Physician supply

Physician supply refers to the number of trained physicians working in a health care system or active in the labour market.^[1] The supply depends primarily on the number of graduates of medical schools in a country or jurisdiction, but also on the number who continue to practice medicine as a career path and who remain in their country of origin. The number of physicians needed in a given context depends on several different factors, including the demographics and epidemiology of the local population, the numbers and types of other health care practitioners working in the system, as well as the policies and goals in place of the health care system.^[2] If more physicians are trained than needed, then supply exceeds demand; if too few physicians are trained and retained, then some people may have difficulty accessing health care services. A physician shortage is a situation in which there are not enough physicians to treat all patients in need of medical care. This can be observed at the level of a given health care facility, a province/state, a country, or worldwide.

Globally, the World Health Organization (WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide,^[3] especially in many developing countries. Developing nations often have physician shortages due to limited numbers and capacity of medical schools and because of international migration: physicians can usually earn much more money and enjoy better working conditions in other countries. Many developed countries also report doctor shortages, especially in rural and other underserved areas. For example, shortages are being discussed in the U.S., Canada, the U.K., Australia, New Zealand, and Germany.^[4][5][6][7]

Several causes of the current and anticipated shortages have been suggested; however, not everyone agrees that there is a true physician shortage, at least not in the United States. On the KevinMD medical news blog, for example, it has been argued that inefficiencies introduced into the healthcare system, often driven by government initiatives, have reduced the number of patients physicians can see; by forcing physicians to spend much of their time on data entry and public health issues, these initiatives have limited the physicians' time available for direct patient care.^[8]

Determinants

Economic Theory and Trends

Patients queue to see a doctor in South Sudan (source: Merlin)

Anything that changes the number of available physicians or the demand for their services affects the supply and demand balance. If the number of physicians is decreased, or the demand for their services increases, then an under-supply or shortage can result. If the number of physicians increases, or demand for their services decreases, then an over-supply can result.

Substitution factors can significantly affect the production of physician services and the availability of physicians to see more patients. For example, an accountant can replace some of the financial responsibilities for a physician who owns his or her own practice, allowing for more time to treat patients. Disposable supplies can substitute for labor and capital (the time and equipment needed to sterilize instruments). Sound record keeping by physicians can substitute for legal services by avoiding malpractice suits. However, the extent of substitution of physician production is limited by technical and legal factors. Technology cannot replace all skills possessed by physicians, such as surgical skill sets. Legal factors can include only allowing licensed physicians to perform surgeries, but nurses or doctors administering other surgical care.^[9]

Demand of physicians is also dependent on a country's economic status. Especially in developing nations, health care spending is closely related to growth of their Gross domestic product (GDP). Theoretically, as GDP increases, the health care labor force expands and in turn, physician supply also increases.^[10] However, developing countries face additional challenges in retaining competent physicians to higher-income countries such as the United States, Australia, and Canada.^[11] Emigration of physicians from lower-income and developing countries contribute to Brain drain, creating issues on maintaining sufficient physician supply. However, higher-income countries can also experience an outflow of physicians who decide to return to their naturalized countries after receiving extensive education and training, without ever benefiting from their gained medical knowledge and skill set.

Number of physicians trained

Increasing the number of students enrolled in existing medical schools is one way to address physician shortage,^[12] or increasing the number of schools,^[13] but other factors may also play a role.

Becoming a physician requires several years of training beyond undergraduate education. Consequently, physician supply is affected by the number of students eligible for medical training. Students that do not finish earlier levels of education, including high school dropouts and those that leave university without an undergraduate degree or associates degree, do not qualify for entrance to medical school. The more people that fail to complete the prerequisites, the fewer people that are eligible for training as physicians.^[1][14]

In most countries, the number of placements for students in medical schools and clinical internships is limited, typically according to the number of teachers and other resources, including the amount of funding provided by governments.^[1] In many countries that do not charge tuition payments to prospective physicians, public funding is the only significant limitation on the number of physicians trained. In the United States, the American Medical Association says that federal funding is the most important limitation in the supply of physicians. The high cost of tuition combined with the cost of supporting oneself during medical school discourages some people from enrolling to become a physician.^[15] Limited scholarships and financial aid to medical students may exacerbate this problem,^[16] while low expected pay for practicing physicians in some countries may convince some that the cost is not appropriate.^[17]

It has been speculated that politics and social conditions can sometimes motivate medical student placements. For example, racial quotas have been cited in some places as preventing some people from enrolling in medical school.^[18] Racial discrimination and gender discrimination, either overt or disguised, have also been cited as resulting in people being denied the opportunity to train as a physician on the basis of their race or gender.^[19]

Number of physicians working

Once trained, the current supply of physicians can be affected by the number of those who continue to practice this profession. The number of working physicians can be affected by:

• The number of medical school graduates who choose to practice as a physician for their career - for example, some might choose instead to work in medical research, public policy or other areas where medical expertise is required; or they may choose a job where no medical knowledge is required.^[1]
• The number of medical school graduates who fail to obtain (or fail to re-qualify for) their license or other professional requirements for legal practice.
• The number of medical school graduates who are unable to find work of their choice - for example, studies in Mexico have found high levels of unemployment among trained physicians in urban areas, even while large rural populations remain medically underserved.^[20]
• The number of physicians who emigrate abroad for better economic and social conditions, also referred to as "Brain drain".
• Changes in the specialty balance - for example, in many countries, the balance is shifting away from medical students becoming general practitioners (GP) because of more attractive pay for medical specialists,^[21] leading to shortages of physicians for primary care.
• Changes in the practice environment - for example, changing legal conditions have been cited in the US, Canada and elsewhere as inciting physician attrition, notably the adoption of laws that require doctors to refer for certain procedures (such as abortion or sex change) with which the doctors disagreed on moral or religious grounds.^[22]
• The number of physicians who retire.
• The number of physicians who work part-time - in particular, while the number working only part-time does not affect the overall number of physicians, it does affect the supply of physician services (e.g. in terms of full-time equivalents). Many physicians may retain their professional license while working part-time or after retiring; consequently, the reported number of active physicians is probably overstated in many jurisdictions.^[23]

Demand for physician services

The demand for physician services is influenced by the local job market (e.g. the number of job openings in local health care facilities), the demographics and epidemiology of the population being served, the nature of the health policies in place for health care delivery and financing in a jurisdiction, and also the international job market (e.g. increasing demand in other countries puts pressure on local competition). As of 2010, the WHO proposes a ratio of at least one primary care physician per 1000 people to sufficiently attend the basic needs of the population in a developed country.^[2]

For example, population ageing has been attributed with increased demand for physician services in many countries, as more previously young and healthy people become older with increased likelihood of a variety of chronic medical conditions associated with ageing, such as type 2 diabetes mellitus, hypertension, osteoporosis, and some types of cancers and neurodegenerative diseases.

Patient Protection and Affordable Care Act (U.S.)

In the United States, the Patient Protection and Affordable Care Act has expanded health insurance coverage and access to an estimated 32 million United States citizens, increasing the demand of physicians, especially primary care physicians, across the country.^[24] Expanded coverage is predicted to increase the number of annual primary care visits between 15.07 million and 24.26 million by 2019. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase.^[25]

The PPACA may have also affected the supply of Medicaid physicians. Incentives and higher reimbursement rates may have increased the number of physicians accepting Medicaid patients leading up to 2014. With the expansion of Medicaid and a decrease in incentives and reimbursement rates in 2014, the supply of physicians in Medicaid may drop substantially, fluctuating the supply of Medicaid physicians. A study examining variation between states in 2005 showed that average time for Medicaid reimbursements was directly correlated with Medicaid participation, and physicians in states with faster reimbursement times had a higher probability of accepting new Medicaid patients.^[26]

Effects of physician shortage

Nations identified with critical shortages of physicians and other health care workers

Physician shortages have been linked to a number of effects, including:

• Lower quantity of medical care for patients, thereby limiting the ability of health systems to meet primary health care goals, such as the Millennium Development Goals.^[3]
• Lower quality of medical care for patients, due to shorter doctor visits.^[27]
• Increased workload and too many patients per doctor resulting in overworked and sleep-deprived doctors, thereby compromising patient safety.^[28][29][30]
• Unnecessary patient deaths while waiting for health care.^[31]
• Higher prices for practicing physicians due to less competition, by the rules of supply and demand in market-driven health care economies.^[32]
• Lower medical costs to consumers. Unlike other industries, as market share grows and competition declines, physicians are less inclined to gross up the frequency or intensity of medical services to maximize reimbursement per limited patient encounter.^[33]

Proposed solutions

A number of solutions, including short-term fixes and long-term solutions, have been proposed to address physician shortages. Some have been tested and applied in national health workforce policies and plans, while others remain subject to ongoing debate.

• Increase the number of medical graduates through increased recruitment of minority students domestically, as well as intensified recruitment of foreign-trained graduates (also known as International Medical Graduates or IMGs).^[34]
• Increase the number of medical schools and classroom sizes.^[35]
• To address physician shortages in rural areas, develop, organize, and locate medical schools to increase the propensity of physicians entering rural practice.^[36] Accepting medical school applicants from rural areas can also increase the proportion of rural physicians.
• Higher medical school enrollment limits.^[37][38]
• Loosen the requirements for entry to medical school, such as eliminating the need for a pre-med bachelor's degree as required in some juridisctions, thereby making the education path more attractive for potential students.^[39]
• Reduce the costs for students to attend medical school, such as through subsidies for (free or reduced) school tuition and more financial aid.^[40]
• Legislate Tuition-Increase Caps for Medical Schools^[41]
• Increase the role of the National Health Service Corps, which help provide debt-relief opportunities for primary care physicians.^[42]
• Increase the number of placements in medical residency following medical school graduation.^[43]
• Improve the political, social and economic conditions in developing countries to prevent brain drain, including fewer wars and conflicts.
• Make better use of other categories of health care professionals, including more Osteopathic Physicians (DOs), nurse practitioners, physician assistants, clinical officers, community health workers, and others.^[44][45]
• Improve physician wages, such as through privatization of health care systems thereby enhancing market attractiveness for people to become doctors.^[46][47][48]
• Improve physicians' perspectives of their future career path, such as though reduced use of temporary employment contracts^[20]
• Provide better incentives for physicians to practice in rural and medically underserved areas - for example, in the U.S., this could include expanding the National Health Service Corps for rural areas.^[45]
• Ensure better practice conditions for physicians - for example, medical liability reforms have been cited as an important factor in the U.S.^[49]
• Increase the use of e-mail and telephone consultations, which allow physicians to treat patients seeking more traditional forms of care.^[50]
• In the United States, to better accommodate the elderly and their demand for healthcare services, increase medical and nursing training in geriatrics and gerontology.^[51]
• Increase use of health care or medical teams (i.e. nurse practitioners and physician assistants) to shift physician workload and allow for increased physician times with patients.^[50]

Global View

In the US alone, the Association of American Medical Colleges (AAMC) estimates a shortage of 91,500 physicians by 2020 and up to 130,600 by the year 2025. However, a bias would clearly exist in their estimates as expanding medical education serves the direct financial needs of the AAMC.^[52] As previously mentioned, the World Health Organization (WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide.^[3] The WHO produced a list of countries with a “Human Resources for Health crisis”. In these countries, there are only 1.13 doctors for every 1,000 people. In the United States, there are approximately 2.5 doctors for every 1,000 people.^[53] One quarter of physicians practicing in the United States are from foreign countries. Thousands of foreign doctors come to practice in the United States each year^[54] while only a few hundred doctors from the United States leave to practice in foreign countries even short-term.^[55]

There are various organizations that assist United States physicians and others in serving internationally. These organizations may be filling temporary or permanent positions. Two temporary agencies are Global Medical Staffing and VISTA staffing. A locum doctor will serve in the temporary absence of another physician. These positions are typically 1-year placements but can vary by location, specialty, and other factors. Agencies that attempt to provide international aid in various ways often have a strong medical component. Some of these organizations helping to provide medical care internationally include Reach Out Worldwide (ROWW), Doctors Without Borders (Médecins Sans Frontières), Mercy Ships, the US Peace Corps, and International Medical Corps.

Additionally, smaller non-profits that work regionally around the world have also implemented task-shifting strategies in order to increase impact. Non profits, such as the MINDS Foundation educated community health workers or teachers to perform simple medicinal tasks, thereby freeing up health professionals to focus on more pressing concerns.^[56]

See also

• Health policy
• Health workforce
• Nursing shortage
• Primary care service area

References