The Council on Graduate Medical Education's 16th Report to Congress on the physician workforce offers "a great deal of precision," but it missed the mark in areas that are key to ensuring accurate predictions of health care workforce needs.
That's the conclusion made in an Annals of Family Medicine article, "COGME's 16th Report to Congress: Too Many Physicians Could Be Worse Than Wasted." Among co-authors of the article, published in the May/June issue of Annals, are Robert Phillips, M.D., M.S.P.H., director of the Robert Graham Center in Washington; Martey Dodoo, Ph.D., senior economist at the Graham Center; and Larry Green, M.D., senior scholar in residence at the Graham Center.
The COGME report, begun in 2003 and finalized this year, predicts an overall physician shortage in 10 to 15 years and recommends increasing medical school enrollment in the next decade by 15 percent over 2002 levels; residency training capacity should be boosted by 3,000 positions by 2015. The report dropped numerical recommendations made in earlier reports regarding which specialties should be encouraged. Rather, physician specialty distribution should derive from market forces, and "a rigid national numerical target is not recommended," it states.
Therein lies the problem. By relying on market forces, the COGME report doesn't address the expectations for tomorrow's physician workforce, said Phillips and his co-authors. The future workforce must meet patients' future needs, which will focus increasingly on chronic care management and prevention of illness and disability.
Other researchers agree. Market forces -- driven more by physician income than by patients' medical needs -- likely will continue to promulgate the current fragmentation and inaccessibility problems plaguing today's health care system, according to Barbara Starfield, M.D., M.P.H., professor in the Johns Hopkins University Bloomberg School of Public Health, Baltimore, and her co-authors.
"Increasing the supply of specialists will not improve the United States' position in population health … and is likely to lead to greater disparities in health status and outcomes," Starfield wrote in "The Effects of Specialist Supply on Populations' Health: Assessing the Evidence" (PDF file: 11 pages / 132 KB. More about PDFs.) in the March 2005 Health Affairs.
Such a trend works against America's stated health goals: to prevent illness and disability, increase accessibility to physician services in underserved urban and rural areas, and contain health care costs, according to the Annals article. "Producing more doctors to do the same things will compete for resources, consume more of our gross domestic product and likely have little impact on the disparities in health and health care well documented in the U.S.," the authors wrote.
David Goodman, M.D., professor of pediatrics at the Center for Evaluative Clinical Studies at Dartmouth Medical College in Hanover, N.H., agrees. The total growth in physician supply does not improve distribution into underserved areas, he reported in "Twenty-Year Trends in Regional Variations in the U.S. Physician Workforce," (PDF file: 8 pages / 216 KB. More about PDFs.) published in the Oct. 7, 2004, Health Affairs.
Regions with low physician-to-population ratios 20 years ago attracted more physicians as the total number of physicians grew. However, those gains were small compared with the growth in high-ratio areas.
"The majority of additional physician labor located in areas with an already large supply," wrote Goodman. Moreover, "High intensity of medical treatment is not associated with better quality or access to care, nor with slower declines in functional health status or lower mortality."
Thus allowing market forces to determine the number and specialty training of future doctors could waste resources in both medical education and patient care, said the authors of the Annals article.
"Great care should be taken before implementing additional enlargement of the U.S. workforce," they wrote. "An excess of physicians may produce no gains in population health even as the effort to produce them starves education and other policy options that are critical to health."
