Combating the Shortage of Primary and Specialty Care Physicians

FOR YEARS, a growing shortage of physicians has been forecast by medical schools and others in the healthcare community, and the threat and resulting concern have quietly crept closer. Gradually, even predictably, patients in rural underserved areas of the United States have begun to see the forecast’s frustrating effects as they’ve been unable to find the healthcare resources and physicians they need.¹ And, by 2030, the country as a whole will face a potentially crippling and widespread shortage of doctors, including primary and specialty care physicians.

The numbers are sobering. In its report “The Complexities of Physician Supply and Demand: Projections from 2016-2030,” the Association of American Medical Colleges (AAMC) foresees the country will experience a shortage of at least 120,000 physicians. To be more specific, the association projects a shortage of between 14,800 and 49,300 primary care physicians by 2030 and a shortage of between 40,300 and 76,900 specialty physicians. What’s worse: This comes at a time when demand for treatment is rising with an aging population.²

In 2018, AAMC President and CEO Darrell G. Kirch, MD, explained that “this year’s analysis reinforces the serious threat posed by a real and significant doctor shortage. With the additional demand from a population that will not only continue to grow but also age considerably over the next 12 years, we must start training more doctors now to meet the needs of our patients in the future.” Echoing Dr. Kirch’s prediction, AAMC Chief Healthcare Officer Janis M. Orlowski, MD, stated: “There is going to be a significant workforce shortage under all of the likely projections. We see that, quite frankly, only getting worse as the population ages.”³

The Roots of the Problem

What has caused this looming threat? First, let’s dispel a common myth. The projected shortage has not been caused by a decreasing number of medical school students. In fact, students’ interest in medical school is at an all-time high, and admissions and graduates have increased. But, hindering this is the disproportionate growth in federally supported residency training positions that new doctors need to complete their training and go into practice. Unless the government raises the federal cap on financial support for graduate medical education, even increased medical school enrollment and graduation rates will not ease the coming shortage.⁴

“Medical schools and teaching hospitals are working to ensure that the supply of physicians is sufficient to meet demand and that those physicians are ready to practice in the healthcare system of the future,” said Dr. Kirch. “To address the doctor shortage, medical schools have increased class sizes by nearly 30 percent since 2002. Now, it’s time for Congress to do its part. Funding for residency training has been frozen since 1997, and without an increase in federal support, there simply won’t be enough doctors to provide the care Americans need.”³

Also contributing to the shortage, as Drs. Kirch and Orlowski alluded, are changing demographics as seniors enter Medicare. Baby boomers will double the number of older Americans by 2040. And, because senior citizens typically have the greatest healthcare needs of any group, the number of doctors in practice must increase simply to remain proportionate to the senior population’s needs. Since boomers outnumber other generations, however, and because of the lengthy time required for doctor training (an average of seven years for primary care physicians who typically require the shortest residency), the physician supply cannot stay apace with the country’s growing needs.⁴

In addition, the Affordable Care Act has enabled many more people of all ages to seek treatment they would not have otherwise had. Consider, too, the more personal reasons for the shortage among physicians. Under the increasing demands a growing and aging population represents, doctors are burning out. One 2011 study found 41 percent of the more than 7,000 doctors surveyed had experienced or were experiencing burnout. And, a 2014 follow-up study showed burnout rates were up among all physicians from all specialties.⁵ Add to this the fact that physicians are growing older themselves and are either working decreased hours or retiring in increasing numbers.⁶

Finding a Hopeful Future

Despite the grim forecast, academic medicine is facing the coming shortage directly and innovatively. The AAMC is taking what it calls a multipronged approach, which includes more focused utilization of team-based care in which health professionals of various disciplines and types work together to ensure patients’ holistic care. Utilizing technology more efficiently in order to lessen doctor’s workloads will help as well. But, Dr. Orlowski believes the most important solution will be training more physicians.⁷

Merely having more doctors, however, does not guarantee a physician shortage will be resolved in rural and inner-city areas. Any approach must also address the maldistribution of primary and specialty care doctors in these areas. “Sixty-seven percent of the health professional shortage areas are in nonurban areas,” explained Erika Schillinger, MD, a Stanford University clinical professor. “Fewer than 1 percent of final-year medical residents would prefer to practice in communities of 10,000 people or less. Basically, people who train in cities set down roots in those cities. They tend to want the connections and amenities of a city. They tend not to come from rural areas to begin with, and then they become acculturated to more urban areas because of their long training there. To change this, perhaps medical schools need to diversify their thinking and reach out to people who have a passion for science and interacting with people from rural and underserved areas. Perhaps medical schools must also change their thinking regarding what makes the best kind of doctor in terms of admissions. Then, we could focus on bringing more medical schools to rural areas in the first place. Students would invest in those communities and be more likely to stay there — especially if they came from them in the first place.” And, responding to some in the medical community who believe the projected physician shortage is inflated and not a common problem, Dr. Schillinger tells them to “get outside of their bubble and go to a rural area or urban underserved community to see the problem firsthand.”⁸

Thankfully, colleges and universities have already begun to recognize the importance of investing in new medical schools that will be located in and specifically serve rural and inner-city areas. These schools will focus on retaining students who have trained there, encouraging them to invest in the communities they are likely from and, hopefully, have come to love. In fact, during the last 15 years, there has been a large increase of new medical schools that focus on underserved areas.

The future Keck Graduate Institute School of Medicine, in Claremont, Calif., is a good example. It will focus on primary care, with the hope that graduates will stay on to practice medicine in eastern Los Angeles County, an area that historically suffers a dearth of healthcare professionals. “Our goal is to recruit them from here, train them here and keep them here,” said Sheldon Schuster, PhD, president of Keck, which is located in a community of mostly Spanish-speaking people. “There is such an incredible demand for people who … understand the community and who speak the language.”⁹

Already, physicians are beginning to practice in underserved areas. Douglas Grover, MD, a psychiatrist who trained at the University of California, Riverside, returned to his hometown of Moreno Valley, Calif., so he could practice his specialty in his underserved community. “If we open more opportunities here [in Moreno Valley] for college students to enter medical school,” he said, “it will provide more physicians over the long run and, hopefully, help with the disparities in these areas.” Dr. Grover hopes, along with many others, that more specialists will see the need to return to their rural hometowns, or to even move to set up practice in high-need communities.⁹

Existing teaching hospitals and medical schools are also adapting methods of instruction and adopting new training programs to better equip incoming physicians who will tackle the rising needs among an aging population. Dr. Schillinger, for example, is an optimistic voice leading future doctors into a demanding profession. As a family doctor and vice chief for education in the division of primary care and population health at Stanford University, she has the privilege of introducing many medical students to primary care. “One of my division’s goals,” she explained, “is to make primary care irresistible to medical students.” As for her own goals, she said, “I feel a responsibility, in a very personal way, to help shape a future of medical education that is so compelling, interesting and relational that it’s really a rewarding career, which it is. It should stay that way.”⁸

But even Dr. Schillinger’s upbeat outlook recognizes primary care, and family medicine in particular, a field she has joyfully devoted her career to at Stanford, is challenging. As a result, primary care is potentially less appealing to medical students than some other types of medicine. “We could pay primary doctors more to encourage medical students to go into primary care,” she suggested. “This is not to say that we are not paid well, but medical students looking at their debt load see that their salary is disproportionate to the relative challenges of the work. Primary care practice is so intensely rewarding. It is also complex, in equal measure, both intellectually and interpersonally.”⁸

Loan repayment, too, is another issue Dr. Schillinger believes could be improved. “More loan repayment for residents who are going to serve in underserved areas would help as well,” she said. “There are also areas of the country that have a surfeit of subspecialists, where access drives demand. [For instance], the more cardiologists they have in Florida, the more interventional bypass surgeries are offered. More procedures are done because there are more specialists. Which is an example of too much of a good thing.”8 But, ensuring primary care physicians in rural and inner-city areas are compensated on par with specialists in cities could distribute primary care doctors in ways that are helpful to the entire country.

What Will Happen?

Even with the best, most effective and diligent efforts to curb the coming primary and specialty physician shortage, there will still be an increasingly problematic healthcare scarcity for some as 2030 and beyond draw closer. But Dr. Schillinger maintains her realistic optimism: “The best-case scenario for the shortage is right now we recognize that this is a real crisis and we engage all hands on deck. We employ team-based care to the maximum, we use technology to the maximum, we redistribute payment models and salaries. We change the culture of training and build programs in rural and urban underserved areas. It will take many years to stem the shortage. We have to start now because our nation’s health depends on it.”⁸

Only time will tell how healthcare systems, medical students and new measures in training and compensation will help patients and doctors in the future. But, it is heartening to know that many passionate physicians, educators and administrators are making decisive, strategic efforts to help as many people as possible now, and many more in the future.