On January 30, 2006, the American College of Physicians (ACP) released a highly publicized report that predicted “the impending collapse of primary care.”1 With many primary care physicians heading toward retirement and fewer young physicians choosing to go into primary care, our nation may well face an impending shortage of primary care physicians. While the ACP has proposed several reforms to help avert the impending crisis, it did not address the role of physician assistants and other nonphysician clinicians (NPCs) in their recent report.
A historical perspective
In his excellent 2004 overview of the physician-supply debate, David Blumenthal traced multiple predictions of medical workforce disaster, beginning with the Flexner report in 1910.2 At that time, the United States was felt to have an oversupply of poorly trained physicians, and the Flexner report led to the closing of many medical schools across the country, with a resulting decrease in new physicians. This restrictive policy continued throughout the first half of the 20th century.
Then in 1959 came the Bane report from the Surgeon General's Consultant Group on Medical Education, which predicted a severe shortage of physicians by 1975. This report led to a shift in public policy and a corresponding growth in both the number and class size of medical schools. Between 1965 and 1980, Blumenthal reports, the number of annual medical school graduates more than doubled, to around 15,000 per year.2 This period of physician shortages also saw the birth of a new career—the PA—with the first class of three PAs graduating from Duke University in 1967.
Attempts to predict future supply of and demand for physicians increased in sophistication in 1981 with release of the report of the Graduate Medical Education National Advisory Committee (GMENAC).3 This distinguished panel of experts predicted a worrisome surplus of physicians by the year 2000. Although the GMENAC report led to a loss of federal support to medical schools and resulted in a stable number of US physician graduates, the 1983 Medicare reforms tied extra payments to teaching hospitals to the number of physician trainees. This resulted in an increase in the number of residency slots, many of which were filled by an influx of foreign medical graduates, and, paradoxically, the number of resident physicians trained in US hospitals actually grew substantially during the 1980s and 1990s.
After GMENAC came a series of reports by the Council on Graduate Medical Education (COGME) in the early 1990s. These reports and others continued to predict a surplus of physicians, particularly in specialty areas. Workforce experts felt that the “managed care revolution” during the mid-1990s would worsen the impending surplus since HMOs apparently were able to care for larger numbers of patients with fewer physicians.4 Once again, Congress responded to warnings of impending physician over supply: in 1997, the Medicare program capped the number of available residency slots.
Dissenting voices were heard over the 20 or so years of predicted physician surpluses, but public policy was based consistently on the conventional wisdom that growth of physician supply would surely outstrip demand by the year 2000. However, the year 2000 arrived, and the predicted glut of physicians did not. Abruptly, it became clear that critics such as Richard Cooper, founder of the Health Policy Institute at the Medical College of Wisconsin, might actually be on the right track in predicting that the US demand for physicians in the 21st century will considerably outpace supply.5
The past several years have seen a dramatic about-face by health policy analysts and by many medical organizations. The most recent report by COGME, released in January 2005, forecasts that there will be a significant shortage by the year 2020.6 Interestingly, this recent report by COGME states specifically that a potential increase in the supply and use of PAs, NPs, and other NPCs was not included as a factor in their projections.