RECENT discussions of the nation's physician work force have focused on its imbalance -- the oversupply of specialists and the shortage of generalists, or primary-care providers. One proposed response: bolster medical schools' efforts to attract students to primary care, with the ultimate goal of producing a majority of graduates committed to generalist practice. But, as David Goodman, M.D., and his colleagues at Dartmouth Medical School suggest with the map above, which displays their calculation of the distribution of generalists in 1996, the shortage may not be as grave as reported -- and, indeed, does not exist if the supply is viewed in the aggregate. The need for more generalists is not national but regional (mostly in rural and inner-city areas). Training more and more generalists is not a solution, Goodman and his colleagues say. The focus must be on giving doctors incentives (such as subsidies) to move to shortage areas.

Specialists and generalists alike tend to establish practices in affluent urban areas, adding to already abundant existing supplies. Nationwide, the distribution of generalists in 1996 ranged from highs of more than 100 per 100,000 residents (in the hospital-referral regions for San Francisco and White Plains, New York, for example) to a low of 34 (in the McAllen, Texas, area, on the Mexican border). Although there are no agreed-upon standards for what constitutes a sufficient supply of doctors for a given population, a number of adequately staffed locales may serve as reference points in determining how many doctors are needed where shortages now exist -- and where excess doctors can be found.

About a third of the U.S. population lives in areas with a higher ratio of generalists than there is in the Minneapolis region, where a primarily managed-care system operates efficiently with 68 per 100,000. If all regions with a higher ratio of generalists were adjusted to match Minneapolis, almost 10,000 generalists would be left over. If the same adjustment were made using as the baseline Wichita, Kansas (61 per 100,000), a mostly fee-for-service region, more than 17,500 generalists would be left over -- fewer than half of whom would be needed to bring the number of generalists in all lower-staffed regions up to Wichita's level. -- Allan Reeder

Map from the Dartmouth Atlas of Health Care 1998, John E. Wennberg, M.D., series editor

The Atlantic Monthly; December 1997; Primary Care to Spare?; Volume 280, No. 6; page 97.