Richard A. Cooper, MD Professor of Medicine and Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA

Evidence abounds that the nation is in the throes of a deepening physician shortage. Patients report difficulty obtaining appointments, not only with specialists, but with primary care physicians. More professional job searches are being requested, spawning an industry of 8,000 physician recruiters or one for every three graduating residents.

More than 20 state medical societies and hospital associations and an equal number of medical specialty organizations have issued reports about shortages, often with the word "crisis" in the title. Both the American Medical Association and the American Osteopathic Association (AOA) have called for an expansion of medical training, as have the Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine. One would expect this to produce a groundswell of efforts to increase the number of physicians, but this is not the case. Indeed, not a single presidential candidate has addressed the physician shortage as a health care issue. Three questions emerge: What must be done to alleviate the future shortages? Why isn't more being done already? And, what will be the consequences of this failure to act?

ALLEVIATING SHORTAGES MEANS EXPANDING GME

A critical step in alleviating projected physician shortages is to increase the number of residents trained annually. With rare exceptions, residency training in the United States is required for licensure to practice here, for both graduates of US schools and international medical graduates (IMGs). Each year, almost 25,000 residents complete graduate medical education (GME), of whom approximately 75% are US graduates and 25% are IMGs. The number of residents ultimately determines the size of the physician workforce.

Between 1961 and 1996, the number of entry-level (PGY-1) residents increased by approximately 350 to 400 per year, a growth rate that kept up with demand. For some of those years, growth was fueled by increased enrollment in US medical schools. After 1980, when enrollment was voluntarily frozen, IMGs contributed more to the total. Then in 1997, fearing a physician surplus, Congress capped Medicare's funding for residency positions at their 1996 levels. Because Medicare is a principal source of financial support for GME, this restriction sharply curtailed further growth in residency training. Now that shortages are upon us, it seems clear that these caps on GME must be lifted and residency programs must be allowed to grow.

WHY ISN'T MORE BEING DONE?

There are two answers to this question. First, although most major organizations have called for training more residents, some analysts still think that we have too many physicians. Second, embarking on the path of training additional residents is complicated.

For several decades, it was thought that the real problem with medical care was too many specialists. In the 1990s, the Council on Graduate Medical Education (COGME) expressed this sentiment in a series of reports. When COGME finally acknowledged that the problem was actually one of shortages, as my colleagues and I had projected, researchers associated with the Dartmouth Atlas Project adopted the task of proving there was an overabundance of specialists. Based on their studies of regional variations in health care, these researchers proclaimed that excessive numbers of specialists were overusing "supply-sensitive care."

As with COGME's earlier studies, Dartmouth's studies were designed to prove preexisting beliefs. For example, to prove their claim that "states where more physicians are specialists have lower-quality care," Dartmouth researchers used statistical constructs of physicians rather than actual numbers of physicians. Interestingly, when the impact of actual physicians rather than Dartmouth's statistical ones is examined, the conclusions are the opposite—physicians (both specialists and generalists) are associated with a higher quality of health care.

In the same vein, to prove their claim that "patients in high-spending regions receive more care than those in low-spending regions but do not have better outcomes," Dartmouth researchers constructed "spending regions" with grossly dissimilar characteristics. For example, their "lowest-spending" regions included many of the nation's most sparsely populated states (eg, Washington, Oregon, Wyoming, Montana, Idaho, Utah, South Dakota, and Minnesota) while their "highest-spending" regions consisted of the nation's most densely populated cities (eg, Chicago, Detroit, Newark, New York, Philadelphia, and Miami). Montana versus Manhattan? How does one even begin to compare health care in such dissimilar places?

WHY DOES REGIONAL VARIATION EXIST?

Studies that we have recently conducted show that regional variation has a different basis. Rather than being caused by greedy specialists, regional variation results from the convergence of two fundamental economic processes, one at the community level and the other at the individual level. At the community level, regions with greater economic capacity have more technologically advanced facilities and a broader range of services; more wealth begets more services. At the individual level, use of health care services relates inversely to personal income; the poor use the most, and they have the poorest outcomes.

These intersecting dynamics come together most dramatically in dense urban areas, where extremes of affluence and poverty coexist. There and elsewhere, variation in the magnitude of the affluence-poverty nexus explains virtually all of the variation in medical care among regions of the country. Rather than impeding growth of the nation's physician workforce based on the mistaken assumption that usage variation is caused by too many physicians employing too many services, efforts should be made to train more physicians in order to reduce future shortages and enable physicians to respond to the growing demand for health care across all income categories.

EXPANDING GME MUST BEGIN NOW

Because the projected shortages will be so substantial— 200,000 too few physicians by 2020 to 2025—the response also must be substantial, and 10,000 PGY-1 positions should be added by 2020. Reaching this goal will require efforts on two fronts: funding and programming.

On the funding front, Medicare's support of GME must be reexamined. Initially established more than 40 years ago when Medicare began, it has since grown unchecked and is fraught with inconsistencies and ambiguities. Although thoughtful critics have commented and recommended changes, there has never been a broad-based reexamination of Medicare GME in the context of national health care goals and economic realities. Such a dialogue is sorely needed and should include program directors, hospital administrators, deans, MedPAC (Medicare's advisory body), politicians, and others. The discussion could take years, as it should, but unfortunately time is scarce.

A decade ago, policy leaders were convinced that surpluses were imminent and capping residency positions was an easy solution. Removing these caps is far more complicated, but that is exactly what is necessary. At the same time, a framework should be created for examining the GME funding formula, recognizing that it must change, but that change must be gradual.

The second front concerns residency programs. Expanding residency training capacity will require new or expanded programs with the necessary depth of faculty, breadth of patients, and quality of education. Here, too, dialogue is critical. It should involve specialty societies, specialty boards, and both the Accreditation Council on Graduate Medical Education and the AOA, which separately accredit MD and DO residency programs. Many questions exist. How much can current programs expand? How many institutions have the necessary case material and supervisory capacity to establish new programs? How much training time is enough for physicians whose training is, in fact, lifelong? And, most importantly, how can the necessary growth be fostered?

A FUTURE WITH TOO FEW PHYSICIANS

Finally, can a projected shortfall of 200,000 physicians by 2020 to 2025 be prevented, even with the best efforts? Sadly, the answer is no. Even if it were possible to add 10,000 more PGY-1 positions by 2020, the gap will exist for decades.

The stagnation of the past decade has accomplished what many hoped for—it has reduced the number of specialists, which will forever change the practice of medicine. What are some of the likely consequences? The first is the transition of basic primary care to a nursing discipline, as shortages in specialty medicine draw larger percentages of medical graduates. The second is a widening gulf between access to care for affluent urban dwellers and access to care for those who have low incomes or live in rural communities. The third is a deepening chasm between physicians and patients, as shortages of physicians limit the time available for each patient and as technical demands force physicians to devote more of their time to the mechanics of care. In ways never imagined, shortages are redefining the ways that physicians practice. Corrective action is long overdue—for our patients and for our profession.