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]

Determinants

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.

Number of physicians trained

Increasing the number of students enrolled in existing medical schools is one way to address physician shortage,^[8] or increasing the number of schools,^[9] 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][10]

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.^[11] Limited scholarships and financial aid to medical students may exacerbate this problem,^[12] while low expected pay for practicing physicians in some countries may convince some that the cost is not appropriate.^[13]

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.^[14] 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.^[15]

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.^[16]
• 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^[17], 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.^[18]
• 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.^[19]

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).^[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.

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.^[20]
• Increased workload and too many patients per doctor resulting in overworked and sleep-deprived doctors, thereby compromising patient safety.^[21][22][23]
• Unnecessary patient deaths while waiting for health care.^[24]
• Higher prices for practicing physicians due to less competition, by the rules of supply and demand in market-driven health care economies.^[25]

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).^[26]
• Increase the number of students eligible for medical school through lower high school and college dropout rates.
• Increase the number of medical schools.
• Bigger medical school classroom sizes.^[27]
• Higher medical school enrollment limits.^[28][29]
• Loosen the requirements for entry to medical school, such as eliminating the need for a pre-med bachelor degree as required in some juridisctions, thereby making the education path more attractive for potential students.^[30]
• Reduce the costs for students to attend medical school, such as through subsidies for (free or reduced) school tuition and more financial aid.^[31]
• Increase the number of placements in medical residency following medical school graduation.^[32]
• 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.^[33][34]
• Improve physician wages, such as through privatization of health care systems thereby enhancing market attractiveness for people to become doctors.^[35][36][37]
• Improve physicians' perspectives of their future career path, such as though reduced use of temporary employment contracts^[16]
• 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.^[38]
• Ensure better practice conditions for physicians - for example, medical liability reforms have been cited as an important factor in the U.S.^[39]

See also

• Health policy
• Health workforce
• Nursing shortage

References

1. ^ ^{a b c d} Dal Poz MR et al. Handbook on monitoring and evaluation of human resources for health. Geneva, World Health Organization, 2009.
2. ^ ^{a b} World Health Organization. Models and tools for health workforce planning and projections. Geneva, 2010.
3. ^ ^{a b} World Health Organization. The world health report 2006: working together for health. Geneva, 2006.
4. ^ Cauchon, Dennis (2005-03-02). "Medical miscalculation creates doctor shortage". USATODAY.com. http://www.usatoday.com/news/health/2005-03-02-doctor-shortage_x.htm. Retrieved 2009-08-20. 
5. ^ Ramirez, Marc (2009-04-18). "Rural doctor shortage called "a crisis" in Washington". The Seattle Times. http://seattletimes.nwsource.com/html/health/2009078934_ruraldocs18m0.html. Retrieved 2009-08-20. 
6. ^ Halsey III, Ashley (2009-06-20). "Primary-Care Doctor Shortage May Undermine Reform Efforts". The Washington Post. http://www.washingtonpost.com/wp-dyn/content/article/2009/06/19/AR2009061903583.html. Retrieved 2009-08-20. 
7. ^ Feasby, Tom (2009-03-30). "Medical schools are working hard to help cure the doctor shortage". Toronto: The Globe and Mail. http://www.theglobeandmail.com/news/opinions/medical-schools-are-working-hard-to-help-cure-the-doctor-shortage/article663115/. Retrieved 2009-08-20. 
8. ^ Burk, Jennifer (2007-05-14). "Medical Schools Look to Grow as Doctor Shortage Looms". Wisconsin Healthcare Workforce Development. http://www.dwd.state.wi.us/healthcare/Archive2007/medical_schools_grow_dr_shortage_looms.htm. Retrieved 2009-08-20. ^{[dead link]}
9. ^ Beene, Ryan (2009-03-18). "Medical schools multiplying, but may not solve doctor shortage". Bridging 96. http://www.crainsdetroit.com/article/20090318/BRIDGING96/903169989/1123. Retrieved 2009-08-20. 
10. ^ Murphy, Mike; Tim Anderson (October 2008). "Dropout rates draw attention". The Midwestern Office of The Council of State Governments. http://www.csgmidwest.org/memberservices/Publications/SLMW/2008/October/p1.pdf. Retrieved 2009-08-20. 
11. ^ Lee, Frank (2009-07-26). "Experts foresee doctor shortage". sctimes.com. http://www.sctimes.com/article/20090726/NEWS01/107260024/1009/Experts-foresee-doctor-shortage. 
12. ^ Rogers, Christina (2008-06-18). "Doctor shortage worsens as student debt rises". AllBusiness.com. http://www.allbusiness.com/education-training/curricula-medical-education/12131282-1.html. Retrieved 2009-08-20. ^{[dead link]}
13. ^ Financiar, Ziarul (2008-01-24). "Doctors can earn over Euro 20,000 per month in private clinics". Honorary Consulate of Romania. http://www.roconsulboston.com/Pages/InfoPages/Businesspages/DoctorPrivate08.html. Retrieved 2009-08-20. 
14. ^ "Shortage of young (white) male doctors". Sunday Star Times. http://www.stuff.co.nz/sunday-star-times/news/179274. Retrieved 2009-08-20. 
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16. ^ ^{a b} Nigenda G et al. "Educational and labor wastage of doctors in Mexico: towards the construction of a common methodology." Human Resources for Health 2005, 3:3.
17. ^ "Another Hurdle to Health Care Reform: Too Few General Practice Doctors". Knowledge@Wharton. 2009-07-22. http://knowledge.wharton.upenn.edu/article.cfm?articleid=2297. Retrieved 2009-08-20. 
18. ^ Lea Singh. New-look Inquisitions want to call doctors in for a little chat. Posted Wednesday, 1 October 2008.
19. ^ Rabin, Roni Caryn (21 October 2009). "Patterns: Number of Doctors Was Overstated, Study Finds". The New York Times. http://www.nytimes.com/2009/10/27/health/research/27patt.html?ref=health. 
20. ^ http://www.parents.com/family-life/fitness/mom-health/shrinking-doctors-appointment/ Template:Link dead
21. ^ Shortage pushes doctors to limit. Posted by Jill Stark, April 20, 2007.
22. ^ Approved Medical Resident Hours Still Resulting In Sleepy Doctors. Posted by ScienceDaily (May 21, 2007).
23. ^ "Sleepy" doctors admit to mistakes. Posted by Celia Hall, The Telegraph, 22 Mar 2007.
24. ^ Private Health Care in Canada. Posted by Robert Steinbrook, N Engl J Med 2006; 354:1661-1664; April 20, 2006.
25. ^ America's reliance fo foreign doctors. Posted by the National Center for Policy Analysis, December 19, 2005.
26. ^ Lakhan SE, Laird C (2009). "Addressing the primary care physician shortage in an evolving medical workforce". International Archives of Medicine 2 (14). doi:10.1186/1755-7682-2-14. PMID 19416533. 
27. ^ http://www.oregonlive.com/health/index.ssf/2009/04/doctors_from_afar_meeting_rura.html
28. ^ http://www.sctimes.com/article/20090726/NEWS01/107260024/1009/Experts-foresee-doctor-shortage
29. ^ Girion, Lisa (2006-06-04). "Needs of Patients Outpace Doctors". Los Angeles Times. http://articles.latimes.com/2006/jun/04/business/fi-doctors4. 
30. ^ http://volokh.com/posts/1240839465.shtml
31. ^ http://www.vancouversun.com/story_print.html?id=1295859&sponsor=
32. ^ Walid MS (2009). "Physician deficit in USA - where is the bottleneck?". GMS Z Med Ausbild 26 (2). doi:10.3205/zma000611. 
33. ^ World Health Organization. Task shifting to tackle health worker shortages. Geneva, 2007.
34. ^ http://www.kevinmd.com/blog/2009/04/how-primary-care-doctor-shortage.html
35. ^ . http://www.roconsulboston.com/Pages/InfoPages/Businesspages/DoctorPrivate08.html. 
36. ^ http://swz.salary.com/salarywizard/layouthtmls/swzl_compresult_national_HC07000025.html
37. ^ Rampell, Catherine (2008-11-14). "Doctors' Salaries and the Cost of Health Care". The New York Times. http://economix.blogs.nytimes.com/2008/11/14/do-doctors-salaries-drive-up-health-care-costs/. 
38. ^ http://www.kevinmd.com/blog/2009/04/how-primary-care-doctor-shortage.html
39. ^ http://sev.prnewswire.com/health-care-hospitals/20081112/CLW00412112008-1.html