Edward Salsberg

Future Supply and Demand for Oncologists : Challenges to Assuring Access to Oncology Services

PURPOSE To conduct a comprehensive analysis of supply of and demand for oncology services through 2020. This study was commissioned by the Board of Directors of ASCO. METHODS New data on physician supply gathered from surveys of practicing oncologists, oncology fellows, and fellowship program directors were analyzed, along with 2005 American Medical Association Masterfile data on practicing medical oncologists, hematologists/oncologists, and gynecologic oncologists, to determine the baseline capacity and to forecast visit capacity through 2020. Demand for visits was calculated by applying age-, sex-, and time-from-diagnosis-visit rate data from the National Cancer Institutes analysis of the 1998 to 2002 Surveillance, Epidemiology and End Results (SEER) database to the National Cancer Institutes cancer incidence and prevalence projections. The cancer incidence and prevalence projections were calculated by applying a 3-year average (2000-2002) of age- and sex-specific cancer rates from SEER to the US Census Bureau population projections released on March 2004. The baseline supply and demand forecasts assume no change in cancer care delivery and physician practice patterns. Alternate scenarios were constructed by changing assumptions in the baseline models. RESULTS Demand for oncology services is expected to rise rapidly, driven by the aging and growth of the population and improvements in cancer survival rates, at the same time the oncology workforce is aging and retiring in increasing numbers. Demand is expected to rise 48% between 2005 and 2020. The supply of services provided by oncologists during this time is expected to grow more slowly, approximately 14%, based on the current age distribution and practice patterns of oncologists and the number of oncology fellowship positions. This translates into a shortage of 9.4 to 15.0 million visits, or 2,550 to 4,080 oncologists-roughly one-quarter to one-third of the 2005 supply. The baseline projections do not include any alterations based on changes in practice patterns, service use, or cancer treatments. Various alternate scenarios were also developed to show how supply and demand might change under different assumptions. CONCLUSIONS ASCO, policy makers, and the public have major challenges ahead of them to forestall likely shortages in the capacity to meet future demand for oncology services. A multifaceted strategy will be needed to ensure that Americans have access to oncology services in 2020, as no single action will fill the likely gap between supply and demand. Among the options to consider are increasing the number of oncology fellowship positions, increasing use of nonphysician clinicians, increasing the role of primary care physicians in the care of patients in remission, and redesigning service delivery.

Physician workforce shortages: implications and issues for academic health centers and policymakers.

A physician shortage is likely given current levels of medical education and training. Because an increase in physician supply through expansion of U.S. medical school capacity will require ten or more years, there is little time left to affect the supply of new physicians in 2020 when a substantial number of baby boomers will be over 70 years of age. Even with a substantial increase in medical education and training capacity, it is unlikely that all of the increased demand for health services can be met with physicians. In addition to the challenges of expanding medical school enrollment, the nation will need to grapple with other ramifications of demand exceeding supply. This includes assessing how to deliver services more effectively and efficiently and the future roles of the physician and other health professionals. These challenges are particularly difficult for medical schools and teaching hospitals, the cornerstones of medical education and training in the United States. Osteopathic and off-shore schools targeted to Americans have been willing and able to grow more quickly and less expensively than U.S. medical schools, in part because of their more narrow approaches to medical education. In addition, physicians from less developed countries continue to migrate to the United States in significant numbers. Medical schools, teaching hospitals, and policymakers will need to address several major questions as they respond to the shortages. They will either confront and address these issues in the next few years or they will be forced to change by others in the future.

An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education.

In 2006, after many months of consideration, the Association of American Medical Colleges (AAMC) recommended that medical schools in the United States increase their enrollment by 30% by 2015 and that residency positions be increased to accommodate the growth in U.S. medical school graduates1. This recommendation is based on the belief that there will be a substantial physician workforce shortage in the future as the economy continues to expand, physicians retire, and patients continue to demand more specialized care. How this prediction will affect the workforce dynamic of orthopaedic surgery and other specialties must be examined carefully. Orthopaedic surgery, like most specialties, has an interest in better understanding how many physicians will be required in the specialty in the future. This is not to suggest that there is one single correct number of physicians in a specialty; in fact, the medical system has proven to be highly adaptive. However, it is in the publics interest to have a distribution of orthopaedic surgeons that promotes high-quality care. Furthermore, it is in the specialtys interest that the number of physicians be sufficient to provide the services that the specialty is best qualified to perform but not so many that physicians are underutilized. Having too few orthopaedic surgeons can lead to access problems for patients and/or to less qualified providers caring for patients with particular problems. Having too many can increase competition, flatten incomes, and reduce procedural volume for individual surgeons and thereby affect quality and outcomes— not to mention possibly increasing unnecessary operations to maintain income levels. Therefore, it is beneficial to both the public and the orthopaedic surgery specialty to have a supply that is close to expected utilization. Achieving balance is easier said than done given the many factors that could influence future supply and demand. One must …

US Residency Training Before and After the 1997 Balanced Budget Act

CONTEXT Graduate medical education (GME) determines the size and characteristics of the future workforce. The 1997 Balanced Budget Act (BBA) limited Medicare funding for additional trainees in GME. There has been concern that because Medicare is the primary source of GME funding, the BBA would discourage growth in GME. OBJECTIVE To examine the number of residents in training before and after the BBA, as well as more recent changes in GME by specialty, sex, and type and location of education. DESIGN Descriptive study using the American Medical Association/Association of American Medical Colleges National GME Census on physicians in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs to examine changes in the number and characteristics of residents before and after the BBA. MAIN OUTCOME MEASURES Differences in the number of physicians in ACGME-accredited training programs overall, by specialty, and by location and type of education. RESULTS The number of residents and fellows changed little between academic year (AY) 1997 (n = 98,143) and AY 2002 (n = 98,258) but increased to 106,012 in AY 2007, a net increase of 7869 (8.0%) over the decade. The annual number of new entrants into GME increased by 7.6%, primarily because of increasing international medical graduates (IMGs). United States medical school graduates (MDs) comprised 44.0% of the overall growth from 2002 to 2007, followed by IMGs (39.2%) and osteopathic school graduates (18.8%). United States MD growth largely resulted from selection of specialties with longer training periods. From 2002 to 2007, US MDs training in primary care specialties decreased by 2641, while IMGs increased by 3286. However, increasing subspecialization rates led to fewer physicians entering generalist careers. CONCLUSION After the 1997 BBA, there appears to have been a temporary halt in the growth of physicians training in ACGME programs; however, the number increased from 2002 to 2007.

Outlook for the future of the obstetrician-gynecologist workforce.

OBJECTIVE The objective of the study was to assess the future physician workforce with a sample of obstetrician-gynecologists. STUDY DESIGN Two separate surveys regarding career satisfaction and retirement plans were sent to random samples of obstetrician-gynecologists under age 50 years (n = 2,000) and over the age of 50 (n = 2,100). RESULTS Obstetrician-gynecologists over the age of 50 years who were working part time or were female were more satisfied than those working full time or were male. Obstetrician-gynecologists (under and over age 50 years) who were concerned about liability and unable to balance their work and personal lives were more dissatisfied. Obstetrician-gynecologists retired earlier than planned because of rising malpractice costs and later than planned because of high career satisfaction. CONCLUSION Low career satisfaction may be adding to the already shrinking physician workforce. Offering part-time work opportunities and alleviating liability concerns may increase career satisfaction and help to combat a future of the physician workforce shortage.

Training Psychiatrists and Advanced Practice Nurses to Treat Tobacco Dependence

The lack of availability of continuing medical education programs on tobacco dependence for psychiatrists and psychiatric nurses is profound. We developed a 2-day curriculum delivered in November 2006 and March 2007 to 71 participants. Ninety-three percent ( n = 66) completed a pretest/posttest, and 91% (n = 65) completed the attitudes and beliefs survey. Scores on the pretest were low (M = 47% correct). Paired t tests found significant increases in raw scores from 6.7 to 13.6, t(65) = —22.8, p < .0001. More than 90% of psychiatrists and nurses indicated that motivating and helping patients to stop smoking and discussing smoking behavior were part of their professional role. Although 80% reported that they usually ask about smoking status, fewer reported recommending nicotine replacement (34%), prescribing pharmacotherapy (29%), or referring smokers to a telephone quit line (26%). Trainings are repeated twice a year because of ongoing demand. Further follow-up should evaluate changes in practices after training.

The physician workforce challenge: response of the academic community.

With 30 million Americans now living in federally designated Health Professional Shortage Areas and increasingly frequent reports regarding shortages in selected medical specialties (eg, geriatrics, primary care, oncology) and within certain states, the United States already faces a physician shortage. Given the growing number of Americans over age 65 (who use twice as many physician services compared with younger patients) and medical advances that have made it possible for more Americans to live longer with chronic disease, this shortage is likely to become even more acute. In response to these facts and numerous other concerns about a US physician shortage, the Association of American Medical Colleges (AAMC) in 2006 called for a 30% increase in student enrollment at Liaison Committee on Medical Education (LCME)-accredited schools by 2015. Concomitant with this recommendation was a call to substantially increase the number of federally supported residency training positions at the nation’s teaching hospitals. The US medical education community has been responding in several ways to the anticipated shortage and need to increase capacity. Individual medical schools have expanded, or are planning to expand enrollment, the AAMC has been closely monitoring key trends and physician practice patterns, and efforts have been initiated to gain a better understanding of related dynamics, such as the rapidly growing number of physicians with degrees in osteopathic medicine (DOs) and international medical graduates (IMGs). Using data from several recent surveys and reports by the AAMC Center for Workforce Studies (CWS), this article discusses the medical education community’s response to the physician shortage along 3 key dimensions: physician entry, physician exit, and changes in the expectations held by the newest generation of doctors. The article then discusses why strategies in addition to medical school expansion also must be considered, and how the broader reexamination of medical education now underway holds the potential for providing some of the flexibility needed in education and training to help address the shortage. Finally, some of the implications specific to surgical specialties will be noted.

Is the Physician Shortage Real? Implications for the Recommendations of the Institute of Medicine Committee on the Governance and Financing of Graduate Medical Education

In July 2014, the Institute of Medicine (IOM) Committee on the Governance and Financing of Graduate Medical Education released its report calling for a major overhaul of the financing of graduate medical education (GME). Several national organizations with an interest in GME faulted the report on the basis that the IOM Committee recommendations would worsen physician shortages. However, this conclusion is based on two questionable assumptions: first, that the nation is already facing a general physician shortage; and second, that the IOM Committee recommendations would make shortages worse. The author argues that although some communities and specialties do face shortages, currently and in the future a general national physician shortage is unlikely. Reasons cited include changes in the delivery system with an increased focus on efficiency and effectiveness; the increased use of interprofessional teams facilitated by the increasing supply of nurse practitioners, physician assistants and other health professionals; and technological advances. The author concludes that the IOM Committee recommendations would support an increase in GME positions in locations and specialties where there is a documented need, in effect removing the current cap on Medicare-funded GME positions. Given the current fiscal environment, the approach recommended by the IOM Committee—steady funding levels but improved targeting to meet documented needs—may be the best strategy for maintaining GME funds and meeting the nation’s physician workforce needs.

The changing physician workforce landscape: implications for physical medicine and rehabilitation.

Salsberg E, Erikson C: The changing physician workforce landscape: implications for physical medicine and rehabilitation. Am J Phys Med Rehabil 2007;86:838–844.

Benefits and pitfalls in applying the experience of prepaid group practices to the U.S. physician supply.

The paper by Jonathan Weiner includes important improvements in the meth- odology used to compare the physician workforce in prepaid group practices (PGPs) with the U.S. physician workforce. It also provides valuable insights for policymakers and re- searchers. Despite the improvements, concerns remain regarding the comparability of the populations served and physician activities in PGPs and the country as a whole. While PGPs appear to offer valuable lessons on how to use physicians effectively and efficiently, it is in- appropriate to use the PGP physician rates to determine the number of physicians needed in the United States.