< back
GUEST COMMENTARY: THE SUPPLY AND DEMAND OF PHYSICIANS, BY SIMON BIEBER
 In recent months, there has been a movement towards reducing the number of foreign physicians who are allowed to practice medicine in the United States. Recent studies from the Council on Graduate Medical Education and six national stakeholder groups in the US conclude that there is a national physician oversupply. To lower this oversupply, one recommendation that has been proposed, is to reduce the number of new foreign physicians permitted to work in the US. This recommendation comes amid concerns that foreign doctors are taking away jobs that would otherwise go to US physicians, particularly to minority US physicians. But the solution, and the problem for that matter, is not so simple. In fact, things are so complex that numerous studies have tried to identify both problems and solutions. One of the most recent studies was done by the North Carolina Rural Health Research and Policy Analysis Center. 
            Supply and demand. It is a notion that is centuries old. Where there is demand, a supply will be sought to meet the demand. When Adam Smith proposed the notion of supply and demand he was talking of economics, of products that could be imported and exported and prices that would be fixed based on supply and demand. While it may seem crude to compare foreign physicians to products that can be imported and exported, the analogy in this case is reasonable. 
 Demand? In America there is a demand for physicians. Rural areas are having problems attracting physicians to practice medicine. As urban culture gains more and more popular appeal, physicians are becoming more and more wary of leaving urban life behind for a rural practice. Thus many rural areas throughout the US have been designated as medically underserved areas, indicating the growing demand for physicians in those areas. 
            Supply?  At first glance supply doesn’t seem to be a problem. In fact according to the Council on Graduate Medical Education, there is seemingly an oversupply of physicians. But things are not always as they seem. Distribution is more of a problem than oversupply. The US population is growing. At the same time, the number of graduating medical students has remained relatively stable. So there are more people requiring medical attention from a pool of doctors that is not growing at the same rate relative to the population. Consequently, although there may be enough US born physicians to meet the required demand, the distribution of US born physicians leaves some communities with too many doctors and others with too few. Typically, urban areas, with the exception of inner cities, have their medical needs met. In this case there is no need for foreign physicians, as it could be argued that foreign doctors may take away jobs from American doctors in an urban setting. However, just as urban life differs from rural life, urban medical needs are being served differently than rural medical needs. While it may be true that there are enough American physicians to fill both needs, it is becoming increasingly difficult to attract American physicians to serve in rural settings. The result is that many rural communities are medically underserved. Therefore, the supply of American physicians is not adequate, because of distribution, to meet the medical needs of the entire US population. Thus, there is a problem of supply. 
So, how has this supply problem been handled in the past? Typically, foreign physicians have been allowed into the US on J visas to complete their residency, with the expectation that the foreign doctor would learn his/her trade in the US, and then take his/her improved skills back to his/her home country. The result should be a win-win. Foreign doctors get the opportunity to learn at the best institutions the world has to offer and thus become better doctors, consequently improving the quality of medical care in his/her native country when he/she returns home. Thus, foreign countries and physicians win. The J visa program is beneficial to the US too. One requirement of the J visa, is that upon completion of residency, the foreign physician must return home for a period no less than two years. However, waivers can be sought that eliminate this two year requirement, providing that the foreign-born physician practice in a rural or urban medically underserved area, helping to better meet America’s health care needs. Thus, in theory it is a win-win. 
            However, the world is filled with ideas that are perfect in theory but useless in practice. Not useless perhaps, but certainly not good. So, what is the problem? Because of the national physician oversupply, many American doctors are having trouble finding work, while many foreign physicians are working in jobs that could be filled by a qualified American doctor. So one solution offered is to reduce the number of new foreign doctors to make jobs available to the American born physicians whose job prospects have suffered due to the physician oversupply. The thinking is that communities, that are dependant on foreign physicians to serve their medical needs, would continue to have their medical needs met, but by American physicians instead of foreign ones. Many ideas have been proposed to ease the transition from rural communities being served by foreign doctors to rural communities being served by American doctors. Among the ideas that have been proposed are an increased role of the National Health Corps Service (NHSC), a more focused recruiting effort to persuade American physicians to practice in rural areas, and better co-ordination between local, state and national health agencies to eliminate the problem of distribution as it relates to health care. 
 There is vast detail associated with each idea, containing both benefits and drawbacks. For example, increasing the role of the National Health Corps Service would reduce the number of areas that would become underserved if foreign doctors were no longer permitted, but the National Health Corps Service has been widely criticized for its dictatorial practices. In West Virginia, a rural recruiter said outright that, “leaving it on the shoulder of the Corps physician…. is not the way,” to replace physician shortages. More focused recruiting has also been suggested, in the belief that if more American physicians were accepting rural postings then there would be less medically underserved areas and consequently less of a need for foreign physicians. However, this strategy has been tried in the past with limited success. Studies show that physicians choose their preference, urban or rural, prior to medical school and thus intense rural recruiting of medical graduates who have already made up their mind to practice in the city is like trying to swim up a waterfall. Lastly, increasing the coordination of health agencies would do much to help ease the problems rural communities would face should foreign doctors no longer be permitted to work in the US, by focusing on solving distribution problems. However, as each agency fights to promote its interest, conflicts will inevitably arise. 
Each idea that has been suggested to solve the problem of medically underserved areas in the US has been tried before. For years health agencies have been trying to foster greater co-operation. For years there have been efforts to recruit American born doctors to practice in rural and inner city areas. For years the National Health Corps Service has existed as an option, viable or not. But because an oversupply of physicians has recently developed, solutions are being sought more actively. However, most of the solutions that are being proposed are tried and tested “solutions” that have failed in the past. Trying to fix the problem of medically underserved areas with solutions that have already proved unsuccessful is like trying to fit a square peg into a circular hole by hitting it harder. It simply doesn’t make sense.
So what now? There is no easy answer. Perhaps the best answer that can be given to the question of how to replace foreign medical graduates is not to replace them. There is a demand for physicians in rural and inner city areas despite the overall national physician oversupply. Health care problems should not be solved through a trial and error approach, as the well being of American citizens would be placed at risk if proposed ideas fail and communities are forced to make do with little or no medical care. Therefore until a viable alternative can be reached, perhaps it is best to employ the “if it’s not broke, don’t fix it,” approach. This would allow American physicians to practice where they please and foreign physicians to fill the gaps and provide medical care to those American citizens who are in need of it.