The Physician Shortage: A Threat to the American Healthcare System

The physician shortage in the United States is a looming crisis. How bad is it and what can we do to address this problem?

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Houston, we have a problem

The Covid pandemic has pushed our nation’s healthcare workers to the brink. Even prior to the pandemic, experts already worried about broad demographic trends in the United States that predicted an increased need for doctors and nurses in the next decade. Now a few years into the incredible stress of the Covid-19 crisis, we’re likely even worse off. While we don’t know yet how many medical professionals actually retired or cut back their hours due to Covid, the trends have been concerning.

We do know that physician burnout rates skyrocketed 50% in the first year of the pandemic. By late December 2021, 63% of physicians reported burnout, compared to just 38% in 2020. It’s important to note that even when the burnout numbers were below 50 percent, we were already calling it a “burnout epidemic.” There is a correlation between burnout and early retirement, so the increased burnout is likely going to make the physician shortage even worse.

Physician financial stress plays a role as well in burnout, as shown by a study in 2018 that increased financial stress decreases physician well being. Your average medical school graduate now owes about $242,000 in student loans. The Covid pandemic shook the certainty that many doctors had in their income, likely increasing burnout as well.

Finally, overnight call duties are a contributor to burnout. When I served as chief of my department of 14 urologists in California, I surveyed their experience with burnout. Overnight call duties were the most frequently cited contributor to their burnout. This connection is supported by academic studies as well.

Read more: The Epidemic of Physician Burnout

How bad is the shortage already?

The AAMC (Association of American Medical Colleges) keeps track of projected physician need in the country. A recent study from 2021 warned of a critical shortage of physicians in the coming decade. Specifically, the estimated shortage is 37,800 to 124,000 physicians by 2034.

Is the physician shortage real?

Before we proceed, it is worth it to understand why we are projected to have a shortage of physicians in the coming years.

After all, in 1976 there was one physician for every 574 Americans. This is vastly different from the current situation. With 1.07 million physicians currently, there is one physician for every 310 Americans.

So why are we worrying about a physician shortage when we have a higher number of physicians than ever?

The answer to this question is complex, but there are a few broad demographic trends that hold the answer:

  • Natural population growth
  • Our aging U.S. population
  • Our aging physician workforce
  • Increase utilization of medical care

The US Census Bureau estimates that the American population will increase 1.8 million people every year for the next 4 decades. More people means that our physician population and hospital systems need to grow as well.

The census also notes that by 2030, the Baby Boomer generation will all be 65 years or older.

Doctors are getting old too

The world has had an aging population for some time. This causes a lot of economic problems as a smaller slice of the population is providing care (and money) to support the elderly. This trend is most noticeable in countries like Japan, where the rapidly graying population is straining the country’s finances like never before.

The US physician population is not immune to these general trends. The AAMC reported: “More than two of every five active physicians in the U.S. will be 65 or older within the next decade.”

The big question is this: How many of our health care providers will actually retire early or on time, versus continuing to work beyond traditional retirement age?

How does a physician shortage manifest?

If you want to see what happens when we have a physician shortage, you might turn your glance to our country’s rural areas. These geographic areas have always had to deal with fewer physicians, due to problems with compensation and access to amenities that new doctors desire. In fact, many rural communities are already designated as “Primary Health Care Professional Shortage Areas.”

In areas like this, a community may be many miles away from a primary care doctor, with even less access to specialty care. If there is a family physician available, he or she might be overwhelmed by the number of patients that need care. This is in contrast to urban areas, where doctors are generally more plentiful.

Across the nation, this situation is already playing out. In the past decade, employed family medicine doctors have complained about patient panels that are too large to provide quality care. From the patient perspective, this means longer response times to messages or lack of access to appointments. It means more patients in the emergency room.

This causes unhappy patients and an unpleasant work environment for everyone involved. Paradoxically, primary care doctors are some of the lowest paid physicians, with just as much student debt as higher paid specialists. This situation can create a vicious cycle where indebted medical school graduates are less likely to go into primary care, which worsens the shortage of primary care physicians.

Despite the projected physician shortage, I don’t think we have to completely despair.

History is a pendulum

It’s always interesting to look at history to give our present context and perhaps give us clues about where the future is headed.

When I look back at historical news articles, America has dealt with physician shortages in the past. In 1961, newspapers warned about a big physician shortage in the near future. To meet the need for physicians in 1975, about 15 years in the future, America needed more medical students, the article stated. There were promises to do just that, as schools like Johns Hopkins promised to increase enrollment.

Oh how the pendulum swings!

Then in the late 1970s, there were dire warnings about a physician surplus. In September of 1976, The Dispatch warned that “America may soon have too many medical schools and a surplus of doctors…” This was a sharp reversal from the situation in 1970, when the Carnegie Council on Policy Studies in Higher Education again warned of a nationwide shortage of physicians. The reversal was fueled by a “dramatic increase in medical school enrollments.”

It’s comforting to see that the health care workforce was able to react so quickly to the nation’s needs.

How do you make new physicians?

So what can we learn from the past? Becoming a doctor is a long and expensive process that takes at least a decade. Let’s consider all the complexities of physician supply, shall we? At the very least, you need four years of college, four years of medical school, and three years of residency training at teaching hospitals.

We arguably have enough universities to meet the need. As we saw in our history lesson above, medical schools have proven their ability to increase enrollment. But how about the residency slots?

Without landing spots for medical school graduates, it is senseless for medical schools to increase enrollment. So obviously, the number of residency slots will have to increase lockstep with the medical school openings for our doctor shortage to improve.

There is good news

We are making some progress. In 2021, Congress passed the “Resident Physician Shortage Reduction Act.” This will increase the number of residency positions by 200 every year for the next 5 years. This will add 1000 resident physicians via new Medicare-supported GME positions.

(Yes, it takes a literal act of Congress to increase the capacity for residency training in our country, since the federal government helps fund residency positions via the Medicare system.)

There is evidence of progress, as the National Resident Matching Program reported a total of 39,205 residency spots in 2022. This is a big increase from 2021, when the NRMP said there were 38,106 positions available. A year prior, in 2020, there were 37,256 positions.

So the number of residency spots are steadily increasing by about 1000 spots a year. This is too slow to meet the projected need for more physicians, but it’s better than nothing.

Conclusion

We are facing a nationwide physician shortage in the next decade of 40,000 to 124,000 doctors. The Covid pandemic has added to a severe physician burnout epidemic, which will likely increase early retirement in our working doctors.

Although residency programs are steadily increasing the supply of residency slots, the process to become a physician starts eight years before residency. So we are turning on the spigot for more doctors, but it’s not likely to fully meet the need for many years to come.

To improve our chances of meeting the needs of our nation, I recommend we pay close attention to the following areas:

  • Physician burnout
  • Overnight call duties
  • Physician debt and personal finance

This will help retain our current physician workforce and hopefully buy us enough time to increase our supply of doctors.

— The Darwinian Doctor

How has the physician shortage affected you? Let me know in the comments below!

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