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Medical Manpower and Urological Practice
0022-5347/84/1316- l 145$0'.2,00/C
VoL June Printed in U.S.A.
THE JOUR.NAJ., OF Ul~OLOG ../
Copyrigh"t © ~.984 by The '\NilEat.:1s & V/ilkin_s Co.
Editorial J\1:EDICAL rvIANPOWER AND UROLOGICAL PRACTICE Various studies and surveys have indicated clearly the danger of overproduction of physicians during this decade, leading to a glut of doctors by 1990. The most serious threats of overpopulation lie in the specialities, including urology. The fundamental question involves adequacy of medical manpower and whether additional physicians will improve the quality of medical care and/or reduce the cost of health care delivery in the United States. The issue is complex and there are no simple answers. On the other hand, it should be pointed out that there are >450,000 licensed physicians in the United States today. Among these more than three-quarters are engaged actively in health care delivery. With this present number we have a supply of physicians that will provide adequately for the health care of the nation according to most surveys. Furthermore, our medical schools are now producing a massively increased number of graduates. Only 30 years ago there were just >6,000 new physicians who graduated from United States medical schools each year, while today we are anticipating a situation in which we confer approximately 17,000 new degrees of Doctor of Medicine annually. Recognizing that the average age of practicing physicians in the United States is <40 years, we can expect to double the number of practicing physicians within the next decade. This problem is compounded further by the number of foreign medical graduates and United States graduates of offshore medical schools who enter this country each year. Why, it may be asked, is an overpopulation of physicians undesirable? Would not a large number of doctors ensure that so-called underserved areas acquire physicians by default? Would not an abundance of physicians serve the supply-and-demand principle, and drive down the cost of medical care? Could we not anticipate that there would be increased competition and, therefore, lower costs of physician services? The answer to all of these and related questions is an emphatic negative. All available studies indicate that each physician added to the medical manpower pool serves only to drive up the cost of health care. Therefore, it is in the greater public interest to maintain a rational physician ratio, graduating only that number of physicians needed to provide adequate medical services. There are many reasons for this, some rational and some hypothetical, but experience indicates that an excessive number of physicians does nothing except increase the cost of medical care, clearly not a desirable goal in this economic climate. Most medical economists estimate that each physician who enters the practicing account for the expenditure of >$300,000 m radiological and bed care costs. This unlimited public demand for medical care services. It is ohvious that our be expe,ctE,d to determine what and which medical ac,~01np
"watch tia!ly the only expensive diagnostic laboratory radiological procedures can invite easily the expenditure of massive amounts of money in the pursuit of even the most pedestrian and nonthreatening symptomatology. It is only the physician who is the gatekeeper to employment of technology, and when there are too many gatekeepers abuse becomes an easy matter. It also is imperative that society address the cost of producing the physician, one of the most expensive commodities that we enjoy today. Whether the embryonic physician attends public or private institutions, the cost of physician education to the public is enormous. First, it is necessary to recognize that the physician trainee is lost to the employ-
ment pool for a lengthy period: 4 years of college, 4 years of medical school and a training interval of 3 to 8 years, depending on the specialty selected. Thus, there is a loss of taxable income and productive activity by that particular individual. Next, we must acknowledge the fact that tax dollars support all forms of higher education, whether in publicly supported or privately endowed institutions. We must recognize further the fact that students in colleges and medical schools have a certain basic cost-of-living expense that is borne by their parents, student loans, government grants or other means that actually represent dollars out of pocket for the educational process. There is then the matter of tuition and unreimbursable cost of education. The average medical school today can document educational costs of approximately $40,000 per student per year for each year of medical education. This is offset by tuition that reflects oniy 10 to 50 per cent of actual costs, depending upon the school involved. Next, we must address the cost of postgraduate education for which the figures are more nebulous, although it is obvious that the annual salary of residents in training reflects in part a student stipend and that the cost of living of these postgraduate students is a societal cost, at least in part. Finally, it is a fact that each graduating medical student in this country has an average debt that now approaches $40,000, and within the next decade it is estimated that each student may graduate with a debt >$100,000. Clearly, these costs will be recaptured in some fashion and the more doctors we have in our society, the greater the magnitude of the total dollar problem. Urology represents only a small fraction of the total medical practice problem and, consequently, the total economic problem, although we ~aust look to our own situation just as the medical community must address the macrocosm of the general socioeconomic aspects of medical care. On the other hand, urology may be impacted even more seriously since the larger specialities, sometimes underemployed, will look to our particularly attractive field of medicine for areas in which to engage in practice and recapture income. Consequently, a reduction in numbers of urologists or in numbers of prospective urologists will not necessarily improve the picture but might rather invite still further abuse by others. The serious considerations involved here invite careful scrutiny and the most deliberate investigation. Urologic manpower has grown rather dramatically. There were only about 5,000 recognized urologic specialists in the United States 10 years Today that number stands at >8,000 and by 1990 it is estimated we could have as many as 12,000 urologists available. This increase is due, in part, to the of our training program but also to the fact that the age practicing is diminishing and we rate than the attrition of the practicing has been responsive to the perceived manpower The of training programs approved for residency has diminished from >190 to <140 at the present time to the efforts of the Residency Review Committee to ensure the highest standards. The iength of training programs has increased in many centers as well. The caliber of applicants for residencies in urology is increasing correspondingly, according to all reports. In short, the future for urology seems bright indeed but, while urology is in a relatively good posture compared to other medical. specialities, there is an implicit threat to the practice of urology from specialities in which there may be an oversupply of practitioners. This clearly is an issue that must be addressed candidly in the near future. James F. Glenn The Mount Sinai Medical Center New York, New York 10029
VoL June Printed in U.S.A.
THE JOUR.NAJ., OF Ul~OLOG ../
Copyrigh"t © ~.984 by The '\NilEat.:1s & V/ilkin_s Co.
Editorial J\1:EDICAL rvIANPOWER AND UROLOGICAL PRACTICE Various studies and surveys have indicated clearly the danger of overproduction of physicians during this decade, leading to a glut of doctors by 1990. The most serious threats of overpopulation lie in the specialities, including urology. The fundamental question involves adequacy of medical manpower and whether additional physicians will improve the quality of medical care and/or reduce the cost of health care delivery in the United States. The issue is complex and there are no simple answers. On the other hand, it should be pointed out that there are >450,000 licensed physicians in the United States today. Among these more than three-quarters are engaged actively in health care delivery. With this present number we have a supply of physicians that will provide adequately for the health care of the nation according to most surveys. Furthermore, our medical schools are now producing a massively increased number of graduates. Only 30 years ago there were just >6,000 new physicians who graduated from United States medical schools each year, while today we are anticipating a situation in which we confer approximately 17,000 new degrees of Doctor of Medicine annually. Recognizing that the average age of practicing physicians in the United States is <40 years, we can expect to double the number of practicing physicians within the next decade. This problem is compounded further by the number of foreign medical graduates and United States graduates of offshore medical schools who enter this country each year. Why, it may be asked, is an overpopulation of physicians undesirable? Would not a large number of doctors ensure that so-called underserved areas acquire physicians by default? Would not an abundance of physicians serve the supply-and-demand principle, and drive down the cost of medical care? Could we not anticipate that there would be increased competition and, therefore, lower costs of physician services? The answer to all of these and related questions is an emphatic negative. All available studies indicate that each physician added to the medical manpower pool serves only to drive up the cost of health care. Therefore, it is in the greater public interest to maintain a rational physician ratio, graduating only that number of physicians needed to provide adequate medical services. There are many reasons for this, some rational and some hypothetical, but experience indicates that an excessive number of physicians does nothing except increase the cost of medical care, clearly not a desirable goal in this economic climate. Most medical economists estimate that each physician who enters the practicing account for the expenditure of >$300,000 m radiological and bed care costs. This unlimited public demand for medical care services. It is ohvious that our be expe,ctE,d to determine what and which medical ac,~01np
"watch tia!ly the only expensive diagnostic laboratory radiological procedures can invite easily the expenditure of massive amounts of money in the pursuit of even the most pedestrian and nonthreatening symptomatology. It is only the physician who is the gatekeeper to employment of technology, and when there are too many gatekeepers abuse becomes an easy matter. It also is imperative that society address the cost of producing the physician, one of the most expensive commodities that we enjoy today. Whether the embryonic physician attends public or private institutions, the cost of physician education to the public is enormous. First, it is necessary to recognize that the physician trainee is lost to the employ-
ment pool for a lengthy period: 4 years of college, 4 years of medical school and a training interval of 3 to 8 years, depending on the specialty selected. Thus, there is a loss of taxable income and productive activity by that particular individual. Next, we must acknowledge the fact that tax dollars support all forms of higher education, whether in publicly supported or privately endowed institutions. We must recognize further the fact that students in colleges and medical schools have a certain basic cost-of-living expense that is borne by their parents, student loans, government grants or other means that actually represent dollars out of pocket for the educational process. There is then the matter of tuition and unreimbursable cost of education. The average medical school today can document educational costs of approximately $40,000 per student per year for each year of medical education. This is offset by tuition that reflects oniy 10 to 50 per cent of actual costs, depending upon the school involved. Next, we must address the cost of postgraduate education for which the figures are more nebulous, although it is obvious that the annual salary of residents in training reflects in part a student stipend and that the cost of living of these postgraduate students is a societal cost, at least in part. Finally, it is a fact that each graduating medical student in this country has an average debt that now approaches $40,000, and within the next decade it is estimated that each student may graduate with a debt >$100,000. Clearly, these costs will be recaptured in some fashion and the more doctors we have in our society, the greater the magnitude of the total dollar problem. Urology represents only a small fraction of the total medical practice problem and, consequently, the total economic problem, although we ~aust look to our own situation just as the medical community must address the macrocosm of the general socioeconomic aspects of medical care. On the other hand, urology may be impacted even more seriously since the larger specialities, sometimes underemployed, will look to our particularly attractive field of medicine for areas in which to engage in practice and recapture income. Consequently, a reduction in numbers of urologists or in numbers of prospective urologists will not necessarily improve the picture but might rather invite still further abuse by others. The serious considerations involved here invite careful scrutiny and the most deliberate investigation. Urologic manpower has grown rather dramatically. There were only about 5,000 recognized urologic specialists in the United States 10 years Today that number stands at >8,000 and by 1990 it is estimated we could have as many as 12,000 urologists available. This increase is due, in part, to the of our training program but also to the fact that the age practicing is diminishing and we rate than the attrition of the practicing has been responsive to the perceived manpower The of training programs approved for residency has diminished from >190 to <140 at the present time to the efforts of the Residency Review Committee to ensure the highest standards. The iength of training programs has increased in many centers as well. The caliber of applicants for residencies in urology is increasing correspondingly, according to all reports. In short, the future for urology seems bright indeed but, while urology is in a relatively good posture compared to other medical. specialities, there is an implicit threat to the practice of urology from specialities in which there may be an oversupply of practitioners. This clearly is an issue that must be addressed candidly in the near future. James F. Glenn The Mount Sinai Medical Center New York, New York 10029