Q&A with Edward Salsberg
Director of the Association of American Medical College’s
Center for Workforce Studies
By Laura Trude
 There has been a lot of concern surrounding the health care insurance reform debates about the adequacy of the national physician supply to provide care for people who may be newly enrolled in health care insurance programs. The AAMC Center for Workforce Studies produces two biennial reports on the national physician supply, one which focuses on states, and another that examines physician data by specialty. I recently had the opportunity to interview Edward (Ed) Salsberg, the director of the AAMC Center about the current state of the national physician supply, what policymakers and others can do to help prepare for increased health insurance coverage, and the recently released 2009 State Physician Workforce Data Book. The latter is a comprehensive biennial report produced by the AAMC Center for Workforce Studies which aggregates data related to current physician supply, medical school enrollment, and graduate medical education in the United States.
How do you hope the 2009 State Physician Workforce Data Book will be used?
It is important for state policy makers to understand how they compare with other states. One of the benefits of our state system is that there really are many natural demonstrations. Each state, by comparing itself nationally, or to states in its region, or to states of similar size, can get some sense of how they compare. In addition to state policy makers, academic medical centers will want to see how their state compares and whether they should be doing more in terms of a medical school or residency training capacity or physician supply. It helps planners in general, and reporters, to have a basic understanding of how the different states compare.
We also put out a book in alternate years on specialties where we compare the 35 or so largest specialties (2008 Physician Specialty Data). That too allows workforce planners, and the public, and reporters, to understand the relative size and the comparison across specialties. Both of the books have been extremely popular and helpful to people interested in the physician workforce.
What are some of the key additions to this year’s state physician workforce data book?
We’ve added a few tables and we’ve added some maps. We’ve found that the maps add an additional dimension, particularly where there were regional differences which are far more apparent in a map than in a table or bar chart. We also added some additional tables, one of which is patient care physicians. One of the challenges to the communities that are interested in physician supply is how they count physicians. There are numerous ways of counting physicians. In the past, we have included the number of active physicians and we still include that data, but we added patient care physicians because some of the states that have a larger academic research establishment, felt that the number of active physicians made it look like they had more physicians than actually provided patient care. So this year we added a separate table on patient care physicians per capita. We also added the primary care physicians per capita. The new report not only updates the data, but provides some additional information to states.
Is there an ideal number of active patient care physicians?
That is a challenging question; the answer is no. People often use national averages as a benchmark but the reality is that each state, each community really, has different needs and no one single number is the right number. I think there is a range, and one might get a sense of that from what the range is among the different states. People often want to know, “What is the right number?” That really requires an assessment of the individual communities and the needs within the communities.
There are a variety of potential benchmarks that one could look at, such as the national average or the physicians per population in some of the communities within the state that seem to be ensuring access. We like to encourage states to collect their own data or analyze existing data and do their own assessment of the adequacy of the physician supply in their communities. The national numbers and the comparative state numbers can be good guidelines to give states some sense of how they compare to the rest of the nation. But it doesn’t substitute for an in-depth analysis within the state.
What are some ways states can conduct their own in-depth analysis of the adequacy of their physician supply?
Many states collect their own data. One particularly popular and cost-effective approach is to collect data with the licensure renewal. States like New York, North Carolina, and Nebraska include basic workforce questions on their licensure renewal, such as how many hours a week they are providing patient care and the location of their practice. That allows the state to get a much better handle on their supply. In some states, for example, which may be attractive to older physicians, such as Florida or Hawaii, they may have a lot of physicians who are practicing part-time or even maintaining their license but not practicing. And so our use of national data can often miss that. But if a state collects its own data as part of its licensure renewal, then they can obtain much better information about how many active physicians there are and how many full-time equivalent physicians there are. And that sort of survey can also provide a lot of information regarding utilization patterns and the demand for services. A number of the state surveys we have done have asked the practicing physicians their perceptions of the adequacy of the supply and whether there are shortages and whether they have more capacity. That information can be extremely informative to state policy makers regarding the capacity and the gaps in service.
I noticed Massachusetts had the highest number of active patient care physicians per 100,000 people, and yet with their health care reform legislation, there has been talk of exacerbated physician shortages in the state.
Most people have focused on the fact that Massachusetts has near-universal coverage. But in terms of physician supply Massachusetts is not typical of the rest of the nation. They have many academic medical centers that are doing extensive research and teaching in a number of medical schools in Massachusetts. Clearly that requires additional physician positions. So Massachusetts is not typical. The question of whether the physician supply in Massachusetts was sufficient or capable of providing services under expanded coverage is unclear. There have been a number of anecdotal reports that the physician supply was inadequate, wait times increased for example. But there have been other anecdotes that suggest people have been able to get access to care with the existing supply. Unfortunately, I have not seen a study that provides me with sort of solid, analytical framework to conclude whether Massachusetts had enough physicians to handle health care reform. Nevertheless, I think the fact that a state with a higher physician to population ratio had some difficulties certainly leads one to be concerned about the challenges of expanding health care reform nationally.
What can policy makers and others do to prepare the United States for increased insurance coverage?
The AAMC has encouraged medical schools to expand their enrollment and they have been doing that. We also recommended that residency training positions be increased, which is a critical factor in determining the future supply of physicians. But even with an increase in medical school enrollment and in GME [Graduate Medical Education] positions, it is not going to be sufficient to meet the nation’s future needs. So we’ve also recommended that there be more effort to look at how to redesign the delivery system to improve efficiency and effectiveness, such as the increased use of teams, including nurse practitioners and physician assistants. States and communities can begin by looking at what their rules and regulations are related to use of non-physician clinicians, or programs that they have to encourage innovations in service delivery.
An important area is the state scope-of-practice laws and regulations. We know that non-physician clinicians can play an important role in making better use of the physician supply and some states have more restricted codes related to nurse practitioners and/or PAs. And so making sure that their scope-of-practice laws are consistent with the majority of the nation is one strategy to help ensure access.
Beyond the total number, there is also a concern about the distribution. One of the worries it that in a shortage, underserved communities are likely to face the greatest shortages as wealthier communities can probably outbid them, and more attractive communities can more successfully recruit physicians. Many states have loan forgiveness programs and they are likely to become more important in the future. States should closely look at: “What are their loan forgiveness programs?” “Are the wages and benefits competitive?” Some states have not increased the amount of the loan forgiveness at a time when medical student debt has been increasing. So looking at whether they can increase the amount in loan forgiveness for physicians going into underserved areas is important. There are a number of steps states can take to better prepare themselves.
The report mentioned that international medical school graduates (IMGs) make up 24.2% of the US physician workforce. Why are so many international medical graduates coming to the US?
The nation has a long tradition of welcoming foreign educated physicians and other health professionals. I think one of the reasons there have been so many in the last decade or so has been that we had far more graduate medical education residency training positions than we had medical and osteopathic graduates, so there was a vacuum where foreign medical graduates were meeting important needs and filling important gaps. Now that we are increasing the number of medical and osteopathic graduates, it is actually getting more competitive for training positions. (IMGs must complete several years of training in the US before they can become licensed as a physician.) Our assessment is that the number of international medical school graduates entering residency training has leveled off in the past three years and we actually expect it may begin to decline some, because the growing number of US MD and DO graduates will make it more competitive for the limited residency training positions. I don’t know how much of a decrease we will see in IMGs; that depends on how many residency positions the nation maintains. We expect that the number of US medical and osteopath graduates will continue to grow substantially over the next decade. In fact, we currently bring in about 7,000 international medical school graduates each year, on top of the 20,000 or so MD and DO graduates, for a total of about 27,000 new physicians each year. We project that between 2009 and 2020, the number of MDs and DOs graduating and going into residency training are likely to rise by about 7,000. So if you don’t substantially increase GME positions we think there will be very little room for international medical school graduates in the next decade. We think that GME is likely to grow a little in any case; the question is, “How Much?” Thus it is very unclear at this point how many international medical graduates the nation is likely to bring in over the next decade.
This could have a number of important implications. Historically, IMGs have tended to fill gaps where US MDs and DOs were not going, both in terms of specialty and geography. In the 1990s, when there was the push for managed care, the number of US MDs going into primary care went up and the number of IMGs going into primary care went down, while the number of IMGs going into specialties went up. But over the last ten years, as more US MDs have gone into specialties, more IMGs have filled the positions in primary care and less so in the specialties. So my guess is that IMGs who are very anxious to get into the US, are less likely to get their first or second choice of training positions, are the ones that are filling some of the historically hard-to-fill residency positions, and that is not just in primary care, that’s in general.
How did the Center for Workforce Studies decide which specialties to include for primary care?
We have a slightly broader definition of primary care than we often see. Clearly, family physicians, general internal medicine physicians, and general pediatricians are usually included, and we included them. We did not include obstetrician-gynecologists; the general prevailing wisdom in the community is that obstetrics is not primary care. We did include adolescent medicine and geriatric medicine in our primary care counts. This is a little unusual but adolescent medicine and geriatric medicine, while focused on a particular population group, are likely to be providing the continuous, ongoing care that one would expect of a primary care physician, and many are providing first contact care. The other reality is that there are only a few thousand physicians in adolescent and geriatric medicine compared to about 241,000 active primary care physicians so the inclusion of these two specialties does not have a significant impact on the overall numbers in primary care. Yes, it’s a little different than what some folks use, but it’s again a relatively small impact.
I was surprised to find that almost 25% of the active physician workforce was 60 or older. How do you think this will affect health care in the US?
I think that’s very important for states to recognize. There’s certainly a lot of concern in many communities, particularly rural communities. They may have one or two physicians and those physicians are aging. These communities are already well aware and concerned about the aging of the physician workforce but I think the data report helps put it in perspective just how large the cohort is that will be reaching retirement age over the next few years. I am very concerned that with the recession, many physicians may be delaying retirement. We know that many Americans in general are delaying retirement. I have no reason to think that doctors are any different. My concern is that many physicians may decide to retire at the same time as the economy improves. So the percent of physicians over 60 is really a warning signal to some states that they really need to be concerned over the next few years as this cohort ages and as the economy improves.
Is there anything else you would like to share?
We are very interested in knowing what data the states and others who are interested in the physician workforce would find helpful. Are there other dimensions of the data we should consider including in the next report? We are going to do the state report and the specialty report every other year, so we’ll do another state physician workforce data book in 2011, and the specialty book will come out next fall. So if there is information that they would find valuable on the physician workforce, please let us know so we can consider it for the next publication.
To contact the AAMC Center for Workforce Studies, send a message to Ed Salsberg at esalsberg@aamc.org or call 202.828.0415. |
