In our first installment of this series on medical care delivery capacity and utilization in the United States (DMUmagazine, summer 2011), we examined key medical system resources and usage patterns among the seven largest developed economies in the world. Curiously, data for the U.S. suggest a relative scarcity of physicians, low use of physician consultations and low hospital inpatient utilization against comparable nations. In this issue, we examine physician supply in greater detail, with an emphasis on factors that influence total supply, productivity and availability.
America’s medical resources:
physician supply in the United States
By Richard F. Belloff, D.B.A.; Kari Dyjak, M.H.A.’17;
and Pamela Raye Bostwick, M.S.O.D.
IT IS SAID that the physician is the center of the medical care system. The analogy of a “quarterback” might also apply: Nothing significant happens in medicine without physician involvement in one way or another. For a nation that lavishes spending on health care, it would seem like the U.S. would be brimming with physicians, and patients would see their physician on a frequent basis.
Using available data from the Organisation for Economic Co-operation and Development (OECD), we see that this is far from being the case. As Exhibits 1 and 2 illustrate, America’s overall physician supply is modest when compared with our global counterparts, and U.S. patients seem to be less willing (or able) to access their doctor.
However, U.S. physicians seem to excel in one area: earnings (Exhibit 3). U.S. physicians lead the world in compensation, and by a wide margin. We are experiencing the world’s highest levels of physician compensation coupled with low patient-to-physician “face time.” Generally speaking, one would consider this relationship as bad news.
While America’s physician supply has consistently increased over time, we are not “keeping up” with the growth experienced by our counterparts.
We have examined the underlying dynamics regarding physician supply, compensation and availability and have gleaned a number of factors that might account for the U.S. experience. Several of these factors may surprise you.
Like all of our cohort countries, U.S. physician supply has increased modestly over the past 15 years. However, as summarized in Exhibit 1, other countries have done better in this regard. Numerous factors impact the overall supply of physicians, including medical school capacity, graduation rates, immigration policies, medical licensing and residency practices. Of course, increasing physician supply takes time; there is no “quick fix” (Dill, 2008). This issue is explored in more detail below.
American medical school “capacity” has not increased sufficiently to meet the demands of an aging population.
Physician supply issues can be ameliorated or exacerbated by corresponding changes on the demand side. A shift in the age demographics within developed countries has increased the overall demand for physician services, and the U.S. is not unique in this regard (Dill, 2008).
One positive for the U.S. is that we have plenty of young, bright students who wish to enter the medical profession. Over time, applicant interest in becoming a physician has increased, in spite of the substantial costs and effort required (Dill, 2008).
However, the U.S. simply does not have adequate capacity to train all of the qualified students who want to become physicians. Currently, both medical school seats and graduate medical residency openings will simply not accommodate all applicants; in this regard, the U.S. compares poorly in our overall capacity to generate large numbers of medical school graduates (Exhibit 4).
In economic terms, we call this a “bottleneck” in that it inhibits the entire system from responding to increased patient demand. Over time, this bottleneck contributes to rising prices, access problems or both.
The U.S./Canadian medical education model is more expensive for the student and takes longer to complete.
Surprisingly, considerable variation exists among our cohort countries in how medical training is conducted, when it starts, how long it takes and where it takes place. Differences also exist in funding, in particular with the U.S. model, which relies on American students’ funding most of their education, largely through student loans.
The notable variation here is when medical training begins (Exhibit 5). In the U.S./ Canadian model, most programs require a bachelor’s degree to gain entrance. The student completes four years of medical school and then a three-year residency program. All told, training a primary care physician normally takes 11 years of post-high school education and residency training (Dyjak, 2012). Hence, most newly credentialed M.D.s and D.O.s will be nearly 30 years old before they begin their medical practice.
European students can normally enter medical school directly from high school. Generally, their medical training is shorter; in many cases the cost is heavily subsidized or tuition-free (Dyjak, 2012).
Consequently, European physicians start their practices at a younger age and with less debt (if any) than U.S. medical graduates. They also have potentially four to five more years of practice over the course of their professional lives. Overall, these factors can add significantly to the capacity of European physicians to meet the demands of an aging patient population.
Shifting demographics and cultural trends have lessened the lifetime “productivity” of the average U.S. medical graduate.
For some time now, the U.S. has been training a greater percentage of female physicians. This trend has clearly positive benefits, as the physician population reflects the composition of the patients they treat.
That said, over the course of a professional career, many women physicians are less “productive” when defined by how many patients that can be treated (Sibert, 2011). This lower productivity is tied to several distinct phenomena particular to women: maternity leave and child-rearing responsibilities. On average, female physicians will take time out from their careers for maternity leave and often return to work on a less than full-time basis. During these periods, they see fewer patients and are thus “less productive” compared to their male counterparts. Female physicians also tend to retire earlier, again reducing the sum total of patients they may see over a lifetime of practice (Sibert, 2011).
Another trend evidenced by both male and female physicians is a shift toward employment rather than solo practice. Overall, employed physicians tend to be less productive, working fewer hours and taking less off-hour call (“Physicians working fewer hours per week,” 2010).
So we see that even as physician supply has increased in the U.S., capacity to see patients per physician has been declining. These shifts further exacerbate supply/ demand problems even as the total physician supply appears to be going in the right direction (Dill, 2008).
Shifting demographics of an aging population may lessen the perceived shortage of primary care physicians but will increase the overall demand for physician services.
There have been many calls to increase the number of primary care physicians in the U.S. However, in the long run, this may well be an inappropriate strategy. As our population continues to age and family size tends to be smaller, the need for obstetricians, pediatricians and family practitioners actually diminishes. We will need more specialists that treat the diseases of aging. These specialties may include geriatrics, orthopedics, cardiovascular diseases, neurology and palliative care (“Aging associated diseases,” 2012).
Building medical schools and residency programs takes time!
It seems clear that the U.S. needs to add medical school capacity over the next two decades (Dill, 2008). The good news is that there are new U.S. medical schools currently under development (Whitcomb, 2009). That said, building new medical schools requires large amounts of capital, and the process from conception to completion can take many years.
Moreover, staffing these medical schools with basic science and clinical faculty is challenging. For a nation that is concerned about having sufficient numbers of physicians to treat patients, asking them to train new physicians as well is problematic (Dill, 2008).
Noteworthy is that for international medical graduates (IMGs), the U.S. is seen as an attractive place to practice, and demand to immigrate here is strong (Vognild, 2009). Hence, policymakers may need to streamline the process for IMG immigration.
At the same time, residency training programs in U.S. hospitals could be increased to accommodate the larger numbers of recent M.D./D.O. graduates needing to complete their medical education. Again, these changes require additional capital and, of course, clinical faculty.
For a nation that spends so much of its income on health care, it is hard to accept the possibility of a physician shortage. That said, there are disturbing trends in this regard, and health policy makers should take note.
Richard F. Belloff, D.B.A., ACHE, is an assistant professor in DMU’s College of Health Sciences. He teaches in both the master of health care administration and master of public health programs. Kari Dyjak is a graduate student in DMU’s master of health care administration program. Pamela Raye Bostwick has a master’s degree in organizational development and is a former health care human resources professional. She currently conducts research in the health care administration field.
Aging associated diseases including Alzheimer’s, dementia and osteoporosis (2012). Retrieved Feb. 12, 2012, from www. disabled-world.com/health/aging/
Physicians working fewer hours per week (2010). Retrieved Feb. 16, 2012, from www.aafp.org/online/en/home/publications/news/news-now/professionalissues/ 20100315jamaworkinghours.html
Dill, M., & Salzberg, E. (2008). The complexities of physician supply and demand. Washington, DC: Association of American Medical Colleges.
Dyjak, K. (2012). Comparative medical education and the U.S. experience. Unpublished MHA independent research paper, Des Moines University.
Vognild, E. A review of international medical graduates in American medicine. Retrieved Feb. 16, 2012, from www.aspr.org/displaycommon. cfm?an=1&subarticlenbr=512
Sibert, K. (June 11, 2011). Don’t quit this day job! New York Times.
Whitcomb, M. (2009). New and developing medical schools. Georgetown: Josiah Macy Jr. Foundation.