In a limited but significant challenge to the decade-old federal government warnings of a doctor glut by 1990, new research has found the first detailed evidence of a potential doctor shortage in several major specialties by the turn of the century.
The new information suggests that the supply of specialists in heart, chest, blood, kidney, gastrointestinal and blood diseases and physicians treating cancerous tumors and infectious diseases may be so outstripped by population growth and the growing complexity of medicine that even cities with populations of 200,000 or more may lack some specialists by 2000.
The study, published today in the Journal of the American Medical Assn., was conducted by researchers at the RAND Corp. in Santa Monica and at the Tufts University School of Medicine in Boston. It appears to substantially conflict with conclusions reached in 1980 and 1981 by the Graduate Medical Education National Advisory Committee, the federal government task force that warned of a growing glut of doctors and called for major initiatives to hold down their numbers.
How the Studies Differ
It was also learned that a team of Boston research experts is working on a more broadly critical assault on the conclusions of the earlier evaluation. The government study's projections have been the basis of a variety of initiatives to hold down the number of new doctors and limit the number of foreign-trained physicians allowed to enter the United States.
As a result of those projections, although the number of doctors in the United States has continued to increase, the growth rate has been curtailed in many fields, the number of students applying to medical schools has dropped and the entry of foreign-trained doctors has been significantly reduced.
The RAND-Tufts team examined the supply of doctors in nine specialties whose practitioners are commonly relied on by general-practice physicians for expert assistance in a variety of critical illnesses. The study did not apply its methodology to surgical specialties.
But the limited analysis found large differences between the number of physicians likely to be available in 1990 and 2000 and projections made earlier by the government study. Because physicians will be increasingly required to learn to use more sophisticated treatments--for cancer and heart disease, in particular--and because of the projected population growth for the rest of the century, doctors will find themselves increasingly hard pressed to provide services to all patients seeking them, the study found.
In cardiology, for instance, the government research team predicted in 1980 that there would be almost double the 7,750 cardiologists it said would be necessary nationwide. The RAND-Tufts study indicated the number of cardiologists likely to be in practice two years from now is far lower--only 10,700, with growth to 17,000 projected by the turn of the century.
Even taking account of distribution inequities in the physician supply--a situation in which specialists tend to cluster in large cities--the new RAND-Tufts evaluation concluded that even drastic changes in distribution would not overcome an overall shortage of doctors in some fields.
"Concern is widespread that the U.S. is training too many subspecialists in internal medicine," the new study concluded. "We concluded that many relatively large cities will be underserved by subspecialists in 2000."
Dr. William Schwartz, who headed the study, said that for consumers of medical services, the new data say "there are still large numbers of people who are not being adequately served by medical subspecialists and there is good reason to allow and encourage growth to bring those highly qualified physicians to areas that are now underserved."
Schwartz took note of the conflict between the new study and the earlier government analysis. "I think we have simply done our study in a very different way," he said. "We are looking at where doctors will be. (The government study) did not do that. We are trying to get down into the real world of where doctors are.
Changes in Technology
"That approach shows that in 1983, a time when people were already talking about too many subspecialists, clearly there were many, many large cities that were underserved or unserved. By 2000, the distribution will be much better, but a good fraction of that increased supply will be required to take care of a growing population and to deal with enormously rapid technological change in medicine."
Schwartz said specialists will be subjected to a constantly growing demand for their services by developments ranging from bone-marrow transplants to the wider dissemination of sophisticated drugs that stop the damage to the heart in a heart attack. Demand for services imposed by such public health emergencies as the AIDS epidemic will also play a role.
Joseph Newhouse, a RAND health care public policy researcher involved in the study, said that the new data underscore the question "of whether we should in some fashion try to restrict the number of subspecialists being trained."
Newhouse said the RAND-Tufts team had not expected to find evidence of shortages and that "this finding surprised all of us. One could (previously) have gotten the impression that we were awash in medical specialists, but the totals just don't support that."