Physician Shortage By 2020

GRAND RAPIDS — A recent forecast of the future supply and demand for physicians in Michigan foresees the state coming up short by the year 2020 — short by as many as 6,000 physicians.

The forecast, which was compiled by Public Policy Associates (PPA) on behalf of the Michigan State Medical Society (MSMS), predicts that 15 years from now Michigan's population is likely to require 36,200 physicians to meet its health-care demands.

However, the forecast indicates that Michigan's physician supply will remain relatively flat or even slightly decline over the next 15 years, fluctuating from 30,000 to 30,500 practicing physicians.

The projected shortage of 6,000 physicians includes a slight falloff in primary care physicians. About one-third of all Michigan physicians provide primary care as family practitioners, internists, pediatricians and OB/GYNs. They serve a broad range of patients and deliver the most basic health-care needs — the preventive health care and health maintenance that serve as the first line of defense. More than 25 percent of Michigan's 12,700 primary care physicians are of retirement age, the report indicates.

Furthermore, as current physicians retire, it's anticipated there won't be a significant increase in the number of new medical school graduates and residents to take their place. The state currently has nearly 30,000 physicians actively engaged in the practice of medicine or in related work, such as medical research, administration or teaching.

According to PPA, a big contributor to the anticipated shortage of doctors is the aging Baby Boom generation, which is 76 million strong. Their numbers are stressing the resources of the health-care system and will continue to do so over the next 30 years as they grow older and need more health care for chronic diseases, acute illnesses and end-of-life care.

The report suggests that some of the help in meeting physician demand will come from the growing number of non-physician clinicians — health-care providers such as nurse practitioners, physician assistants, nurse-midwives, chiropractors, acupuncturists, naturopaths, optometrists, podiatrists, nurse anesthetists and clinical nurse specialists.

According to the Association of American Medical Colleges, just under 36,000 individuals applied to medical school in the 2004-2005 school year, down from about 49,000 applicants 10 years ago.

Earlier this year, the AAMC recommended that enrollment in U.S. medical schools be increased 15 percent by 2015. If schools respond to the recommendation, the result would be an increase of about 2,500 M.D. graduates per year, according to the AAMC.

John M. MacKeigan, M.D., immediate past president of the Michigan State Medical Society, said people in medical circles are talking about the meaning and value of health care to the economy and the meaning and value of health care to the individual in terms of decreased disability and improved quality of life. Those are the types of issues being discussed, rather than "the perception that medicine is just a liability of cost," he said.

Health care is one of the largest segments of Michigan's economy — employing more than 424,500 people directly and 254,340 indirectly, according to a study released in June by Partnership for Michigan's Health. The top three counties in terms of direct health-care jobs are WayneCounty with 92,813 direct health care jobs, OaklandCounty with 78,531 direct jobs, and KentCounty with 35,376 direct jobs.

"Health care is the largest part of the economy in many cities, so those aspects of value are part and parcel of trying to change the perception of medicine these days," MacKeigan said.

"This discussion is being undertaken at many levels with business and the government to understand the complexities of health care, the encumbrances to physicians in practicing, and the level of dissatisfaction among physicians."

Medical malpractice is one encumbrance. The public needs to understand that issues of liability can drive physicians out of the field and reduce access to health care for everybody, he said. Furthermore, he added, people need to realize that an under-funded Medicaid program limits their choices for primary care.

It's getting "impossible" to recruit people in pediatric surgery and pediatric specialties, MacKeigan said, and in many of those specialties the number of applicants or the number of residencies being filled are down about one-third. He said there are only three pediatric surgeons in Grand Rapids. For all three, 40 percent of their business is Medicaid, yet Medicaid and Medicare payments to physicians have been flat or declining.

"They are barely able to survive economically," MacKeigan said. "They cannot recruit another pediatric surgeon. They're not going into the specialty, because of those factors. When they're gone, our children and our grandchildren will not have pediatric surgeries if there is decreased reimbursement and if there are not more pediatric surgeons trained."

Complicating that is the fact that fewer med school students are choosing primary care. The trend over the last five years has been that about one-fifth of the openings in general surgery go unfilled by American graduates. Why? Because primary care doctors are the "feeder" for all surgical specialties, MacKeigan said.

"If people don't understand the complexities of health care in general, they're not going to understand why there are fewer people applying to med school than … 10 years ago. They're not going to understand why the physicians that are being educated are choosing specialties that are not always at the front lines of health care.

"It's about night call, it's about the workload, it's about stress, it's about decreased reimbursement, and it's about the meaning of medicine and how people are appreciated."

So it's a quality of life issue, not simply a matter of recruiting more students and building more classroom space.

In the economics of health care, physicians are not the major expense and driver, as was thought in the 1970s and '80s when medical schools reduced their output of students, he said. There has been only one M.D. (allopathic) medical school added to the lineup of U.S. med schools in the past 35 years, though a number of D.O. (osteopathic) schools have been added over that time period, MacKeigan said.

Canada just opened its 18th med school and another is planned. Canada, Australia, Britain and other countries are ramping up, but this country hasn't even begun the discussion, he pointed out.

"We can't find money for higher education, much less med schools. It's harder to find teachers. Very little of medical education at the graduate level is done with paid personnel — it's done with volunteer help. But with decreased reimbursement, there's less time for physicians to devote to education on a volunteer basis. So it's a complex, multi-factorial issue."