Projected physician shortage requires multi-faceted approach

AMA's Moving Medicine video series amplifies physician voices and highlights developments and achievements throughout medicine.

In today’s episode of Moving Medicine, AMA Chief Experience Officer Todd Unger talks with AMA Chief Academic Officer Sanjay Desai, MD, on how and why we need to address a projected physician shortage. For more information, visit SaveGME.org

Speaker

• Sanjay Desai, MD, AMA chief academic officer

Unger: Hello. This is the American Medical Association's Moving Medicine video and podcast. Today I'm joined by Dr. Sanjay Desai, the AMA's chief academic officer and group vice president of medical education in Chicago, and he's going to discuss how and why we need to address a projected physician shortage now. I'm Todd Unger, AMA's chief experience officer in Chicago.

Dr. Desai, thank you so much for joining us. Many hospitals have had to deal with staff shortages off and on through the last two years, but there were also projections of a physician shortage even prior to the pandemic. Has the pandemic made this situation worse, or do we have any data that gives us a better picture of what's happening and what to expect?

Dr. Desai: Well, Todd, first, thanks for having me again. And it has made it worse. I think there has been a physician shortage. It's a complicated problem because it deals with not just numbers, but also distribution and specialty type of physicians in the country. And the pandemic's made it worse. According to the Association for American Medical Colleges, the U.S. is facing a shortage of up to 124,000 physicians by 2034, just over 12 years from now.

Unger: That's a lot. Big number.

Dr. Desai:  It's a big number, and it includes almost 50,000 primary care doctors, Todd. I mean, there's no question that, again, this existed before and the pandemic has only made it worse. There's been research on this as well. The Mayo Clinic Proceedings article that was just published in December, it actually showed that AMA researcher who worked on this and their colleagues found that burnout, that workload, fear of infection through this pandemic, anxiety or depression due to COVID, and just the numbers of years in practice were all associated with an intent to reduce the number of hours that physicians are working or even leave practice altogether. This was based on a broad survey of doctors in 2020. So it's just soon after the pandemic started. And one in five doctors, that's twice as many as nurses, that's twice the number as many nurses, said that they plan to leave the profession in the next two years. So it really is a second time.

Unger: That's a stunning statistic, 20% on top of pre-pandemic. What are those other factors that were looming, driving the shortage, so to speak?

Dr. Desai: Yeah. Well, I think it's a couple of different trends that interact together in a way that makes things worse. So first is that the physician workforce itself, the average age of physicians is getting older. In fact, more than two out of every five active doctors right now will be 65 or older in the next decade. And so that's going to, again, compound the workforce reduction that we're describing.

And so while this physician workforce is decreasing because of the burnout, because of the hours that physicians want to be working less because of what they're experiencing, and then this aging population, at the same time, the U.S. population is growing. And so the population in this country is expected to grow more than 10% over the same time period that we just described the physician workforce is going to be aging. And so these two forces combined make for a shortage that's very complicated.

Unger: So definitely, combination of aging out, so to speak, and then pandemic-driven departures, that does create quite a challenge. So let's just talk about right now, how do we address this?

Dr. Desai: Not only so the U.S. population's growing, the physicians are aging, and therefore, we'll have reduction in workforce, but at the same time, the U.S. population's getting older. This is an important other problem to keep in mind because older patients we know take more time and care. And therefore, just the amount of time, the amount of care that needs to be delivered proportionally are also going to be increased in terms of what we require of our physicians. So again, many forces as you described, which is a stark projection.

Unger: So major changes in both supply and demand that are creating a situation that's going to be tough to deal with. Let's talk about how do you go about addressing a challenge like that? Is it just a matter of getting more young people interested in medical school, or more than that?

Dr. Desai: It's a lot more than that, actually. As I said in the beginning, this is far more than a numbers issue. It goes into the types of physicians that we need in the country. Ultimately, the product of medical education is to produce a physician workforce that is capable and qualified to equitably care for our patients in our communities. And therefore, we not only need the right number, we need the right diversity of physicians. Again, we need physicians that resemble the diversity of our patients that resemble the life experiences of our patients that are in the right specialties and in the right parts of the country, the right physicians serving the right communities.

And so there has to be a tremendous amount of thought that goes into how to create the right incentives, particularly for our young physicians that are just emerging into their careers, to give them the right incentives to choose the specialties that we need most and to practice in the areas that we need the most physicians. And so that's a complicated problem beyond just the numbers of physicians.

Unger: So Dr. Desai, this is quite a challenge. The AMA has been working on a number of issues. Let's start with those that are related to medical school. What are we up to?

Dr. Desai: Yes. AMA has been investing this heavily, Todd. We spent the last decade essentially with the accelerating change in medical education program, convening leading institutions and offering grants related to medical schools and reimagine and to graduate medical education programs, working to create a more diverse pathway for young physicians through scholarship assistance, through mentoring and through other mechanisms to enter medical school and to graduate medical school and enter this profession.

We're also working, in collaboration with others, to alleviate the exorbitant costs of medical school education. It's one of the largest barriers that keeps students from pursuing the field. Typically, young doctor in the U.S. leave school with $200,000 in medical student loan debt, which is, again, a tremendous barrier.

And then we're also helping at the federal level. So we're urging Congress to act, to provide funding, to create and make sustainable medical schools and residency programs that have their roots that are in the area, in the neighborhoods, communities that educate diverse populations.

Unger: Well, as you said before, complex issue, way more than just creating more medical students, because the other challenge there is about residency slots. Can you talk a little bit about how that works?

Dr. Desai: So in our country, this is a system that was created decades ago, residency slots are funded through Medicare. So it's called GME financing. And then there's a formula that really many would argue is antiquated at this point because it was created decades ago, that decide how many residency spots are available for or funded in specific hospitals, in specific communities and cities in our country.

And so the ability to train more physicians after medical school is dependent upon funding from Congress, and federal support for these residency physicians has remained stagnated essentially to a federal cap that is dramatically short of what the country needs in the face of a growing U.S. population. And Medicare's current cap on financial support for graduate medical education is preventing physicians or, sorry, preventing hospitals from expanding the numbers of physicians they offer to train physicians.

Unger: Again, this is another area that AMA has been quite active in resolving issues around this, and I understand there's been some progress on this issue for the first time in a while. What's happening? And is it going to make a big difference?

Dr. Desai: There is, Todd. I mean, Congress is acting now. It's starting to act last year. In the first increase since 1996, Congress provided a thousand new Medicare-supported residency physicians through this Consolidated Appropriations Act of 2021. It's a good start. The reality is, as we've talked about, we're going to need many more slots to alleviate the current and projected shortage that we have. And these positions also come with certain restrictions.

So it's pretty complicated, but there's, for example, no more than 200 slots that are available each fiscal year. No one hospital can have more than 25 additional spots in total. And then there's a number of different restrictions related to each year and each program and how many spots can get the type of areas that they can be used, for example, in rural areas, and if they're funded specifically for new medical schools or branch campuses that have opened more recently.

Unger: And that gets to some of the AMA comments and requests about this particular legislation. Do you want to outline some of the key changes we'd like to see?

Dr. Desai: Yes. The AMA, I think, has been very active here. They applaud CMS for adding these new slots and at the same time, they have concerns. So we sent a comment letter last June outlining the concerns that the AMA has and many of them have yet to be addressed.

So one concern is just the timing. So currently, March 31st is the deadline where CMS analysis, the new slots each year, and this doesn't align with the calendar of the academic year for residency programs. And so the AMA is advocating that we move the deadline to October 1st to give residencies a chance to hear the new numbers and to be able to line up their recruitment accordingly.

Another concern is that it doesn't allow enough expansion. And so the rule allows, as I mentioned, just one new slot per program per year, and this can't exceed five years. And so the AMA believes this needs to be expanded at least to three spots per year and a total of 15 over five years, instead of five, at a cap for five years. Again, just an attempt to meaningfully expand these programs.

Unger: And as a former residency program director yourself, you have personal experience with the challenge of running a program. What do program directors think about this issue? And does it affect their ability to recruit and train top talent?

Dr. Desai: Absolutely, Todd. I think this is something at the forefront of our mind every recruitment cycle. We struggle every year because we have far fewer positions than qualified applicants. And we have missions to diversify our programs, to resemble, again, the patients and the communities that we serve and to meet our budgets, and these are incredibly difficult constraints with the funding that we have. So these programs to expand GME funding and to distribute them in a way that is going to be most effective will allow all of us to meet our missions more effectively.

Unger: Well, in addition to the letter that was sent in February referenced before, are there any other AMA advocacy efforts underway in this particular area?

Dr. Desai: Yes. The AMA, again, as we mentioned, is very active. The AMA is part of the GME Advocacy coalition. It supports a number of bills that would aid graduate medical education. One of those bills is the bipartisan Resident Physician Shortage Reduction Act of 2021, and this gradually provides 14,000 new Medicare-supported residency positions or 2,000 spots a year, beginning in 2023.

And so we have put forth comment letters on a number of GME issues and have a GME compendium that discusses some of these major issues in GME, as well as with our other advocacy work. So we believe more GME funding is something the AMA and other leaders in medicine have long been advocating for. SaveGME.org talks more about these efforts and why they're so important and how to get physicians involved at the grassroots level, which would very much welcome.

Unger: Well, Dr. Desai, thank you so much for being here today and talking about what is obviously a really critical issue and time to engage on. This will continue to be an important issue for the AMA, and we'll continue to talk with your team as things progress.

Once again, the website to learn more about this issue, SaveGME.org. So stay tuned for another episode, and click subscribe on our YouTube channel, or check out all of our videos and podcasts at ama-assn.org/podcasts. Thanks for joining us today. Please take care.

Disclaimer: The viewpoints expressed in this video are those of the participants and/or do not necessarily reflect the views and policies of the AMA.