Honest question about the physician shortage

[Kurk]

"Under every combination of scenarios modeled, the United States will face a shortage of physicians over the next decade, according to a physician workforce report released today by the AAMC (Association of American Medical Colleges). The projections show a shortage ranging between 61,700 and 94,700, with a significant shortage showing among many surgical specialties."

With socialized medicine looming around the corner no one's going to argue that US physicians will be seeing a decline in patients.

My question is what changes are going to be (or already have been) enacted to meet demand?

I really don't think the expression "Only pursue medicine if you can't see yourself doing anything else" is going to fly anymore. What rational person would choose to enter a much more physically, emotionally, academically, financially, etc, demanding field if easier alternatives exist? Medicine is a choice not a calling for most people.

So what are the options to meet demand?

- we increase the number of CNPs and PAs like we've been doing now but at the cost of quality of care since they're less trained.

- we open up more med schools——okay...easier said than done and you need more accompanying residencies to go with it.

- bring in foreign doctors——still need more residencies and it affects the "brain drain" issues in their countries; a win for us but a loss for them.

- ???


The earliest appointment I could get to see my PCP is in September! Insane!

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[Lawpy]

With socialized medicine looming around the corner no one's going to argue that US physicians will be seeing a decline in patients.

With Trumpcare/GOP ACA repeal/AHCA actually being seriously considered, I don't think we'll be seeing socialized medicine any time soon.

 

[7331poas]

What makes you think socialized medicine is around the corner? The reds are in power and half the country supports them.

 

[Lost in Translation]

Need to open up more residency spots and need to increase compensation for going into primary care in order to make those fields more attractive to graduates.

 

[gyngyn]

Need to open up more residency spots and need to increase compensation for going into primary care in order to make those fields more attractive to graduates.

There are already thousands of unfilled residency spots in primary care. There are only going to be more of them after the merge.

 

[efle]

From what little discussion I've seen on these forums, the bottleneck is mostly the residencies for some of the things mentioned, e.g. surgical specialties like Ophtho. I don't think the problem is lack of interested med students. And you def can't have a midlevel doing your corneal transplant. So you need more residency spots.

 

[Kurk]

With Trumpcare/GOP ACA repeal/AHCA actually being seriously considered, I don't think we'll be seeing socialized medicine any time soon.

I'm a pessimist so say that the orange orangutan and his cronies weren't in power—we'd still have a shortage though not to this extent. Medicaid is still socialized medicine.

 

[gyngyn]

I'm a pessimist so say that the orange orangutan and his cronies weren't in power—we'd still have a shortage though not to this extent. Medicaid is still socialized medicine.

Shortages are largely regional. Specialty "shortages" have more to do with re-reimbursement than physician numbers.
This will not be fixed by adding more residency positions and certainly not by adding more medical schools.

 

[LizzyM]

Much of primary care can be shifted to mid-levels with no decline in quality. My kids rarely saw a physician during childhood because the private practice we used passed that on to a nurse practitioner who was well qualified to provide preventive care to healthy children.

 

[bananafish94]

If you think "socialized medicine" is right around the corner, you haven't been reading the news.

 

[akwho]

Maldistribution, not shortage. Large swathes of country especially urban/rural poor areas with lack of access to care. Oversupply of physicians in major metro markets. The solution isn't more residency slots, it's loan repayment programs for urban/rural underserved areas with the hopes those physicians will become entrenched in those areas and not move. That would be the cheapest way to do it.

 

[Kurk]

If you think "socialized medicine" is right around the corner, you haven't been reading the news.

I'm rootin for the republicans but if push comes to shove and we get Eliz Warren next election I can't say it'd be in my favor.

Shortages are largely regional.
This will not be fixed by adding more residency positions and certainly not by adding more medical schools.

How so regional? Not just bumble**** I'm sure; I live in the suburbs of a mid-tier city and it sucks.

 

[Kurk]

Maldistribution, not shortage. Large swathes of country especially urban/rural poor areas with lack of access to care. Oversupply of physicians in major metro markets. The solution isn't more residency slots, it's loan repayment programs for urban/rural underserved areas with the hopes those physicians will become entrenched in those areas and not move. That would be the cheapest way to do it.

so all these studies are wrong? It's all about distribution more than numbers? I doubt it.

 

[7331poas]

I'm rootin for the republicans but if push comes to shove and we get Eliz Warren next election I can't say it'd be in my favor.

...then there wont be socialized medicine. I am guessing you are actually against single payer?

 

[LizzyM]

Part of the "shortage" relates to reimbursement. A recently learned of a young man with Medi-Cal insurance who needs Mohr surgery performed by a dermatologist in the LA area to treat a rare skin cancer. This guy (friend of my nephew) can't find a derm who will take Medi-Cal. I'm sure that the reimbursement offered by Medi-Cal makes it not worth the doctor's time to provide that needed procedure for that patient. Does that mean there are a shortage of dermatologists in southern California? Do we need more specialists in that area so that some will be so hungry that they will be willing to take a pittance to practice their trade on folks who are covered by the Medicare expansion?

I thnk that in a single payer system, some docs would work for cash only rather than take government reimbursement and derms would be at the top of that list.

 

[bananafish94]

I'm rootin for the republicans but if push comes to shove and we get Eliz Warren next election I can't say it'd be in my favor.

The Obama Administration couldn't even get a public option passed through an extremely Democratic House and Senate, so I really wouldn't expect anything close to what you're describing in the near future. And this is coming from someone who is most definitely not rooting for the Republicans.

 

[Mad Jack]

There are already thousands of unfilled residency spots in primary care after the Match. There are only going to be more of them after the merge.

This is incorrect- in the NRMP match, only around 300 primary care spots went unfilled. There are plenty of IMGs and DOs willing to take primary care spots, so generally they fill.

Press Release: 2017 NRMP Main Residency Match the Largest Match on Record - The Match, National Resident Matching Program

 

[gyngyn]

This is incorrect- in the NRMP match, only around 300 primary care spots went unfilled. There are plenty of IMGs and DOs willing to take primary care spots, so generally they fill.

Press Release: 2017 NRMP Main Residency Match the Largest Match on Record - The Match, National Resident Matching Program

Yes, I should have been more clear. Unfilled by US medical students would have been more precise.

 

[Mad Jack]

Yes. Unfilled by US medical students would have been more accurate.

I guess my point is that we could expand primary care almost indefinitely, as there are plenty of bodies willing to fill those spots. They may not be American bodies, but many of the best physicians I've worked with have been FMGs.

 

[DaWeasel]

To take a different point of view, why would any practicing physician want more physicians? That just increases the competition from a business standpoint. I haven't started medical school so I don't benefit from this at the moment, but it's just economics 101 that if the supply of doctors increased, the income of all doctors would decrease. That isn't in the self-interest of current or future doctors.

 

[Kurk]

To take a different point of view, why would any practicing physician want more physicians? That just increases the competition from a business standpoint. I haven't started medical school so I don't benefit from this at the moment, but it's just economics 101 that if the supply of doctors increased, the income of all doctors would decrease. That isn't in the self-interest of current or future doctors.

Exactly. You can't have a socialized system coexist with a privatized one and expect the doctors to take the lower-paying government reimbursements just for the hell of it if they have plenty of other clients who'll pay more for their time.

 

[Mad Jack]

To take a different point of view, why would any practicing physician want more physicians? That just increases the competition from a business standpoint. I haven't started medical school so I don't benefit from this at the moment, but it's just economics 101 that if the supply of doctors increased, the income of all doctors would decrease. That isn't in the self-interest of current or future doctors.

Because some of is actually care about patients getting much needed care, not just our own financial interests.

 

[Mad Jack]

Exactly. You can't have a socialized system coexist with a privatized one and expect the doctors to take the lower-paying government reimbursements just for the hell of it if they have plenty of other clients who'll pay more for their time.

Actually, you can, it's done in several European countries.

 

[aldol16]

This may be a naive viewpoint from someone outside the profession, but I don't see a good reason why we can't expand many medical school classes - not to Caribbean school levels but substantially increased from current levels. When you ask people involved in medical education, they usually give some BS excuse about not having enough resources, etc. but it seems to me that if bureaucracy wants to expand, it can and will expand. I just think there's a lot of bureaucratic inertia here and a lot of schools like boasting about their small class sizes.

 

[7331poas]

This may be a naive viewpoint from someone outside the profession, but I don't see a good reason why we can't expand many medical school classes - not to Caribbean school levels but substantially increased from current levels. When you ask people involved in medical education, they usually give some BS excuse about not having enough resources, etc. but it seems to me that if bureaucracy wants to expand, it can and will expand. I just think there's a lot of bureaucratic inertia here and a lot of schools like boasting about their small class sizes.

The reason is because doctors wont have jobs leaving school just like law schools

 

[DaWeasel]

Because some of is actually care about patients getting much needed care, not just our own financial interests.

I wasn't making a value judgement on it, just pointing out it's not practical to expect doctors to advocate against their own interests.

 

[Kurk]

Actually, you can, it's done in several European countries.

So in the UK private clinics will take NHS patients out of their own altruistic interests over wealthier clients?

 

[Mad Jack]

So in the UK private clinics will take NHS patients out of their own altruistic interests over wealthier clients?

The systems co-exist was my point, not that all doctors take all insurance. People that can afford better care get it, and doctors that don't want to work in the NHS are allowed to do so.

 

[aldol16]

The reason is because doctors wont have jobs leaving school just like law schools

Well, the increase in medical school class size would presumably be mirrored by an increase in primary care residencies. The money for funding those residencies might be a problem with the current political climate but if money is the only problem, then that at least is fixable in theory.

 

[Mad Jack]

I wasn't making a value judgement on it, just pointing out it's not practical to expect doctors to advocate against their own interests.

Physicians often are more keen to look after the public than their own interests. Something something ethics, something something altruism.

 

[Mad Jack]

Well, the increase in medical school class size would presumably be mirrored by an increase in primary care residencies. The money for funding those residencies might be a problem with the current political climate but if money is the only problem, then that at least is fixable in theory.

It isn't the only problem, the other issue is adequate training capacity. There are only so many hospitals with decent pathology.

 

[JJRousseau]

The systems co-exist was my point, not that all doctors take all insurance. People that can afford better care get it, and doctors that don't want to work in the NHS are allowed to do so.

My understanding is that's not true. Your training, which takes 12-20 years after medical school (which people typically finish at 24), as a junior doc is always done in service of the NHS. That said many consultants choose to still work for the NHS, because pay and pension are pretty outstanding.


Edit: it's certainly true that the systems coexist. But I think there is some mandatory service in the NHS built into training. That said until 2005 or so, medical school like all higher degrees at "universities", which were then strictly classified, was free. Now, only the Scots have free tuition.

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[aldol16]

Actually there will be a 30% increase in the number of US MD grads in the decade ending 2019. Graduates from DO schools have nearly doubled in the past 20 years.

The limiting factor is the funding and structural differences between medical school education and medical training in residency. The former are seats in a class that are under the control and fund raising of the institution. The latter are employment training slots funded almost exclusively via medicare dollars. While the educational oversight and training is typically associated with a medical school, they are at the mercy of government funding. while some new slots, particularly family medicine, were funded during Obama's time, the current is unlikely to do much about it

Ah, that's interesting. But is that effect mainly from the opening of new medical schools? It seems like the institutions in the top 20 or even top 50 love to brag about their small class sizes and haven't expanded class size in years.

I think the current funding system is perhaps flawed since, as you say, residency slots are basically employment slots and so hospitals should take those on as part of operating costs and absorb the costs into their own budget. That might increase the burden on a hospital significantly, but hey, they're getting labor out of it at a significant discount. Sure, residents aren't full doctors yet, but they run a non-trivial portion of the hospital's daily business. Although Congress froze the number of Medicare-funded residencies in the 90s, hospitals are still free to create non-Medicare-funded slots that can be funded by their own revenue. Since residents generate revenue for the hospital, there has to be a point where the marginal revenue product of labor cuts the marginal cost of that extra unit of labor - and that should be the number of new spots the hospital should create. I think the main reason why hospitals are not doing this is because of the bureaucratic hurdles they would have to jump through.

I wouldn't say Congress won't do anything about it - just that the changes they make will more likely than not be in the opposite direction.

 

[aldol16]

It isn't the only problem, the other issue is adequate training capacity. There are only so many hospitals with decent pathology.

Do you believe that all U.S. teaching hospitals are operating at 100% capacity with regard to training physicians?

 

[JJRousseau]

Also, I was under the impression that by dollars spent, the majority of medical care in this country IS socialized, regardless of the OP's red scare framing of the question.


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[aldol16]

Also, I was under the impression that by dollars spent, the majority of medical care in this country IS socialized, regardless of the OP's red scare framing of the question.

A lot of Medicare is already run by the private-sector. Medicaid is an open-ended entitlement funded by the federal government, but most of that might not be true by the end of next week.

 

[efle]

Also, I was under the impression that by dollars spent, the majority of medical care in this country IS socialized, regardless of the OP's red scare framing of the question.


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From a quick google search, it looks like private insurance about 1/3rd, medicare and medicaid about 1/5th each (the rest things like out of pocket, or hospital eats it).

Someone correct if the above is wrong.

 

[aldol16]

Increase has been both in both new institutions and in adding seats to existing places. But the latter is problematic due to limited clinical rotations. Hospitals and doctors that may have once gladly worked in training medical students a generation or two ago, no longer want the burden. programs need to be formal and approved not simply being on the wards. Private physicans who once expected they would be training med students while on rounds with private patients no longer afford the time and energy in a vast changed world of medical practice. And the reduction in hospital beds and hospital stays has reduced opportunties. NYC is essentially maxed out for rotations where you may have 12 med students on a patient. Its one of the reasons why the LCME does not write specific regulations for the number of students in a rotation as it would have the effect of forcing fewer students. Hospitals get much of their funding from Medicare effectively and cant simply eat the cost of residents. Some places by me have simply moved to more cost effective midlevels, especially with the reduced administrative cost of managing a residency program. There are no easy answers to this issue

Well, like I said, they wouldn't be eating the cost since residents generate revenue. Let's assume that a hospital is willing to expand residency spots in the primary care specialties that experience physician shortages - they'll fund these spots through the revenue generated from those same residents. Since there is clearly a demand for physician labor in those primary care disciplines that isn't being met, they have a market to expand into. Since residents generate revenue for the hospital, there has to be a point where the marginal revenue product of labor cuts the marginal cost of that extra unit of labor - and that should be the number of new spots the hospital should create. They'll earn money by meeting the increased medical demand, take some of that money out to pay the residents, and have some left over as profit. It can't be that no level of revenue would entice them to take on the costs of non-Medicare-funded residency spots. I think most of it has to do with bureaucracy and the administrative tasks associated with creation of new residencies.

 

[JJRousseau]

From a quick google search, it looks like private insurance about 1/3rd, medicare and medicaid about 1/5th each (the rest things like out of pocket, or hospital eats it).

Someone correct if the above is wrong.

https://www.cms.gov/Research-Statis...onalHealthExpendData/Downloads/highlights.pdf

I stand corrected - not majority, but a plurality. Both in the cases where spending is measured by direct reimbursement or ultimate sponsor. That's 2015.


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[aldol16]

Medicare run by private sector still relies on government funding to run

Then how "socialized" it is depends on one's particular definition of "socialized." Medicare Advantage plans aren't exactly a single-payer system but they necessarily involve government as you say.

 

[raiderette]

Actually, Congress could do a lot. Block grants to states for federal programs means that state legislators will ultimately decide how much money gets to GRE programs. Fewer residency programs mean that states with a physician shortage will have a harder time attracting attendings. My home state is listed as a great med state for malpractice and tort reform but we have a lousy record when it comes to prenatal care and lower than average number of OB/GYN. Part-time legislators determine if states have enough doctors.

 

[aldol16]

Actually, Congress could do a lot. Block grants to states for federal programs means that state legislators will ultimately decide how much money gets to GRE programs. Fewer residency programs mean that states with a physician shortage will have a harder time attracting attendings. My home state is listed as a great med state for malpractice and tort reform but we have a lousy record when it comes to prenatal care and lower than average number of OB/GYN. Part-time legislators determine if states have enough doctors.

I don't think I've heard of any legislators wanting to turn Medicare into block grants... That goes beyond the third rail. I don't think Medicaid funding is tied as closely to GRE programs as Medicare.

 

[Mad Jack]

My understanding is that's not true. Your training, which takes 12-20 years after medical school (which people typically finish at 24), as a junior doc is always done in service of the NHS. That said many consultants choose to still work for the NHS, because pay and pension are pretty outstanding.


Edit: it's certainly true that the systems coexist. But I think there is some mandatory service in the NHS built into training. That said until 2005 or so, medical school like all higher degrees at "universities", which were then strictly classified, was free. Now, only the Scots have free tuition.

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And residency and fellowship force you to accept Medicare and Medicaid, what's your point? Training is training.

 

[Mad Jack]

Do you believe that all U.S. teaching hospitals are operating at 100% capacity with regard to training physicians?

The most recent analysis I looked at showed them at about 90% capacity.

 

[JJRousseau]

And residency and fellowship force you to accept Medicare and Medicaid, what's your point? Training is training.

The point is doctors for some period of time are must be a part of the NHS... they can't take their degree and run to insurance reimbursement as was suggested in the quoted post. Pointing out that the US uses a similar mechanism to ensure Medicare and Medicaid need is met at lower cost reinforces the point. If we went for Medicare for all, I suspect the first solution would be to increase training slots and lengthen training time.



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[johnnxyz]

Physicians need a more powerful lobby in Congress or they're going to continue to get their asses handed to them on a platter, regardless of which party is in charge and what healthcare legislature they pass. Although I feel like ACA repeal is in the economic self interest of the doc community.....Same way coal miners voted Trump even though he thinks global warming is a Chinese hoax

 

[7331poas]

Well, the increase in medical school class size would presumably be mirrored by an increase in primary care residencies. The money for funding those residencies might be a problem with the current political climate but if money is the only problem, then that at least is fixable in theory.

jobs...not residencies.

The only way this could work is if the expanded seats are done with a conditional acceptance that you enter primary care.

 

[psychMDhopefully]

There are already thousands of unfilled residency spots in primary care. There are only going to be more of them after the merge.

Im guessing you've been removed from the residency app process for a while now, there are only a couple hundred spots, if that, left after the SOAP

The earliest appointment I could get to see my PCP is in September! Insane!

And for the OP saying he/she has to wait to September to see their PCP, Im in a mid sized city ~200k population, are there are literally dozens of primary care clinics I can walk into whenever, and be seen by an MD if I prefer. Now in my home town which is really rural, my PCPs schedule is full for the rest of the year. So yes its a distribution problem no need for more residencies, or mid levels. Back home I have to wait weeks months to see a dentist, here I have dental practices competing for me, I just call around and see what the best prices I can get for certain procedures. People want to live where there is stuff to do.

 

[aldol16]

The most recent analysis I looked at showed them at about 90% capacity.

So if we take the average number of PGY-1 positions to be 29,000, then 100% capacity would be about 33,000 spots. Since that's an average, if primary care residencies are at less than 90% capacity, then the "extra" spots would disproportionately go to them. There would still be a massive shortage of physicians, which means that the only way to solve the problem would be to create more teaching hospitals/expand programs.

 

[aldol16]

jobs...not residencies.

The only way this could work is if the expanded seats are done with a conditional acceptance that you enter primary care.

The residency you get is directly correlated with the kind of job you get. Someone who finishes an internal medicine residency isn't suddenly just going to go into an orthopedic surgery job. Expanding the number of seats in primary care residencies would directly translate to more physicians entering into those primary care jobs. Sure, there's no guarantee that you're going to get more people to apply to those primary care spots just by expanding your medical school class size, but market supply and demand forces will force more people into primary care. You've just finished medical school and don't have the stats, etc. to match into the competitive specialties - do you just call it quits and go flip burgers? Or do you try to match into a program that is less competitive and now has more slots?