Trends: Trends In The Physician Workforce, 1980-2000

Over the past twenty-five years the nation has struggled with a series of physician workforce issues: determining the appropriate number of physicians needed and the appropriate number to produce; the role of international medical school graduates; the mix of primary care and non–primary care physicians; efforts to increase the number of underrepresented minorities in medicine and the supply of physicians in rural areas; and the impact of the growing number of female physicians. This paper documents physician workforce trends over the past twenty years, especially as they relate to these issues. B etween 1960 and 1980 the number of allopathic medical schools in the United States grew from 85 to 126, and the number of graduates more than doubled from 7,081 to 15,113.1 The nation’s physician supply grew rapidly, from 235,303 active allopathic physicians in 1965 to 316,491 in 1975.2 In 1976, in response to concerns about the rapidly growing supply of physicians, the Graduate Medical Education National Advisory Committee (GMENAC) was established to advise the nation on how many physicians were needed in the United States.3 In 1980 GMENAC concluded that the nation faced a potentially serious surplus and recommended that it limit the number of medical school positions and severely restrict the number of international medical school graduates (IMGs) entering the United States.4 When GMENAC issued its report in 1980, there were 459,555 active physicians in the United States.5 The surplus GMENAC envisioned was based on an estimate that the number of physicians would grow to 535,750 by 1990 and 642,950 by 2000 unless steps were taken to reduce the growth in physicians.6 Concerns about a potential surplus escalated with the publication of several papers in the early 1990s suggesting that the expansion of managed care and its emphasis on primary care would lead to an even greater surplus of physicians than predicted by GMENAC, especially medical and surgical specialists.7 In fact, Jonathan Weiner estimated that under certain managed care expansion scenarios, the nation required 138–144 patient care physicians per 100,000 population—well below the 191 physicians per 100,000 population suggested by GMENAC.8 Since the nation already had 238 active physicians per 100,000 in 1990 and was experiencing a period of growth in physician supply, the specter arose of a massive surplus of physicians by the turn of the century.9 This concern was echoed by the national Council on Graduate Medical Education (COGME). In several reports between 1992 and 1998, COGME reaffirmed its concern about a potential surplus of physicians.10 T r e n d s H E A L T H A F F A I R S ~ V o l u m e 2 1 , N u m b e r 5 1 6 5 ©2002 Project HOPE–The People-to-People Health Foundation, Inc. Edward Salsberg is executive director of the Center for Health Workforce Studies, University at Albany, State University of New York. Gaetano Forte is a research associate there. on O cber 8, 2017 by H W T am H ealth A fairs by http://conealthaffairs.org/ D ow nladed fom In 2000 there were approximately 780,000 active physicians in the United States, or 276 physicians per 100,000 population (Exhibit 1). U.S. physician supply grew by more than 320,000 physicians between 1980 and 2000. However, despite the sharp growth in supply, there is little indication of a U.S. surplus of physicians. Several recent examinations of the balance of supply of and demand for physicians suggest that the nation may be facing a shortage instead.11 The Center for Health Workforce Studies at the University at Albany, State University of New York, surveys physicians completing training in New York annually to assess the relative demand, by specialty, for physicians entering practice. Initially, it was thought that there would be an indication of “saturation” in some specialties, since New York State has a very high physician-to-population ratio (estimated at 305 physicians per 100,000 population in 2000—well above the numbers recommended by GMENAC and COGME).12 Yet despite this high ratio, based on the experience of residency program graduates in the job market, there has been no indication of a general surplus. For example, between 1998 and 2001 only 18 percent of 5,312 respondents had to change their practice plans because of limited job opportunities.13 Despite the growing supply, this percentage has remained essentially unchanged each year. The most commonly reported reason for new physicians’ having difficulty finding a satisfactory practice opportunity was limited practice opportunities in desired locations rather than a general lack of practice positions. Similar findings have been reported in California in 2000 and 2001.14 Although an earlier report suggested that some new physicians were unemployed, the experience in New York and California over the past several years indicates that only a tiny percentage of physicians do not have confirmed practice plans shortly before graduation because of the lack of practice opportunities.15 In this paper we trace the path of U.S. physician supply analysis and recommendations, based on the published reports by government bodies and academic analysts during the past twenty years, as well as on our own work at the Center for Health Workforce Studies. U.S. Medical School Graduations And IMGs Entering Medicine The growth in physicians between 1980 and 2000 reflects a number of factors. As expected by GMENAC, the increased level of production of U.S. medical schools in the 1980s 1 6 6 S e p t e m b e r / O c t o b e r 2 0 0 2 H e a l t h T r a c k i n g EXHIBIT 1 Trends In U.S. Physician Supply And Projections, Selected Years 1980–200