The U.S. Census Bureau projects that the total U.S. population will grow from 286 million people in 2000 to 325 million people in 2010. Should the average number of physician visits per person per year remain constant at 2.5, population growth will account for 97 million more physician visits per year in 2010 than occurred in 2000.

Recruitment Pervasive:

As a result of these factors, physicians, particularly specialists such as radiologists, cardiologists, orthopedic surgeons, and anesthesiologists, are in extremely high demand. According to a 2002 survey conducted by Merritt, Hawkins & Associates, over 85% of hospitals in the United States are actively recruiting physicians, while an additional five percent plan to actively recruit physicians in the next six months. The firm estimates that some 65% to 75% of physician medial groups also are actively recruiting physicians.

Clearly, the demand for physician services in our wealthy, health conscious society will do nothing but increase in the coming years.

A DIMINISHING SUPPLY

Growth in demand for physician services has been accompanied by a shrinking supply of physicians available to provide services.

New Entrants:

The number of physicians entering the market has increased in recent years, as has the number of physicians per population. Nevertheless, the number of U.S.-trained physicians, and the number of U.S. medical schools, has remained virtually constant for the last 20 years. Increases in the number of new physician entrants over the last two decades have been driven almost entirely by international medical graduates (IMGs).

This trend is diminishing, however. The number of IMGs entering U.S. residencies has decreased significantly in the last several years, due in part to the imposition in 1998 of the Clinical Skills Assessment Test (CSAT), which IMGs must take to obtain Educational Commission for Foreign Medical Graduates (ECFMG) certification. The CSAT is only given in Philadelphia, which makes it very difficult for most IMGs to take, since they must foot the bill to travel from such places as India and Taiwan. Since the CSAT requirement was imposed, the number of IMGs receiving ECFMG certification has fallen about 50%, from 11,814 in 1998 to 5,934 in 2001.

In addition, the events of 9/11 have made it more difficult for IMGs training in the U.S. on J-1 visas to remain here when their residencies are over. "J-1" physicians must find a U.S. government agency willing to sponsor them for a "waiver" if they wish to practice medicine here. Since 9/11, the U.S. Department of Agriculture, the main federal sponsor of "J-waivers" has stopped sponsoring waivers, though the Department of Health and Human Services may pick up the slack. In addition, the government is looking much harder at which students will be allowed to come to the U.S.

With no plans to increase the number of U.S. medical schools significantly, and with the government looking to cut Medicare-related funding of residency programs, the supply of new U.S. trained physicians can only be expected to remain static in coming years, with significant declines in the number of IMGs.

In addition, it is important to consider that the types of physicians being trained have changed in the last several years. Throughout most of the 1990s and even today, the message put forth by many in medical, academic and government establishments is that we need more primary care physicians and fewer specialists. Medical students heeded this message in the 1990s and entered primary care residencies in greater numbers, while eschewing many specialty areas, as the graph below illustrates.

Number of Residents by Specialty
		1993-94		1998-99
Family Practice		7,796		10,607
Internal Medicine		20,603		21,130
Pediatrics		7,460		7,728
Orthopedic Surgery		3,029		2,759
Oncology		647		204
Pulmonary Diseases		948		153
Rheumatology		400		247
Gastroenterology		1,027		929
Anesthesiology		5,696		3,603
Radiology		4,236		3,687
General Surgery		8,243		7,859

Source: JAMA, 10/99

However, it was precisely during these years that the demand for specialists, rather than decreasing under the gatekeeper model, significantly increased. While medical school graduates now are selecting specialty residencies in greater numbers, the extended time required for medical training ensures a shortage in many specialty areas for at least the next five years.