For the last several years, many health care organizations have been sounding the alarm over the coming shortage of doctors across virtually all fields of medicine. Many of these projections cite 2025 or 2030 as the date when finding a doctor is going to become especially difficult. And they're taking that longer-range view because it takes a really long time to become a doctor – generally 12 to 15 years' worth of education and training after high school to become a licensed physician in the United States. So if this coming shortage is going to be averted, changes in the way health care is delivered in America need to begin now. Earlier this month, the Association of American Medical Colleges released new research looking at the complexities of physician supply and demand between 2016 and 2030. The report states that "physician demand continues to grow faster than supply, leading to a projected shortfall of between 42,600 and 121,300 physicians by 2030." This total includes a projected shortage of 14,800 to 49,300 primary care physicians. For non-primary care specialties, the projected shortfall ranges from 33,800 to 72,700 doctors. That's a big number of doctors who'll be missing, a complex problem that has numerous causes. First among them is simple demographics – America is home to a growing and aging population. Between 2016 and 2030, the U.S. population is expected to grow about 11 percent to 359.4 million. During that time, "population under age 18 is projected to grow by only 3 percent, while the population aged 65 and over is projected to grow by 50 percent," the AAMC report notes. Because older people tend to consume more health care services, this means a higher demand that will be difficult to meet with current supply. In addition, achieving population health goals such as reducing obesity and diabetes are also going to increase demand for some specialist doctors. What's more, the supply of doctors seeing patients full-time is also dwindling as many baby-boom generation doctors are readying for retirement and leaving the workforce. This shortage is further compounded by the fact that "we haven't turned out any greater number of specialists or residents who train in primary care or specialty since 1997," says Dr. Lawrence Braud, an ear, nose and throat specialist in private practice in Baton Rouge, Louisiana, and vice president and chair of the private practice subcommittee of the Physicians Foundation, a nonprofit that supports physicians. "Congress froze that number in 1997 [over fears of creating a doctor surplus] and it's been frozen ever since, even though the population of the U.S. has increased by 50 million in that period of time," he says. The AAMC reports that "although medical schools have increased enrollment by nearly 30 percent since 2002, the 1997 cap on Medicare support for graduate medical education (GME) has stymied the necessary commensurate increases in residency training, creating a bottleneck for the physician workforce." Dr. Janis Orlowski, chief health care officer with the Association of American Medical Colleges, says when the number of GME slots paid for with federal funds were frozen in 1997, "it was clearly stated that this was temporary. [Congress was] going to freeze them and evaluate what the need is, and that has not happened. So we have worked to have bipartisan legislation introduced in order to have a modest increase in the number of GME slots. We're not saying this is the whole solution to the physician shortage, but this is an important move that has to happen." The Resident Physician Shortage Reduction Act of 2017 (H.R.2267) was introduced to Congress to increase the number of residency slots for both primary care and specialty physicians in the U.S. by 15,000 over five years, but Braud says "even if it passes, there's got to be money to fund it. With the cost issues, I don't think it's going anywhere really rapidly." Plus, even if the number of residency slots were increased tomorrow, it might take up to a decade to feel the impact of that expansion, so this isn't going to be a quick fix to the problem. "Each of these programs has to develop everything that goes into adding on additional residents, so that's a problem without a great answer as far as how it's handled and taken care of in an expeditious fashion," Braud says. Which Specialty Fields Will be Hardest Hit? Not all specialty fields will be impacted the same way by the expected shortfall. Orlowski says "we are particularly concerned about some of the surgical subspecialties – general surgery and vascular surgery appear to have some concerns." Braud says he anticipates that specialty fields that treat the diseases of aging are also likely to feel the pinch between increased demand and less supply, including "neurology, pulmonology, orthopedics and ophthalmology. There's already a big problem with psychiatry, and I think that's just going to get worse," Braud says. Two recent workforce studies from the American College of Rheumatology painted a sobering picture of the number of doctors who will be available to treat people with rheumatic diseases, which include that hallmark of old age, osteoarthritis. Other fields are also looking at major shortfalls because of their own demographic make-up. "Especially in fields like pulmonology, where probably about 70 percent of the doctors are over age 55 now, you can see within the decade they can all be approaching retirement and not enough people are coming along to fulfill those spaces," Braud says. Orlowski also notes that "psychiatry is one of those fields where there are actually more older physicians. There's not an even distribution, so there's not only a demand, but there's also aging going on in psychiatry." Data from the AACM report backs this up, noting that across the board, "more than one-third of all currently active physicians will be 65 or older within the next decade. Physicians between ages 65 and older account for 13.5 percent of the active workforce, and those between ages 55 and 64 make up nearly 27.2 percent of the active workforce." In addition, Orlowski says, "the other area that I think is important to highlight, in light of discussions of the opioid crisis, is behavioral health. Again, I don't want to underplay the [impact on] primary care, but in light of what we're seeing with the aging of the population and our opioid substance abuse issues, those are areas that are of concern." She also notes that inequitable access to care is an important part of the discussion of this physician shortage. "Those who are under-insured or uninsured, live in rural areas and underrepresented minorities actually don't have equitable access to health care." So she says although it's good to ask "how many doctors do we need in the future" the second way to ask the question is, "how many doctors do we need in order to have equal access? We don't want to say, 'access is OK – let's move forward with this number.' Access isn't OK," and the unequal distribution of physicians across the United States means that the physician shortfall is already being felt acutely in some locations. Despite these challenges, both Orlowski and Braud say there's hope that this looming crisis can be solved. One strategy – to increase the number of physician extenders such as advanced practice nurses and physician assistants – "has helped somewhat," but that benefit has been more readily felt in primary care than in the specialty fields, Braud says. That's because the highly focused nature of the specialists' work makes it more challenging for health care providers who don't have that same level of training or experience to offer the same quality of care. And Orlowski says it's important that quality of care doesn't diminish in the quest to improve access. "You don't want to move to [a new delivery approach] if it's not going to improve quality of care." Still, Orlowski says that increasing the use of technologies like telehealth and moving toward a more inter-professional team approach by "adding pharmacists, social workers, dietitians, and others to the health care team," may help ease the shortfalls. She says the AAMC is studying new care delivery approaches, and while they probably won't offer the whole solution, they will most likely be part of it. Source
