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With increased efficiency and cost savings forcing physicians and others in the health care industry to change the way they practice, policymakers have assumed that the country's alleged oversupply of physicians would become obvious, physicians' incomes would decline, medical specialization would be less appealing, and physicians would have a harder time finding employment, leading to fewer graduates choosing medical careers.
The latest annual report to Congress by the Physician Payment Review Commission (PPRC) points out that evidence exists to validate some of these trends, but in general the data are "ambiguous."
While the effort by managed care and federal health officials to make primary care a more important sector of medicine does appear to be increasing the ranks of primary care practitioners, "there seems to be a continuing demand for physicians in highly specialized fields," the PPRC notes with some surprise. And contrary to many analyses over the last several years, data on the aggregate supply of physicians in the U.S. do not indicate that an oversupply exists.
In only a few specialty areas did resident physicians report that they had a difficult time finding a job, according to 1995 AMA data cited by the PPRC. While anesthesiologists, gastroenterologists, and ophthalmologists had the most difficulty in finding full-time clinical work--20.7 percent of gastroenterologists claimed to have been unable to find full-time employment--overall, the percentage of residents who indicated facing this obstacle increased only slightly, from 6.3 percent to 6.9 percent--compared with the previous year's survey. Specialties in which it became harder for graduates to obtain full-time work included internal medicine, pediatrics, ophthalmology, and general surgery; reports from anesthesiologists, cardiologists, and plastic surgeons indicated they had an easier time than in the preceding year.
Family practice specialists had the most success finding full-time clinical work, with fewer than 1 percent saying they could not locate such employment.
While the PPRC found that recent studies indicate a gradual decline in specialty interest among new physicians, it uncovered no data painting a doom-and-gloom scenario for medical specialty practice. One trend that should please policymakers, however, is the steadily increasing attraction of primary care. In 1996, 32 percent of U.S. medical school graduates said they were planning for that career path, twice the percentage headed in that direction just five years ago, but equivalent to the figure for 1980. Psychiatry's statistics show that for 1996, 1.3 percent of graduates planned to enter that specialty, down from 1.6 percent five years ago and 2.8 percent in 1980.
Statistics on physician income do reflect the greater reliance managed care is placing on primary care providers. Median physician income for all physicians was down about 2.5 percent in 1995, a situation the PPRC says is "directly (though weakly) associated with an increase in managed care penetration." In general, patterns are inconsistent, however, with income for some specialists continuing to rise, though not as dramatically as it has for primary care generalists, family practitioners, and pediatricians. Yet internists, though in a primary care specialty, have seen an income decline over the last two years.
In contrast to conclusions in last year's report to Congress, the commission notes that more recent data on physician income and total number of first-year residents fail to verify the much-heralded overabundance of physicians in the U.S. In only three specialties--anesthesiology, obstetrics-gynecology, and orthopedic surgery--did the number of first-year residents drop from the preceding year. In addition, the PPRC concludes that this increase is not attributable to continuing growth in the number of international medical graduates (IMG's) filling residency slots. From 1994 to 1995, their numbers dropped from 7,000 to 5,300. Some specialties countered the IMG trend, however, particularly psychiatry and anesthesiology, which continue to see annual increases in the percentage of first-year residency slots filled by IMG's.
It seems clear from data reviewed by the PPRC that accounts of the country's oversupply of doctors and shifts in the way medical care is delivered have not deterred college graduates from pursuing medical careers. For the 1995-96 academic year, applications to U.S. medical schools rose 3 percent to an all-time high of 46,591, according to the commission.
In an attempt to interpret the conflicting and surprising data, the PPRC suggests that market forces may be hindered in reining in health care costs and altering the supply and specialty mix of physicians as long as the federal government generously subsidizes physician training. The growth in organized systems of care may translate into a demand for fewer physicians, especially specialists, but teaching hospitals feeling the pressure to economize "may be more dependent than ever on using residents to meet service needs," the commission says.
Also, market forces may be acting on the physician workforce in a manner opposite from the one policymakers had counted on. "Uncertainty about future prospects in law, business, engineering, and other professional fields," the commission theorizes, may in fact be driving the growing interest of recent graduates in the medical profession.
One area in which physician employment trends have shown a dramatic shift centers on practice arrangements, especially those available to new physicians. The PPRC points out, "In 1995, the share of physicians who are employees increased to 39 percent, up from 36 percent in 1994. At the same time, the share of self-employed physicians dropped to 55 percent from 58 percent. . . . A related trend is the growth in salaried positions rather than offers of income guarantees or other forms of compensation."
(Psychiatric News, June 6, 1997)