The U.S. faces a projected shortage of between 37,800 and 124,000 physicians within 12 years, according to “The Complexities of Physician Supply and Demand: Projections From 2019 to 2034” (PDF), a report released by the Association of American Medical Colleges (AAMC).
Specific AAMC projections by 2034 include shortages of:
- Between 17,800 and 48,000 primary care physicians .
- Between 21,000 and 77,100 non-primary care physicians.
This includes shortages of:
- Between 15,800 and 30,200 for surgical specialties.
- Between 3,800 and 13,400 for medical specialties.
- Between 10,300 and 35,600 for other specialties.
Questions:
We asked MOCMS member physicians Dr. John Strobel, MD and Dr. Michael Teague, MD to respond to this topic by posing the following questions:
- Why do you believe more aren’t going into medicine?
- What solutions would you propose to deal with this?
Responses:
John Strobel, MD
Clinical Cardiac Electrophysiology
We have known for years that a physician shortage has been coming. Greater than 60% of all cardiologists are >55! The aging population of our patients has only exacerbated the problem. As the supply of physicians is declining the demand for their services is growing.
It is my impression that there are many young people who want to enter medicine, but simply can’t. In my own family, I have 3 nieces and nephews who wanted to go to medical school but were initially denied entry. All 3 eventually gained admission, and they have excelled in medical school and beyond.. Thus, I believe the first step needs to be to expand medical school class sizes. I do not believe we will see a reduction in the quality of students. The next issue is that many medical students are not able to find residency positions after graduation. These problems can only be solved by federal funding for medical school and graduate medical education so that more spots are available.
In addition to training more physicians, we need to shift the balance from specialty care to primary care. Primary care doctors could treat many of the issues that cardiologists address. At least part of the reason that medical students choose specialty medicine over primary care is related to the debt that they incur during their training. Although federal legislation could address this, I think individual states could do the same thing. What if the state of Indiana subsidized the entirety of a medical students training in return for a promise to practice in our state? Would more students enter primary care without a huge burden of debt, which exceeds $200,000 on average, and does not include premedical education debt?
I would shorten medical education for both primary and specialty care. I’m certain that you could train a cardiologist in less than the currently required 6-7 years. Perhaps implementing a “fast track” which includes 2 years of primary care before entering cardiology training, which could also be shortened to 2-3 years. The fear is that quality will decline but from my own experience I’m certain that this will not occur.
Finally, and perhaps the most difficult issue, is how to keep practicing physicians in medicine for a longer period of time. Again, there are no easy solutions for physician burnout, but most I have seen are band-aids that don’t address the underlying causes. I have been practicing for 24 years and obtain great satisfaction from seeing my patients enjoy happier and healthier lives. It is the external “death by a thousand cuts” that often leaves physicians feeling dissatisfied and wanting to leave medicine. The endless messages, clerical work, and administrative duties take away from my ability to focus on treating my patients.
References:
- Fry, E. Resigned to the “Great Resignation?”. J Am Coll Cardiol. 2022 Jun, 79 (24) 2463–2466. https://www.jacc.org/doi/10.1016/j.jacc.2022.05.004
- Narang, A, Sinha, S, Rajagopalan, B. et al. The Supply and Demand of the Cardiovascular Workforce: Striking the Right Balance. J Am Coll Cardiol. 2016 Oct, 68 (15) 1680–1689. https://www.jacc.org/doi/10.1016/j.jacc.2016.06.070
- Hanson, Melanie. “Average Medical School Debt” EducationData.org, September 17, 2023. https://educationdata.org/average-student-loan-debt
Michael Teague, MD
Family Medicine
I really think this is a multifaceted problem. First and foremost, I don’t think the allure of medicine has completely worn off for undergraduate students. Many students want to go into medicine, but there are frankly not enough spots in medical schools to fit all of the interested students.
Or, in another way, we don’t have the medical school slots in the right places. For instance, Indiana has two medical schools for the entire state. So if you’re a student wanting to go into medicine in the state of Indiana, there are only about 500-600 slots for which to fight. It’s very competitive. Sure, you could go out of state, but then you are having to pay out of state tuition on an already exorbitant cost.
So, the first problem is that we don’t have enough spots in medical schools for the numbers of doctors we need and the locations of those schools are inconvenient for those students who are from the middle of the country.
Another part of this problem is that physicians in this day and age are expected to do a lot of administrative work and deal with insurance companies instead of simply seeing their patients and providing care plans. This has created a tremendous amount of burnout amongst physicians and has resulted in many suggesting they are not satisfied with their jobs. The administrative burden placed on physicians is frequently quoted as the most dissatisfying part of their jobs and this results in many hard-working young people who in decades past might have chosen medicine instead deciding to bypass medicine to a less regulated sector of work with better work-life balance and similar pay.
As a Primary Care Physician, I would be remiss if I didn’t point out that, of the statistics alluded to in this article, over HALF of the physician shortage on its way is expected to be in the primary care sector. There are a tremendous number of reasons for this which smarter people than I have spent pages describing. But as succinctly as possible, the administrative burden described above is largely pushed to the primary care physician.
With more government involvement into medicine and the continued complexity of insurance and job requirements, primary care physicians are relegated to glorified social workers in some visits. Not only is this the expectation of the Nursing Home, patient family, insurance company, or employer, but sometimes our specialty offices even do this unknowingly.
Medical Students rotate with PCPs and see physicians spending several hours per week doing FMLA paperwork and various other visits that are simply a requirement for some program and they decide that this is not why they wanted to go into medicine! Students want to clinically help patients and use critical thinking to develop diagnostic and therapeutic plans. They are not interested in checking boxes for various programs.
If you couple this with the disparity in pay between specialty physicians and primary care physicians, it is a losing argument. Until reimbursement for the diagnostics and care coordination provided by primary care physicians is recognized and improved, we will continue to see very smart students decide that going into specialty care over primary care is simply the financial prudent thing to do. Not only can some of the administrative burden be avoided, but you additionally put yourself in a much better financial position at a time when the average physician ends medical school with between $200-300 thousand student loans regardless of specialty chosen. Going into a higher paid field certainly pays off in a goal of getting out of that debt!
The time for some of the solutions has long passed unfortunately, but still some things can be done.
First, I would financially incentivize physicians to be involved in medical education. Many physicians do this, but it tends to be voluntary and uncompensated. Being involved in education TAKES TIME. Either physicians do this and end up pushing their clinical work into their family time, or they have to block their schedules which reduces access and ultimately results in taking a pay cut so as to do something they enjoy. That’s a losing philosophy and we need to at least compensate physicians for their time.
By doing this, we could increase the pool of physicians interested in providing education, which has been a barrier to increasing the number of medical students in the country, and this would have to be a nationwide process because the entire country will need to work together to address this need.
Once done, I would look at the states in the middle of the country and try to increase medical student enrollment by 10,000 students or more by opening several schools in the mid-west where there is tremendous need. I would probably gear these schools more toward osteopathic medicine and set them in rural areas, advertising them as training for students interested in providing primary care. Much of medical school is pretty standard and is the backbone of what a residency training can build on, but all of the examples and the hands-on training experienced in these schools would be primary care related.
Creation of additional scholarships and provision of financial guidance would be a requirement in the first week of school so as to ensure all students are aware of their options to reduce student debt burden. The goal would be to encourage as many of these students in these more rural areas to consider a career in Primary Care, and to provide as many financial resources to attempt to have many of these students end with little to no student debt due to their agreement to go into a Primary Care field.
Another consideration might be for these universities to offer ONE cost for students. Instead of having in-state and out-of-state tuitions, possibly consider offering the same tuition to all students attending the school so if students want to come from out of state, they aren’t financially penalized for the altruistic choice of going into medicine.
Another, less physician friendly, portion of this solution is that we would simultaneously need to increase utilization of Advance Practice Providers and encouragement of team-based care in especially our rural areas. Increasing utilization of well-trained and appropriately supervised Nurse Practitioners and Physicians Assistants is something that could very quickly help chip away at the provider shortage.
However, there’s a lack of training for physicians on how to appropriately utilize these team-based care models and there’s a generational gap in patient acceptance of these models. Despite this, the fastest way to increase the provider pool is to provide education to physicians for how to collaborate well, and employ these Advance Practice Providers in areas where you have a few physicians and therefore double your care delivery access. There’s a reality that the training of an APP takes less time than a medical student so to quickly address this shortfall, I feel utilizing APPs to their fullest is an absolute necessity.
Finally, something medicine has done a terrible job of in recent years is lobbying our federal government. Changes in the overall complexity of the American Health Care system needs to be considered and fought for. Pharma and large insurance companies have for far too long had the ear of our legislators. It’s time for Physicians to actually have a voice for change regarding Medicare reimbursement, various restrictions on care provisions that reduce clinical care provision, and the many frustrating administrative requirements placed on physicians in order to simply get a patient the medicine/treatment/services they need to improve their medical situation. The AMA has unfortunately long ago fallen short of what we need as a voice for physicians in Washington.
