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Responding to physician shortage

AAMC's Edward Salsberg, M.P.A.

By Jesse Smith

The Association of American Medical Colleges’ (AAMC) Center for Workforce Studies, and the American College of Physicians (ACP) have both recently responded with reports that address the various manifestations of shortage – geographic and specialty maldistribution in addition to aggregate shortfalls – and offer suggestions to academic institutions and policymakers.

Each report uses different sources of support for its recommendations and, although definitive proof of future shortages is not available, the length of medical school education means that should projected shortages eventually occur, they’ll only be averted by actions taken now before all data is available.

Physician Shortage Projected

Recommendations in the AAMC report – The Physician Workforce: Position Statement, released in February 2005 – are based on projections that shortages will occur. Center for Workforce Studies director Edward Salsberg, M.P.A. says that in addition to news reports of isolated shortages in communities around the nation and COGME’s call for expanded medical school enrollment, in-house data analysis found that the physician/population ratio will peak around 2016 and fall as the population grows. The report didn’t pinpoint a precise or definitive ratio, Salsberg says. “It’s not that we think there should be 250.4 doctors to every thousand people. It’s that there’s a reason to be concerned that the ratio will peak as the population continues to expand.”

Indicative of the uncertainty regarding projected shortages, the report acknowledges “definitive conclusions await further analytic work.” But Salsberg reasons that the recommendations present a win-win situation: they may alleviate potential future shortages, but, should the projections prove incorrect, could lead to a surplus that would allow the United States to reduce its dependence on foreign medical school graduates.

And according to the report, the danger of a shortage is far greater than that of a surplus. A shortage coupled with the aging Baby Boomer population – a group that will require increasingly more care – would strain resources, Salsberg says, and further aggravate shortages in areas already underserved.

The report’s main recommendation is that medical institutions increase their enrollment by 15 percent over a decade. As with the ratio of physicians to population, however, this number does not address a defined threshold of what is an appropriate number of physicians, while the organization is currently considering a proposal that will replace this call with one suggesting schools grow enrollment by as much as 30 percent.

Salsberg says that this recommendation faces the largest obstacles of any in the report. Logistics, including classroom space, and costs limit the increases that many schools can make. He says, however, that the call for a 30 percent boost will necessitate new schools – a topic that he says is being discussed in terms of allopathic institutions, and one already being realized among osteopathic institutions.

The report offers additional recommendations, including better informing students of specialty choices to alleviate potential specialty maldistributions, and creating greater opportunities for students to serve in underserved communities to ward off possible geographic maldistributions. The report also calls for further research and analysis of physician supply and demand, the constitution of the physician population, and the factors driving physicians to make the choices they do.

In a second recent report on the physician workforce, the ACP addresses specifically projections of primary care shortage, and is more a call on policymakers than academic institutions. The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care, released this January, cites multiple outside sources to demonstrate an impending shortage of primary care physicians. One study from the Department of Health and Human Services found that aging of the Baby Boomers will drive demand for primary care physicians from 106,000 in 2000 to 147,000 in 2020; at the same time, a 2005 Academic Medicine study found that only 27 percent of third-year internal medical residents planned to enter general internal medicine, a fall from 54 percent in 1998.

The ACP cites economic concerns as the largest factor driving this shift. According to ACP President-elect Lynn Kirk, M.D., Medicare undervalues evaluation and management services, has a disproportionately adverse impact on primary care physicians through its sustainable growth rate formula and utilizes a payment policy that discourages primary care physicians from offering the best preventative and comprehensive care. Coupled with increasingly high student debt, these economic factors lead students away from the choice to enter primary care. “The payment system for primary care is dysfunctional,” says Kirk.

The ACP paper makes four calls: policymakers should consider a primary care system known as advanced medical home – a comprehensive, “one stop shopping” network of resources; Medicare must reform its reimbursement policies; Congress should provide funding to study means of improving both the quality and efficiency of care and replace the sustainable growth rate formula with a model that provides all physicians with predictable updates.

The report expands on the second call – reforming Medicare reimbursement of primary care physicians – by offering solutions that could alleviate the economic forces driving students away from primary care:

· Increase overall reimbursement for primary care.

· Reimburse physicians for email and telephone conversations to decrease time-intensive in-person meetings.

· Consider reimbursement for time spent coordinating care outside visits.

· Support technology that would help patients control chronic diseases in order to stave subsequent complications.

As with the AAMC report, the ACP’s recommendations recognize demographic shifts in both the physician and general populations, but do not spell out specific demand benchmarks. Salsberg agrees that market forces will have an impact on supply, citing the growth of osteopathic institutions and Caribbean schools in response to the United States’ need for more physicians. Demand, he suggests, may also solve shortage issues be exacerbating the already increasing delegation of health tasks to physician assistants and nurse practitioners.

While neither report addresses other aspect of physician shortage – geographic and specialty maldistribution – in great detail, that issue has been documented to some extent in Pa.

Young physicians, seeking a greater balance between their professional and personal lives, are working fewer hours than their predecessors, who are themselves nearing retirement age. This is of particular concern for Pa., a state that in a 2003 Pennsylvania Medical Society study ranked 41st in the percentage of physicians under 35.

Suggesting further shortages, Foreman explains that liability disparities across states will create an “unwinding market” in which the best physicians will get the best positions in locations economically favorable in terms of malpractice and reimbursement, while the poorest states will be left with the poorest physicians, increasing malpractice and driving the crisis into a disintegrating cycle.

A 2005 Pew Charitable Trusts-funded survey from the Project on Medical Liability in Pennsylvania found that liability concerns are impacting specialist supply and access to high-risk procedures in the state. The survey – which included respondents in general surgery, neurosurgery, orthopedic surgery, obstetrics/gynecology, emergency medicine and radiology – found that less than four percent of respondents would definitely relocate out of state within in two years as a result of liability concerns, but just under 30 percent reported that they were somewhat or very likely to do so. In addition, one-third reported that they were likely to retire within two years out of similar concerns. Of possibly greater impact, however, is the fact that 42 percent either reduced or eliminated high-risk procedures, and 50 percent are likely to follow within two years.

That impacts not only patients, but medical students as well. Another study conducted by the same groups indicates that liability concerns will likely exacerbate shortages with residents expressing a lack of willingness to practice in Pennsylvania. The survey – which included respondents in anesthesiology, emergency medicine, general surgery, obstetrics and radiology – found that a third planned to leave the state after completing their residencies. More than two-thirds either somewhat or strongly agreed that liability concerns made them less eager to practice medicine; one-third regretted the choice outright.

In addition to creating statewide shortages, liability concerns are also responsible for geographic maldistributions of specialties. For example, as reported in Physician’s News Digest <https://physiciansnews.com/cover/504.html> Philadelphia and the surrounding five counties – the region in the state where malpractice plaintiffs are most successful – have recently experienced a significant shortage of obstetricians. High liability costs have resulted in a loss of 25 percent of staffed OB beds from 1993 to 2003, leading to a squeeze of remaining resources, largely at academic centers. Reports of spot shortages of neurosurgical services in southeastern Pa. <https://physiciansnews.com/cover/205.html> have also caused concern.

Academic Medicine’s Response

Academic institutions are heeding the AAMC call. Salsberg says that in response to the group’s call for a 15 percent enrollment boost, approximately half of all academic medical institutions have either already increased enrollment or are planning to do so – a group that includes several Pennsylvania schools.

According to Dean Thomas Nasca, M.D., Jefferson Medical College boosted its enrollment from 228 to 255 in August (an increase of 11.8 percent), and grew its nursing and occupational and physical therapy programs. The increase is possible as a result of an expansion at the school that includes a new 129,000 square-foot education building currently under construction.

The Penn State College of Medicine made improvements of its own, renovating classrooms and adjusting teaching schedules to accommodate enrollment growths. According to Richard Simons, M.D., vice dean for educational affairs, the school began discussing increases four years ago and in 2004 saw its class size rise from 125 to 135; it plans to grow that to a final 145 in August 2006.

Resources at other institutions, however, limit the extent to which those schools can grow their enrollments. Barbara Schneider, M.D., vice dean of education and academic affairs at Drexel University College of Medicine, cites that as the reason her institution is unable to dramatically increase its enrollment to the extent called for by the AAMC. Still, Drexel was able this year to handle a moderate increase: after hitting a high of 250 several years ago, the class size dropped to 225 before climbing to 236 and rising again to its current size of 255.

Temple University School of Medicine faces similar resource issues but is working to correct those. According to Dean John Daly, M.D., the school will this fall break ground on a new facility that will allow the institution to increase its class size by 10 percent when completed in May 2009, and again by an additional 10 percent.

The University of Pennsylvania School of Medicine has not yet boosted enrollment but is in talks to do so. According to Gail Morrison, M.D., Penn’s vice dean of education, the school is considering growing its class of approximately 150 students by 20.

Other institutions have responded by increasing enrollment through the creation of branch campuses – a move especially popular among osteopathic institutions.

In 2004, the Lake Erie College of Osteopathic Medicine opened a branch campus in Bradenton, Florida (LECOM-Bradenton), according to Associate Dean of Academic Affairs Robert George, D.O. That branch currently enrolls 320 students in two classes and anticipates a four-class enrollment of 1,600 – a student body that would make it the nation’s largest medical school. And according to spokesperson Carol Weisl, the Philadelphia College of Osteopathic Medicine (PCOM) opened its own branch in Suwanee, Georgia last August with an inaugural class of 84 students.

Locally, osteopathic aggregate enrollment will increase in several years with the creation of a new medical school in Pennsylvania: the Robert Morris University College of Osteopathic Medicine (RMU-COM). According to Foreman, the school plans to open in 2008 with a class of approximately 100 students.

Schneider suggests that this enrollment growth is valuable, not only to the nation and state, but to foreign communities as well. Foreign medical graduates currently occupy approximately one-quarter of residencies. Often these students are among the best of their home nations and, as a result, those nations lose valuable assets. Increasing domestic enrollment, she suggests, will enable U.S. students to fill more residency positions, allowing other nations to retain their brightest physicians.

These modest increases are a preliminary step, but their value may be negated without an increase in resident positions – the number of Medicare-funded positions has been capped since the passing of the Balance Budget Act of 1997. Proponents of a cap removal argue that doing so will allow teaching institutions to respond to both increased enrollments and shifting market dynamics.

Enrollment boosts have also generated concern that widespread growth will lead to a decrease in the overall quality of the student population. Jefferson, however, has not seen an issue of quality in this year’s enlarged class. According to Nasca, the class’ MCAT scores and GPAs are identical to those of the previous incoming class. He adds that the school receives more than 8,000 applications each year – a pool with more qualified candidates than the institution can accept, even with its increased enrollment.

Foreman suggests that quality concerns may be quelled through efforts to improve math and science education in secondary schools. He suggests that institutions sponsor junior and high school programs that can address deficiencies in those areas and, through concerted efforts, can also focus specific efforts on underrepresented ethnic and racial minority groups, exposing them to the profession and increasing the likelihood that those students will enter the field.

Addressing Geographic and Specialty Maldistribution

Foreman also suggests that local recruiting similar to that proposed by RMU-COM can alleviate Pa.’s physician shortfalls. “We look at Pitt and what a wonderful institution it is, but it’s attracting the best students from across the country who return back home to California and other states when they’ve completed their schooling,” he says. “It’s going to take new schools and programs like [RMU-COM] to value and push for finding people here and keeping them here.”

RMU-COM will address physician shortage in Pa. by attempting to recruit half of each class from western Pa. With only the University of Pittsburgh School of Medicine as a local option (an institution that is currently studying the projected shortages but has no firm plans to increase enrollment or adjust its recruitment practices), and many students leaving the state in pursuit of medical education, RMU-COM hopes to keep as many as half of each graduating class in the region, says Foreman.

The enrollment boost remedy, however, raises a potential danger of an altogether different shortage – faculty. As stated above, enrollment increases are limited by the resources of a particular institution. But a recent study led by Drexel researchers indicates that medical school faculty are increasingly dissatisfied with their jobs – 20 percent exhibited symptoms consistent with clinical depression and 29 percent often feel withdrawn from relations. In addition, it found the average amount of time faculty spend with students has fallen from 21 percent in 1984 to 15 percent. The study does not suggest a shortage of faculty exists or is even imminent, but calls on institutions to develop greater support and encouragement systems for faculty to continue attracting young people to the field.

In response to the projected shortage within both rural and ethnic and racial communities, several institutions have either developed or strengthened existing programs that expose students to these communities, understanding that such exposure often impacts a student’s choice of where to practice.

Drexel actively seeks students committed to community welfare, requiring community service of its applicants. Its students then have the opportunity to work with traditionally underserved populations in free clinics located in Philadelphia’s Chinatown, Salvation Army locations and shelters.

PCOM offers its students the chance to work in one of five health care centers, four of which treat underserved populations – one is in a rural community in Sullivan County, Pa.; three are in North and West Philadelphia communities with large minority populations.

Several institutions further recognize that recruitment for these underserved areas and populations will likely quell the shortage as students representing these communities are more likely than others to return to them.

Jefferson Medical College began in 1974 its Physician Shortage Area Program (PSAP). The program recruits students from rural areas who are committed to becoming family physicians in those areas; its students now account for 21 percent of Pa.’s rural family practitioners, although they represent only one percent of the state’s medical school graduates.

In addition, the college is increasing the number of scholarships it offers underrepresented minorities in an effort to attract more with the hopes that their communities will in turn be better served.

Penn State College of Medicine in Hershey has adopted a similar approach to Jefferson’s PSAP. Through the Robert Wood Johnson Foundation-funded Generalist Physician Initiative, the school developed a recruitment plan that targeted high school and undergraduate students likely to enter primary care, refined its curriculum to better focus on primary care, provided greater community-based primary care opportunities and worked to identify underserved areas as points of practice entry for young physicians. As a result, the percentage of its students entering primary care increased from 36.9 percent to 48.4 percent from 1993 to 2000. The school continues to utilize these techniques developed as part of the initiative.

Data is encouraging in suggesting that the underrepresentation of racial and ethnic minorities may be shifting – a move that could alleviate shortages in minority communities as these students are most likely to practice in such communities. Nationally, for the 2005-2006 year, the number of Hispanic applicants rose 6.4 percent; the number of Asian American applicants rose 8.1 percent. The number of black applicants, however, was static, while black enrollment fell. But multiple institutions indicate their willingness to expand their recruitment efforts to better attract these groups.

Specialty maldistribution appears to be a difficult shortage to address. The AAMA’s position statement offered no substantial guidance to medical schools beyond suggesting that they provide their students with “up-to-date and comprehensive information” on all specialties. Several institutions interviewed for this article emphasized the value as role models of faculty members who represent underrepresented practices, although the Drexel study suggests that this value is significantly compromised.

Economic forces appear to drive such maldistribution, with students often forced to choose based on the financial success they’re likely to see in a chosen field. “It’s difficult to ask a medical school grad with more than $100,000 of debt to choose a field that doesn’t pay as well as another,” says Jefferson dean Thomas Nasca. “While society needs and desires primary care physicians, those services are undervalued, and it’s difficult for students to choose the field until we solve that problem.”

The AAMA released its own report on student debt, and recommended that medical schools find ways to generate money to support students, be it alumni solicitations or the support of communities in return for a student’s service. It also suggested the expansion of both loan forgiveness programs and the deductibility of loan interest.

As a means of alleviating the economically-based shift from primary care in Pa., the state has developed a loan repayment program for physicians practicing primary care in a Rural or Urban Health Professional Shortage Area. The repayments will cover up to $64,000 for practitioners serving a minimum of three years.

Penn’s Gail Morrison suggests that these changes are the only ones that can affect specialty – as well as geographic – maldistributions, saying Penn and other academic institutions are unable to alter a student’s choice of where and what to practice. The school has even had to forfeit funds earmarked for loan forgiveness for physicians practicing in underserved fields and communities because few students were willing to commit to such practice early in their educational careers.

Some suggest, however, that market forces will be the greatest factor in addressing specialty maldistributions.

“It’s a marketplace phenomenon,” says Temple dean John Daly. “A decade ago we thought hospital-based anesthesiology would decrease, that hospitals wouldn’t offer those positions. As a result the number of students entering that field went down, but subsequently the need arose and students now see that as a very sought-after specialty. As the number of specialists increases, students will start to flip into primary care.”

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