Twenty-Year Trends in the Ohio Generalist Physician Workforce

Journal of Family Practice, Dec, 1998 by P. Tennyson Williams

BACKGROUND. Many factors contribute to the variations seen in physician workforce projections, including assumptions about attrition, new physician entry, and geographic requirements. Our study offers data for benchmarking future research into this complex issue.

METHOD. At 5-year intervals starting in 1975, data were collected for each Ohio county by local physician census takers.

RESULTS. Total Ohio family physician rates per population did not increase appreciably during the 20-year period. A decrease in the number of allopathic family physicians was balanced by an increase in the number of osteopathic family physicians, many of whom were graduates of the state's first osteopathic medical school, which graduated its first class in 1980. Rates of general internists and general pediatricians increased. In 1975, the percentage of physicians older than 59 years was higher for family physicians than for general internists and general pediatricians. By 1995, this disparity in age distribution had greatly decreased. Rural family physician rates per 100,000 population decreased, and urban rates increased, while both urban and rural rates increased for general internists and general pediatricians.

CONCLUSIONS. Variations in accounting for clinical time used for non-generalist clinical and nonclinical activities may explain a large part of the difference between generalist head count and full-time equivalency (FTE) study results; together these activities can be said to make up a "fourth compartment" contributing to improper specialty designation. The decrease in the percentage of family physicians older than 59 years indicates that the future supply of practicing family physicians is not in jeopardy. The rural family physician workforce is decreasing, while the general internist and general pediatrician rural workforce is increasing, but the total rural workforce is still well below the urban workforce. Neither component of the rural workforce appears to have stabilized.

KEY WORDS. Physicians, family; manpower; supply; distribution (J Fam Pract 1998; 47:434-439)

The criteria for assessing the generalist component of the physician workforce have been debated for years. In 1910, Flexner[1] was commissioned to study the quality of medical education, because a surplus of physicians was perceived to be related to large numbers of inadequately educated graduates of proprietary medical schools. At that time, there was 1 physician for every 586 citizens of Ohio (171 per 100,000 population). Early estimations of the adequate number of physicians were based on patient demand,[2] but the 1933 study by Lee and Jones[3] proposed basing that judgment on medical need. Knowles,[4] however, identified many problems in assessing need. The Graduate Medical Education National Advisory Committee (GMENAC) report[5] calculated physician workforce requirements by updating the needs assumptions of the Lee and Jones study and projected 1990 rates per 100,000 population to be 36.1 for family physicians, 30.0 for general internists, and 15.4 for general pediatricians--for a total of 81.5 generalists per 100,000 population.

Studies that followed the GMENAC report used demand-based assumptions to project future physician supply and need. Most supply-side assumptions are similar because they are quantitatively assessable and the data are available for calculation. Need-side assumptions, however, are subject to unknowns, such as the future health system choices of the American public and changes in medical technology and disease burden.

Schonfeld et al[6] and Mason[7] first introduced data from health maintenance organizations (HMOs) showing fewer physicians per 100,000 enrollees than the per capita numbers in the fee-for-service (FFS) system. HMO studies have found that GMENAC projections of need are excessive; they projected the need at 50 to 60 physicians per 100,000 enrollees.[8-11] Tarlov[12] recommended that lower rates of physicians need to be used for HMOs than for FFS systems and called the HMO system the third compartment.

The Eighth Report of the Council on Graduate Medical Education (COGME)[13] reviewed 5 major studies[11,14-17] and tested the recommendations of the Council's 1992 Third Report[18] that residency positions be reduced to 110% of the total of all United States allopathic and osteopathic medical graduates and 50% of these enter generalist careers. This review found projected rates of physician need (per 100,000 population) of 60 to 80 for generalists and 85 to 105 for specialists, and confirmed the validity of the 1992 recommendations. All 5 studies agreed that without change there will be a future surplus of specialists, while the generalist physician workforce will be equal to the need. A specialist surplus will hinder the shift of the health care system toward primary care and prevention.[11]

Problems in interpreting physician workforce studies arise from the lack of uniform criteria for either the supply or the need side of the equation. Some studies do not segregate the generalist physician component of care or recognize a difference in requirements for urban and rural settings. Few researchers recognize that all physicians are not the same, regarding their clinical productivity. Feil and colleagues,[19] Goodman and coworkers,[20] Grumbach et al,[21] Kindig[22] Rosenblatt and coworkers,[23] and Tarlov[24] all addressed these problems and made suggestions for achieving a consensus of definitions and methods for future studies. Schwartz and colleagues[25] observed that other occupations, such as sports medicine, occupational medicine, and health plan administration, occupy unencumbered physician time and reduce the actual full-time equivalency (FTE) of the clinical practice, especially of generalist physicians. In contrast, HMO data are reported in FTE terms. Grumbach et al[21] studied physician counts by using 4 different definitions of generalist physician and found that the conventional head-count method overestimates by as much as 25%, because specialty practices are included in generalist definitions. Table 1 characterizes differences in the generalist physician rates of several studies.