[Demographic forecasts of medical workforce supply in France (2000-2050). What numerus clausus for what future?]

Bui Dang Ha Doan, Danièle Lévy, Jeanne Pavot
Cahiers de Sociologie et de Démographie Médicales 2004, 44 (1): 101-48

UNLABELLED: In France, medical training and graduation of medical doctors are under the full control of the State. A numerus clausus barrier is established between the first year and the second year of medical schools. The first year is open to all students having successfully completed their secondary schooling (18 years old) but the number of those allowed to start the second year is decided every year by the government. Foreign medical graduates can practise only if they have obtained authorization from the State. Theoretically, the authorities have all means for shaping the size of the medical workforce, either in the short term (e.g. by importing foreign medical graduates to fill up vacant posts) or in the long run (by increasing or decreasing the numerus clausus, or student intake, to cope with shortage or oversupply of doctors). In practice, due to various constraints, the issue is far from simple (resistance to change, divergent lobbying forces and, more importantly, lack of relevant information).

METHODS: In this study, the forecasting techniques of demography are used to assess the future trends of supply of medical doctors, on the basis of the formula t2 = t1 + e - l t1 is the medical workforce at the beginning of the period t2 is the medical workforce at the end of the period e is the number of doctors entering the medical workforce (new national graduates or foreign graduates) during the period l is the number of doctors leaving the medical workforce (death, retirement, out migration) during the period. Calculations are performed for each 5-year age group and for the successive 5-year periods. At the end of a 5-year period, one obtains the number of professionally active doctors in each 5-year age group and, by addition, the total number of active physicians in the country. The starting point of the projection work is December 31st 2000 when the French medical profession numbered 200,800 (i.e. 334 physicians per 100,000 population). As concerns the inflow e (physicians entering the profesion), calculations are performed step by step: number of students starting the 2nd year of medical schools: two basic hypotheses are adopted as concerns the future intake decided by the government, 8000 and 6000 (Table A) from the numerus clausus barrier (2nd year of medical training) to the 6th year of medical training from the 6th year to graduation (the residency period) from graduation to registering in the Medical Council (effective start of the career) moreover, it is assumed that from 2000 through 2025, for each 5-year period, 1200 foreign medical graduates are allowed to join the national medical workforce; after 2025, this number will decrease to 300. As concerns the outflow l, a "professional life table" is used to determine the numbers of doctors of each age-group who leave the career by death, retirement, outmigration ... during each 5-year period (Table B).

CONTEXT: From 1965 onwards, the number of students entering the medical schools grew steadily. The numerus clausus system, established in 1972, became effective five years later. However, due to resistance to change, the number of students allowed to start the 2nd year of medical schools reached a really low level only at mid-80's. In other words, during the period 1974-1994, France experienced a significant "graduate boom". The young doctors graduated during these two decades were in extremely high numbers and fueled a strong feeling of manpower oversupply. But from mid-90's onwards, the annual number of new graduates decreased (as a result of the low numerus clausus decided from mid-80's). In hospitals, post vacancies became frequent. In ambulatory care, medical practitioners encountered great difficulties to find locum tenens. From 2000 onwards, the term of manpower shortage was openly evoked in public debates. Starting 1999, the authorities increased again the numerus clausus which reached 5100 in October 2003. The mood was in favor of an upward trend. As a matter of fact, the numerous physicians graduated during the 1974-1994 boom period will begin to retire around the year 2010 and the French medical profession would sharply decrease without a vigorous growth of the numerous clausus. As started above, this projection work adopts two basic hypotheses as concerns the numerus clausus: the number of medical students allowed into the 2nd year, will progressively increase in October 2007 either to 6000 or to 8000 and will remain constant later on.

RESULTS: With a 8000 student intake, the number of physicians (200,800 in 2000) will increase to 209,300 in 2010 then will slowly decrease to 205,900 in 2030. After, it will grow again and reach 229,500 in 2050. With a 6000 student intake, the number of physicians will also increase to 209,300 in 2010, then will rapidly decrease to 173,700 in 2030. The downward trend will stop in 2035. After, a slow growth will take place and the medical profession will number 173,500 in 2050 (Table C and Fig. 1). In other words, if a numerus clausus of 8000 is decided, the large retirement of the 1974-1994 graduate boomers (during the period 2010-2030) will be nearly offset by the newcomers. At the same time, the aging of the medical workforce will be stopped. Instead, a new younging process of the medical profession will take place again after 2020 (Fig. 2 and Fig. 3). As it was the case during the early 70's, the younging process or pouring in of new graduates in great numbers may possibly fuel a strong perception of oversupply and lead to a sharp decrease of the numerus clausus after 2020 (sec variants Ib, Ic, IIb, IIc in Table A and C). As the numerus clausus has been increased during the first decade of the century, the two opposite moves (upward and downward) will create once again a phenomenon of "graduate boom". The boom will be far more important with a student intake of 8000 (Table F and Fig. 5) than a student intake of 6000 (Table G and Fig. 7). Even with 8000 students, the boom will not appear if the intake (numerus clausus) is not decreased after 2020. Consequently, if the decision is made today to increase sharply the student intake, we should be sure not to have to decrease it strongly in two or three decades. A less important increase decided today will not totally fill the gap when those graduated during the period 1974-1994 will retire and the national number of physicians will diminish. But such a decision will probably avoid the appearance of a feeling of oversupply in the coming decades and its subsequent problems (decreased student intake and, a decade later, a new graduate boom).

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