The Future Endocrinology Workforce

Harry R. Kimball

President, American Board of Internal Medicine Philadelphia, Pennsylvania 19106-3699

Address all correspondence and requests for reprints to: Harry R. Kimball, M.D., 510 Walnut Street, Suite 1700, Philadelphia, Pennsylvania 19106-3699.

It is hardly a secret that predicting physician workforce need is, at best, a risky business. Most attempts have been unsuccessful, sometimes even spectacular failures, as was true for the much publicized prediction in 1994 of a looming excess of 165,000 patient care physicians by 2000 (1). In that study, future needs were based on the relatively parsimonious utilization of specialists by managed care panels. However, because of strong public backlash to policies that limited access to specialists and other cost containment measures, the expected market share for managed care and the predicted physician surplus failed to materialize. The point is not that this particular workforce prediction erred but that any workforce forecast is highly dependent on the accuracy of assumptions about the healthcare delivery system, the prevalence of human disease, and the pace of technological advance. For example, the Graduate Medical Education National Advisory Committee (GMENAC) studies of the early 1980s could hardly have foreseen the HIV epidemic or predicted the rapid incorporation of endoscopic surgery into everyday clinical practice. When it comes to workforce predictions, therefore, it is essential to remember that none will be completely true because there are just too many unknowns. And, given the long timeline for training doctors and lacking reasonable certainty about future healthcare needs, trying to tweak the physician workforce to remain in perfect balance is likely a fool’s errand.

Elsewhere in this issue of the Journal of Clinical Endocrinology & Metabolism is a detailed and useful analysis of the many factors affecting the endocrinology workforce (2). It is important to note that because the sponsors of this study (professional societies, advocacy organizations, and training directors) have a significant stake in the outcome, the potential for bias does exist. That said, the authors describe a wide array of variables that affect assessments of the balance between specialist supply and demand. On the supply side, the workforce model takes into account the impact of newly trained endocrinologists, practice patterns, and retirement rates. On the demand side, it factors in Medicare claims data, National Ambulatory Medical Care Survey (NAMCS) office visits, selected Health Maintenance Organization benchmarks, income and age demographics, and the increasing incidence of diabetes in the population. Very importantly, the model is interactive so predictions can be updated as new information becomes available.

Six scenarios extending to 2020 are presented. Of these, only one (scenario 1), in which current supply is deemed adequate and demand increases proportionally with population growth, forecasts a rough balance of specialist supply and demand for 2020. All other scenarios assume a current gap of 15% in supply and, not surprisingly, each continues to show varying degrees of specialist undersupply for the next two decades. The greatest gap occurs in scenario 6, which assumes a 1% increase annually in per capita income and in the prevalence of diabetes, a modest growth for managed care and disproportionate Medicare usage of endocrinology services. The authors believe this scenario is the most realistic but conclude that scenario 5 (no adjustment for the prevalence of diabetes) is conservative and the most defensible. It predicts a 25–30% shortage of endocrinologists by 2020.

The authors estimate that a 12–15% undersupply of endocrinologists currently exists. Anecdotally, it seems reasonable to assume that some shortage exists, but it is unclear how this estimate was exactly calculated. The authors wisely point out that improvements in education, pharmacology, and management by nonendocrinologists could offset the effects of an increase in the prevalence of diabetes but such improvements in diabetic care could also substantially reduce any gap now extant in the profession.

A significant weakness of the workforce predictions in this study is its use of outdated supply data. The number of endocrinologists entering training has substantially increased over the 1997 levels used as baselines. Annual American Board of Internal Medicine tracking data document that 2002 entry rates are approximately 30% higher than in 1997 (220 vs.171 trainees) and closely mirror first-time takers of the American Board of Internal Medicine’s endocrinology examination (227 in 2002) (3). Whereas it is unlikely that such gains will continue, neither are they likely to decline much unless Medicare funding for training medical subspecialists collapses. The steady increase in endocrinology trainees parallels a 5-yr trend toward greater interest in all medical subspecialties; subspecialization rates in 2002 are 56% compared with the historically low 39% in 1997. Increases of this magnitude in the production of endocrinologists will have substantial effects on the workforce projections presented in this study. Moreover, in this same 5-yr time frame, there has been an 11% decrease in international medical graduates (to 45%) entering endocrinology training programs. Because all International Medical Graduate trainees do not stay in the United States, this change, if sustained, will further ameliorate the projected undersupply of future endocrinologists.

In summary, the comprehensive workforce model for predicting the future supply and demand for endocrinologists described herein is a welcome step forward in bringing greater rationality to discussions of the adequacy of the physician workforce. The scenarios presented will provoke debate; but to be credible and persuasive, they should be based on more current information.

Footnotes

The opinions presented are those of the author and may not necessarily represent those of the American Board of Internal Medicine.

Received March 17, 2003.

Accepted March 19, 2003.

References

  1. Weiner J 1994 Forecasting the effects of health reform on US physician workforce requirement: evidence from HMO staffing patterns. JAMA 272:222–230[Abstract]
  2. Rizza RA, Vigersky RA, Rodbard HW, Ladenson PW, Young Jr WF, Surks MI, Kahn R, Hogan PF 2003 A model to determine workforce needs for endocrinologists in the United States until 2020. J Clin Endocrinol Metab 88:1979–1987[Abstract/Free Full Text]
  3. American Board of Internal Medicine Examination data and statistics. American Board of Internal Medicine website (www.abim.org)




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