and periodic comprehensive assessments are essential to guiding
decisions by the medical education community, prospective physicians,
policy makers, and others concerned with Americans’ health. The
Council hopes that this report will provide this guidance.
Summary
and Recommendations
The Council on
Graduate Medical Education (COGME) assessed the likely future supply,
demand, and need for physicians in the United States (U.S.) through
2020 for both generalist and non-generalist physicians. The models
used for the projections are based on historical patterns of use of
services and physician practice patterns applied to the expected U.S.
population and the physician workforce through 2020. Where changes
are occurring or have occurred in the historic patterns, this report
incorporates the best available information and discusses their likely
implications. The models used build on the physician forecasting models
of the Health Resources and Services Administration (HRSA)/Bureau
of Health Professions (BHPr).1 The use of these models
helps to ensure some consistency with prior work and facilitates comparisons
of the new forecasts with prior forecasts.
Scenarios have
been constructed around the best understanding of changes occurring
in health care and in medicine. For each scenario, the report presents
a sensitivity analysis indicating what the impact might be if that
factor were to change to a lesser or greater extent than current understanding
portends.
The report forecasts
future supply based on the age, gender, specialty distribution,
and educational background of the existing supply and current trends
in new entrants into residency training from U.S. allopathic and osteopathic
schools, from Canadian medical schools, and from foreign medical schools.
The report also forecasts future demand and need for
physician services based on the historical patterns of use of services
by age, gender, insurance status, type of area (urban or rural), and
managed care penetration. Estimates of future need are based primarily
on the assumption that the use of physician services by the uninsured
would increase to the level of those with health insurance if resources
were available to meet their needs. It is also assumed that the removal
of other barriers to use would also contribute to some increase in
service use. Further, the report presents an analysis of supply, demand,
and need for generalist and non-generalist specialties.2
This report includes
the results of the data analysis and describes methodologies used
to forecast supply, demand, and need and the potential impact of changes
in the factors that influence each of those. The report also includes
recommendations to better assure that the future supply meets future
demand and need.
KEY
FINDINGS
- Under current
production and practice patterns, the supply of practicing
physicians in the U.S. is expected to rise from 781,200 full-time
equivalent (FTE) physicians3 in 2000 to 971,800 in 2020,
a 24 percent increase. However, growth is expected to slow considerably
after 2010, reflecting increased rates of physician separation due
to the aging of the current physician workforce and the relatively
level annual number of new physician entrants since 1980. After
2015, the rate of population growth will exceed the rate of growth
in the number of physicians. The per capita number of physicians
is forecasted to rise from 283 per 100,000 Americans in 2000 to
301 in 2015 but then drop to 298 in 2020. Under alternative assumptions
regarding physician lifestyle changes (such as hours worked) and
increased productivity, the effective supply of physicians (FTEs)
may grow to nearly 1.08 million physicians in 2020. The most probable
aggregate projection suggests that the supply of physicians will
number approximately 1.02 million FTEs in 2020.
- At the same
time, for a number of reasons and under a number of scenarios and
models, the demand for physicians is likely to grow
even more rapidly over this period than the supply. It is likely
that the demand for physician services will grow to between 1.03
million and 1.24 million physicians in 2020. The three major factors
driving the increase in demand will be: a) the projected U.S. population
growth of 50 million persons (18 percent) between 2000 and 2020;
b) the aging of the population, as the number of Americans over
65 increases from 35 million in 2000 to 54 million in 2020; and
c) the changing age-specific per capita physician utilization rates,
with those under age 45 using fewer services and those over age
45 using more services.
- The need
for services, reflecting primarily the use of services under universal
insurance and increased utilization review processes, is also expected
to increase over the period. Need is projected to grow to between
1.09 and 1.17 million physicians in 2020.
- If the Nation’s
population continues to use services in the future as it has in
the past, and if physicians practice in the future as they have
in the past, then the Nation is likely to face a shortage of physicians
in the coming years.
- When
the midpoint of the projected range of future supply and demand
is used, the Nation is projected to face a shortage of about 85,000
physicians in 2020.
- When
the midpoint of the projected range of supply and need is used,
the Nation is projected to face a shortage of about 96,000 physicians
in 2020.
- The models
and alternative scenarios used to make the predictions included
a number of factors that could have a major impact on supply, demand,
and need and, consequently, on a potential gap in the physician
supply.
- Many
of these factors are likely to add to the shortage of physicians.
Some of these have been included in the report as scenarios
that could have an impact on the supply or demand for physicians.
These include the following:
- Changing
lifestyles for the newest generation of physicians, with
the possibility that new physicians will work fewer hours
than their predecessors;
- Continuation
of the rate of increase in the use of physician services
by those over 45, which has been increasing for the past
20 years, and increased use of services by the baby-boom
generation compared to prior generations; and
- Expected
increases in the Nation’s wealth that would contribute
to continued increases in the use of medical services.
Other
factors could also lead to larger shortages and are not
included in the baseline projections or alternative scenarios.
These include the following:
- A
potential increase in non-patient care activities by physicians,
including research and administrative activities;
- A potential
change in practice patterns for physicians over 50, including
a reduction in hours worked before retirement and earlier
retirement patterns;
- Possible
increases in departures from practice due to liability concerns
of physicians;
- Decreases
in hours worked by physicians in training;
- Possible
decreases in immigration of graduates of foreign medical
schools;
- Possible
increases in the number of physicians limiting the number
of patients on their panel (sometimes referred to as “boutique
medicine”);
- Advances
in genetic testing that could lead to increases in the use
of services as individuals learn they are at risk for certain
illnesses or conditions; and
- Additional
medical advances likely to keep individuals with chronic
illnesses alive longer without curing their illnesses.
- A
number of factors also may limit future shortages. These include
factors for which estimates of their impact are presented in the
report under different scenarios. These include the following:
- Increases
in productivity, such as through improved technologies and
information systems; and
- More
effective utilization review and quality assurance efforts
to weed out inappropriate or unnecessary services.
Other factors
not included in the supply, demand, and need projections
with the potential to reduce projected shortages include the following:
- Increases
in the supply and use of nurse practitioners, physician assistants,
and other non-physician clinicians;
- Increases
in costs and cost sharing; and
- Medical
breakthroughs that decrease service use.
- There
are already a growing number of reports of, and concerns with, shortages
in specific specialties. These include such specialties as radiology
(Sunshine 2001), anesthesiology (Schubert et al 2001; Miller and
Lanier 2001; Schubert et al 2003), cardiology (Foot et al 2000),
rheumatology (Boyce 2003), nephrology (Neilson et al 2001), pulmonary
disease/critical care (Angus et al 2000; Pronovost et al 2002),
and child psychiatry (Kim et al 2001).
- Although the
percentage of the Nation’s physicians who are generalists has
increased slightly over the past decade, it is currently about 38
percent, well below the 50 percent target recommended in COGME’s
Third Report. Even in the Kaiser Health Plans, only about
40 percent of their physicians in 2001 and 2002 (Weiner 2004) were
generalists. Results of surveys of new physicians completing training
in New York and California indicate that demand for generalists
is less than demand for most non-generalists, further weakening
the case for the 50 percent generalist goal (Nolan et al 2003a,
2003b).
RECOMMENDATIONS
Preamble
The State
of the Nation’s health care workforce directly affects both the
health of the American public and the economics of health care. It
is not our intent to codify or explicitly endorse the current health
care system. Given the constraints and confines of the available data,
these recommendations are a feasible and realistic approach to physician
workforce planning.
In light of the
likely gap between the expected supply, demand, and need for physicians
in the future, COGME recommends that the Nation undertake a multi-pronged
strategy that includes: a modest increase in medical education and
training capacity over the next decade; efforts to increase physician
productivity; and increased tracking and assessments of the supply,
demand, and need for physicians. In addition, because underserved
communities are most likely to be affected by shortages, COGME recommends
that the National Health Service Corps (NHSC) and other Federal programs
designed to address geographic and specialty maldistribution and to
increase diversity be expanded. Specific recommendations are presented
below.
- To meet
the future physician workforce demand and need in the U.S., COGME
recommends that:
- The
number of physicians entering residency training each year be
increased from approximately 24,000 in 2002 to 27,000 in 2015;
and
- The
distribution between generalists and non-generalists should
reflect ongoing assessments of demand; therefore, COGME does
not recommend a rigid national numerical target.
The analysis presented
in this report indicates that the Nation is likely to be facing a
shortage of physicians in the coming years, particularly in non-generalist
specialties. To begin to address this likely shortage, COGME recommends
that the total number of physicians entering residency training in
the U.S. be increased to 27,000 per year over the next decade. This
action would lead to an increase in the Nation’s physician workforce
by about 3 percent (30,000 physicians) by 2020. Although this level
of new entrants into medicine will be insufficient to meet future
needs, it is an important step.
This physician
workforce goal is presented as an absolute number rather than as a
percentage of the number of U.S. medical graduates in a specific year.
This absolute number is easier to understand and track, and therefore
should be a more useful target for the Nation. When presented as a
percentage of medical school graduates, the recommended number of
entrants into residency training is equal to 158 percent of the number
of 1993 U.S. medical graduates and 150 percent of the 2000 U.S. medical
school graduates.
Currently, approximately
37 percent of new physicians are entering generalist specialties,
and 63 percent are entering non-generalist specialties. COGME recommends
below that the Nation undertake studies to track overall specialty-specific
need, demand, and distribution and to share this information with
the medical education and training community. Specialty-specific need
and demand for physicians are likely to vary over time and by region.
Therefore, a single national goal is inappropriate. Physicians should
be encouraged to select specific specialties with shortages. This
selection could be facilitated by providing physicians information
on practice opportunities by specialties and, where appropriate, should
be offered such fiscal incentives as loan repayment opportunities.
- Increase
total enrollment in U.S. medical schools by 15 percent from their
2002 levels over the next decade.
To assure reasonable
access to care for Americans in coming years, COGME recommends that
total U.S. allopathic and osteopathic medical school enrollment be
increased by 15 percent by 2015. This step will require a combination
of increased enrollment at existing medical schools and, potentially,
the establishment of a number of new medical schools.
A modest increase
in medical school enrollment over the next decade will have only a
limited impact on the total supply of physicians in 2020 but would
provide a base for responding to future needs. Decisions on medical
school capacity need to be made now if the Nation is going to be able
to produce more U.S. medical school graduates in 2015 and beyond.
Between 1982
and 2001, the number of medical students in the U.S. increased 7 percent
while the U.S. population grew 23 percent, leading to a 13 percent
net decrease in medical school students per capita in the U.S. Between
2000 and 2020, the U.S. population is projected to increase by 18
percent while medical school capacity is scheduled to increase by
only about 4 percent, leading to a further decrease in per capita
medical students. The recommended 15 percent increase would still
leave the number of medical students per capita well below the 1980
level.
If the actual
shortage is not as significant as predicted in this report, the modest
increase of about 3,000 new U.S. graduates per year by 2015 would
allow the U.S. to reduce its current reliance on the approximately
5,200 international medical school graduates (IMGs) who enter residency
training each year. This policy would be consistent with those advocated
by many observers (Mullan 2000). Most IMGs come from countries that
have far fewer physicians per capita than the U.S. has.
Given the uncertainty inherent in long-term forecasting of supply,
demand, and need, and the cost of a major expansion in medical school
capacity, COGME does not recommend that the Nation attempt to address
all the possible shortages through a dramatic increase in medical
education capacity at the present time. Rather, COGME recommends that
the medical education community increase enrollment moderately now
and that the Nation take other steps that have the potential to reduce
future shortages. Although it may be necessary to increase enrollment
more than 15 percent in the coming years, the decision should be made
based on further study over the next few years, as discussed in recommendation
five below.
At this time,
the Council is not recommending a new Federal program to encourage
new medical schools or increased enrollment at existing medical schools.
It is hoped that the medical education community and States will respond
to the recommendations in this report and to the growing evidence
of unmet physician workforce needs.
- Phase
in an increase in the number of residency and fellowship positions
eligible for funding from Medicare to parallel the increase in U.S.
medical school graduates recommended above.
Over the next
decade, teaching hospitals will need to increase the number of training
positions to accommodate the increasing number of U.S. medical school
graduates. The current cap on the number of residents and fellows
eligible for Medicare reimbursement strongly discourages teaching
hospitals from increasing the number of residents. To encourage a
modest increase in residents, COGME recommends that the cap be increased
slowly over the next decade.
The current cap
was intended to discourage increases in the number of physicians trained
in the U.S. It was conceived and approved when there was a period
of concern with potential surpluses of physicians and when it appeared
that managed care would reduce the use of health care services. As
the Nation now looks at its physician needs for 2015 and beyond, the
far greater likelihood is a physician shortage. The Medicare policy
should be adjusted to help meet future physician needs that will be
driven in large part by the growing number of elderly covered by the
Medicare program. In light of the growth in graduates of osteopathic
schools over the past decade and the increasing number of entrants
to allopathic schools, it is important to begin to increase the GME
cap as soon as possible.
- Develop
systems to track the supply, demand, need, and distribution of physicians,
and undertake a comprehensive re-assessment within the next 4 years
to guide future decisions on medical education capacity.
Given the costs
of increasing medical education and training capacity and the uncertainty
inherent in any effort to forecast physician workforce many years
into the future, it is strongly recommended that the Nation develop
systems to track physician workforce supply, demand, need, and distribution
on a regular and consistent basis. This recommendation is especially
important in light of the many years needed to make changes in the
supply of physicians.
In addition to
ongoing tracking, COGME recommends that the Nation undertake a comprehensive
re-assessment within the next 4 years that would consider the many
factors that could have an impact on the physician workforce in the
future in greater depth than the current re-assessment. Major industries,
especially those in which changes in production require both substantial
investments and many years to implement, exemplify this point. The
leaders in these industries recognize the critical role of regular
assessments of the current and future marketplace. The current study
considers available data, but important gaps exist in these data as
well as in our understanding of physician practice patterns. In addition,
some information (e.g., retirement patterns of the baby-boom generation
of physicians) cannot be known at this time.
- Additional
specialty-specific studies are needed to better understand the physician
workforce needs and to inform the medical education community and
policy makers of the Nation’s specialty-specific needs.
On the basis of
available data, the Nation appears to have a ratio of 38 percent generalist
specialties and 62 percent non-generalist specialties. This greater
demand for non-generalist specialties is borne out by surveys of new
physicians completing residency training in the U.S. and the growing
number of reports of shortages in non-generalist specialties (Schubert
et al 2003; Miller and Lanier 2001; Schubert et al 2001; Foot et al
2000; Kim et al 2001; Suneja et al 2001; Neilson et al 2001; Angus
et al 2000; Pronovost et al 2002; Sunshine 2001; Organ 2002; Etzoni
et al 2003; Fleming et al 2003).
Experience over
the past decade has demonstrated that medical students, physicians
in training, residency programs, and teaching hospitals respond to
marketplace signals on supply and demand for different specialties.
Unfortunately, specialty-specific studies have been conducted only
sporadically in the past and often used questionable research methods
and data. The Federal Government should take a leadership role in
developing and encouraging common methodologies for specialty-specific
studies.
Providing the
medical education community and policy makers with better information
on current and future needs and on gaps in physician supply by specialty
should contribute to a specialty mix more consistent with national
needs. Accurate and timely information and data are a prerequisite
for an effective market of any type. This information should help
guide Federal policies related to the physician workforce.
- Promote
efforts to increase the productivity of physicians.
The Nation should
consider several steps to promote productivity improvements. These
steps include:
- Funding
to evaluate the effectiveness and efficiency of alternative models
of care, and practice and organizational arrangements;
- Evaluation
of specific new technologies;
- Dissemination
of information to physicians on the effectiveness of alternative
models of care, new technologies, and other strategies to improve
productivity; and
- Introduction
of reimbursement policies to support implementation of productivity
enhancements.
A modest annual
rate of increase in physician productivity would have a major long-term
impact on the number of new physicians needed by the Nation. These
steps could also encourage physicians to practice longer rather than
retire or leave medical practice, thus effectively increasing the
supply of physicians.
New technologies and improvements in existing technologies have the
potential to increase productivity, improve quality, and increase
physician satisfaction. Particularly promising is the potential for
the electronic medical record and other advances in information technology.
These advances have the potential to increase efficiency and effectiveness,
to reduce the time needed for documentation, and to speed the retrieval
of needed information. Remote patient monitoring systems, telecommunications
advances, and Internet access to the latest medical knowledge and
technologies have the potential to increase the number of patients
who can be cared for by a physician.
There are a number
of barriers to the expansion of effective new technologies. First,
many of these technologies require an enormous investment to develop
and acquire. Second, many new technologies are still to be perfected
and are evolving rapidly, leading to appropriate caution on the part
of physicians and the organizations that use them. A third barrier
for certain types of technologies is reimbursement policies. For example,
if insurers do not cover group sessions or interactions between physician
and patient over the Internet, then these approaches will be less
attractive to physicians and patients.
- Expand
programs and develop policies that:
- Address
geographic maldistribution of physicians,
- Improve
access to care for underserved populations and communities,
- Promote
appropriate specialty distribution and deployment,
- Promote
workforce diversity, and
- Support
analyses of data related to these issues.
The projected
shortage of physicians is likely to have the greatest impact on underserved
and poorer communities that have historically had the greatest difficulty
recruiting and retaining physicians. To assure access for our most
needy citizens, it will be important to maintain and expand programs
that support access to physician services by underserved populations.
In anticipation of future shortages, the number of scholarship and
loan repayment awards under the NHSC should be increased.
As indicated in
this report, shortages for non-generalists are likely. Although generalists
play a central role in underserved communities, these communities
also require access to non-generalists. Therefore, COGME recommends
that the NHSC be expanded to include non-generalist specialties. These
awards should be targeted to specialties with documented shortages
in underserved communities. Giving underserved communities access
to non-generalists should be accomplished while maintaining an emphasis
on access to primary care services. By identifying specialties experiencing
shortages for purposes of the NHSC program, the Federal Government
would also send an important message to medical students about specialties
in need.
Title VII of
the Public Health Service Act includes programs specifically designed
to encourage practice in rural and other underserved areas, to increase
the diversity of the workforce, to promote more effective medical
and interdisciplinary education, and to collect and analyze workforce
data. These programs play a critical role in helping assure access
to needed services and will be particularly important in a period
of physician shortage. COGME recommends that these programs receive
continued support.
In addition to
physician workforce programs that directly address needs in health
care delivery, policy exerts its influence through reimbursement and
regulatory actions. For example, direct and indirect GME payments
through Medicare, as well as differential payments for health care
services, have an influence on training opportunities, medical specialty
choices, and career location decisions. These influences should be
evaluated, understood, and more closely aligned with health care policy
goals.
RELATED
ISSUES OF CONCERN
Distribution
of Physicians: This analysis assesses the total number of
physicians across the country and does not assess supply, demand,
or need by State, region, or locality. It is possible for the Nation
to have enough or even more than enough physicians in aggregate and
still have significant shortages in specific communities. Although
having an adequate supply nationally will make it easier to address
distribution issues, increasing the supply will not in and of itself
address issues of maldistribution of physicians. Although this
issue is not the focus of this report, it is an issue of great importance
to the Nation and to COGME. Given the shortages predicted in this
report, it is likely that currently underserved areas will face greater
shortages in coming years if steps are not taken to ameliorate the
overall physician supply shortage. The Council intends to undertake
a review of programs and strategies to address the distribution of
physicians and to make recommendations in a future report for better
assuring an adequate distribution of the physician workforce.
U.S. Medical
School Graduates and International Medical School Graduates (IMGs):
There are two major sources of new physicians in America: graduates
of U.S. medical schools and graduates of non-U.S. medical schools.
The Nation could address the predicted future shortage by increasing
the number of physicians from one or both of these sources. This report
neither recommends an increase in the number of IMGs entering residency
training as a way to address future shortages, nor recommends a decrease
in the number of IMGs entering the U.S. It is not the purpose of this
report to assess the pros and cons of using IMGs to meet physician
workforce needs in the U.S., but it is recognized that the issues
of IMG policies, U.S. medical school capacity, and the total number
of physicians produced in the U.S. are interrelated. Clearly, if a
decision were made to reduce the reliance on IMGs, it would be necessary
to increase U.S. medical school enrollment more than recommended above
to achieve the goal of 27,000 new entrants in 2015. Conversely, an
increase in the number of IMGs entering the U.S. would reduce the
need for more U.S. medical graduates.
Impact of
Reimbursement Policies on Demand for Physician Services: Undoubtedly,
the demand for a specialty or group of specialties is affected by
reimbursement policies. Low levels of reimbursement for services can
depress demand below need. The models used in the current reassessment
of supply, demand, and need rely heavily on historical patterns of
use that have been influenced by reimbursement policies. Results of
recent surveys of residents completing training in California and
New York show that the incomes of non-generalists are significantly
higher than the income of generalists and that the gap is growing
(Nolan et al 2003a, 2003b, 2003c). Although the imbalance between
the income of generalist and non-generalist physicians is not the
focus of this report, it probably affects the measurement of demand
and need. It may be appropriate to reassess the relative levels of
reimbursement of generalists and non-generalists under current reimbursement
systems, including Medicare.
Unnecessary
Services:
Some research findings suggest that some services provided by physicians
may be of marginal benefit or even unnecessary (Weiner 1994, 1995,
2004; Fisher et al 2003a, 2003b). Drawing on recent research on staffing
ratios in prepaid group practices and the relationship between health
status and aggregate physician service utilization, the report presents
what the impact would be on demand and need if some process were found
to identify and eliminate unnecessary or ineffective services.
Some have suggested
that the number of physicians educated and trained in the U.S. should
take this into account (i.e., the Nation should produce fewer physicians
because some services are unnecessary). However, in the absence of
programs and policies that effectively identify and eliminate the
unnecessary or inappropriate services, constraining supply is likely
to lead to even greater shortages and delays in access to services
for the public at large. Such shortages and delays might occur especially
in underserved communities and among vulnerable populations.
Background
The Council on
Graduate Medical Education (COGME) was authorized by Congress in 1986
to assess physician workforce trends, training issues, and financing
policies, as well as to recommend appropriate Federal and private-sector
efforts to address identified needs. One of the most important physician
workforce issues for COGME and the Nation is the assessment of the
number, specialty, and geographical distribution of physicians that
would need to be educated and trained to assure access to quality
care for Americans. For the last decade, a series of physician workforce
policy goals held by COGME have centered around its “110/50-50”
recommendations. These goals and recommendations should be revised.
First articulated
in its Third Report, Improving Access to Health Care Through Physician
Workforce Reform: Directions for the 21st Century (1992), the
110/50-50 recommendations called for reducing the number of physicians
entering residency training from what was then 140 percent to 110
percent of the number of graduates from allopathic and osteopathic
medical schools in the U.S. in 1993. Conceptually, the 110 percent
would be sufficient to ensure that all U.S. medical school graduates
would be able to enter graduate medical training, as well as IMGs
equal in number to 10 percent of the U.S. graduates. The Third
Report called for increasing the percentage of graduates who complete
training and enter practice as generalists from the level then at
30 percent to at least 50 percent. COGME’s Eighth Report,
Patient Care Physician Supply and Requirements: Testing COGME Recommendations
(1996), provided underlying physician supply and requirements projections
that tended to support the reasonableness of the recommendations.
COGME’s Fourteenth Report, COGME Physician Workforce Policies:
Recent Developments and Remaining Challenges in Meeting National Goals
(1999), in calculating the progress made toward the COGME goals, found
that as of 1997 and 1998, the Nation’s first-year residents amounted
to approximately 129 percent of the number of graduates from allopathic
and osteopathic medical schools in the U.S. in 1993. This report also
found that it would be necessary to reduce the number of first-year
residents by about 3,400 to reach the 110 percent goal set by COGME
in 1992.
The Fourteenth
Report identified several recent developments that were likely
to affect the supply or demand, or both, for physician services. These
developments include: the evolving nature of managed care, the growing
supply of non-physician clinicians, and the growing representation
of women in medicine. In this 1999 report, the Council stated its
intention of re-assessing the appropriateness of its 110/50-50 recommendations
in light of recent developments.
Supply
of Physicians, 2000-2020
OVERVIEW
OF METHODOLOGY: BASELINE MODEL AND FACTORS AFFECTING FUTURE SUPPLY
The forecast of
physician supply in the U.S. between 2000 and 2020 is based on the
Physician Supply Model (PSM). This model, developed and maintained
by the Bureau of Health Professions (BHPr), HRSA, DHHS, produces projections
of the supply of physicians by type (Medical Doctor [MD] and Doctor
of Osteopathy [DO]) and specialty for 1995 through 2040. For the purposes
of this report, the years of interest are 2000 through 2020, and the
specialty groups of interest are generalists and non-generalists.
This section presents the total supply forecasts and factors affecting
the overall supply of physicians in the U.S. Projections for generalists
and non-generalists appear in Section V, “Physician Supply, Demand,
and Need.”
The unit of analysis
for the assessment is a full-time equivalent (FTE) active physician.
This unit includes all physicians active in medicine, regardless of
whether they are providing patient care. It is estimated that about
6 percent of active physicians in 2000 were not providing patient
care. Many of these physicians were involved in teaching, administration,
and research (Pasko and Seidman 2002). Since one goal of the project
is to assess the number of physicians that would need to be produced
to meet future needs, it is necessary to include non-patient care
physicians as well as active physicians in the projections. To take
into account the fact that some physicians practice less than full-time,
for this analysis, supply, demand, and need are calculated in terms
of full-time equivalents; that is, two physicians working half-time
are equal to one FTE.
The calculation
of future physician supply begins with the number of physicians entering
residency training. The methodology includes the following steps:
- The PSM begins
with the active base year physicians by type and post-medical school
graduate year (PGY).
For each forecast
year:
- The
base year physicians are aged, and age-specific death and retirement
rates are applied.
- The physicians
are summed over all ages to calculate the base physicians by type
and PGY.
- Specialty distributions
are applied by type and PGY.
- Activity distributions
are applied by type, specialty, and PGY.
- New entrants
by year (2001 through 2020) of each type of physician indicated
below, using the data described, are tallied:
- United
States Medical School Graduates (USMGs): New graduates from U.S.
medical schools and percentage of females by year;
- Canadian
Medical School Graduates (CMGs): New graduates from Canadian medical
schools and percentage of females by year;
- IMGs:
International medical school graduates who are GME entrants and
percentage of females by year; IMGs who are non-GME entrants and
percentage of females by year;
- New entrants
are aged over the period 2000 through 2020 for each and the appropriate
age and type-specific death and retirement rates are applied;
- Specialty distributions
are those applied by type and PGY to new entrants;
- Activity distributions
are those applied by type, specialty, and PGY to new entrants;
- Forecasts of
base year physicians and new entrant physicians by type, PGY, specialty,
and activity are summed over PGY to produce final forecasts (Bannister
et al 2001).
The forecast totals
are then converted to FTEs. Table 1 presents the results of the baseline
supply model.
The supply of
physicians is projected to grow by some 190,000 FTEs (24 percent)
between 2000 and 2020.4 Over the same time period, the
U.S. Census Bureau projects an 18 percent growth in the U.S. population,
yielding a net 5 percent growth in the physician-to-population ratio.
As indicated in Table 1, the supply expressed as FTEs per capita peaks
around 2015, and then begins to fall, as the rate of population growth
begins to outstrip the rate of growth in the supply of physician FTEs.
The data used
in the PSM for this project were derived from the following sources:
- Current
supply and characteristics:
- American
Medical Association (AMA) Physician Masterfile
- American
Osteopathic Association (AOA) Masterfile
- Distribution
by age, gender, and IMG status: AMA Physician Masterfile
- New U.S.
graduates 2000 by age and gender: Association of American Medical
Colleges (AAMC), AMA, and AOA Masterfile
- New CMGs
and IMGs: AMA Graduate Medical Education data
- Retirements,
deaths, and departures:
Analysis of AMA Physician Masterfile patterns 1990 through 1995
Given this methodology,
it is clear that the model takes a number of basic factors into account
in making projections. These factors include:
- The overall
number of new entrants into the physician workforce and the source
of the new entrants (i.e., U.S. medical schools or abroad);
- The gender
distribution of the current physician supply and of new entrants
and its effect on the relative number of hours spent in professional
activities (to calculate FTEs);
- The age distribution
of the current physician supply;
- Retirement,
death, and other separation rates of the current physician supply;
- The specialty
distribution of the current physician supply and the specialty choices
of new entrants; and
- The rates of
different types of professional activities (e.g., patient care,
teaching, and research) of the current physician supply.
These factors
are included in the supply projection model through the use of historical
rates and trends derived from both previous research and the data
sources listed above. Below, these factors are discussed in more detail,
and any assumptions made in the baseline model are revealed.
New
Entrants
Number of U.S.
medical school graduates: The baseline model assumes that the
number of U.S. allopathic medical school graduates will remain essentially
constant through 2020 at 16,000 per year. It also assumes that osteopathic
graduates will continue to increase from about 2,300 in 2000 to 3,000
in 2009, and then stabilize at that level. It further assumes that
the number of Canadian entrants into the U.S. health system will slowly
rise from 191 in 2000 to 247 in 2020. Thus, for most of the period,
it is assumed that there will be about 19,000 new USMG, CMG, and DO
entrants each year. Table 2 presents the estimated entrants into the
health care system between 2000 and 2020 as used in the model. Figure
1 shows the number of allopathic and osteopathic graduates over the
past 20 years and the forecast for 2001 through 2020. Figure 2 depicts
the extent to which the growth of the U.S. population has exceeded
the growth in the number of students enrolled in U.S. medical schools.
The medical school
community has discussed the possibility of new medical schools and
increases in enrollment at existing medical schools (e.g., see Cooper
2003; Mullan 2003; Wood 2003; Hallock et al 2003; as well as Mullan
2000). Several new schools are in various stages of development or
accreditation (e.g., in Florida, Arizona, and Texas).
[D]
[D]
Several additional
new schools are being discussed in other locations, but this development
is likely to add only a modest number of new physicians to the supply
over the next several years. This is the case because of the time
it takes before new medical schools produce practicing physicians,
as well as the modest nature of current development efforts. This
expansion is not factored into any models described in this analysis.
Moreover, several other important issues related to the expansion
of medical education in the U.S. would have to be addressed before
any large-scale expansion could occur.
Number of international
medical school graduates: The baseline model assumes 5,200 new
IMG entrants per year based on historical trends. An analysis of AMA
GME data and the AMA Physician Masterfile indicates that this is close
to the experience throughout the 1990s. Given recent political developments
(i.e., the tragic events of September 11, 2001; increased scrutiny
of immigrants domestically; Operation Iraqi Freedom; as well as a
host of others), it is possible that future immigration policies will
limit the flow of IMGs into the U.S. in coming years.
It is certainly
conceivable that the current inflow could decrease in the near future.
Any decrease in the number of IMGs entering the physician supply without
a simultaneous increase of USMG, CMG, and DO entrants would lead to
fewer physicians than are currently projected. At the same time, it
is also conceivable that the number of IMGs could increase because
of the recent upswing in U.S. citizens attending medical schools abroad
(Salsberg and Forte 2002). These potential changes are not factored
into any models described in this analysis.
Women in Medicine
Women have made
great strides in medicine over the past 20 years, nearly tripling
their representation in the profession. Currently making up about
25 percent of the physician workforce, women will continue to become
a larger part of the workforce because they currently make up nearly
50 percent of the students enrolled in U.S. medical schools (Salsberg
and Forte 2002).
A number of studies
have documented that women work fewer hours over the course of their
professional work life than men (Kletke, Marder, and Silberger 1990;
Bobula 1980; Martin et al 1988; Cooper 1994; Australian Medical Workforce
Advisory Committee/Australian Institute of Health and Welfare [AMWAC/AHIW]
1996, 1998; Sullivan and Buske 1998; Forte and Salsberg 1999). This
phenomenon may reflect time taken for child rearing, for providing
care for elderly parents or other relatives, and for taking care of
other family concerns. The baseline model accounts for the gender
difference as it is based on historical work patterns. As Table 3
shows, the FTE-to-physician ratio decreases over time. This decrease
is indicative of the increasing representation of women in the physician
workforce as well as the aging of the workforce.
