Facing shortage, we can't just pull doctors out of a hat

A message to all physicians from AMA President Cecil B. Wilson, MD.

By Cecil B. Wilson, MDis an internist in private practice in Winter Park, Fla. He served as chair of the AMA Board of Trustees during 2006-07 and was AMA president during 2010-11. Posted Jan. 10, 2011.

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It has begun. In the first dozen days of this new year, more than 120,000 baby boomers have: a) turned 65 (at a rate of one every eight seconds); b) become Medicare eligible; and c) joined the list of people who may have difficulties in accessing a physician.

This is not a surprise, of course, but I hope that the oft-repeated statistic will force our nation and our government to face the harsh reality of America's current physician shortage, our growing underserved populations, and the dismal issue of access for those newly insured after 2014 under provisions of the Patient Protection and Affordable Care Act.

And a new physician pipeline that makes many people very nervous.

The shortages

Here's how it currently stacks up:

  • We anticipate a deficiency of at least 125,000 physicians by 2025.
  • Already, 22 states and 17 medical specialty societies are reporting shortages.
  • Despite the last-minute reprieve on SGR -- the apocryphally named sustainable growth rate formula -- many of us have been forced to limit the number of Medicare patients simply because we no longer can afford to serve them.
  • For decades, we have watched the physician population move into cities and high-population areas, leaving vast areas of this country woefully underserved.
  • There still is a primary care shortage -- at least partially because pay differentials for primary care physicians make it even more difficult to repay medical school debts, which average $155,000.
  • We see an even larger shortage in the Hispanic, black and other minority communities -- partly because of high medical school costs but also because there are few role models for those kids.
  • And then there is 2014, the year of shrinking access. That year, when the full provisions of the health reform law kick in, we will see 32 million more patients -- people who up to now have been uninsured and often without a physician.
  • If all that isn't enough, HHS estimates that a third of today's practicing physicians will retire during the next decade.

The situation is serious for the patients who do not have or cannot get a physician's care. It presents considerable challenges for those of us in medical practice as well.

Fortunately, the health reform law does begin to address the situation. Likewise, there are other small steps under way that slowly are making a difference.

Medical education and training

Although medical school tuition remains a huge stumbling block, especially for minorities, first-year medical students are on the increase -- predicted to be up 21% by 2013 over 2009. Many programs are growing; moreover, nearly two dozen new medical schools have opened, sought accreditation or been announced in the past three years.

This is good news.

However, we are not seeing a parallel growth in residency slots. Today there are about 110,000 residents nationwide. That is an 8% increase since 1987, but still far too few.

The number of Medicare-funded residency programs was capped at about 100,000 by the Balanced Budget Act of 1997. In addition, fewer states can afford to offer GME funding with Medicaid dollars: 41 states today, down from 49 in 2005.

The AMA has worked actively to get Washington to increase the number of government-paid residencies -- and we can report some success in the health reform law's provision to fund 889 new primary care residency positions. This is commendable, but it is far fewer than the nation needs.

Reaching underserved geographies

As far as geographic coverage and physician access for specific populations, we can look to programs such as the National Health Service Corps that offer medical loans repayment to new physicians who practice in underserved areas.

The 2009 stimulus package and health reform law designated nearly $300 million for the NHSC to fund primary care practitioners. NHSC plans to have nearly 11,000 clinicians caring for more than 11 million people by the end of this year, a threefold increase since 2007.

Individual medical schools also are taking steps to build physician populations in underserved areas. One example is the new Texas Tech Paul L. Foster School of Medicine in El Paso, which aims to supply physicians for El Paso, the Texas-Mexico border area and west Texas. Currently, this region has fewer than half the national average of 254 doctors per 100,000 residents.

Increasing minority physicians

Underrepresented minorities in the ranks of physicians -- only 6% compared with 30% of the overall population -- is another problem that will only grow as our current minority groups swell to dominate the population by 2050.

On the upside, the AAMC has a major initiative to increase minority enrollment.

Since 2002 the AMA has sponsored Doctors Back to School, a mentoring program that sends minority physicians into schools to share their stories, serve as role models and raise awareness about the need for more minorities in medicine. In 2010, nearly 250 physicians participated. The AMA Foundation is one of many organizations that offer scholarships to minority medical students.

Individual medical schools also have initiatives to encourage minority physicians. Montefiore Medical Center in the Bronx, N.Y., sponsors a summer program designed to encourage black, Hispanic and Native American high school and college students to pursue medical careers. In Illinois, the University of Chicago Pritzker School of Medicine's Academic Medicine Program helps disadvantaged college students get the credentials needed for medical school applications.

In the meantime ...

All the examples I have listed -- new medical schools, new residency options, programs to encourage minorities and place physicians in understaffed areas -- are commendable. But they are not enough. The numbers -- whether you consider them from the perspective of a physician or a patient -- are simply staggering.

I know some believe that since we already have too few physicians to handle our growing senior population, we should address that problem first, before we take on 32 million more newly insured patients.

To those Cassandras, I say that is not only unacceptable, it is morally reprehensible.

The health reform law was passed to alleviate an untenable situation in this wealthy nation. A nation, I might add, that has a history of rising to the occasion, as I believe we can and must do once again.

In a perverse sort of way, the growing access problem may provide the pressure to persuade our nation -- and Congress -- to do what we must do, and to do it now.

We must continue to expand medical schools.

We must address the high cost of medical education.

And we must eliminate the CME bottleneck. Resident and fellow training programs cannot be paid solely through Medicare. One answer is an all-payer system, financed by insurance companies and others who have a stake in America's health.

I know as Americans we can do this. And I look forward to the AMA and our physician community playing an important role.

Cecil B. Wilson, MD is an internist in private practice in Winter Park, Fla. He served as chair of the AMA Board of Trustees during 2006-07 and was AMA president during 2010-11.

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