Americans alive today have never experienced a real physician shortage. Sure, there have been occasional dips every few years in certain specialties, like when we worried that we may not have enough obstetricians to go around. And after the need for HMO gatekeepers went away, a shortage of primary-care physicians developed and is worsening. But a widespread, sustained doctor drought is American healthcare’s disaster without a preparedness plan.
Peter Fine, president and chief executive officer of Banner Health in Phoenix, disputes the notion of a “looming physician shortage” over the next 10 years or longer. Forget “looming,” Fine says—the shortage is already here. Each of the 20 facilities that Banner operates in seven Western states is already feeling adverse effects, he says. “It is playing out everywhere, whether it is a rural or an urban marketplace. We have not produced enough physicians to serve the population we have in this country. This is only going to get worse because we are not producing enough physicians to meet the needs of the population we have today or the baby boomers of tomorrow.”
The timing really could not be worse. One out of three practicing physicians in the United States is over the age of 55, and many of them are expected to retire in the next 10 or 15 years. Meanwhile, U.S. medical schools have not provided for the loss of 33 percent of the nation’s physician work force. A number of studies have estimated that by 2020 the United States will be short anywhere from 24,000 to 200,000 physicians. Additionally, some anecdotal evidence suggests that younger physicians are not willing to put their lives on hold and work 80-hour weeks that include weekends, nights and emergency department on-call duty like their elders—which means it may take two younger physicians to cover the work of one retiring physician.
As with any industry, the business model follows the labor pool. The days when American hospitals and medical groups could backfill their service or revenue or quality issues by throwing more doctors at the problem are soon to be over, because physicians will be either unavailable or too expensive. With fewer revenue engines in white coats to go around, hospitals will have to begin processes now to explore opportunities for nurses, technicians and other professionals to close the gap. Where are the family docs?
E. Robert Schwartz, MD, spends a lot of his time trying to lure talented young medical students into primary care. As chairman of the Department of Family Medicine and Community Health at the University of Miami’s Leonard M. Miller School of Medicine, he acknowledges that it’s a struggle. “If you look at what young people are picking these days, it’s radiology, anesthesiology … a lot of the technical specialties. They tend to have very defined hours, high mobility and high incomes,” he says.
Schwartz says the physician shortage will be exacerbated by a lack of primary-care physicians—healthcare’s gatekeepers who diagnose and coordinate care. The drive to graduate more physicians, he says, should also focus on encouraging more medical students to enter primary care; many new med school students encounter “academic negative pressures” that discourage the pursuit of family medicine, Schwartz says. “Students who come into medical school are clean slates. They are learning how to become doctors, not necessarily specialists.”
The 2007 National Resident Matching Program survey found that only 2,680 medical school seniors—24 percent—plan to specialize in internal medicine, down from 54 percent in 1998. The American College of Physicians warns that if the trend continues, there won’t be enough physicians to provide diagnoses and coordinate care for an aging population, leading to more fragmented, inefficient, expensive healthcare. Another 2007 survey—this one by the Irving, TX-based physician staffing service Martin, Fletcher—showed that primary-care physicians, including internists, hospitalists, family practitioners and pediatricians, were the lowest-paid among the 3,500 physicians representing 17 medical specialties who responded to the physician compensation survey, with median annual salaries ranging from $146,000 to $171,000. The top compensation went to subspecialists who earned more than twice as much. Invasive cardiologists, for example, reported a median annual salary of $440,000; radiologists, $392,000; orthopedic surgeons, $383,000; gastroenterologists, $368,000; and urologists, $325,000.
ACP President David Dale, MD, a professor of medicine at the University of Washington in Seattle, says medical students aren’t dumb; they know that primary-care physicians earn less money, work longer hours and often face higher malpractice risks than many subspecialists. For medical students graduating with loans averaging $130,000, the choice is not difficult. “We have a shift in the sense of what it is to be a doctor. We have people who want to carve out jobs that protect them rather than necessarily serve the public,” he says.
Not everyone believes steering medical students into primary care is such a good idea, however. Richard “Buz” Cooper, MD, a professor of medicine at the University of Pennsylvania and a co-chair of the Council on Physician and Nurse Supply, doesn’t argue about the importance of primary-care physicians. But he believes the United States may lack as many as 200,000 physicians and 800,000 nurses by 2020. In the face of such monumental shortages, Cooper says, medical students should concentrate on the highly technical specialties like cardiology or orthopedics.
“We are not going to have nurse practitioners doing joint replacements, but we are going to have nurse practitioners doing primary care,” he says. “So we are going to have to fix it across the board but disproportionately fix the high-tech specialties with more doctors and disproportionately fix primary care with more nurse practitioners. Some don’t necessarily want it that way, but whether you do or not, that is what the circumstances will force.”
With medical school graduates flocking to better-compensated, more prestigious subspecialties, Schwartz says primary care is increasingly becoming attractive to foreign medical school graduates. Last year, the Miller school had 1,600 applicants for its eight family practice residencies, of which 1,000 applicants were foreign medical school graduates. While Miller’s location and prestige allows it to be choosey, Schwartz contends the rising numbers of foreign medical school students raises quality issues and ethical issues about the “brain drain” of physicians from other countries. “If every medical student who comes to the U.S. wants to stay here, then to some extent you’ve done a huge disservice to other countries.”The future is now
Like Banner Health’s Fine, many practicing physicians, hospital administrators, physician staffing providers and other healthcare professionals say the physician shortage is already here. “We are in the trenches on this, seeing it every day,” says Kurt Mosley, vice president of business development at physician staffer Merritt Hawkins & Associates. “Six or seven years ago we would call Mayo or Johns Hopkins and they would say, ‘We’ve got more CVs than we can shake a stick at.’ They call us now and say, ‘We are in desperate need of doctors.’ That is like saying the Yankees can’t get anyone to play with them. When that happens, I know we have a shortage.”
Recent data supports Mosley’s experience. The American Hospital Association’s 2007 Survey of Hospital Leaders found that 55 percent of hospitals experienced across-the-board gaps in specialty coverage in their emergency departments in the past two years, with shortages in neurology and orthopedics leading the list. The top reasons for the coverage gaps? Physician lifestyle issues, an inability to attract physicians, and physicians either leaving or retiring.
Eventually, such shortages trickle down to patients. A July study by the Massachusetts Medical Society found that shortages in primary care, psychiatry, anesthesiology, cardiology, gastroenterology, neurosurgery and urology were adversely affecting patient access to care. “Massachusetts may be leading the nation in healthcare reform, but we’re falling behind in a critical aspect of patient care, and that’s the supply of physicians,” says MMS President B. Dale Magee, MD. The report blamed the shortage on “a deteriorating practice environment” that includes the cost of doing business, income and liability costs.
Senior leaders elsewhere in the country paint a similar picture. Frank Sacco, president and chief executive officer of the South Broward Hospital District, says the Fort Lauderdale area’s public healthcare system is feeling the pinch, primarily with a shortage of primary-care physicians, but also in gastroenterology, neurology, obstetrics and general surgery, along with a projected shortage in orthopedics in the near future. “Our patients aren’t going unseen, but sometimes there are long waits going into doctors offices,” he says.Can hospitals do anything about it?
Every one to two years for the past decade, the South Broward Hospital District has compiled a physician-demand study to help the healthcare system project its needs for the next two to five years. The report looks at the age of physicians and queries doctors about their retirement plans; the study also considers general population demographics. “As we project out five years, things are looking pretty bleak in primary care. In some of the specialties they are probably manageable, but there are some areas of concern, primary care being the biggest,” Sacco says.
To successfully recruit and retain physicians, Sacco says hospitals need to understand what problems they can’t control. “It starts with Medicare reimbursement. It’s too low,” he says. “Then the managed care contracting gets indexed to Medicare, so in many cases that is even lower. And their cost of malpractice insurance is getting higher—that is what we are hearing from that senior physician, maybe 50 or older, who is saying, ‘This is not the same practice I came to.’ As a hospital executive, we can’t address any of those three things for them, unless they are employed by us,” Sacco says.
So which factors can a hospital control? Sacco says senior leaders’ best hope for retaining physicians is to give them quality service and care while offering them an opportunity to use hospitalists to handle their admissions. “Many physicians find if they can stay in their offices they can enhance their incomes and not have dead time traveling to the hospitals,” Sacco says.
Fine says Banner Health has “moved very aggressively” to contract or hire hospitalists at the system’s larger hospitals, but not just because it gives primary-care physicians more time at their practices. “It makes sense from a clinical quality perspective to have highly specialized people in an acute-care environment like that,” he says.
Recruiting and retaining physicians means offering them “a menu of options in which they can relate to us,” Fine says. Increasingly, that includes hiring physicians as hospital employees both in clinical and academic roles. Banner has a total of 527 employed physicians, 302 of whom are in Arizona. Of those 302 physicians, 55 of them participate in the medical education program. “Does that cause us to use more resources in the development of expertise for physician practice management? The answer is yes,” Fine says. But if that’s what it takes to recruit physicians or keep them on staff, he adds, “we are going to continue to do that.”
Still, finding enough physicians is not merely a question of hiring doctors as hospital employees—some physicians just aren’t interested. Sacco and Fine say recruiting and retaining also means creating an active partnership and strengthening relationships with independent physicians and physician groups by using their systems’ resources to improve the physicians’ practices. Fine says Banner Health has used its resources to help physicians affiliated with the system access electronic medical records and provide other services that might otherwise be prohibitively expensive, particularly for smaller practices. Banner and SBHD also help affiliated physician groups recruit new physicians. “Probably the trend I favor the most is the one that makes the physician the most comfortable,” Fine says.
Recruiting and retention must be a consistent top priority for hospitals, not just a temporary initiative to fill a pressing clinical need, says Merritt Hawkins’ Mosley. He adds that hospitals have to maintain a line of communication with physicians to let them know their concerns are heard. “A lot of doctors feel like they are painted into a corner. You hear so many stories about doctors opening competing surgery centers with hospitals. Well, a lot of them tell us, ‘We aren’t mad at the hospital; we just want to practice in a more productive environment. We try to work with the hospital, and the lines are all backed up.”
Many organizations make recruiting appeals that boast about everything from a health system’s “vision” to a newly constructed medical wing to the nice beaches down the street. But such recruitment tactics may be misguided, Mosley says. “The doctors tell us, ‘We don’t care about the vision. We care about whether our lab results come back in six hours or 24 hours so I can practice medicine efficiently and effectively.”
Despite the volumes of data showing that whatever shortage providers are currently experiencing will only worsen in the coming years, Mosley contends the nation’s hospitals haven’t done as much as they could to address the physician supply—in part because hospital administrators have forgotten the leading role that physicians play in the delivery of healthcare. “As somebody told me,” Mosley says, “without doctors, hospitals are just empty hotels with mediocre food.”John Commins is editor of HealthLeaders Florida Healthflash. He may be reached at email@example.com
Filling the Demand
The throngs of baby boomers nearing retirement age are a frequently cited component of the physician shortage puzzle. But the nation isn’t just getting older—it’s getting crowded, too.
The United States’ population is increasing by about 25 million people per decade and will hit 400 million in about 40 years. To deal with the rising demand, the Association of American Medical Colleges in 2006 called for a 30 percent increase in the number of graduating physicians from the nation’s 125 accredited medical schools. Earlier this year, 71 medical school deans reported that they planned to increase their enrollment by five or more medical students per year by 2012, with first-year enrollment projected to climb to 19,300, a jump of 17 percent when compared with first-year enrollment in 2003. The AAMC is also estimating that five new medical schools will be ready to open by 2012, supplying another 250 first-year students. The United States is also relying more heavily upon foreign medical school graduates; the AAMC’s call for 30 percent growth in the number of medical school graduates factors in a 5,000- to 6,000-student annual influx from foreign medical schools.
“If we tried to drastically reduce international medical school graduates, we would need to go from that
30 percent to a 60 percent increase in U.S. graduates to meet the demand,” Edward Salsberg, director of the Center for Workforce Studies for the Association of American Medical Colleges says. “If someone
said ‘Let’s stop international medical school graduates,’ we would be in very serious trouble.” —John Commins
‘I Know I’m a Dinosaur’
David Nichols, MD, concedes that he is a relic. The 59-year-old family physician came to White Stone, VA, 28 years ago, put in 90-hour work weeks and built a small practice that now includes two younger physicians and three physician assistants serving several thousand people in this coastal community near the mouth of the Rappahannock River. He has dedicated his life to serving his community and nearby Tangier Island, 25 miles out in Chesapeake Bay, where for the last three decades he has flown himself and his associates nearly every Thursday to provide the island’s residents with, often, their only access to healthcare.
In general, he says, younger physicians are talented and dedicated, but aren’t willing to put in the long hours that senior colleagues like Nichols simply assumed came with the territory. “The next generation of family practice doctors doesn’t want to work as hard as we did, so it’s probably going to take two of them to equal what one of us has been doing. I can see that happening right now,” he says. “I don’t fault them for that. They have a different perspective, and it’s pretty logical what they are saying. They put a greater emphasis on family and time off and less emphasis on working all the time.”
The current working climate for primary-care physicians isn’t helping, he says, with Medicare reimbursements facing cuts and malpractice liability rising every year. The more time needed to complete paperwork, meet OSHA requirements and address other business-side concerns means less time with patients, reducing the quality of care and revenue.
Nichols’ tiny practice illustrates a growing problem with the nation’s physician supply, particularly in rural areas, says Edward Salsberg, director of the Center for Workforce Studies for the Association of American Medical Colleges. “There are two factors at work on the supply side that concern us: the aging of the physician work force and the work hours of the new generation of physicians who are replacing them.”
With women now constituting roughly 50 percent of U.S. medical students, a recent AAMC survey of physicians younger than 50 found that 24 percent of female physicians were working part-time, compared with 2 percent of their male colleagues. “Women have child-bearing responsibility and often take off some time to do those other important things. We want to be clear that it is not a bad thing. The reality is women have other responsibilities,” Salsberg says. —John Commins