Context Physician shortages are appearing, yet controversy about their significance
and uncertainty about their remedy exist.
Objectives To sample the perceptions of medical school deans and state medical
society executives about the adequacy of physician supply, to determine the
perceived impact of any shortages on medical schools, and to assess the capacity
of medical schools to expand.
Design, Setting, and Participants Medical school deans in the United States and Puerto Rico were surveyed
by means of a structured questionnaire, and officials of US state medical
societies were queried by means of open-ended telephone interviews. Information
was obtained from 58% of medical school deans and 86% of state medical society
Main Outcome Measure Reported perceptions of shortages or surpluses of physicians by specialty
and plans to increase medical school class size.
Results Approximately 85% of both deans and medical society respondents perceived
shortages of physicians, usually in multiple specialties, while 10% perceived
surpluses, usually coexisting with shortages. Among deans reporting shortages,
83% described a negative impact on their schools. Recent or planned increases
in class size were reported by 27% of deans and expansion capacity by another
34%, but 7% noted recent decreases in class size. Applied generally, these
changes in class size could yield 7.6% additional matriculants annually.
Conclusions Physician shortages are prevalent and they are negatively affecting
medical schools. Little capacity exists to alleviate these shortages through
class size expansion.
Analyses of trends in health care indicate that, at current rates of
production, there will be too few physicians to meet future needs.1,2 This conclusion is supported by warnings
of physician shortages by some medical specialty organizations3-6 and
state medical societies7-9 as
well as by signals from the marketplace, which indicate that young physicians
are in greater demand10-12 and
that patients are having greater difficulty in accessing physicians.13,14 Two years ago we published an analysis1 that projected substantial physician shortages over
the next 2 decades. Shortly thereafter, the Association of American Medical
Colleges changed its longstanding position from one that called for a reduction
in residency output to avert inevitable surpluses15 to
one that acknowledged neither surpluses nor shortages.16 In
September 2003 the Council on Graduate Medical Education (COGME) fully reversed
its earlier position, calling instead for an expansion of medical training
at the undergraduate and graduate levels.17 Nonetheless,
strong sentiments favoring restrictions on physician supply persist.18-20 Amid these cross-currents,
we solicited the perceptions of medical school deans and state medical society
officials about the status of physician supply in their regions. We also inquired
of deans whether, if more physicians were needed, their medical schools could
The first survey, conducted by telephone and Internet, assessed the
perceptions of deans of allopathic medical schools about the status of physician
supply in their regions, the effects of any supply imbalances on the ability
of their medical schools to accomplish their missions, and the potential for
their schools to change class size. A total of 73 (58%) of 126 deans responded.
Seventy of these responses were from deans of mainland medical schools (35
states plus the District of Columbia) and 3 were from deans of schools in
Puerto Rico. The 70 responding mainland schools were similar to nonresponding
schools in terms of their regional distribution and the proportion that were
public or private.
The second survey, directed to state medical societies, consisted of
a telephone interview of a member of the society's executive staff. A single,
open-ended question was asked: "Are there any problems with physician supply
in your state?" Responses were supplemented by information from published
this manner, information was obtained from 44 (86%) medical societies (43
states plus the District of Columbia). Those states from which no responses
were available were Alaska, Florida, Hawaii, Louisiana, Montana, North Dakota,
and South Carolina.
Medical School Deans: Perceptions of Shortages and Surpluses
Of the 70 responding deans from mainland schools, 62 (89%) cited shortages
of physicians in at least 1 specialty (Table 1). Six deans (9%) also reported surpluses, and 8 others (11%)
were either uncertain or believed that there were no shortages or surpluses.
Respondents who cited shortages usually identified 3 to 4 specialties. The
severity of shortages was characterized as minimal or anecdotal in 12% of
cases but critical in 35%. In 7 instances, deans from 3 or more medical schools
in a single state responded, and good agreement existed both in terms of the
particular shortages of specialties cited and the severity of the shortages.
Deans from the 3 Puerto Rico schools reported fewer shortages and more surpluses.
Specialists. The most frequently cited shortages
were in anesthesiology (50%) and radiology (44%) (Table 1). Shortages of medical subspecialists were noted by 39%
of responding deans, usually in multiple subspecialties, with shortages in
cardiology, gastroenterology, and geriatrics cited most frequently. Other
nonsurgical specialties that often were cited included dermatology, psychiatry,
emergency medicine, and the pediatric subspecialties. Among the surgical disciplines,
shortages were noted in both general surgery (17%) and the surgical subspecialties
(21%). The severity of various shortages generally corresponded with the frequency
with which they were reported. Conversely, 3 deans reported surpluses in cardiology
Primary Care Physicians. Shortages within the
adult primary care disciplines were cited by 30% of responding deans. Whereas
shortages in general internal medicine tended to be referred to as "severe,"
those in family practice tended to be "medium" or "minimal," and 2 deans (3%)
noted surpluses in family practice. Only 6% to 7% reported shortages in general
pediatrics and obstetrics/gynecology.
Medical Schools' Missions. Fifty-two of the
deans from the mainland medical schools who reported shortages commented on
the impact that such shortages were having on the missions of their schools.
Eighty-three percent noted problems, most often in the areas of clinical teaching
and patient care. Specific issues included difficulty in faculty recruitment
and retention, pressure on faculty salaries, reduced clinical volume and clinical
revenue, insufficient numbers of patients for clinical teaching, insufficient
preceptor sites, inadequate faculty time for teaching, and threats to the
integrity of residency and fellowship programs and to research.
State Medical Society Executives: Perceptions of Shortages and Surpluses
The 44 responses from state medical society executives were similar
to those of the deans, with 82% reporting shortages of physicians in at least
1 specialty. Only 5 executives (11%) cited physician surpluses, 2 in states
that also had shortages, and 11% were uncertain about the status of supply
in their states.
Specialists. Like the deans, medical society
respondents cited shortages among specialists more frequently than among primary
care physicians, but only slightly (61% vs 54%). However, shortages of specialists
were generally more severe. Physician shortages in medical subspecialties
were cited most often (43%); surgical subspecialists were cited by 30% and
shortages in general and/or trauma surgery by 14%. Six other specialties that
frequently were cited were anesthesiology, psychiatry, emergency medicine,
dermatology, radiology, and neurology, with the shortages in anesthesiology
and radiology being characterized as most severe. However, 4 medical society
respondents (9%) reported surpluses of specialists.
Primary Care Physicians. Half of the state
medical society respondents cited existing or developing shortages in family
practice and/or general internal medicine, although, as reported by the deans,
these shortages tended to be marginal or anecdotal, and 4 respondents (9%)
reported surpluses of primary care physicians. Shortages in obstetrics/gynecology
were noted by 25% of the respondents, but only 4% cited shortages in pediatrics.
Like the deans, many medical society respondents expressed concern about the
distribution of primary care physicians.
Capacity for Expanding Medical School Class Size
Current Expansion Plans. Responding deans from
59 mainland medical schools commented on the potential for expanding class
size. Expansions are already under way in 10 of these schools (17%), with
an average of 8 additional matriculants (equal to 8% of class size). Five
of these schools are planning additional expansions of 15% to 20%, and 6 others
are planning similar growth. In contrast, 4 schools have reduced class size
or are planning to do so by an average of 22%. The net of these changes is
equal to 2.1% growth in the number of matriculants among the 59 respondent
Future Expansion Potential. Of the 43 deans
of medical schools that have no current or near-term plans for expansion (or
that are planning decreases), 23 indicated that their schools could not expand.
The other 20 reported the ability to expand by an average of 22 students (19%),
which, averaged over the 59 respondents, is equivalent to 5.5% of the current
class size. Together with the actual and planned expansions and reductions
that previously were cited, aggregate class size among the 59 respondent schools
could potentially increase by 7.6% over the next few years. Assuming that
this sample of schools is representative of the entire group of US allopathic
schools, the potential exists to increase the total number of allopathic matriculants
Limitations on Expansion. The median class
size of the 16 schools that are expanding or have immediate plans to expand
is 104 students, while the median class size of those that have no plans to
expand is 150 students. Similarly, 8 of the 20 schools that have expansion
potential have fewer than 100 students, while only 3 of the 20 that lacked
such potential were of this smaller size. Thus smaller schools have more expansion
capacity than larger ones.
In 70% of institutions, deans reported that a major factor preventing
expansion or limiting its magnitude was the lack of sufficient facilities,
most commonly for preclinical teaching. In addition, one third of deans cited
limitations in clinical teaching facilities, preceptor sites, or in the volume
of patients available for teaching; one fourth of deans reported limitations
in the availability of faculty. Several cited a lack of sufficient positions
for residents, who serve a teaching role. Limited financial resources also
were cited, sometimes related to state funding and sometimes to clinical revenues.
Only 8% of respondents cited no significant obstacles to expanding class size.
We found a widespread perception among medical school deans and medical
society executives that shortages of physicians exist, particularly in the
non–primary care specialties. More than 80% of each group reported shortages,
usually in multiple specialties. Only 6 of 70 responding US deans and only
4 of 44 medical society executives reported either a lack of shortages or
the presence of physician surpluses in the absence of concomitant shortages.
It should be noted, however, that respondents encompassed only 58% of medical
schools and 86% of medical societies, and, despite similarities between respondents
and nonrespondents, it is not clear whether these responses were fully representative.
A particularly disturbing result was the observation that more than
80% of the deans who commented on the impact of shortages on their schools
noted negative effects on faculty recruitment and retention, clinical education,
clinical revenues, and related matters. For some, a lack of faculty jeopardized
clerkship opportunities and even threatened the integrity of fellowship training
Another revelation was the limited potential for medical schools to
expand. In a previous evaluation of this potential,21 we
noted that most of today's medical schools had expanded during the 1960s and
1970s, making further expansion unlikely, and, while the new schools built
during this earlier period are smaller and could potentially expand more,
there are fewer of them. The deans' responses support this formulation. Approximately
one third of the deans of medical schools (principally those with smaller
class sizes) reported that their schools are in the midst of expanding or
have plans to do so, although the magnitude of these expansions is only 16%.
Another one third of schools have no immediate plans to expand, although they
could do so by 15% to 20%. These schools also were skewed to those of smaller
size. Conversely, a few larger schools are in the process of reducing class
size. Taken together, the actual and potential expansion of capacity of all
respondent schools, including both those that are able to expand and those
that are not, was only 7.6%. This contrasts sharply with the substantial contribution
that the expansion of existing schools made to increasing medical school output
in the 1960s and 1970s.
The perceptions of deans and medical society executives concerning physician
shortages, coupled with a growing consensus among forecasters about the future
demand for physicians,1,22-24 cannot
be ignored. Yet the difficulties inherent in expanding undergraduate medical
education suggest that the process will be more challenging than in the past,21,25,26 and the task of enlarging
graduate medical education poses still more challenges. These hurdles underscore
the imperative to address physician shortages and begin to expand medical
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