July 1995 Bulletin

Doubts U.S. work force commission will occur

But physician supply problem persist

The highly discussed national "solution" to altering the supply of primary care and specialist physicians is dead, but the problems linger, said B. Jerald McClendon, director of the office of research and planning, Bureau of Health Professions, Department of Health and Human Services.

McClendon reminded the National Orthopaedic Leadership Conference discussion on physician work force in May that the 1994 national health care reform debate produced a number of studies by commissions, foundations, and others which came to a general consensus that there was no national physician work force policy. Many proposed a national commission that would develop policies to insure that 50 percent of the medical school graduates would be primary care physicians; there would be a reduction to 110 percent from 140 percent in the percentage of medical school graduates trained in graduate medical school. The physician supply policy would be implemented through a federally-administered graduate medical education allocation system.

Basic problems

"That didn't happen and it won't happen," he asserted. But, he added, the basic problems of the number of physicians and the physician-population ratio are still here.

McClendon pointed out that between 1950 and 1970, the ratio of physicians to the population was about level, although the number of physicians grew to 240,000 from 170,000. Because of a perceived shortage of physicians in the 1960s, the number trained was increased. By 1970, there were 114 physicians per 100,000 persons. Currently, there are 190 physicians per 100,000 and the trend line is rising.

In 1960, he said, there were about 60 generalists per 100,000 and 60 specialists per 100,000. "Since then the growth of generalists has been essentially flat while the number of specialists has increased tremendously," McClendon said. "If we continue on the current course, by the year 2020, there will be 148 specialists per 100,000 people and 66 generalists per 100,000 people.

He pointed out that from 1960 to 1970, the percentage of active primary care physicians declined from 50 percent to about one-third, and reached exactly one-third in 1975. "We've gone almost 20 years at one-third generalists and two-thirds specialists," he said.

Need a policy

"Most people will argue that this is the market stabilizing. If we want to increase generalists to 40 percent or 50 percent, you will need a policy to force it to that level."

Although some observers believe that market conditions will eventually produce the desired change in the ratio, McClendon said that considering how stable the ratio has been, "statisticians would wonder how fast it will happen."

There have been a number of studies looking at the future requirements of primary care and specialist physicians. The work of his statisticians indicates that at least a 40-60 or probably 50-50 ratio of generalists and specialists and a cutback in GME training to 110 percent from 140 percent "makes sense."

He cautioned the audience that the findings of these studies are for specialists in the aggregate and don't apply to any specific specialty. He explained that some specialties are in surplus, some have shortages, and some are in balance.

McClendon offered the audience a view of how to look at future requirements of orthopaedic surgeons. Between 1975 and 1992, the number of self-designated orthopaedic surgeons reported by the American Medical Association's Physician Characteristics and Distribution in the U.S. (PC&D) increased about 560 a year. In 1992, the PC&D indicates there were about 21,000 self-designated orthopaedic surgeons.

There is a wide range of estimates of how many orthopaedists are needed - from as few as 3.9 per 100,000 in some HMO settings to an upper range of 7.9 per 100,000.

In a mature physician specialty, the retirement and death rate is about 2 percent a year. He used a 1 percent figure for the ranks of orthopaedic surgeons because the specialty grew rapidly only in the last 15 years.

Need reduction

McClendon said that if there are about 20,000 self-designated orthopaedic surgeons and if there is a 1 percent retirement-death rate, there is a need for 200 new orthopaedic surgeons a year to replace those who leave. Assuming there is a need for eight orthopaedists per 100,000 persons and the population growth of 2 1/2 million a year, there would be a requirement of 200 orthopaedic surgeons to take care of the additional population. That's a total requirement of 400 orthopaedists, compared with 560 to 600 now being added to the ranks, he said. That means, there should be a reduction in the number of orthopaedists being trained.

In the year 2000, the number of orthopaedists may have climbed to 22,000 and the attrition rate of orthopaedists may have increased to 1.3 percent. To replace those orthopaedists and cover the population growth, it may require 500 orthopaedic surgeons, which is still a small surplus of the current number of orthopaedists being added to the ranks.

However, by the year 2010, the annual requirement may have climbed to 600 new orthopaedists a year. If there was a previous reduction of training of orthopaedists, producing 450 or 550 a year, the production of new orthopaedists would have to be increased.

McClendon stressed that projecting the future requirements for physicians was an art, not a science.

Two graphs are available depicting the trend of orthopaedic training.
Source: American Academy of Orthopaedic Surgeons, research department

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