In the spring of 2001 the United States Census Bureau released population data from its brief for the 2000 census. While the issuance of this census data carries obvious political implications for state redistricting and Congressional representation, it also offers a basis for meaningful comparisons between the growth of the US population and physicians in this country.
NATIONAL TRENDS
As part of an ongoing trend dating to the early post-World War II era, the American population as a whole, and the Sunbelt region in particular, experienced continued growth. In the year 2000, the US population totaled 248 million, up 13.2% from the 1990 census; the South and West regions of the United States continue to witness the most impressive growth, with population increases of approximately 18% since 1990 (see Figure 1).
US and Physician Population Data, 1990–2000
National data on the number of physicians mirrored these trends, though growth in the physician population more uniformly distributed itself across the country. The total number of licensed, practicing physicians in 2000 increased more than 23% over its 1990 total with the growth distributed relatively equally (17–26%) among the 4 major geographic regions (see Figure 1). It bears noting, however, that this increase in the total population of licensed, practicing physicians may actually mask an approaching physician shortage. Demographic analysis by Dr. Richard Cooper, Director of the Health Policy Institute at the Medical College of Wisconsin,1 and Dr. Fitzhugh Mullan in the July 2000 New England Journal of Medicine2 point toward a physician shortage in the United States which will become apparent after 2010 as a series of demographic trends involving physicians, medical school enrollment and a “graying” American population intersect.
STATE TRENDS
National figures imply the physician population has generally kept pace with the growth in the general population; however, a closer analysis of state-specific data presents a more cautionary tale. While the total growth in physician population outpaced the increase in the general population, this was not the case for individual states. Between 1990 and 2000, 5 states appear to have experienced a decrease in the number of licensed practicing physicians: Delaware, Hawaii, Maryland, Utah and Wisconsin (see Figure 1).
While physician totals offer one measuring stick, perhaps a more important variable in assessing the distribution of the physician population is an examination of the ratio of physicians to the general population. Examining this ratio reveals that an even greater number of states saw the number of physicians per 1,000 in the population either decline or remain static: California, Colorado, Delaware, Hawaii, Maryland, Nevada, Tennessee, Texas, Utah, and Wisconsin. While the number of physicians per 1,000 population increased nationally from 2.19 in 1990 to 2.40 in 2000, it actually declined in each of these 10 states. Perhaps more troubling, the figure for 8 of these 10 states is below the 2.40 national average (see Figure 1).
Even these figures fail to address an even more critical factor—the distribution of the physician population within a state. State and national officials have long recognized the existence of medically underserved areas within this country. State medical boards may consider monitoring physician-population data as one possible indicator of likely areas of pressure both from the public and the media. A physician shortage (whether real or perceived) carries the potential for immense political and public pressure on state medical boards to respond to this issue.
ADDRESSING THE ISSUE
The challenges associated with meeting the needs of medically underserved populations often spark political means for remedying the situation. In the early 1990s, North Dakota Sen. Kent Conrad sponsored legislation designed to assist rural areas in gaining additional physicians—in this instance through a pilot program designed to ease visa restrictions on qualified overseas physicians willing to practice in a medically underserved rural region.3 This program was a direct response to factors observable through reference to physician-general population demographics.
Recent investigative legislation in California had state representatives and the medical licensing community exploring methods to increase the population of qualified physicians among its medically underserved populations, in particular the Hispanic community. One avenue currently being explored involves relaxing or amending California’s current licensure requirements to allow physicians licensed in Mexico to provide medical services in these areas for a specified period of time. If California provides a reasonably accurate barometer, one may expect similar pressures on Texas and other states where the Hispanic population represents the fastest growing segment of the population.
Not all legislative measures have been effective in addressing the underlying demographic issues behind physician distribution and access to health care. In Florida, the political pressure to address health care for a perceived medically underserved population led to demands for differing standards for physician licensure. Despite concerns voiced by both the Florida Board of Medicine and the Florida Medical Association, the state legislature created The Florida Medical Licensing Examination (FMLE) as an alternative pathway to medical licensure for a select group of foreign individuals. Since its implementation 4 years ago, fewer than 50 individuals have actually passed the examination and become eligible for licensure in Florida—but the initiative has created considerable political controversy for many in the state.
CONCLUSION
The changing demographic face of America’s population and the demands these demographics place on the physician population may bring state medical boards increasingly under pressure to account for the availability of medical care within their jurisdiction. Though solutions to complex, multi-causal problems such as medically underserved areas are beyond the realm of any single agency to remedy, state medical boards may consider monitoring demographic data such as the following to assist them in anticipating legislative directives:
state population totals;
an accurate count of the active, licensed physicians within the state;
the distribution of these physicians throughout the state;
trends among the medical school applicants and graduates within the state;
the number and composition of the state’s physicians in residency programs—and their likelihood for remaining in-state; and
the state’s reliance upon licensed physicians arriving from out-of-state medical schools and residency programs.
Close monitoring of physician demographic data in relation to the general population does not provide easy or automatic solutions to problems with the availability and distribution of health care within a state. However, such data may facilitate meaningful discussions among members of state medical boards grappling with these issues.
Statistical Resources:
For national demographics, see the United States Census: “Population Change and Distribution: Census 2000 Brief” at www.census.gov
The Federation of State Medical Boards provides an annual release of physician data including numbers for active, licensed physicians. For the most recent statistics, see “Annual Summary of Board Actions” at www.fsmb.org
For statistical data on applicants and matriculates of American medical schools see the Association of American Medical Colleges (AAMC) at www.aamc.org
For statistical information on the nation’s physician population in resident training, see the Accreditation Council on Graduate Medical Education (ACGME) at www.acgme.org
For statistical data on the medical students and graduates (including total number tested and performance) on the United States Medical Licensing Examination (USMLE) see www.usmle.org
Footnotes
↵ 1 Cooper, Richard A., MD. “The Expanding Scope of Practice of Non-Physician Clinicians and Implications for Medical Practice.” Medical Licensure in the 21st Century: Symposium Proceedings, September 6–7, 2000 Washington, DC. St. Barthelemy Press, 2002.
↵ 2 Mullan, Fitzhugh, MD. “The Case for More U.S. Medical Students.” The New England Journal of Medicine. July 20, 2000.
↵ 3 Newman, George S. “Foreign Medical Graduates at a Crossroads: Recent Events and Future Possibilities.” Interpreter Releases: Report and Analysis of Immigration and Nationality Law. Vol. 73, No. 3, January 14, 1995
