Subspecialty Leadership at a Time of Specialty Excess

A recent analysis suggests that the United States will face a surplus of 163 000 physicians by the end of the decade and that 85% of that surplus will be specialist physicians [1]. Further, the growth of managed care organizations, which use physicians in proportion to the needs of a defined population, is putting relentless pressure on the market for physician services.

These marketplace dynamics have stimulated a major debate about how best to achieve a physician work force that meets the nation's needs. Arguments for active management of the physician work force, as opposed to relying solely on market forces, are compelling. First, decisions about choice of specialty are made early in medical training and are heavily influenced by the culture of academic medical centers—which emphasizes technologically intensive, highly specialized care. Second, practicing physicians face market forces that only incompletely penetrate the ivory tower to affect the size and composition of training programs. Third, the size and composition of training programs are driven primarily by service needs in hospitals, not larger societal goals. Fourth, the current Medicare subsidy for graduate medical education has no strings attached, allowing teaching hospitals to develop and expand training programs with ongoing taxpayer support. Fifth, existing antitrust statutes severely limit the capacity of organized medicine to voluntarily manage graduate medical education.

On the other hand, strong arguments for …