What's a few thousand ophthalmologists, more or less?

In the 1970s, when I began medical school, dire predictions of physician shortages abounded. Congress passed a law to get U.S. medical schools to solicit transfers of students from non-U.S. schools for their third and fourth years, so as to address the looming undersupply.

Fifteen years later, we were told that U.S. health-care costs were spiraling out of control due to an oversupply of physicians, providing an excessive amount of services (including alleged unnecessary surgery), ordering too many tests, and prescribing too many medications. Workforce analyses projected a surplus of physicians, especially subspecialists.

The problem was to be solved by limiting growth of medical schools and by training more primary-care doctors (cognitive fields) and fewer subspecialists and surgeons. The primary-care doctors, so the strategy went, would handle most problems much more cost-effectively than the subspecialists, and act as "gatekeepers" to reduce costly referrals to subspecialists.

Now the pendulum has swung back with the prediction that there may be up to a 35% undersupply of ophthalmologists by the next decade or two,^1,2 especially with the aging of the U.S. population. The shortage of geriatricians is especially acute today.

According to some health-care policy experts, we are always in crisis. But depending on the decade, the crisis changes from an alleged undersupply to an alleged oversupply of physicians.

Challenging predictions To be fair, the science of predicting future needs of the U.S. patient population is apparently full of challenges. Past studies have consistently underestimated growth of our population. Our country continues to attract massive numbers of immigrants (both legal and illegal), and people continue to want to come here to make a better life for themselves and their children. We hope that optimism about life in the Unites States is well-placed, and it may well be that immigration will continue to exceed expectations.

Also, advances in medical care have not been accurately predicted. For example, when I started my residency, there was essentially no therapy for age-related macular degeneration. Patients were seen, diagnosed, informed that they had an untreatable disorder, possibly offered a referral for a low-vision evaluation, and often not asked to return.

Now, this condition is managed with frequent visits, diagnostic tests, photodynamic therapy, and injections of anti-vasoproliferative agents. Because the number of elderly, at-risk patients has grown, the work involved in caring for these patients has ballooned.

The idea that primary-care doctors (internists, pediatricians) would handle the vast majority of eye problems is seriously flawed, in my opinion. As I mentioned in a recent column ("Ophthalmology?!-Who needs to learn that?" Ophthalmology Times, March 15, 2005), the vast majority of U.S. medical schools do not require any ophthalmology rotation, and many primary-care physicians graduating today will never own an ophthalmoscope!

What to do? What are the poor department chairmen to do? Do we believe the latest projections of ophthalmologist shortages and increase our training slots? Do we discount the latest pronouncements and stay the course? Or do we heed the previous projections of oversupply and downsize our programs?

The stakes seem reasonably high. If we have an oversupply, our graduates might not have good jobs waiting for them, physicians will have less satisfying careers, and our society's health-care costs may bankrupt the country if a serious oversupply occurs in all subspecialties. If we have an undersupply, patients might suffer due to lack of access, and ophthalmic practices will find it harder to hire young associates at a reasonable salary.

My ophthalmologist friends in practice tell me they are quite busy, and that smart, hard-working medical students that become well-trained ophthalmologists will not need to worry about having plenty to do. I suspect that if the demand for our services does dramatically increase over time, innovative ophthalmologists and industry will likely respond with new solutions for providing cost-effective care.