The Physician "Surplus" and the Decline of Professional Dominance

Two immediate circumstances cast a shadow over [physicians, voluntary hospitals, and medical schools'] future: the rapidly increasing supply of physicians and the continued search by government and employers for control over the growth of medical expenditures.

—Paul Starr, The Social Transformation of American Medicine (emphasis added)

This essay examines the relationship that Paul Starr hypothesized in The Social Tranformation of American Medicine (1982) between the supply of physicians (both allopaths and osteopaths) and their professional dominance, a relationship, he argued, that began to turn negative about the time of the passage of Medicaid and Medicare in 1965. In particular, Starr posited that an increasing number of physicians, dubbed a "surplus," would become an essential condition in reducing their dominance over the health care system, while abetting the larger process of corporatization that the medical profession was experiencing (421-427). In the pages that follow, I first outline the main points of Starr's argument, one that was also accepted by many others (Mick 1980). Second, I discuss how and why growth in physician supply has not contributed as much as was predicted to a putative decline in medicine's privileged professional status. Finally, I propose that whether physician supply is in surplus (or shortage) is a socially constructed conclusion that depends on the technical pitfalls of making such judgments and the interests of the arguer. I also propose that Starr used surplus in two different senses—a health policy approach and an economics approach. This not only causes confusion about what the mechanism for the loss of dominance was supposed to be, but also leads to the conclusion that too much was made of supply as a major causal factor contributing to the supposed loss of professional dominance during the late twentieth century.

The Late 1970s, Early 1980s: Context

In the late 1970s, the federal government established the Graduate Medical Education National Advisory Committee (GMENAC) to determine what number of physicians the nation would require as the twentieth century ended. GMENAC was established at the end of a decade that witnessed increasing discussion about whether the physician shortage of the 1950s had not given way to a surplus. After several decades of federal largesse to increase the number of both medical schools and medical graduates, many observers thought that the nation was on the verge of overproduction, particularly among the ranks of specialists. GMENAC's charge was to investigate and quantify this phenomenon. In 1980, after a series of interim and special reports on study methodology, the final report appeared. It concluded that the nation would have a surplus of 70,000 physicians (allopaths and osteopaths) by 1990 and 145,000 by 2000 (GMENAC 1980). The results were not unexpected, given the growing climate of skepticism about the necessity of further federal spending to support medical education. Still, the impact of the study was incalculable. Many of the nation's most respected health care observers added to the chorus of voices that dissected the meaning and the consequences of the "new" surplus (Ginzberg and Ostow 1984). Starr's hypothesis was a natural extension of what many believed to be true: the nation was about to be overwhelmed with physicians, and the real challenge was to figure out how it would affect the health care system.

How the Surplus Was Supposed to Emasculate Medicine

At the crux of Starr's proposal that a surplus of physicians would undermine their dominant status is the notion that an oversupply relative to demand would adversely influence their market power in the health sector, as there might be more physicians available to practice than anyone would want or could pay for. Physicians, as members of other highly trained occupational groups have experienced, might find themselves underutilized, even unemployed, or otherwise needing to find other forms of work or to accept medical work not entirely to their liking, including practicing in specialties in which they did not train. Not only might physicians be forced to work in undesirable locales and practice settings, but they might also be forced to accept reduced incomes. Furthermore, physicians would find that...