Physician supply

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Physician supply refers to the number of trained physicians working in a health care system or active in the labour market.[1] The supply depends primarily on the number of graduates of medical schools in a country or jurisdiction, but also on the number who continue to practice medicine as a career path and who remain in their country of origin. The number of physicians needed in a given context depends on several different factors, including the demographics and epidemiology of the local population, the numbers and types of other health care practitioners working in the system, as well as the policies and goals in place of the health care system.[2] If more physicians are trained than needed, then supply exceeds demand; if too few physicians are trained and retained, then some people may have difficulty accessing health care services. A physician shortage is a situation in which there are not enough physicians to treat all patients in need of medical care. This can be observed at the level of a given health care facility, a province/state, a country, or worldwide.

Globally, the World Health Organization (WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide,[3] especially in many developing countries. Developing nations often have physician shortages due to limited numbers and capacity of medical schools and because of international migration: physicians can usually earn much more money and enjoy better working conditions in other countries. Many developed countries also report doctor shortages, especially in rural and other underserved areas. For example, shortages are being discussed in the U.S., Canada, the U.K., Australia, New Zealand, and Germany.[4][5][6][7]

Several causes of the current and anticipated shortages have been suggested; however, not everyone agrees that there is a true physician shortage, at least not in the United States. On the KevinMD medical news blog, for example, it has been argued that inefficiencies introduced into the healthcare system, often driven by government initiatives, have reduced the number of patients physicians can see; by forcing physicians to spend much of their time on data entry and public health issues, these initiatives have limited the physicians' time available for direct patient care.[8]

Determinants[edit]

Economic Theory and Trends[edit]

Patients queue to see a doctor in South Sudan (source: Merlin)

Anything that changes the number of available physicians or the demand for their services affects the supply and demand balance. If the number of physicians is decreased, or the demand for their services increases, then an under-supply or shortage can result. If the number of physicians increases, or demand for their services decreases, then an over-supply can result.

Substitution factors can significantly affect the production of physician services and the availability of physicians to see more patients. For example, an accountant can replace some of the financial responsibilities for a physician who owns his or her own practice, allowing for more time to treat patients. Disposable supplies can substitute for labor and capital (the time and equipment needed to sterilize instruments). Sound record keeping by physicians can substitute for legal services by avoiding malpractice suits. However, the extent of substitution of physician production is limited by technical and legal factors. Technology cannot replace all skills possessed by physicians, such as surgical skill sets. Legal factors can include only allowing licensed physicians to perform surgeries, but nurses or doctors administering other surgical care.[9]

Demand of physicians is also dependent on a country's economic status. Especially in developing nations, health care spending is closely related to growth of their Gross domestic product (GDP). Theoretically, as GDP increases, the health care labor force expands and in turn, physician supply also increases.[10] However, developing countries face additional challenges in retaining competent physicians to higher-income countries such as the United States, Australia, and Canada.[11] Emigration of physicians from lower-income and developing countries contribute to Brain drain, creating issues on maintaining sufficient physician supply. However, higher-income countries can also experience an outflow of physicians who decide to return to their naturalized countries after receiving extensive education and training, without ever benefiting from their gained medical knowledge and skill set.

Number of physicians trained[edit]

Increasing the number of students enrolled in existing medical schools is one way to address physician shortage,[12] or increasing the number of schools,[13] but other factors may also play a role.

Becoming a physician requires several years of training beyond undergraduate education. Consequently, physician supply is affected by the number of students eligible for medical training. Students that do not finish earlier levels of education, including high school dropouts and those that leave university without an undergraduate degree or associates degree, do not qualify for entrance to medical school. The more people that fail to complete the prerequisites, the fewer people that are eligible for training as physicians.[1][14]

In most countries, the number of placements for students in medical schools and clinical internships is limited, typically according to the number of teachers and other resources, including the amount of funding provided by governments.[1] In many countries that do not charge tuition payments to prospective physicians, public funding is the only significant limitation on the number of physicians trained. In the United States, the American Medical Association says that federal funding is the most important limitation in the supply of physicians. The high cost of tuition combined with the cost of supporting oneself during medical school discourages some people from enrolling to become a physician.[15] Limited scholarships and financial aid to medical students may exacerbate this problem,[16] while low expected pay for practicing physicians in some countries may convince some that the cost is not appropriate.[17]

It has been speculated that politics and social conditions can sometimes motivate medical student placements. For example, racial quotas have been cited in some places as preventing some people from enrolling in medical school.[18] Racial discrimination and gender discrimination, either overt or disguised, have also been cited as resulting in people being denied the opportunity to train as a physician on the basis of their race or gender.[19]

Number of physicians working[edit]

Once trained, the current supply of physicians can be affected by the number of those who continue to practice this profession. The number of working physicians can be affected by:

Demand for physician services[edit]

The demand for physician services is influenced by the local job market (e.g. the number of job openings in local health care facilities), the demographics and epidemiology of the population being served, the nature of the health policies in place for health care delivery and financing in a jurisdiction, and also the international job market (e.g. increasing demand in other countries puts pressure on local competition). As of 2010, the WHO proposes a ratio of at least one primary care physician per 1000 people to sufficiently attend the basic needs of the population in a developed country.[2]

For example, population ageing has been attributed with increased demand for physician services in many countries, as more previously young and healthy people become older with increased likelihood of a variety of chronic medical conditions associated with ageing, such as type 2 diabetes mellitus, hypertension, osteoporosis, and some types of cancers and neurodegenerative diseases.

Patient Protection and Affordable Care Act (U.S.)[edit]

The implementation of the Patient Protection and Affordable Care Act will expand health insurance coverage and access to an estimated 32 million United States citizens by 2014, increasing the demand of physicians, especially primary care physicians, across the country.[24] Expanded coverage is predicted to increase the number of annual primary care visits between 15.07 million and 24.26 million by 2019. Assuming stable levels of physicians’ productivity, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate this increase.[25]

The PPACA will also affect the supply of Medicaid physicians. Incentives and higher reimbursement rates would increase the number of physicians accepting Medicaid patients until 2014. With the expansion of Medicaid and a decrease in incentives and reimbursement rates in 2014, the supply of physicians in Medicaid may drop substantially, fluctuating the supply of Medicaid physicians. A study examining variation between states in 2005 showed that average time for Medicaid reimbursements was directly correlated with Medicaid participation, and physicians in states with faster reimbursement times had a higher probability of accepting new Medicaid patients.[26]

Effects of physician shortage[edit]

Nations identified with critical shortages of physicians and other health care workers

Physician shortages have been linked to a number of effects, including:

Proposed solutions[edit]

A number of solutions, including short-term fixes and long-term solutions, have been proposed to address physician shortages. Some have been tested and applied in national health workforce policies and plans, while others remain subject to ongoing debate.

Global View[edit]

In the US alone, the Association of American Medical Colleges (AAMC) estimates a shortage of 91,500 physicians by 2020 and up to 130,600 by the year 2025. However, a bias would clearly exist in their estimates as expanding medical education serves the direct financial needs of the AAMC.[52] As previously mentioned, the World Health Organization (WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide.[3] The WHO produced a list of countries with a “Human Resources for Health crisis”. In these countries, there are only 1.13 doctors for every 1,000 people. In the United States, there are approximately 13.22 doctors for every 1,000 people. One quarter of physicians practicing in the United States are from foreign countries. Thousands of foreign doctors come to practice in the United States each year[53] while only a few hundred doctors from the United States leave to practice in foreign countries even short-term.[54]

There are various organizations that assist United States physicians and others in serving internationally. These organizations may be filling temporary or permanent positions. Two temporary agencies are Global Medical Staffing and VISTA staffing. A locum doctor will serve in the temporary absence of another physician. These positions are typically 1-year placements but can vary by location, specialty, and other factors. Agencies that attempt to provide international aid in various ways often have a strong medical component. Some of these organizations helping to provide medical care internationally include Reach Out Worldwide (ROWW), Doctors Without Borders (Médecins Sans Frontières), Mercy Ships, the US Peace Corps, and International Medical Corps.

Additionally, smaller non-profits that work regionally around the world have also implemented task-shifting strategies in order to increase impact. Non profits, such as the MINDS Foundation educated community health workers or teachers to perform simple medicinal tasks, thereby freeing up health professionals to focus on more pressing concerns.[55]

See also[edit]

References[edit]

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  4. ^ Cauchon, Dennis (2005-03-02). "Medical miscalculation creates doctor shortage". USATODAY.com. Retrieved 2009-08-20. 
  5. ^ Ramirez, Marc (2009-04-18). "Rural doctor shortage called "a crisis" in Washington". The Seattle Times. Retrieved 2009-08-20. 
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