Jesse M. Ehrenfeld, MD, MPH: 5-step solution to address physician shortage

AMA President Jesse M. Ehrenfeld, MD, MPH

In his address to the National Press Club on Oct. 25, 2023, AMA President Jesse M. Ehrenfeld, MD, MPH, spoke about the physician shortage in the U.S., what it means for doctors, patients and the health system, and presented a five-step solution to begin to address it. Download the complete transcript (PDF).

There is an insidious crisis going on in medicine today that is having a profound impact on our ability to care for patients, and yet isn’t receiving the attention it deserves. This crisis is physician burnout. Let me share three quick anecdotes—all very personal to me—that illustrate the problem.

Two years ago, a dear friend of mine and medical school classmate, an emergency room physician in California who worked tirelessly on the frontlines throughout COVID, took his own life. He was an energetic and loving soul … a brilliant and caring doctor … who felt the weight of the pandemic on his shoulders. He struggled to get out from under it. I knew he struggled, but I didn’t know how to help him. And he didn’t know how to ask for help.

I am still deeply troubled by his death, just as I am haunted knowing there are thousands of people in his community who can no longer receive his care.

More recently, another exceptional physician, a woman whom I recruited to lead the LGBTQ health clinic at Vanderbilt University Medical Center, abruptly quit the program, no longer able to cope with political pressures and distorted half-truths about the work she was doing. I watched her post pictures online hugging her friends and colleague’s goodbye as she packed up her family to move to another state to practice medicine unfettered by restrictive state laws.

Sadly, she is not the first, the last or the only physician I know who has made the difficult choice to leave a community or a state they love because of legislative overreach, in order to practice medicine the way they know medicine should be practiced.

And just the other day, I walked into the physicians lounge at the Medical College of Wisconsin in Milwaukee where I am an anesthesiologist. There I saw an experienced colleague whom I know well completely break down – so clearly exhausted and overwhelmed.

This is a picture of our health care system in 2023, and it is not a happy or uplifting one.

Physicians everywhere—across every state and specialty—continue to carry tremendous burdens that have us frustrated, burned out, abandoning hope … and in increasingly worrying numbers, turning our backs on the profession we’ve dedicated our lives to.

It’s estimated that more than 83 million people in the U.S. currently live in areas without sufficient access to a primary care physician.

In large parts of Idaho and Mississippi, pregnant women can’t find OBGYNs to care for them. Ninety percent of counties in the U.S. are without a pediatric ophthalmologist. 80 percent are without an infectious disease specialist. More than one-third of Black Americans live in cardiology deserts.

And in Florida, my own parents lost their primary care physician because the Medicare payment rate for doctors has plummeted over the last two decades and pushed many independent physician practices toward financial ruin.

The physician shortage that we have long feared—and warned was on the horizon—is already here. It’s an urgent crisis … hitting every corner of this country—urban and rural—with the most direct impacting hitting families with high needs and limited means.

Imagine walking into an emergency room in your moment of crisis—in desperate need of a physician’s care—and finding no one there to take care of you.

That’s what we’re up against.

And so while our current physician shortage is already limiting access to care for millions of people, it’s about to get much worse.

Consider that roughly two in three doctors admitted to experiencing burnout during the pandemic, according to a survey from the AMA, the Mayo Clinic and Stanford Medicine. That’s the highest level of burnout ever recorded by the AMA.

Consider that one in five physicians surveyed during the pandemic said they planned to leave medicine within the next two years, while one in three said they’d cut back on their hours.

Consider that nearly half of all practicing physicians in the U.S. today are over age 55. And while medical school applications are up, it can take a decade or more to educate and train a physician.

Consider that foreign-trained physicians, called International Medical Graduates or IMGs, face enormous obstacles—such as immigration and green-card delays—to practice medicine in the U.S.

Consider that the average young doctor now leaves medical school more than $250,000 in debt, and that this heavy debt load has huge implications for our health system, often forcing aspiring physicians to bypass primary care and less populated, rural areas in favor of more lucrative specialties in or near large cities.

It’s no wonder why the American Association of Medical Colleges projects a national physician shortfall of at least 37,000—and possibly well over 100,000— over the next decade.

Why is this happening?

Ask physicians and they’ll tell you:

• An increasingly impersonal and bureaucratic health care system that places enormous administrative hassles and burdens in our lap each day, and leaves us feeling powerless to make any meaningful change.

• Physicians today, on average, spend about two hours on paperwork for every one hour we spend with patients.
   

• An attack on science that undermines trust in our medical institutions, and too often leads to threats and hostility directed at us and other health care workers.
   

• Government intrusion into health care decisions and aggressive efforts in many states to criminalize care supported by science and evidence.
   
• Increasing consolidation across health care that is giving more power to our nation’s largest hospitals, health systems and insurers, and less autonomy and fewer choices to patients and doctors.
   
• Widening health disparities for historically marginalized communities, by race and by gender, between wealthy and low-income, and people living in urban and rural settings.
   
• The twin health crises of firearm violence and drug overdose.
   
• And for the last 20 years, a shrinking Medicare reimbursement rate for physicians that has pushed many small, independent practices to the brink of financial collapse and jeopardized care for millions of America’s seniors.

I want to pause on that last point for just a moment because while physicians understand the financial pain of our current Medicare model, I don’t think the public at-large is aware… nor do they know just how much they have at stake in our unsustainable Medicare system.

When you adjust for inflation, the payment rate to physicians who care for Medicare patients has dropped 26 percent since 2001, which was my first year of medical school, with additional cuts planned next year. 26 percent!

I don’t know many businesses in any industry that could withstand a 26 percent drop in revenue and still survive—much less an industry like ours which is so essential to the health and well-being of our nation. Meanwhile, we’ve seen high inflation, rising personnel costs, and increased practice costs that exacerbate these payment cuts.

Considering what my colleagues went through during the pandemic, this kind of financial blow is simply unconscionable, and it requires immediate attention from Congress before even more payment reductions kick in at the end of the year.

Congress must take action. Today.

Why is this an issue for patients to worry about?

Because when doctors lack the resources they need to keep their practices open, they close their offices. Or they reduce their hours. Or they make do with antiquated technology and equipment, or fewer support staff. Or they limit the number of new Medicare patients they take, or stop seeing Medicare patients altogether.

Either way, it’s patients who suffer, especially older adults, or those with limited mobility who may lose access to essential care … who may have to wait months longer to get an appointment … or who may have to travel much further away to see a doctor they don’t know.

As I mentioned, this is the situation my parents faced with their own primary care physician. They are in their 70s and, like many their age, they suffer from a variety of chronic diseases and have mobility limitations.

Too many seniors, like my parents, have gotten the same letter notifying them that their doctor was no longer able to see Medicare patients. This usually leads to a frustrating and frantic search for a replacement and too often harm, as delays occur, things get missed in the transition, and patients often end up having to travel farther to receive necessary services.

Sadly, this is a story that is playing out all over America. It’s affecting parents and grandparents, anyone who relies on Medicare for their doctor’s care … and all of us who care for them and their well-being.

So, how can we fix this?

Our nation’s physician shortage is a complex challenge that doesn’t allow for quick and easy solutions. But it is not hopeless.

In fact, there are five steps we must take – solutions with bipartisan bills pending in Congress right now – that would make a huge difference in our ability to hold onto the physicians we have… and strengthen our physician workforce so that our nation can better respond to an aging population, and the next public health crisis we will eventually face.

Step one is giving doctors the financial support they so desperately need to take care of us. This is critical for our colleagues in private practice that are the backbone of our nation’s health care system, reaching millions of Americans in rural communities whose health often suffers because they already lack access to care and have few options if the local physician closes down.

We need Congress to pass the bipartisan bill that was introduced in the House of Representatives earlier this year, the Strengthening Medicare for Patients and Providers Act, H.R. 2474, which would do what the AMA has long advocated for … provide physicians with annual payment updates to account for practice cost inflations as reflected in the Medicare Economic Index.

This would simply put physicians on equal footing as inpatient and outpatient hospitals, skilled nursing facilities and others who receive payment through Medicare.

We need Congress to pass meaningful Medicare payment reform … that step is essential.

Step two is reducing administrative burdens like the overused, inefficient prior authorization process that insurers use to try to control costs.

Physicians and their staff spend an average of two business days a week completing prior authorization paperwork, including submissions and appeals when insurers inappropriately deny care for treatments already in wide use. This onerous process not only frustrates doctors and drives up health care costs, it’s downright demoralizing for patients.

Nearly 80 percent of physicians in one AMA survey say they’ve had patients abandon treatment due to prior authorization struggles with health insurers. And two-thirds said prior auth delays led to additional office visits, another factor driving up health care costs.

This issue also lies in the hands of Congress with the bipartisan Improving Seniors’ Timely Access to Care Act, which would expand prior auth reforms finalized by CMS. It’s also in the hands of the Biden Administration, which can significantly improve the prior authorization landscape if it finalizes proposed regulations … and in the hands of state legislatures, many of which are considering their own reform measures.

About a dozen states have already passed comprehensive prior auth reforms this year, many based on AMA model bills, but much more needs to happen.

Reforming our antiquated Medicare payment system and fixing the broken prior authorization process are two pillars of our AMA Recovery Plan for America’s Physicians that we released last year, and which remains the focus of our state and federal advocacy efforts.

Step three in addressing our physician shortfall is securing passage in Congress of three bipartisan bills that seek to expand residency training options, provide greater student loan support, and create smoother pathways for foreign-trained physicians, who already comprise about one-quarter of our nation’s physician workforce.

This is particularly important to address shortages in medically underserved areas of the country.

The AMA supports the Conrad 30 and the Physician Access Reauthorization Act bills now in Congress, which would make necessary improvements to the J-1 visa waiver programs to address physician shortages, especially in rural and underserved areas, but also promote a more diversified workforce. The Conrad 30 bill also provides worker protections to prevent doctors from being mistreated.

We also strongly support the Healthcare Workforce Resilience Act, which would recapture 15,000 unused employment-based physician immigrant visas … the Retirement Parity for Student Loans Act, which allows retirement plans to make voluntary matching contributions to physicians during residency …

… and the Physician Shortage GME Cap Flex Act, which expands residency training programs in primary care or other specialties that are facing shortages.

Step four is to stop criminalizing health care that is widely recognized as safe, and that is backed by science and many years of evidence.

Predictably, the U.S. Supreme Court’s decision last year to overturn Roe v. Wade has radically changed the health care landscape in America—for both patients and physicians.

Fourteen states have enacted outright bans on abortion, and seven others have enacted partial bans.

Unrelated to the SCOTUS decision but just as damaging, 22 states have enacted laws restricting or banning gender-affirming care.

Let me be clear: These efforts—fueled by misinformation and a heated attack on science and evidence-based care—have forced government into the most intimate and difficult decisions a person can make. They have sown confusion for physicians and patients and opened deep political rifts between neighboring states. They have made physicians—and other health care workers—the target of attacks and intimidation.

They have caused aspiring young physicians to reconsider where they will attend medical school and where they will ultimately practice. And they have needlessly jeopardized the health of millions of Americans.

Step five is making sure that physicians aren’t punished for taking care of their mental health needs.

Every physician I know has a friend or colleague affected by burnout, or has themself confronted symptoms of emotional exhaustion or detachment from their work.

Physicians, in fact, die by suicide at twice the rate of the general population, an alarming statistic that puts my classmate’s struggles into context.

It's important to say that not all feelings of professional burnout lead to thoughts of suicide, but the fall out can still have widespread and lasting repercussions for doctors and patients alike. The roots of physician burnout go much deeper than every day frustrations we all experience and, instead, point to systemic issues in our health care system that are highlighted in our Recovery Plan for Physicians.

What’s worse is that physicians are often reluctant to seek help for their mental health over fears that it will jeopardize their license or employment because of outdated and stigmatizing language on medical board and health system application forms that ask about a past diagnosis.

In fact, four in 10 physicians in a recent Medscape survey said they have not sought mental health treatment because they worry about their medical board or employer finding out and potential repercussions. Seeking therapeutic interventions early helps protect against crisis situations later.

So, while the AMA and others are pushing for legislative fixes to address the drivers of burnout … while we’re working in collaboration with national medical licensing and credentialing organizations on this issue … we’re also urging states and physician employers to audit their own licensing and credentialing applications and remove questions that ask about past diagnoses of a mental illness or substance use disorder, or past counseling to help with one.

In its place, we encourage medical boards, hospitals, and health systems to focus on whether a current health condition, such as depression exists that, if left untreated, would adversely affect patient safety. And once outdated language is changed, we must be intentional about promoting these revisions far and wide so that physicians know it’s safe to prioritize their own mental health.

Seeking care for burnout, mental illness, or a substance use disorder is a sign of strength — an act that takes courage and deserves our health system’s unconditional support. And, in fact, the health of our patients, and our nation, depends on more physicians seeking help for their mental health and well-being before they abandon medicine altogether.

Our nation’s physician shortage is not a problem to set aside and deal with tomorrow. It is an urgent problem we need to address today.

We must take action to create a stronger and more resilient physician workforce to care for an ever-changing nation.

We must ensure that you, me, and everyone else in America has a physician to care for them, or a parent, or a family member, in their time of need.

Most of these solutions have bills pending in Congress with strong bipartisan support, and momentum growing in many states to put other safeguards in place.

There isn’t much that our two major political parties see eye to eye on right now, but on these issues they do. We just need the will—and the urgency—to get it done. We need leaders in Congress to step forward and make this happen.

Sadly, every day we wait the size of this public health crisis grows.

We need action today.

Thank you.

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