a special program of the National Emergency Medicine Association (NEMA) 

Week: 565.7 Guest: Dr. Jordan Cohen, President, Association of American Medical Colleges Topic: Why we have a surplus of doctors Producer/Host: Steve Girard

NEMA: Six of the nation's premier medical organizations came together recently to expose what they believe is a pending surplus of physicians...and make recommendations on how to change the situation. The consensus statement on the state of physician numbers was issued by the American Medical Association, American Association of Colleges of Osteopathic Medicine, the National Medical Association, the American Osteopathic Association, the Association of Academic Health Centers, and the Association of American Medical Colleges. Teaching hospitals, trying to fill a community's needs, and benefiting from a federal stipend for residencies, offer about 25 thousand positions each year...which are necessary for a med school graduate to become a licensed doctor. About 17 thousand of those spots are taken by U.S. medical school graduates, the remaining 8 thousand by graduates of foreign med schools. Dr. Jordan Cohen, president of the Association of American Medical Schools, says 25 thousand resident positions are too a time when it seems our evolving health system is demanding fewer doctors....

COHEN: And those analyses have been quite convincing, to suggest that as the country moves more and more toward a managed care mode of organizing health care services, the need for physicians, particularly for highly specialized physicians, is significantly less than has been the need in the previous arrangement...the fee-for-service kind of arrangements. The reason for that is that managed care does a lot of its management and creates much of the savings that are attributed to managed care, through a more organized way of utilizing specialized physician that the savings that are created by managed care come largely from the reduction in hospitalizations, and the reduction in referrals to various kinds of specialties that are limited according to the perceived needs rather than the simple election on the part of the patients. Now one can argue, and I think quite reasonably argue whether that's the right kind of medical care for this country, but it certainly, as far as the eye can see, the managed care approach to cost containment and to organizing medical care services is certainly going to be with us and seems to be expanding, and is likely to continue to expand for some period of time. So, that's one issue. Another is the recognition that many other kinds of health care professionals: nurses, nurse practitioners, physician's assistants, pharmacists, and a host of others, are also coming into the managed care organizations and are doing a lot of health care services that heretofore had been performed, not exclusively, but certainly largely, by physicians. So the more the health care needs of the country are being taken care of by non-physician health care providers, obviously the fewer physicians will be needed as well. So I think, personally, and this is certainly true of all the organizations that signed on to this consensus statement, that the evidence is quite compelling that the country is going to be facing a significant oversupply of physicians, if it doesn't already have one, it will very soon have one, just on the basis of the physicians that are in the pipeline. Now let me add to that, if I could, one other thought that's important for people to recognize....clearly, if we were faced with a choice between having too few physicians and having too many physicians, there's no question about where the right answer to that would be. We clearly would want to have more physicians than we need rather than having too few physicians...because of the obvious implications of having a physician shortage...but the issue that we're facing is not one of that stripe, it is rather, "Are we facing an ample supply of physicians, or a really, very large surplus of physicians"?...and as I've indicated, most students of this area strongly believe the latter. And that being the case, we think there are steps that should be taken to modify that.

NEMA: That does kind of tie into the next two things I wanted to address...the first is the general thinking that the more doctors we have...the better the under served in our country will be. And given that we are headed into a great oversupply of physicians, what will the effects of that situation be?

COHEN: What about the need for physicians in areas that are still under served? And that's an extremely important issue, and one that the consensus document addresses. It is true, and this is why the assertion that we have a doctor oversupply strikes many people as being bizarre, because they're living in areas where, in fact, there aren't enough doctors, or they have to wait a couple of months to get a doctor's appointment. How could there be a doctor surplus if that's the case? Well, the fact is that in the face of this oversupply of physicians, we have another major problem in this country... and that is a geographic maldistribution of physicians. We do not have an even distribution of physicians across the population. There are some areas, notable the suburbs of large cities, where there is clearly an ample supply of physicians, but there are other areas, particularly remote, rural areas where physicians services are either very limited or, in fact, nonexistent altogether. So the question is, "how do we address that problem"? Implicit in the previous public policy, if you will, has been the notion that if we just make more doctors, they will eventually go to the areas where there are still under served people. And that has proven to be simply a false assumption... because the reasons that areas of the country, rural areas in particular, are under served by physicians, has to do with a lot of the disincentives that exist for physicians moving in those areas. And they include the fact that many physicians, most physicians by now, are married to a spouse who also has a career, or certainly aspirations for employment... and in many instances, those opportunities are not available in some of these remote areas. There's the education issue of how children of the physician is going to be educated, and the desire to be in an area where educational opportunities are available, there's the issue of professional isolation...of physicians working in areas where there are no other physicians around to interact with and to provide the kind of professional support desire, in fact, need. And the answer to that dilemma is to focus programs specifically on that set of issues, not just make more doctors in hope that they will eventually filter into these remote areas. Your second question had to do with, "what's wrong with having too many doctors...why is that a problem"? fact, many economists have argued that if you have more doctors, it'll drive the prices down, and it'll be a good thing for the country to have a great surplus of physicians because the cost of health care will fall as a result of that. Well, the evidence actually is just the contrary, as a matter of's been shown time and again, if you add doctors to an area where you already have an ample supply, more doctors create more demand for their services. There's almost an unlimited desire for physicians' services when they're available, it's quite another thing to ask whether those physicians' services are all needed...that's another debate. So, the notion that more doctors will produce lower health care costs is actually just the other way around... the more doctors we produce, the predictable result will be that health care costs will actually rise. So that's one issue. Another has to do with how attractive the medical profession will be under circumstances of underemployment, or frank unemployment of physicians. One of the things that this country has gotten used to...quite happily used the fact that we have been able to attract to the medical profession the very most talented young people that our country produces, and we have never had in this country the prospect of unemployment of physicians. And one has to ask whether or not we're still going to be able to attract the kind of talent the country has become accustomed to, and I think deserves to have as it's doctors... whether we're going to be able to attract that talented group of people into a profession when the prospects for ultimate employment are not certain...and we'd also like to avoid medicine becoming a less attractive career for fear that it might attract less talented individuals. So those are some of the arguments that are in play in terms of disadvantages of having a large surplus of physicians.

NEMA: The consensus statement on this issue recommends the number of entry level positions at teaching hospitals be brought back in line with the number that graduate from U.S. med schools, that resident positions be supported by a national fund rather than by Medicare only, and that a physician advisory panel be established to monitor the size and makeup of work force. What do you feel are the chances that Congress will soon address the issues your Association and the other organizations have outlined and expressed concerns about...?

COHEN: The fact that this consensus has been reached broadly, within these organizations representing such a broad spectrum of medicine, will hopefully have an impact on the awareness of policy makers and lawmakers as to the issues that we've been discussing. Is there a prospect for a very rapid response to this? I don't see it at the moment...there's no vehicle currently in Congress, no law, no piece of legislation that would accomplish what we're talking about. But I think we are seeing more receptivity to these ideas, and I would hope that within some reasonable period of time we'd get some response.

NEMA: Dr. Jordan Cohen, President of the Association of American Medical Colleges. Under the consensus recommendations, with fewer federally funded resident positions, foreign medical school graduates could complete their education here, but would be obligated to return to their country to practice.

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NEMA: Thanks for joining us for today's program. If you have any comments or suggestions, contact this station. Or visit our home page at: a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I'm Steve Girard at The Heart of the Matter.