PhysicianSupply_NEJM - The n ew england journal of m...

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The new england journal of medicine n engl j med 350;17 april 22, 2004 1780 health policy report New Steam from an Old Cauldron — The Physician-Supply Debate David Blumenthal, M.D., M.P.P. The debate about the physician workforce is back. Just yesterday, it seems, the conventional wisdom was a confident prediction that we faced a worri- some surplus of physicians. 1-3 But today, a swell- ing chorus of experts contends that we may face an equally worrisome shortage of physicians. 4,5 The shift has occurred suddenly enough to inflict cog- nitive whiplash on policymakers and physicians who have not been schooled in the arcane science of projecting the supply of and demand for physi- cians. Indeed, some observers may be tempted to conclude that assessing workforce needs is a fool’s errand, one that is too technically difficult and too mired in controversy to be useful. To dismiss this reemerging debate, however, would be a mistake. Those with the patience to look beyond the clashing numbers will find much to learn from the controversy over the current and future adequacy of the supply of physicians. Physi- cians have always been vital to the health and the health care of their patients. Appropriately, the present debate raises questions vital to the future of the U.S. health care system. These questions concern, among other subjects, the intrinsic value of health care services, our collective ability to in- fluence the future of the health care system, and the future attractiveness of the venerable profession of medicine. This report examines the new debate about the physician workforce. First, I review past and cur- rent efforts to assess and manage the supply of phy- sicians. Next, I examine the fundamental method- ologic, ideological, and social questions that lurk beneath the debate — the debates beneath the phy- sician workforce debate — and I conclude with a comment on the ways in which policymakers are likely to react to the revival of this controversy. from flexner to gmenac In some ways, the history of the physician-supply debate begins, like so much else in modern medi- cine, with the Flexner report, which was published in 1910. Implicit in this document was the conclu- sion that the United States at the time had an over- supply of poorly trained physicians that had been produced by an unregulated, largely proprietary sys- tem of medical education. 6 One effect of the revo- lution that resulted from the Flexner report was a decrease in the supply of physicians owing to the closing of medical schools that were considered educationally deficient. Between 1900 and 1930, the ratio of physicians to the population in the United States fell from 173 per 100,000 to 125 per 100,000 7 as the medical establishment sought to produce “fewer but better doctors.” 6 During the Depression and World War II, no major reassessment of the supply of physicians was conducted. A 1932 report by a commission on med- ical education concluded that the supply of physi-
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PhysicianSupply_NEJM - The n ew england journal of m...

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