Correcting the physician shortage isn’t an easy solution

There is no doubt that Affordable Care Act has changed the landscape of medicine in the U.S.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.

As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Physicians (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260,000 physicians by the year 2025: which translates to an additional 52,000 primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The Times suggests that the shortage is all about an imbalance between residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5 to 10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.

Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and less time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day — resulting in less than 10 minutes per patient — in order to meet overhead and practice expenses.  In a separate article in the Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed: ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.

The answer to the physician shortage may be more political than not; politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make health care reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles: not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own, at all costs.  I think that there is still hope to save medicine in the U.S.  It is my hope that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best: bond with patients and treat disease.  (As opposed to typing into a computer screen and filling out endless reams of electronic paperwork.)  It is my hope that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my hope that the art of medicine can be saved before it is too late.

Kevin R. Campbell is a cardiac electrophysiologist who blogs at his self-titled site, Dr. Kevin R. Campbell, MD.

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  • QQQ

    “Moreover, as the ACA continues to evolve, physicians are now realizing
    lower compensation rates, increased work hours, more administrative
    duties and less time spent caring for patients.”
    Ladies and gentlemen, welcome to the brave new world where foolish
    politicians make decisions about every aspect of your daily life and how
    to price it. Please pay close attention that the issue is about
    commissions to middlemen not actual health care. Lobbyists and
    politicians will determine the outcome, it will be enshrined in law and
    YOU WILL PAY THE BILL! I feel healthier already, how about you? One last
    thing, whatever happens, you can be sure it won’t apply to the members
    of Congress or their staffs in big daddy government. Have a nice day.

    • LeoHolmMD

      Big time.

  • Markus

    We ought to look at changing medical education. In the US it is typical to get a four year degree before four mor years of medical school. In many places this is done in six years by starting the basic sciences earlier. This would save on the enormous expense of education as well as get people through faster.
    There remains the issue of the income differential between primary care and specialists which makes it financially quite rewarding to specialize.

    • T H

      2+4 programs should not be the only way for people to enter medicine. Late bloomers need an avenue as well.

  • SteveCaley

    Whether or not it is wise, there will be increasing energy spent on “broadening the scope of practice” for intermediate-level licenses. America has already swallowed the elephant – that medical care in the days of the internet is easy – just look at WebMD! It will swallow the pea of “Doctor-PA” very soon.

  • LeoHolmMD

    Unfortunately, the AAFP has not checked how many “help wanted” signs are out for primary care. No one gives a rats about demand in a government driven marketplace. All production will do is drive down wages. Don’t mistake disparity with shortage. The solutions are completely different.

  • buzzkillerjsmith

    The NYT article shed light on the primary care shortage, which is good. Of course they totally botched the analysis of its causes.

    The mainstream media is working on it. They’re getting better, focusing more on the income differential as the cause of the PC shortage. This cause is obvious to us, barely worth discussing, but it’s not their world.

    Getting the causes right is critical in helping improve things of course.

  • Bob

    That’s Government for you always measuring input without measuring quality or quantity.
    It takes until age 30 to become and active and proficient physician and around 5 years less for nurses. And after 30 to 35 years the school loans are paid off the children grown and savings sufficient to do what the other professionals do, relax, vacation, finances sufficient to cut back or retire. And then there are the higher than normal death rates. In essence about a third of the existing physician and nurse supply are “Boomers” who according to the government statisticians will live and work at highly productive rates forever and never need replaced!
    Perhaps I am the only one who notices or comments that as the start date in life for healthcare caregivers is later than most other licensed professionals and there has always been a shortage. Hospital and clinic physicians do not work the hours of those who own and operate private practices, and don’t really want to care for government patients which are the majority of hospital, clinic and academic patients, in which all employees work to contract of 40 hours. So as 32 million [10% more of the population and a quarter of those said to not have health insurance before hit where do the other "missing 30%" get care?
    And how many physicians whether in hospitals, academia, clinics or Private practices will take government lower payments they have to "jump through hoops" to obtain? It's enough to make you pause and consider what it does to your life. Knowing that a third of all government funds spent on healthcare [$1 trillion] is waste, fraud an abuse that no government agency has been able to find let alone to reduce or stop, doesn’t bode well for increasing PCP rates, and does nothing to expand 8 or 12 hour days or increase caregiver supplies.
    So what happens when the majority of physicians “work to contract” or only take non-government insurance patients with commercial insurance with their employers? Will only the “working class” have care?

    Watch and see!

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