Medical miscalculation creates doctor shortage
By Dennis CauchonUSA TODAY
After a glut was predicted a decade ago, the number of physicians isn't keeping up with the demands of a wealthy, aging population
TALLAHASSEE, Fla. — Retired fisherman Billy Bodiford was diagnosed with prostate cancer in October. The doctor who found the cancer is the only urologist available in Taylor County, Fla. (pop. 19,200) — and he visits just one day a month.
The doctor sent Bodiford from his hometown of Perry to Tallahassee 50 miles away for surgery. “You can't get the type of operation I needed in my town,” says Bodiford, 68, who was hospitalized for six days in December and is feeling better.
Bodiford experienced what many Americans may soon face: a shortage of physicians that makes it hard to find convenient, quality health care. The shortage will worsen as 79 million baby boomers reach retirement age and demand more medical care unless the nation starts producing more doctors, according to several new studies.
The country needs to train 3,000 to 10,000 more physicians a year — up from the current 25,000 — to meet the growing medical needs of an aging, wealthy nation, the studies say. Because it takes 10 years to train a doctor, the nation will have a shortage of 85,000 to 200,000 doctors in 2020 unless action is taken soon.
The predictions of a doctor shortage represent an abrupt about-face for the medical profession. For the past quarter-century, the American Medical Association and other industry groups have predicted a glut of doctors and worked to limit the number of new physicians. In 1994, the Journal of the American Medical Association predicted a surplus of 165,000 doctors by 2000.
“It didn't happen,” says Harvard University medical professor David Blumenthal, author of a New England Journal of Medicinearticle on the doctor supply. “Physicians aren't driving taxis. In fact, we're all gainfully employed, earning good incomes, and new physicians are getting two, three or four job offers.”
The nation now has about 800,000 active physicians, up from 500,000 20 years ago. They've been kept busy by a growing population and new procedures ranging from heart stents to liposuction.
But unless more medical students begin training soon, the supply of physicians will begin to shrink in about 10 years when doctors from the baby boom generation retire in large numbers.
“Almost everyone agrees we need more physicians,” says Carl Getto, chairman of the Council on Graduate Medical Education, a panel Congress created to recommend how many doctors the nation needs. “The debate is over how many.”
Getto's advocacy of more doctors is remarkable because his advisory committee and its predecessor have been instrumental since the 1980s in efforts to restrict the supply of new physicians. In a new study sent to Congress, the council reverses that policy and recommends training 3,000 more doctors a year in U.S. medical schools.
Even the American Medical Association (AMA), the influential lobbying group for physicians, has abandoned its long-standing position that an “oversupply exists or is immediately expected.”
“The truth is, we don't know if there's a shortage of physicians,” says AMA President John Nelson, a Salt Lake City obstetrician. “It looks like there are enough physicians for the short term, but maybe we need more because of the aging population.”
The United States dramatically expanded the number of doctors being trained in the 1960s and 1970s, creating two new physicians for every one that retired, says Richard Cooper,director of the Health Policy Institute at the Medical College of Wisconsin.
But the production of new doctors has changed little since 1985. Today, new physicians roughly equal the number of doctors retiring. Within a decade, baby boom doctors licensed in the 1960s, 1970s and 1980s will retire in large numbers that will outstrip the 25,000 new doctors produced every year, Cooper says.
The effective number of physicians will fall even more, Cooper says, because doctors work shorter hours today. “The public expects good, innovative health care, but we're not producing enough physicians to provide it,” Cooper says.
The marketplace doesn't determine how many doctors the nation has, as it does for engineers, pilots and other professions. The number of doctors is a political decision, heavily influenced by doctors themselves.
Congress controls the supply of physicians by how much federal funding it provides for medical residencies — the graduate training required of all doctors.
To become a physician, students spend four years in medical school. Graduates then spend three to seven years training as residents, usually treating patients under supervision at a hospital. Residents work long hours for $35,000 to $50,000 a year. Even doctors trained in other countries must serve medical residencies in the USA to practice here.
Medicare, which provides health care to the nation's seniors, also is the primary federal agency that controls the supply of doctors. It reimburses hospitals for the cost of training medical residents.
The government spends about $11 billion annually on 100,000 medical residents, or roughly $110,000 per resident. The number of residents has hovered at this level for the past decade, according to the Accreditation Council for Graduate Medical Education.
In 1997, to save money and prevent a doctor glut, Congress capped the number of residents that Medicare will pay for at about 80,000 a year. Another 20,000 residents are financed by Veterans Affairs and Medicaid, the state-federal health care program for the poor. Teaching hospitals pay for a small number of residents without government assistance.
Medicare, which faces enormous financial pressure in coming decades, already spends 3% of its budget training physicians and may not have the resources to spend more.
Cooper says the nation needs 200,000 more physicians because aging and wealthy countries demand more health care.
The portion of U.S. income spent on health care rose from 8.8% in 1980 to 15.4% in 2004 and will reach 18.7% in 2014, according to Medicare estimates. That means more doctors are needed, whether it's for hip replacements or prescribing new drugs.
Demographic changes in the medical profession also contribute to the need for more physicians. Nearly half of new physicians are women, and studies show they work an average of 25% fewer hours than male physicians, Cooper says.
Physicians older than 55 work about 15% less than younger doctors. And medical residents have been limited to 80-hour weeks since 2003, ending decades of 100-plus-hour weeks.
Most worrisome, the retirement of baby boom physicians means the number of doctors will start falling just as the first baby boomer turns 70 in 2016, says Ed Salsberg, a workforce specialist at the Association of American Medical Colleges.
The United States stopped opening medical schools in the 1980s because of the predicted surplus of doctors. The Association of American Medical Colleges dropped this long-standing view in 2002 with the statement: “It now appears that those predictions may be in error.” Last month, it recommended increasing the number of U.S. medical students by 15%.
Florida State University's College of Medicine, the first new medical school since 1982, will graduate its first class this year. Arizona, Nevada, California and Florida are considering opening additional medical schools. Other states are considering expanding theirs.
Florida State won approval from the state Legislature to become the nation's 126th medical school by emphasizing family practice and other specialties needed in rural areas and inner cities, where the doctor shortage is already acute.
Florida State medical student Shannon Price, 34, plans to return to her hometown of Perry when she becomes an obstetrician in 2010. She knows firsthand how having too few doctors hurts Perry.
The only person in her family to attend college, Price worked in a munitions factory after high school. Laid off, she went to junior college, then became a nurse.
“People go without health care in my hometown,” she says. “Women go five or six years without Pap smears. We'd deliver babies in the emergency room. My family didn't go to the doctor, other than occasional visits to the health department.”
Doctors' Memorial Hospital in Perry is paying Price's medical school tuition to encourage her return. “She could go anywhere she wants in the country, yet she wants to come back here,” hospital administrator Rick Brown says. “We appreciate that.”
Because physicians are affluent and in short supply, they tend to locate where they want to live — not, as McDonald's or a Chinese restaurant might, where the most customers are.
Jackson Hospital, a 120-bed hospital in Marianna, Fla., a town of 6,200 an hour west of here, needs a urologist, a radiologist, an ear, nose and throat specialist and a gynecologist. “It's supply and demand, and it's hard to get doctors here,” hospital administrator Charles Ellis says.
Particularly scarce are old-fashioned specialists — general surgeons, radiologists, anesthesiologists — who have a wide range of duties. Jackson Hospital has one radiologist who does the work of two or three doctors. He works 15 to 18 hours a day.
New radiologists are not very interested in traditional radiology, Ellis says. They prefer cutting-edge radiology using catheters to treat cancer, blood clots and other problems, which is more lucrative and has predictable hours.
“It's hard to find a radiologist and orthopedic surgeon who want to focus on broken bones, especially at 3 a.m.,” Ellis says. “But that's what we need.”
Some medical policy specialists say the USA doesn't have too few doctors, just poor distribution of them.
“We have more and more physicians taking care of fewer and fewer patients,” says Kevin Grumbach, chairman of family and community medicine at San Francisco General Hospital.
He says doctors gravitate to high-paying practices — such as sports medicine and total body scans — that serve the wealthy and well-insured at the expense of Medicare patients and others.
“It's wrong to think that we can produce more physicians and have them trickle down to where they are needed,” says Grumbach, who favors a government-run, national health care system. “Investing billions of dollars to produce more doctors is a foolish way to spend money.”
Others worry that more physicians will drive up the cost of medical care, not make it cheaper and more accessible. Physicians will order more tests, more procedures and more drugs — without improving the nation's health, they say.
“Doctors create their own demand,” says physician Don Detmer, co-chairman of an Institute of Medicine committee that, in 1996, recommended cuts in funding for medical residents. “If we produce an abundance of doctors, there's little incentive for the system to become more efficient.” The Institute of Medicine is an independent group created by Congress for advice on medical issues.
But Cooper, a former medical school dean, says it's foolish to limit doctors as a way to control health care costs. “Doctors don't drive medical costs,” he says. “Sickness does.
“We face at least a decade of severe physician shortages because a bunch of people cooked numbers to support a position that was obviously wrong,” Cooper says. “This is a desperate situation. And we need to act now because it takes a long time to train a doctor.”
