![Medical doctors per 1,000 people, OWID](https://upload.wikimedia.org/wikipedia/commons/3/31/Medical_doctors_per_1%2C000_people%2C_OWID.svg)
Physician supply refers to the number of trained
physicians working in a
health care system or active in the
labor market.
[Dal Poz MR et al]
''Handbook on monitoring and evaluation of human resources for health.''
Geneva, World Health Organization, 2009. The supply depends primarily on the number of graduates of
medical schools
A medical school is a tertiary educational institution, or part of such an institution, that teaches medicine, and awards a professional degree for physicians. Such medical degrees include the Bachelor of Medicine, Bachelor of Surgery (MBBS, M ...
in a country or jurisdiction but also on the number continuing to practice
medicine
Medicine is the science and practice of caring for a patient, managing the diagnosis, prognosis, prevention, treatment, palliation of their injury or disease, and promoting their health. Medicine encompasses a variety of health care pr ...
as a
career
The career is an individual's metaphorical "journey" through learning, work and other aspects of life. There are a number of ways to define career and the term is used in a variety of ways.
Definitions
The ''Oxford English Dictionary'' defi ...
path and remaining in their country of origin. The number of physicians needed in a given context depends on several different factors, including the
demographics
Demography () is the statistical study of populations, especially human beings.
Demographic analysis examines and measures the dimensions and dynamics of populations; it can cover whole societies or groups defined by criteria such as ed ...
and
epidemiology
Epidemiology is the study and analysis of the distribution (who, when, and where), patterns and determinants of health and disease conditions in a defined population.
It is a cornerstone of public health, and shapes policy decisions and evide ...
of the local population, the numbers and types of other
health care practitioners working in the system, and the
policies and goals in place of the health care system.
[World Health Organization]
''Models and tools for health workforce planning and projections.''
Geneva, 2010. If more physicians are trained than needed, supply exceeds demand. If too few physicians are trained and retained, some people may have difficulty accessing
health care services. A physician shortage is a situation in which there are not enough
physicians to treat all
patients
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care ...
in need of medical care. That can be observed at the level of a given
health care facility, a province/state, a country, or worldwide.
Globally, the
World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...
(WHO) estimates a shortage of 4.3 million physicians, nurses, and other
health workers worldwide,
[World Health Organization]
''The world health report 2006: working together for health.''
Geneva, 2006. especially in many
developing countries
A developing country is a sovereign state with a lesser developed industrial base and a lower Human Development Index (HDI) relative to other countries. However, this definition is not universally agreed upon. There is also no clear agreem ...
. Developing nations often have physician shortages because of limited numbers and capacity of medical schools and because of
international migration
International migration occurs when people cross state boundaries and stay in the host state for some minimum length of the time. Migration occurs for many reasons. Many people leave their home countries in order to look for economic opportunities ...
since physicians can usually earn much more money and enjoy better working conditions in other countries. Many developed countries also report doctor shortages, which traditionally happened in rural and other underserved areas. Reports as recent as January 2019 show that high-growth areas like
Phoenix, Arizona
Phoenix ( ; nv, Hoozdo; es, Fénix or , yuf-x-wal, Banyà:nyuwá) is the capital and most populous city of the U.S. state of Arizona, with 1,608,139 residents as of 2020. It is the fifth-most populous city in the United States, and the on ...
, are experiencing shortages. Shortages exist and are growing in the United States, Canada, the United Kingdom, Australia, New Zealand, and Germany.
Several causes of the current and anticipated shortages have been suggested, but not everyone agrees that there is a true physician shortage, at least in the United States. On the
KevinMD medical news blog, for example, it has been argued that inefficiencies introduced into the healthcare system, often driven by government initiatives, have reduced the number of patients physicians can see. By forcing physicians to spend much of their time on data entry and public health issues, the initiatives have limited the available time for direct patient care by physicians.
Determinants
Economic theory and trends
Anything that changes the number of available physicians or the demand for their services affects the
supply and demand balance. If the number of physicians is decreased or the demand for their services increases, an undersupply or shortage can result. If the number of physicians increases or demand for their services decreases, then an oversupply can result.
Substitution factors can significantly affect the production of physician services and the availability of physicians to see more patients. For example, an
accountant can replace some of the financial responsibilities for physician who own their own practice and allow for more time to treat patients. Disposable supplies can substitute for labor and capital (the time and equipment needed to sterilize instruments). Sound record keeping by physicians can substitute for legal services by avoiding malpractice suits.
However, the extent of substitution of physician production is limited by technical and legal factors. Technology cannot replace all skills possessed by physicians, such as surgical skill sets. Legal factors can include allowing only licensed physicians to perform surgeries but nurses or doctors to administer other surgical care.
The demand of physicians is also dependent on a country's economic status. Especially in developing nations, health care spending is closely related to growth of the
gross domestic product
Gross domestic product (GDP) is a monetary measure of the market value of all the final goods and services produced and sold (not resold) in a specific time period by countries. Due to its complex and subjective nature this measure is oft ...
(GDP). Theoretically, as GDP increases, the health care labor force expands and, in turn, physician supply also increases. However, developing countries face additional challenges in retaining competent physicians to higher-income countries such as the
United States
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territori ...
,
Australia, and
Canada
Canada is a country in North America. Its ten provinces and three territories extend from the Atlantic Ocean to the Pacific Ocean and northward into the Arctic Ocean, covering over , making it the world's second-largest country by tot ...
. The emigration of physicians from lower-income and developing countries contribute to
Brain drain and creates issues on maintaining sufficient physician supply. However, higher-income countries can also experience an outflow of physicians who decide to return to their naturalized countries after they have received extensive education and training, and such nations never benefit from their gained medical knowledge and skill set.
Number of physicians trained
Increasing the number of students enrolled in existing
medical schools is one way to address physician shortage, and another is increasing the number of schools, but other factors may also play a role.
Becoming a physician requires either
several years of training beyond
undergraduate education
Undergraduate education is education conducted after secondary education and before postgraduate education. It typically includes all postsecondary programs up to the level of a bachelor's degree. For example, in the United States, an entry-le ...
or a
professional undergraduate degree with a duration longer than that of a typical undergraduate degree. Consequently, physician supply is affected by the number of students eligible for medical training. Students who do not finish earlier levels of education, including
high school dropouts
Dropping out refers to leaving high school, college, university or another group for practical reasons, necessities, inability, apathy, or disillusionment with the system from which the individual in question leaves.
Canada
In Canada, most ind ...
and in some places those who leave university without an
undergraduate
Undergraduate education is education conducted after secondary education and before postgraduate education. It typically includes all postsecondary programs up to the level of a bachelor's degree. For example, in the United States, an entry-le ...
or
associate degree, do not qualify for entrance to
medical school. The more people that fail to complete the prerequisites, the fewer people become eligible for training as physicians.
In most countries, the number of placements for students in medical schools and
clinical internships is limited, typically according to the number of teachers and other resources, including the amount of funding provided by governments.
In many countries that do not charge
tuition payments
Tuition payments, usually known as tuition in American English and as tuition fees in Commonwealth English, are fees charged by education institutions for instruction or other services. Besides public spending (by governments and other public bo ...
to prospective physicians, public funding is the only significant limitation on the number of physicians trained. In the United States, the
American Medical Association
The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016.
The AMA's sta ...
says that federal funding is the most important limitation in the supply of physicians. The high cost of tuition combined with the cost of supporting themselves during medical school discourages some people from enrolling to become a physician. Limited
scholarships
A scholarship is a form of financial aid awarded to students for further education. Generally, scholarships are awarded based on a set of criteria such as academic merit, diversity and inclusion, athletic skill, and financial need.
Scholarsh ...
and financial aid to medical students may exacerbate that problem, and low expected pay for practicing physicians in some countries may convince some that the cost is not appropriate.
It has been speculated that politics and social conditions may motivate medical student placements. For example,
racial quota
Racial quotas in employment and education are numerical requirements for hiring, promoting, admitting and/or graduating members of a particular racial group. Racial quotas are often established as means of diminishing racial discrimination, add ...
s have been cited in some places as preventing some people from enrolling in medical school.
Racial discrimination
Racial discrimination is any discrimination against any individual on the basis of their skin color, race or ethnic origin.Individuals can discriminate by refusing to do business with, socialize with, or share resources with people of a certain g ...
and
gender discrimination
Sexism is prejudice or discrimination based on one's sex or gender. Sexism can affect anyone, but it primarily affects women and girls.There is a clear and broad consensus among academic scholars in multiple fields that sexism refers primaril ...
, either overt or disguised, have also been cited as resulting in people being denied the opportunity to train as a physician on the basis of their race or gender.
Number of physicians working
Once trained, the current supply of physicians can be affected by the number of those who continue to practice that profession. The number of working physicians can be affected by:
*The number of medical school graduates who:
**Choose to practice as a physician for their
career
The career is an individual's metaphorical "journey" through learning, work and other aspects of life. There are a number of ways to define career and the term is used in a variety of ways.
Definitions
The ''Oxford English Dictionary'' defi ...
; for example, some might choose instead to work in
medical research,
public policy
Public policy is an institutionalized proposal or a decided set of elements like laws, regulations, guidelines, and actions to solve or address relevant and real-world problems, guided by a conception and often implemented by programs. Public p ...
, or other areas in which medical expertise is required, or they may choose a job in which no medical knowledge is required.
**Fail to obtain or requalify for their license or other
professional requirements for legal practice.
**Are unable to find work of their choice; studies in Mexico have found high levels of unemployment among trained physicians in urban areas even while large rural populations remain medically underserved.
*The number of physicians who:
**Exit the workforce, such as by retiring.
**Migrate abroad for better economic and social conditions, also referred to as "
brain drain."
**Work part-time; in particular, the number working only part-time does not affect the overall number of physicians, but it affects the supply of physician services (e.g. in terms of
full-time equivalent
Full-time equivalent (FTE), or whole time equivalent (WTE), is a unit that indicates the workload of an employed person (or student) in a way that makes workloads or class loads comparable across various contexts. FTE is often used to measure a ...
s). Many physicians may retain their professional license while they work part-time or after they retire. Consequently, the reported number of active physicians is probably overstated in many jurisdictions.
*Changes in the specialty balance; for example, in many countries, the balance is shifting away from medical students becoming
general practitioners (GP) because of more attractive pay for
medical specialists
A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include those branches of medicine that deal exclusively with children (paediatrics), cancer (oncology), ...
, which leads to shortages of physicians for
primary care
Primary care is the day-to-day healthcare given by a health care provider. Typically this provider acts as the first contact and principal point of continuing care for patients within a healthcare system, and coordinates other specialist care ...
.
*Changes in the practice environment; for example, changing legal conditions have been cited in the US, Canada and elsewhere as inciting physician attrition, notably the adoption of laws that require doctors to refer for certain procedures (such as abortion or sex change) with which the doctors disagree on moral or religious grounds.
Demand for physician services
The demand for physician services is influenced by the local job market (e.g. the number of
job openings in local health care facilities), the demographics and epidemiology of the population being served, the nature of the
health policies in place for health care delivery and financing in a jurisdiction, and also the international job market (e.g. the increasing demand in other countries puts pressure on local competition). As of 2010, the WHO proposes a ratio of at least one
primary care physician
A primary care physician (PCP) is a physician who provides both the first contact for a person with an undiagnosed health concern as well as continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis. The term ...
per 1000 people to sufficiently attend the basic needs of the population in a developed country.
For example,
population aging
Population ageing is an increasing median age in a population because of declining fertility rates and rising life expectancy. Most countries have rising life expectancy and an ageing population, trends that emerged first in developed countries ...
has been attributed with increased demand for physician services in many countries, as more previously young and healthy people become older with increased likelihood of a variety of
chronic medical conditions associated with ageing, such as
type 2 diabetes mellitus
Type 2 diabetes, formerly known as adult-onset diabetes, is a form of diabetes mellitus that is characterized by high blood sugar, insulin resistance, and relative lack of insulin. Common symptoms include increased thirst, frequent urinatio ...
,
hypertension,
osteoporosis, and some types of
cancers
Cancer is a group of diseases involving abnormal cell growth with the potential to invade or spread to other parts of the body. These contrast with benign tumors, which do not spread. Possible signs and symptoms include a lump, abnormal bl ...
and
neurodegenerative
A neurodegenerative disease is caused by the progressive loss of structure or function of neurons, in the process known as neurodegeneration. Such neuronal damage may ultimately involve cell death. Neurodegenerative diseases include amyotrophic ...
diseases.
US Patient Protection and Affordable Care Act
In the United States, the
Patient Protection and Affordable Care Act has expanded health insurance coverage and access to an estimated 32 million
United States citizens
Citizenship of the United States is a legal status that entails Americans with specific rights, duties, protections, and benefits in the United States. It serves as a foundation of fundamental rights derived from and protected by the Constituti ...
, increasing the demand of physicians, especially
primary care physicians
Primary or primaries may refer to:
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Works
* ...
, across the country. Expanded coverage is predicted to increase the number of annual primary care visits between 15.07 million and 24.26 million by 2019. If stable levels of physicians' productivity are assumed, between 4,307 and 6,940 additional primary care physicians would be needed to accommodate that increase.
The Act may have also affected the supply of
Medicaid
Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and per ...
physicians. Incentives and higher reimbursement rates may have increased the number of physicians accepting Medicaid patients up to 2014. With the expansion of Medicaid and a decrease in incentives and reimbursement rates in 2014, the supply of physicians in Medicaid may drop substantially and cause the supply of Medicaid physicians to fluctuate. A study examining variation between states in 2005 showed that the average time for Medicaid reimbursements was directly correlated with Medicaid participation, and physicians in states with faster reimbursement times had a higher probability of accepting new Medicaid patients.
Effects
![SOWM2010 critical shortage](https://upload.wikimedia.org/wikipedia/commons/f/fe/SOWM2010_critical_shortage.svg)
Physician shortages have been linked to a number of effects, including:
*Lower quantity of medical care for
patients
A patient is any recipient of health care services that are performed by healthcare professionals. The patient is most often ill or injured and in need of treatment by a physician, nurse, optometrist, dentist, veterinarian, or other health care ...
, which limits the ability of health systems to meet
primary health care
Primary health care, or PHC, refers to "essential health care" that is based on scientifically sound and socially acceptable methods and technology. This makes universal health care accessible to all individuals and families in a community. PHC in ...
goals, such as the
Millennium Development Goals
The Millennium Development Goals (MDGs) were eight international development goals for the year 2015 that had been established following the Millennium Summit of the United Nations in 2000, following the adoption of the United Nations Millenn ...
.
*Lower quality of medical care for patients because of shorter doctor visits.
*Increased workload and too many patients per doctor resulting in overworked and sleep-deprived doctors, which compromises
patient safety
Patient safety is a discipline that emphasizes safety in health care through the prevention, reduction, reporting and analysis of error and other types of unnecessary harm that often lead to adverse patient events. The frequency and magnitude of ...
.
*Unnecessary patient deaths while waiting for health care.
*Higher prices for practicing physicians because of less competition by the rules of
supply and demand in market-driven
health care economies.
*Lower medical costs to consumers; compared to other industries, as market share grows and competition declines, physicians are less inclined to gross up the frequency or intensity of medical services to maximize reimbursement per limited patient encounter.
*The shortage of obstetricians in parts of the United States has led to coining of the phrase "maternity desert."
Maternity deserts
There are thousands of women in the United States who live in counties that do not have obstetrical care available. Arizona has two counties with no care available for pregnant women. Awareness to the lack of access to care is increasing in Arizona, and the Phoenix area seems to be heading toward a maternity desert.
From 2009 to 2019, there was a 12% reduction in obstetricians delivering babies in Arizona despite a growth in the general population.
Proposed solutions
A number of solutions, including short-term fixes and long-term solutions, have been proposed to address physician shortages. Some have been tested and applied in national
health workforce policies and plans, while others remain subject to ongoing debate.
*Increase the number of medical graduates through increased recruitment of minority students domestically, as well as intensified recruitment of foreign-trained graduates (also known as
International Medical Graduates An international medical graduate (IMG), earlier known as a foreign medical graduate (FMG), is a physician who has graduated from a medical school outside of the country where he or she intends to practice. The term non-local medical graduate may be ...
or IMGs).
*Increase the number of medical schools and classroom sizes.
*To address physician shortages in rural areas, develop, organize, and locate medical schools to increase the propensity of physicians entering rural practice. Accepting medical school applicants from rural areas can also increase the proportion of rural physicians.
*To address physician shortages in high population growth areas in the United States unfreeze the 1996 Graduate Medical Education (GME) freeze/cap instituted by Congress.
*Higher medical school enrollment limits.
*Loosen the requirements for entry to medical school, such as eliminating the need for a pre-med bachelor's degree as required in some jurisdictions, thereby making the education path more attractive for potential students.
*Reduce the costs for students to attend medical school, such as through subsidies for (free or reduced) school tuition and more financial aid.
*Legislate tuition-increase caps for medical schools.
*Increase the role of the
National Health Service Corps, which help provide debt-relief opportunities for primary care physicians.
*Improve the political, social and economic conditions in developing countries to prevent brain drain, including fewer wars and conflicts.
*Make better use of other categories of health care professionals, including more
nurse practitioner
A nurse practitioner (NP) is an advanced practice registered nurse and a type of mid-level practitioner. NPs are trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose disease, formulate and prescribe ...
s,
physician assistants,
clinical officer
A clinical officer (CO) is a gazetted officer who is qualified and licensed to practice medicine.
In Kenya the basic training for clinical officers starts after high school and takes four or five years ending on successful completion of a one-y ...
s,
community health worker A community health officer is a member of a community who is chosen by community members or organizations to provide basic health care, health and medical care within their community, and is capable of providing preventive, promotional and rehabilit ...
s, and others.
*Improve physician wages, such as through privatization of health care systems thereby enhancing market attractiveness for people to become doctors.
[
*Improve physicians' perspectives of their future career path, such as though reduced use of temporary employment contracts]
*Provide better incentives for physicians to practice in underserved areas – for example, in the U.S., this would include expanding incentives for the National Health Service Corps in rural, urban, and suburban areas experiencing shortages.
*Ensure better practice conditions for physicians – for example, medical liability reforms have been cited as an important factor in the U.S.
*Increase the use of e-mail and telephone consultations, which allow physicians to treat patients seeking more traditional forms of care.[http://content.healthaffairs.org/content/29/5/799.full.pdf+html]
*In the United States, to better accommodate the elderly and their demand for healthcare services, increase medical and nursing training in geriatrics
Geriatrics, or geriatric medicine, is a medical specialty focused on providing care for the unique health needs of older adults. The term ''geriatrics'' originates from the Greek γέρων ''geron'' meaning "old man", and ιατρός ''iatros ...
and gerontology.
*Increase use of health care or medical teams (i.e. nurse practitioners and physician assistants) to shift physician workload and allow for increased physician times with patients.
Global view
In the US alone, the Association of American Medical Colleges
The Association of American Medical Colleges (AAMC) is a nonprofit organization based in Washington, D.C. that was established in 1876. It represents medical school
A medical school is a tertiary educational institution, or part of such an i ...
(AAMC) estimates a shortage of 91,500 physicians by 2020 and up to 130,600 by the year 2025. However, a bias would clearly exist in their estimates as expanding medical education serves the direct financial needs of the AAMC. As previously mentioned, the World Health Organization
The World Health Organization (WHO) is a specialized agency of the United Nations responsible for international public health. The WHO Constitution states its main objective as "the attainment by all peoples of the highest possible level of ...
(WHO) estimates a shortage of 4.3 million physicians, nurses and other health workers worldwide. The WHO produced a list of countries with a “Human Resources for Health crisis”. In these countries, there are only 1.13 doctors for every 1,000 people, while in the United States, there are approximately 2.5 doctors for every 1,000 people. One quarter of physicians practicing in the United States are from foreign countries. Thousands of foreign doctors come to practice in the United States each year while only a few hundred doctors from the United States leave to practice in foreign countries even short-term.
There are various organizations that assist United States physicians and others in serving internationally. These organizations may be filling temporary or permanent positions. Two temporary agencies are Global Medical Staffing and VISTA staffing. A locum
A locum, or locum tenens, is a person who temporarily fulfills the duties of another; the term is especially used for physicians or clergy. For example, a ''locum tenens physician'' is a physician who works in the place of the regular physician. ...
doctor will serve in the temporary absence of another physician. These positions are typically 1-year placements but can vary by location, specialty, and other factors. Agencies that attempt to provide international aid in various ways often have a strong medical component. Some of these organizations helping to provide medical care internationally include Reach Out Worldwide (ROWW), Doctors Without Borders (Médecins Sans Frontières
(MSF; pronounced ), also known as Doctors Without Borders, is a humanitarian medical non-governmental organisation (NGO) or charity of French origin known for its projects in conflict zones and in countries affected by endemic diseases. ...
), Mercy Ships, the US Peace Corps
The Peace Corps is an independent agency and program of the United States government that trains and deploys volunteers to provide international development assistance. It was established in March 1961 by an executive order of President John F ...
, and International Medical Corps
International Medical Corps is a global, nonprofit, humanitarian aid organization that provides emergency medical services, healthcare training and capacity building to those affected by disaster, disease or conflict." It seeks to strengthen med ...
.
Additionally, smaller non-profits that work regionally around the world have also implemented task-shifting strategies in order to increase impact. Non profits, such as the MINDS Foundation educated community health workers or teachers to perform simple medicinal tasks, thereby freeing up health professionals to focus on more pressing concerns.
See also
* Health policy
* Health workforce
* Medical desert
*Nursing shortage
A nursing shortage occurs when the demand for nursing professionals, such as Registered Nurses (RNs), exceeds the supply locallywithin a health care facilitynationally or globally. It can be measured, for instance, when the nurse-to-patient ...
* Physician shortage in the United States
* Primary care service area
References
{{Reflist, 2
Medical education
Physicians
Health economics