Foreign-educated doctors (IMGs): The chart shows the rise in the number of practicing physicians according to their place of medical education — the United States or abroad.8 Foreign-educated doctors who successfully complete an accredited residency or fellowship program in the United States are often recruited to remain here and serve where American doctors will not. Between 1980 and 1999, the number of IMGs practicing here nearly doubled, while the number of active native physicians rose 58%. According to a University of North Carolina at Chapel Hill study, the states with the highest rate of foreign-educated doctors are Florida and West Virginia (45%), North Dakota (40%), and Illinois (39%). States with more than 20% IMGs in rural areas are New York, Kansas, Georgia, Kentucky, Louisiana, North Carolina, and Texas.
The practice of recruiting foreign-trained doctors is controversial. Among the complaints: "…allowing foreign physicians to remain in the United States after completing their graduate medical education could contribute to a general oversupply of physicians, which could drive up medical costs" (General Accounting Office). After the September 11 terrorist attacks, the policy of granting visa waivers to foreign doctors came under scrutiny.9
Are There Too Many Doctors? Experts have said yes for decades. To illustrate the complexity of the issue, we offer quotes from three news reports.
(1) October 25, 2001 — Sacramento, California: "Speaking at a panel discussion Thursday, health care experts disagreed strongly about whether California is suffering from a physician shortage. The five panelists … offered a wide range of views on the issue, ranging from accusations that managed care has eroded the state's ability to recruit the best and the brightest, to denials that there even is a shortage. However, on one key issue four of the five agreed: California does suffer from a shortage of specialists." The shortage was blamed "on warnings issued in earlier years of a surplus of specialists that influenced many medical students to pursue careers in primary care." (Silber)
(2) July 21, 2002 — New York: "Some medical specialties and geographical areas are suffering from a glut of doctors and hospitals… Supply seems to drive demand. More hospitals in an area mean many more days spent in hospitals with no discernible improvements in health. More medical specialists mean many more specialist visits and procedures." (Kolata; describing a study from Dartmouth Medical School)
(3) September 5, 2002 — New York: "A study led by Edward Salsberg, executive director of the Center for Health Workforce Studies at the University of Albany in New York, cites evidence to suggest that the nation may be facing a future doctor shortage. US medical schools produced only 12% more graduates between 1980 and 2000, while the US population grew 24%, the study finds. And minorities continue to be sorely underrep- resented among medical school graduates, it said." (Pallarito)
Minorities Are Underrepresented in the Physician Workforce: Minorities make up only about 10% of practicing physicians and enrollment of minorities in medical schools has been falling, abetted by anti-affirmative-action policies adopted in some states. Minority physicians are more likely to serve patients in underserved communities and some people believe that physicians who are themselves products of a cultural tradition may be more sensitive to minority patients. Satel contends, however, that "Only a handful of studies have been devoted to the question of whether patients' outcomes are better if they and their doctors are of the same race. Many of these studies were conducted with psychiatric patients, and the majority show that the clinician's race has very little to do with how black and white patients fare in their treatment and recovery."
Geographic Maldistribution of Physicians: According to the Council on Graduate Medical Education (COGME), geographic maldistribution — the tendency for physicians to practice in affluent urban and suburban areas — leaves inner-city and rural communities struggling to attract sufficient healthcare professionals. "This is the central paradox of the American health care system: shortages amid surplus."
Who Will Care for the Elderly? The AGS Foundation for Health in Aging (which lobbies for increased funding for geriatric training) reports that the nation's need for geriatricians is critical (the elderly population, now at 12% of the total, will triple by 2050).
Physicians Against Managed Care: Kevin Grumbach describes the 1990s as "the era of the wholesale market for physician labor," a reference to the physician's changing role under managed care. Patients no longer shop for physicians, Grumbach writes; rather, HMOs act as "bulk purchasers of physician services." Physicians Who Care (http://www.hmopage.org/) complains: "HMOs have introduced a novel innovation in American Health care: incentives for physicians not to treat patients." Critics say managed care places profits before sound medical practice. With their incomes declining, doctors are fighting back. In 1999 members of the American Medical Association voted overwhelmingly to form a national doctor's union. In 2001 The Medical Society of the State of New York brought lawsuits against six of the state's largest managed care companies, charging "that the companies systematically harm both patients and physicians by systematically engaging in illegal practices and routinely breaching the terms of contracts with physicians. … The suits specifically point to the insurance carriers' continual arbitrary denial of medically necessary care, capricious reductions in reimbursement claims," etc.10 Dr. Donald Timmerman says the lawsuits are a way for doctors to regain "dignity and a chance of becoming an active participant in this country's healthcare system."
Sources: Chart: Statistical Abstract of the United States: 2001, p106; Primary source: American Medical Association, Chicago, IL, Physician Characteristics and Distribution in the U.S. (annual). GAO, "Foreign Physicians: Exchange Visitor Program Becoming Major Route to Practicing in U.S. Underserved Areas," and "Health Workforce: Ensuring Adequate Supply and Distribution Remains Challenging, " http://www.gao.gov/. Pallarito, Karen, "US Health Worker Shortage Endangers Public," Reuters Health, Sept 5, 2002, http://www.nlm.nih.gov/medlineplus/. Kolata, Gina, "Study finds health care spending doesn't correlate with wellness," July 21, 2002, http://seattletimes.nwsource.com/. Silber, Judy, "Health Care Experts Say California Needs More Medical Specialists," Knight Ridder/Tribune Business News, Oct 25, 2001 p1. COGME, "Physician Distribution and Health Care Challenges in Rural and Inner-City Areas," Feb 1998, http://www.cogme.gov/. "NY Physicians Launch Major Litigation Against Managed Care Insurance Carriers," http://www.rcms.org/. Page, Leigh, "Litigious pushback," Modern Physician, June 2002. AGS Foundation for Health in Aging, "Public Policy: The Critical Shortage of Geriatricians," http://www.healthinaging.org/. Satel, Sally, "Health and Medical Care," in Beyond the Color Line: New Perspectives on Race and Ethnicity in America, Thernstrom, Abigail, and Stephan Thernstrom, eds., http://wwwhoover.stanford.edu/homepage/books/fulltext/colorline/default.htm. Information retrieved September 26, 2002.
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