Physician surplus and its remedies.

Through the passage of time (and the passing of an examination or two), resident physicians transform themselves into unrestricted practitioners. Whether you see this as a good thing or not depends on your perspective. To the residents themselves, this metamorphosis is no less beautiful than a chrysalis becoming a butterfly. Others, though, may deem it a variation of the kitten/cat problem articulated by Ogden Nash—residents are nice, but they one day become attending physicians, and of them we have too many. In the 1960s, flush with an expanding economy and Great Society ideals, the government embarked on a mission to mint more physicians. It rewarded medical schools for training doctors and paid residency programs for providing graduate medical education (GME). These systems are still in place today. Through an elaborate scheme, created ostensibly to compensate teaching hospitals for tertiary care and unpaid services, the government’s Medicare program subsidizes the direct and indirect costs of GME. The word “subsidize” may give the impression that this payment is small. Even by government standards, it is far from that. In 1997, the Medicare GME allocations totaled about 7 billion dollars. Let’s put this amount in perspective: it is enough to cover the tuition and living expenses of every medical student in the United States, with enough left over to send them all to business school as well. At a time when increasing the number of medical practitioners received universal acclaim, this program was a boon to all. Hospitals got the cash. Residents got the jobs. And, society got the work done. Now we have a surplus, some say, and the governmental funding of GME is an open question. It may be worthwhile wondering whether we do indeed have a surplus of physicians. This question may be hard to answer. Surplus labor is typically defined as an excess of job seekers, relative to the amount of work available. In medicine, this may not be the best definition. There is always work to be done; it is just not always clear whether there are funds to pay for that work. Most models of physician manpower demand ignore this issue and simply assume that we are practicing the right amount of medicine today and that supply should be calculated from that rate. This may be incorrect; an article in JAMA 281:446–453 1999, makes a good case that we may be doing too much. Although it is necessary to make some assumptions in any model, of course, the inferences drawn are especially dubious if even the aptness of the base line rate (let alone future variance) is questioned. The prediction of future demand for orthopaedic services is especially difficult for two reasons. First, our professional mandate overlaps with those of our colleagues: neurosurgeons, podiatrists, rheumatologists, and chiropractors also treat “orthopaedic” problems. A shortage or excess in any of those fields will perforce alter the need for orthopaedic surgeons. Second, there is the issue of medical progress. You can imagine the effect on orthopaedic surgery if the COX-2 inhibitors successfully palliate all but the worst cases of arthritis. Similarly, if we discover a gene therapy for cartilage regeneration or osteoporosis prevention, our practice will change. Progress may simply put many of us out of business. Consider the following: dentistry has shriveled, some may say, now that fluoride in the water has decreased the incidence of dental cavities. On the other hand, some fields thrive even in the face of such progress. Thoracic surgeons were threatened with extinction when tuberculosis waned. Who knew that cardiopulmonary bypass was coming? Likewise, general surgeons discovered all sorts of uses for the laparoscope, now that peptic ulcers (formerly their bread and butter case) are managed successfully by internists. Either fate, i.e., obsolescence or opportunity, may befall orthopaedic surgery. My sense is that with the aging of the population, there will be more arthritis, more hip fractures, and in short, a need for more orthopaedic surgeons. But let’s assume that there is an impending surplus; if not among orthopaedic surgeons (who number less than 5% of all physicians) then, at least, in general medicine. What does it mean? At first glance, a surplus of physicians may seem like a good thing. If many Americans go without medical care, having more doctors to provide that care would seem to be beneficial. Moreover, the principles of Economics 101 dictate that a large labor pool should depress the price of labor; that a “surplus” of physicians should make medical care cheaper. In practice, though, neither supposition has been proven true. From the Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA. Address correspondence to: Joseph Bernstein, M.S., M.D., Department of Orthopaedic Surgery, 3400 Spruce Street, Philadelphia, PA 19104. The University of Pennsylvania Orthopaedic Journal 12: 89–92, 1999 © 1999 The University of Pennsylvania Orthopaedic Journal