More than 20 years ago, as the Clinton health plan was being debated, a broad consensus developed that the United States was training too many physicians, although too few generalists. Leaders in medicine and government called for regulations to reduce the output of new physicians by 25%, while assuring that 50% were trained in primary care.
In my first workforce paper, published in 1994, I argued that changing the formula for who would provide care would be wrong, given the uncertainties about what kinds of care would be available in the future.1 I also pointed out that physicians are not the only care providers. Advanced practice registered nurses (APRNs), physician assistants (PAs), and others must be factored into the equation. And in two papers in JAMA that quickly followed, I demonstrated that the projections of physician surpluses that had stimulated efforts to curtail production were in error.2,3 Regulating to reduce future physician supply could be a disaster.
Nonetheless, the Balanced Budget Act of 1997 largely froze federal support for physician training, making a shortage of physicians inevitable. But what would that mean? Would there be a shortage of care? Or would others rise to the occasion?
I addressed this coming dilemma a few years later, stating that the available supply of physicians would, in large part, determine which services physicians will provide.4 In the face of shortages, physicians would inevitably be drawn to those complex areas of specialty medicine that demanded their attention most, while other disciplines evolved to fill important gaps. The question, therefore, was not whether there would be shortages of clinicians capable of providing “physician services.” The public's needs would be met. The question was who those clinicians would be.
In fact, an evolutionary process that would answer that question had been in motion for a century. Kendix and Getzen documented that although physicians represented more than one-third of all caregivers in 1900, they accounted for fewer than 10% in 1990.5 And they account for even fewer today. Much of the expansion in the supply of caregivers can be accounted for by lower-skilled aides and related disciplines, but over the past 75 years a disproportionate amount has been due to the advent of new, more highly skilled disciplines, first baccalaureate nurses, technicians, and therapists and then APRNs, PAs, and others. In 1998, I chronicled the accelerating growth in both numbers and practice prerogatives among these latter disciplines.6,7
Moreover, the level of education among the more highly skilled disciplines began to increase. Today, more nurses are trained at the baccalaureate level and fewer at the certificate or associate levels. PAs are increasingly trained at the master's level, and APRNs are entering an era in which new graduates will be at the level of doctor of nursing practice, a change mandated for pharmacy graduates a decade ago. While in 1995, only 25% of PAs were awarded master's degrees, that figure has risen to about 90%. Beyond that, as I chronicled a few years ago, increasing numbers of PAs are gaining further advanced training and certification in various specialties.8
Successes in PA education are almost unparalleled. The total number of PAs being trained has climbed steadily, more than doubling over the past 15 years, and PA training programs are projected to grow from 190 in 2013 to about 225 by 2020. However, we have projected that the production of PAs will still fail to meet demand, as the supply of physicians falls further behind the need for physician services that we had projected earlier.9
This decline in physician supply is due not only to inadequate numbers being trained. One factor is the increasing number of female physicians, whose hours available tend to be slightly lower compared with historic standards; lifestyle changes among male physicians also are reducing the “effective” supply of physicians. However, three other dynamics are proving to be even more important:
- Industrialization and regimentation. Residency training is now limited to 80 hours per week. In a manner that my generation never experienced, young physicians are learning how to leave the care of patients midstream. Responsibility is time-limited. This approach fits well with a parallel process at the level of healthcare systems, which is leading to the consolidation of hospitals and the merger of hospitals and physician practices into industrial giants. In his 1996 book, Donald Berwick, later a director of the Centers for Medicare and Medicaid Services, wrote that “No longer is the physician, paternalistically committed to the patient, the driving force in medical care. This isolated relationship is no longer tenable or possible. Healthcare has become an industry.”10 The book, New Rules: Regulation, Markets, and the Quality of American Medicine, has proven to be the blueprint for American medicine. The resulting transition of medical practice from a profession, with its open-ended commitment, to a trade, with its more circumscribed responsibilities, already has had a serious effect on the aggregate contributions of physicians.
- The “quality-industrial complex.” More than 100 organizations are involved in measuring quality or in offering ways to monitor and improve care, and others are immersed in developing systems of electronic health records. Managers are the most rapidly growing segment of the healthcare workforce, and major industries and consulting firms are rushing to participate. Although it is hard to argue against higher quality or better records, the efforts to establish systems for both are proving to decrease the time efficiency for most physicians.11
- Satisfaction and morale. Unsurprisingly, surveys have found morale among physicians to be low, with more than half holding a negative view of the profession and a similar percentage who would advise their children not to enter it.12 Many are leaving active practice, some to the pharmaceutical or medical equipment industries; others to legal, regulatory, or investment fields; and some to administrative positions in the quality movement. A surprising number of physicians in the midst of their careers, principally women, are choosing simply to leave professional life altogether. These dynamics all conspire to reduce the contributions of physicians to patient care.
What will this mean for the PA profession? The simple answer is that it will call for more PAs and higher levels of skill among them—and not only new graduates but practicing PAs, who will be called upon to undertake more complex and demanding tasks, for which they will need additional training.
But as PAs, APRNs, and others move up the complexity gradient, who will be left for the more routine tasks that they traditionally provided? Just as the past century saw a transition of care to newer disciplines, PAs among them, our resilient and resourceful society seems certain to mold to these new realities by spawning new healthcare disciplines. This is the context in which the PA profession will evolve. It seems well positioned for the challenge.
1. Cooper RA. Regulation won't solve our workforce problems. Internist
2. Cooper RA. Seeking a balanced physician workforce for the 21st century. JAMA
3. Cooper RA. Perspectives on the physician workforce to the year 2020. JAMA
4. Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood)
5. Kendix M, Getzen TE. US health services employment: a time series analysis. Health Econ
6. Cooper RA, Laud P, Dietrich CL. Current and projected workforce of nonphysician clinicians. JAMA
7. Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomous providers of patient care. JAMA
8. Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med
9. Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advance practice nurses, and physician assistants. J Am Coll Surg
10. Brennan TA, Berwick DM. New Rules: Regulation, Markets, and the Quality of American Medicine
. San Francisco, CA: Jossey-Bass, Inc., 1996.
11. McDonald CJ, Callaghan FM, Weissman A, et al. Use of internist's free time by ambulatory care electronic medical record systems. JAMA Intern Med