that is how the term is used in, for instance, Chapter 5. The committee recognizes that the broader primary care team will include various other health care personnel, such as therapists, nutritionists, social workers, allied health personnel, and office staff. This range of professionals is reflected, for example, in the vignettes used in Chapter 3 to illustrate the scope of primary care. Finally, yet other health professionals, such as dentists, deliver primary care within their own fields and disciplines (IOM, 1995a), but as they are not likely to be responsible for the large majority of health care needs of all people, they are not discussed further here.

Workforce Trends And Supply Projections: Physicians

Overall Levels of Supply

An extremely contentious set of issues in the United States in recent years has involved the numbers of physicians and their distribution by geographic area and specialty. Today, essentially all experts agree that the overall levels of physicians in the country point to a surplus; some in fact would characterize the level as a significant oversupply.

These issues were explored in a recent report by an Institute of Medicine committee on aggregate physician supply (IOM, 1996a, pp. 3–4). The report concluded that

  • the nation, at present, clearly has an abundant supply of physicians—which some members of the committee were prepared to label a surplus;
  • judgments about the implications of those numbers must be made in the context of the overall U.S. health care system and the components of that system of greatest concern—the quality and costs of health care and access to services;
  • the increase in the numbers of physicians in training and entering practice each year is sufficient to cause concern that supply in the future will be excessive, regardless of the assumptions made about the structure of the health care system; and
  • the steady growth in numbers of physicians coming into practice is attributable primarily to ever-increasing numbers of IMGs [international medical graduates], about which the committee is very concerned.

Other very recent publications are divided. For example, a minority viewpoint has been laid out by Cooper (1995), who argues that projections of the demand for and supply of physicians using more up-to-date assumptions show "no evidence of a major impending national surplus" (p. 1534). Cooper also draws attention to more than twofold differences across the states in the physician-to-population ratios; to the rapid growth of a wide array of nonphysician clinicians (including NPs and PAs); and to the need to develop policies that take



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