This Date in UCSF History: Too Many Specialists, Too Little Diversity in Health Professions

Originally published on May 22, 1997.

A report by UCSF researchers released last week says there are too many specialists in the state and recommends that California medical schools and residency programs reduce the number of specialists currently trained by at least 25 percent.

“For more than 15 years, health care experts have sounded an alarm about the impending oversupply of physicians, particularly specialists,” says lead author Janet Coffman, MPP, associate director of workforce policy and analysis at the UCSF Center for the Health Professions.

Coffman maintains that California’s medical schools and residency programs “have been slow to respond to these warnings, and now many parts of the state have a serious oversupply of specialists.”

State spending on the education of specialists who are simply not needed has contributed to the high cost of health care, according to co-author Kevin Grumbach, MD, director of research for UCSF Center for the Health Professions.

“California is now oversaturated with specialists,” he says. “It just doesn’t make sense to invest 10 or more years of medical education to train a specialist who is not needed and who will not be able to find work in the state.”

The report, which was released by the UCSF Center for the Health Professions in conjunction with the California Primary Care Consortium, says that by the year 2010, the state will have 37% more physicians than necessary if the population growth rate continues to slow.

The report also finds that the Bay Area has the highest ratio of physicians to population, twice that of South Valley/ Sierra.

Furthermore, the Bay Area has the highest concentration of specialists, with an excess of 50 to 85%.

The report, which also examined the ethnicities of California’s physicians, concludes that Latinos and African Americans are underrepresented among the state’s physicians. In California, Latinos comprise 26% of the population but only 4% of physicians. African Americans comprise 7% of the population but only 3% of physicians.

Medical Schools Must Take Action

The authors of the report, titled “California Needs Better Medicine: Too Many Specialists, Too Little Diversity, Poor Distribution,” make several recommendations to prevent further physician oversupply in California.

First, residency programs must cut the number of specialist residency positions by at least 25%. Such cuts will match the future supply of physicians to the future requirements, the report says.

Secondly, California’s medical schools must freeze enrollment at the current level, which is “just about the right level to meet the population’s needs [for the future],” says lead author Janet Coffman.

Thirdly, California’s medical schools must maintain efforts to encourage medical students to pursue generalized careers.

According to the study, approximately 400 California medical school graduates enter generalist training programs each year, but there are 1,117 first-year generalist positions available.

Although the report admits that the future need for generalist physicians is unclear, it recommends that California provide adequate resources to support the current number of residency positions.

The authors speculate that non-physician providers (i.e., advanced practice nurses, physician assistants) may be used more extensively in the future, and thus recommend that California not increase or decrease the total number of generalist residency positions.

The report also recommends that California increase enrollment of underrepresented minorities in medical schools and residency programs.

From 1995 to 1996, enrollment of minorities among entering students decreased by 20% in UC medical schools.

“Unless we make great strides in correcting the imbalance between the racial/ethnic makeup of physicians as compared to the general California population,” says Grumbach, “under-representation will only worsen — especially among Latinos, the fastest-growing population and the least-represented among physicians in the state.”

The authors add that the recent decision of the UC Regents to end affirmative action threatens progress in this regard.

Finally, the report urges more communication between all public and private medical schools and residency programs. State officials must find ways to coordinate such action on a statewide basis.

Implications for Med Students

New graduates in specialties are having significant trouble finding positions, according to Janet Coffman. One in five graduates in surgery and one in four graduates in hospital-based specialties are having difficulty obtaining full-time employment.

For comparison, about one in 20 graduates in generalist subspecialties (OB/Gyn, pediatrics, internal medicine, etc.) are having difficulty.

Are opportunities really scarce? Perhaps not, says Coffman.

A student who completes medical school in California has, on average, about 1.4 to 1.5 positions from which to choose.

If the above recommendations are implemented, according to Coffman, the cuts will affect sub-specialty fellowships (which people enter one or more years after residency training) more than it will affect first year residency positions.

Thus, there will still be plenty of choices out of medical school: about 1.5 positions for each graduate nationwide, says Coffman. The study’s recommendations have implications for pre-medical students as well as medical students, Coffman feels.

If a freeze is placed on medical school enrollment, then pre-meds can expect the same or greater competition for admission.

Pre-medical students should evaluate their career goals and “ask themselves if medicine is really for them,” says Coffman.

Coffman feels that medical students must also do some career evaluating, for “while people need to make choices [based on] what they enjoy doing, it’s also important for those choices to be informed about the demand for physicians.”