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Country Faces a Shortage of Generalist Physicians for Adult Primary Care

Researchers predict a shortage of 35,000-44,000 adult care generalists in 2025, but they say the supply of primary care for children will be adequate.

The United States faces an impending shortage of generalist physicians to provide primary care for adults, according to a study published April 29 as a Health Affairs Web Exclusive.

By 2025, the nation will be short 35,000 to 44,000 adult care generalists practicing family medicine (FM) and general internal medicine (GIM), say researchers from the University of Missouri and the U.S. Department of Health and Human Services. The researchers project an adequate supply of generalist care for children, however, provided by physicians practicing FM and general pediatrics.

"The demand for primary care is increasing because of a growing and aging population," said lead author Jack Colwill, MD, MU professor emeritus of family and community medicine. "At the same time, fewer physicians are becoming generalists, and more are opting for more lucrative and less demanding careers as specialists. If we don't take steps to rectify this imbalance, the result will be an increasingly stressed and poorly coordinated medical system."

Because generalist physicians treat patients primarily through ambulatory care, Colwill and his co-authors use data from the National Ambulatory Medical Care Survey as a proxy for the demand for generalist care. The researchers project that the number of ambulatory care visits for adult Americans - age 20 and over - would increase 29 percent between 2005 and 2025, given an adequate supply of caregivers. The Census Bureau predicts the number of adults will increase only 21 percent during this period. However, the number of Americans over age 65 is projected to rise 73 percent, and these older adults seek care from generalists almost three times a year - twice the rate of adults under 65.

Over the 2005-2025 period, demand for generalist care for children will also grow, but at a slower rate. The number of children will increase 12 percent, and the number of expected ambulatory visits by children will increase 13 percent, say Colwill and co-authors James Cultice, an operations research analyst at the Health Resources and Services Administration (part of HHS), and Robin Kruse, PhD, MSPH, an MU research assistant professor of family and community medicine.

Declining Numbers of Graduates and an Older, More Female Workforce Will Hold Down the Generalist Physician Supply For Adults

Against this background of rising demand, the number of physicians graduating from generalist residency programs has been declining since the late 1990s. Total graduates increased in the early 1990s, reaching 9,348 in 1998, but by 2005 the number of graduates from generalist programs had decreased to 7,289, only 1 percent above the 1995 level.

Using HRSA's physician supply model, Colwill's team projects that the supply of generalist physicians caring for adults will increase over the next two decades, but by only 11 percent, assuming 2005 graduate numbers. This is less than half of the projected 29 percent predicted increase in workload for these physicians, but the picture is actually worse than this: The generalist physician workforce will become increasingly older and female, and older and female physicians tend to work fewer hours on average. Adjusting for age and sex results in a generalist physician workforce for adults in 2025, that is only 7 percent above 2005 levels. This translates into a shortage of 35,000 generalists in 2025.

But the picture is yet worse. Preliminary data from 2006 and 2007 indicate the number of graduates from generalist residency programs continued to decline. If the 2002-2005 rate of decline continues through 2008, that would result in a projected 2025 adult care generalist workforce only 2 percent above 2005 levels, translating into a shortage of 44,000 generalists to care for adults.

By contrast, the researchers anticipate that supply and demand for children's generalist care in 2025 "will be approximately in balance."

Authors Recommend More Support for Educating Generalists, "Medical Home" Model

Colwill and his colleagues make several recommendations to address the impending shortage of adult generalist care they document. "At the top of the list," they say, is modifying reimbursement to foster development of the "medical home" models put forward in various forms by the generalist physician specialties. Under these models, teams of physicians, nurse practitioners, and physician assistants provide rapid access to patients for acute needs and care management for chronic illnesses using in-person visits, telephone and e-mail consultations, and electronic medical records. The medical home approach "has potential to increase job satisfaction for providers as it improves care."

Colwill and his co-authors add: "All avenues must be tried to increase funding for residency positions for FM and GIM. Had graduate numbers remained at 1998 levels, the projected shortfall in 2025 would have been modest. Student interest in generalist careers can be enhanced if medical schools renew their commitment to education of generalists as they did in the 1990s. Further, incentives such as forgiveness of loans for primary care practice would tip the scales for many medical students and residents as they select a specialty and type of practice."

The authors conclude by noting that shortages could be alleviated if interventions produced four additional generalist graduates in each FM and internal medicine residency program annually.

The article by Colwill and co-authors is online at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.27.3.w232.

For more information, contact Jack Colwill, MD, at (573) 884-7701.

April 2008