Why HMOs, the Federal Government and Hospitals Prefer a Surplus of Physicians

The results of the 1998 National Resident Matching Program ("the match") offer us an opportunity to assess current physician workforce trends in American medicine. First, the trend toward increased interest by U.S. graduates in the generalist fields noted in 1997 has reached a plateau (Table 1). The percentage of U.S. seniors entering a primary care residency program is approximately the same as in 1997. Increases in the number of U.S. seniors matching into generalist internal medicine and pediatrics specialties were balanced by a drop in the number of U.S. seniors matching to family practice residency programs. An increase of 110 is noted in the number of U.S. seniors selecting internal medicine in 1998 when compared to 1997. Pediatrics showed an increase of 106, while family practice showed a decline of 161 in the same years. Anesthesiology and diagnostic radiology showed renewed strength. Both specialties recruit into postgraduate year-1 (PGY-1) and postgraduate year-2 (PGY-2) programs with the majority at PGY-2. From 1997 to 1998, anesthesiology at PGY-2 went from 173 to 270 and diagnostic radiology from 381 to 482.

In psychiatry, 428 U.S. seniors matched into general psychiatry at the PGY-1 level in 1998 versus 462 in 1997, a decline of 7.36%. From 1993 to 1997, the average match of U.S. seniors into general psychiatry was 460. Other matches in 1998 included 37 U.S. seniors into PGY-2 general psychiatry, 22 U.S. seniors into internal medicine/psychiatry and 13 U.S. seniors into peds/psych/child psychiatry. Data are not available on family practice/psychiatry.

While 428 PGY-1 general psychiatry residency positions were filled with 1998 U.S. seniors, 396 positions were filled with nonseniors. These included USFMGs (U.S. citizens who attend medical schools outside the United States and Canada), 77; non-USFMGs (international medical school graduates), 254; osteopaths, 38; Canadians, 3; pre-1998 graduates of U.S. medical schools, 23; and one Fifth Pathway student...this once important route for USFMGs to enter medical training in the United States is now seldom used.

Growth in the non-U.S. senior sector in the 1998 match in psychiatry is predominantly in osteopaths and USFMGs. In the overall match and in general psychiatry, non-USFMG (IMGs) numbers declined. However, the match understates the number of international medical graduates recruited because many, indeed most, are recruited outside of the match. This year, an estimated 3,000 physicians, most of whom are IMGs, will obtain residency positions outside of the match. In psychiatry, they number approximately 300.

Finally, it should be noted there was a slight increase (0.25%) in the total number of positions (PGY-1 and PGY-2) offered in the 1998 match compared to the prior year (22,451 and 22,396, respectively).

Analysis

This year's match showed little change in the pattern seen since 1993 in current U.S. seniors entering psychiatry (Table 2). Recent interest has focused on the development of internal medicine/psychiatry programs. With only 22 students selecting them, it is unlikely these will become a major force in the training of the next generation of psychiatrists. Data are not available on interest in family practice psychiatry; however, in addition to international medical graduates, osteopaths and USFMGs are also playing a growing role in filling such positions.

As we assess this year's recruitment data, we must again ask what continues to bog down our recruitment of U.S. graduates into psychiatry despite major advances in our understanding of mental disorders and advances in pharmacological and psychological therapies. For example, how does the perceived economic uncertainty of our profession impact U.S. graduates? Will society fund psychiatrists to treat an array of mental disorders utilizing pharmacotherapy, psychotherapy or a combination when appropriate; or will society only fund psychiatrists to treat patients with medications? The future size of our profession and future recruitment efforts hinge on how we and society address these questions, and on how we communicate the excitement of our discipline to the present generation of medical students.

Finally, the real story of the 1998 match is that in spite of two decades of discussion of a growing physician surplus by numerous government commissions and last year's reduction of Medicare funding of house staff positions, no reduction of house staff positions has occurred. The match offered 22,348 in 1992, while in 1997, there were 22,396 and in 1998, there were 22,451. We must consider why no reduction has occurred.

In 1990, the Consumer Price Index (CPI), exclusive of medical care, increased by 5.2% and physician services by 7.1%. In 1993, when the nonmedical CPI rose 2.7%, physician services increased by 5.6%. In 1996, the CPI, exclusive of medical care, increased by 2.8% and physician services by 3.6%. The decreased inflationary pressure of physician services follows historic economic models. Additionally, a surplus of physicians in the late 1990s has now helped to drive down hospital expenses by providing residents as moderately priced hospital-based labor. In 1990, hospital room rates rose 10.9% and in 1996 only 4.9%. In clinical practice, the focus of economic power has shifted from doctors to third-party payers. Consequently, the surplus of physicians has allowed managed care organizations and Medicare to benefit from that surplus and drive down physician charges.

Despite expressed concerns by government agencies about the surplus of graduate physicians and residents, the net effect of the surplus is to restrain the growth of medical costs. For these reasons, until it can be proven that a physician surplus has negatively impacted patient care or until U.S. medical graduates cannot obtain medical positions, I do not anticipate a reduction of house staff positions.