Can the looming physician shortage be stopped?

While the nation debates the policy and payment issues in healthcare, a quiet crisis may be brewing behind the scenes.

Further reading: How federal policy has worsened the U.S. primary care shortage

“Access to care,” is the buzzword used by every administrator, policy maker and payer who wants to relay a convincing viewpoint. But, behind the vague phrases, there are real issues and real numbers when it comes to patients’ access to care.

The United States faces a physician shortage estimated to be between 40,800 and 104,900 physicians by the year 2030¹, according to the American Association of American Medical Colleges (AAMC)-that may translate into a situation in which patients cannot see a doctor when they need to.

Is there a looming physician shortage?

The recent data, which was requested by the AAMC and gathered by IHS Markit, a global information firm, does not differ from previous estimates gathered by other organizations. For example, in 2013, the Health Resources & Services Administration, which is part of the U.S. Department of Health and Human Services, projected a shortage of 20,400 primary care physicians by 2020.²

Despite these alarming results, the projections are somewhat controversial because the factors that are involved in calculating the need for physicians are quite complex and not necessarily clear-cut. While a simple calculation looking at the ratio of physicians to individuals in the population may seem that it should be straightforward and consistent, it is not.

Blog: Here is the PCP crisis solution and it's simple

As life expectancy increases, largely as a result of medical advances, individuals who live longer consume more medical care. Soft data suggests that physicians are retiring at a younger age due to regulatory burdens, and that more young physicians are opting for non-clinical careers.

On the flip side, many argue that medical care does not always need to be provided by physicians, and that physician extenders can provide some medical care to patients at a reduced cost. In fact, this solution was one of the proposals set forth by the AAMC. ³

The question is whether adjustments in patient care delivery coupled with modest increases in the available training spots for doctors will be enough close the gap between projected supply and demand for physicians.

The physician supply pipeline

The supply of physicians available to provide care to patients is not something that can be quickly or easily adjusted. Over the past 14 years, the number of medical students graduating from U.S. medical schools has increased 25% between 2002 and 2016. This increase in medical student positions is part of a long-term plan aimed at reducing the size of the physician shortage. Yet, graduating medical students are not trained or licensed to practice medicine, and need additional residency training before they can care for patients.

The number of physicians who are able to become qualified to practice medicine is largely controlled by the number of residency slots available to train physicians.

Next: What are doctors saying?

As the number of applicants to the National Residency Matching Program (NRMP) has risen in recent years, the number of residency slots has also slowly increased, with 2016 offering the highest number of residency spots ever in a match up to that point, and 2017 offering an increase over 2016. ⁴

Further reading: Is work-life balance a reality for physicians?

This is in large part a result of the Resident Physician Shortage Reduction Act of 2015, a government-sponsored effort aimed at preventing a potential crisis in access to physician care.

The act allows for an increase in the number of residency positions for each year from 2017 through 2021, under the direction of the Secretary of Health and Human Services, generally setting the aggregate number of increases in the resident limit to 3,000 in each year.⁵

This law has indeed had an impact on residency spots, which should increase the number of physicians that patients have access to. Whether the overall physician population chooses to stay in medicine is another question mark that few, if any, can predict.

What doctors say

But doctors say that the impact of these changes is not happening fast enough for underserved patients, and some physicians believe that other changes need to take place to keep physicians in practice.

In the news: Medical residents angered at extended work hours

One primary care physician, who does not want his name used because it could affect his career, suggests a different solution, which involves making it easier for foreign medical school graduates (FMGs) to have access to jobs. An FMG himself who completed his residency training in an American family medicine program, he recently signed a contract to work in an underserved area after years of trying to find a job. He explains that he had difficulty due to visa sponsorship issues.

The state hospital where he finally found a job had been advertising to fill the position for two years prior to signing him.

He says, “Now, with the recent halt in premium processing, the prospect of my job is uncertain. I have a signed agreement with the state and they have approved a waiver to allow me to work in an underserved area. However, due to United States Immigration and Citizenship Service (USCIS) halt, my start date has been delayed indeterminately. As a result, those underserved patients will be unattended.”

Practicing physicians in some specialties are feeling the crunch.

Next: What can be done?

Arpa R. Iyer MD, a psychiatrist, assistant professor and faculty at Frisco Counseling and Wellness, UT Southwestern Medical Center, says that there is a growing national shortage of physicians, which, although seen throughout the nation, is felt most significantly in rural areas.

“In a system where not enough physicians are trained, and attending physicians are increasingly opting out of medicine due to burnout, the solution to the physician shortage is a complex one,” she says. “Part of my training was in London where my co-students and I were surprised to find that our British medical student peers appeared significantly happier, less stressed and more balanced.

“We can prevent losing some of our practicing physicians by changing the system into one that is more supportive of physician wellness, by encouraging mental health support when needed and by recognizing the non-work related needs of physicians too,” she adds.

Karima Benameur, MD, a neurologist, also agrees that supporting physicians is important, but adds that non-physician providers can help reduce the burden.

Further reading: Why are women leaving medicine?

“There is a 10% shortage of neurologists,” she says. “Solutions include addressing burnout, but also training advanced practice providers (APPs) adequately. They get very little to no training in neurology. Hiring them from school and expecting them to function in a neurology clinic or ward does not work, but I don't think not using APPs is the solution either... so training APPs is best.”

Doctors who have left medicine for administrative roles are not completely insulated from the realities of the physician shortage. One physician executive even expressed a tinge of guilt at not providing direct patient care. He explains that he receives a number of job applications from doctors who are trying to find work in the health insurance industry, and that many of them are looking to escape from the pressures of medical practice.

He suggests that improving the physician work environment would prevent attrition from medicine, which could help alleviate the effects of the physician shortage.

1.     https://www.aamc.org/download/458082/data/2016_complexities_of_supply_and_demand_projections.pdf

2.    

3.     https://news.aamc.org/for-the-media/article/gme-funding-doctor-shortage/

4.     http://www.nrmp.org/press-release-2017-nrmp-main-residency-match-the-largest-match-on-record/

5.     https://www.congress.gov/bill/114th-congress/house-bill/2124