Twenty years ago the Council on Graduate Medical Education (COGME) was established by Congress to assess physician workforce trends and needs. Two of the critical domains that COGME was charged with assessing were the supply and distribution of physicians in the United States and the current and future shortages or surpluses of physicians in medical and surgical specialties and subspecialties. Having accomplished this, COGME makes policy recommendations to the US government.
The basis for much of the commentary by Farley et al1 in this issue of the Journal is based on the COGME 2005 report.2 This report found that the supply of physicians will increase 24% by 2020; however, the demand for physician services will grow even more because the US population will increase by 18% (50 million), and our aging population will require a disproportionate amount of time and care. The COGME report also noted that additional strain on our health care system may occur because lifestyle priorities for younger physicians could reduce the number of hours worked, and the historically wealthy baby boomer generation will undoubtedly require and demand more time from their physicians. Other factors that could contribute to a physician shortage include early retirement in favor of lifestyle or elimination by liability exposure; possible limitations on immigration of foreign medical graduates into the United States; medical advances prolonging life for individuals with chronic disease; and an increase in non-patient care activities by physicians. Over the next 25 years, the number of individuals older than age 65 years is predicted to double to 70 million people.
In the short range, I see no obvious solution to the increase in the orthopaedic workforce. The number of orthopaedic residents in Accreditation Council for Graduate Medical Education (ACGME)-accredited programs has remained constant, at about 625, over the past decade. Expansion of the residency complement, both in terms of new residency programs and increased numbers in existing programs, has not occurred to any significant degree. The American Osteopathic Academy of Orthopedics has 315 approved residency slots and graduates more that 50 orthopaedic surgeons per year.3 From my perspective, the combined osteopathic and allopathic orthopaedic graduates do not meet the existing and future workforce deficit. Until the federal cap on graduate medical education reimbursement by Medicare is removed, I see no answer to this problem.
Increasing the number of orthopaedic surgeons cannot be accomplished without increasing the number of orthopaedic residents.
Interestingly, the presumed caregiver deficit is being addressed in several ways. International medical graduates who complete US residencies usually enter the US workforce.
Annually this comprises approximately 6,400 physicians (approximately 25% of all residency graduates). Long term, this “outsourcing” trend could prove to be a slippery slope for the quality and quantity of health care delivery in our country. The number of osteopathic physicians has increased from 1,000 in 1980 to 3,000 annually in 2006; however, this represents only 10% to 15% of residents graduating annually. Perhaps some of the void will continue to be filled by nonphysician clinicians, such as physician assistants and nurse practitioners.
A press release from the Association of American Medical Colleges on February 12, 2007, indicates that enrollment in US medical colleges is expected to increase 17% by 2012, to nearly 19,300 students.4 However, given the length of time it takes to get a medical degree and finish residency, this is not a short-term solution.
If we agree with the supply-side concerns expressed by Farley et al,1 there will be a future deficit of orthopaedic surgeons. Advocacy by our Academy and subspecialty societies using data such as that provided by COGME is a reasonable starting point for addressing the possible shortage. Unfortunately, I believe the problem is much bigger than orthopaedic surgery. Providing sufficient numbers of competent caregivers in all fields of medicine will be a herculean challenge. The health care budget, which is now 15% of the gross domestic product, cannot be sustained. In the short term, our policymakers will focus on access to health care and cost containment. Workforce deficits, I believe, will take a back seat until access to care reaches crisis proportions.
1. Farley FA, Weinstein JN, Aamoth GM, et al: Workforce analysis in orthopaedic surgery: How can we improve the accuracy of our predictions? J Am Acad Orthop Surg
2. Council on Graduate Medical Education: Physician Workforce Policy Guidelines for the United States, 2000-2020
. January 2005. Available at: http://www.cogme.gov/report16.htm
. Accessed March 22, 2007.
3. American Osteopathic Academy of Orthopedics. http://www.aoao.org
. Accessed March 28, 2007.
4. Association of American Medical Colleges: U.S. medical school enrollment projected to increase by 17 percent. Available at: http://www.aamc.org/newsroom/pressrel/2007/070212.htm
. Accessed March 23, 2007.