America’s 1 million-doctor shortage is right upon us

The doctor is disappearing in America.

And by most projections, it’s only going to get worse — the U.S. could lose as many as 1 million doctors by 2025, according to a Association of American Medical Colleges report.

Primary care physicians will make up as much as one-third of that shortage, meaning the doctor you likely interact with most often is also becoming much more difficult to see.

Tasked with check-ups and referring more complicated health problems to specialists, these doctors have the most consistent contact with a patient. But 65 million people live in what’s “essentially a primary care desert,” said Phil Miller of physician search firm Merritt Hawkins.

Without those doctors, our medical system is “putting out forest fires — just treating the patients when they get really sick,” said Dr. Richard Olds, the president and chief executive officer of Caribbean medical school St. George’s University, who is using his institution’s resources to help alleviate the shortage.

Dr. Ramanathan Raju, president and chief executive officer of public hospital system NYC Health + Hospitals, goes even further saying, “we lack a basic primary care system in this country.”

“I think we really killed primary care in this country,” said Raju. “It needs to be addressed yesterday.”

The primary care gap is particularly acute in about one-third of states, which have only half or less of their primary care doctor needs being met. Connecticut is a standout among the group, at about 15%, with Missouri (30%), Rhode Island (33%), Alaska (35%) and North Dakota (37%) following shortly after, according to government statistics.

“The real problem is we don’t have enough doctors in the right places and in the right specialties,” Olds said, noting that doctors tend to cluster in big cities, and are far more scarce in rural areas, small communities and parts of some big cities.

But how did this shortage come about, and why such an acute change?

Here’s what’s involved:

How doctors get paid: Choosing to go into primary care is also a choice to take a pay cut.

Starting salaries in high-paying specialties can range from $ 354,000 (general surgery) to $ 488,000 (orthopedic surgery), while primary care fields average about a $ 200,000 starting salary, from$ 188,000 (pediatrics) to $ 199,000 (family medicine), according to a Merritt Hawkins report.

The pay disparities reflect America’s “fee for service” health care model, which compensates providers based on the number and type of services they complete, and which inherently favors specialists.

Reform-minded critics say compensation should instead be based on a period of time a patient is cared for. They argue that this structure would incentivize preventative care and prevent unnecessary (and costly) medical procedures. The Centers for Medicare and Medicaid Services is in the very early stages of considering this global payment model.

Experts say it’s not just that primary care doctors get paid less — they also typically work longer hours and have to be well-versed in a wide array of medical issues, to refer patients to the appropriate specialists.

Our culture is also part of the problem, Raju said, since “it’s not very glamorous to tell that I went to some primary care doctor. It’s glamorous to say, ‘I went to a cardiologist.’”

Paired with hundreds of thousands of dollars of debt, it’s a recipe for a shortage, Olds said.

“From the patient standpoint, the most important doctor you have is the primary care doctor, who’s paid the least,” Olds said. “We pay for procedures, drugs and expensive tests, but we don’t pay doctors to think and care and manage patients’ health care problems.”

More demand: People are living longer and thus need more medical care, shooting doctor demand up; AAMC’s 2015 report calculates an 11% to 17% growth in total doctor demand, of which a growing and aging population is a significant component.

The shortage is one that’s been stewing for decades, but of late was exacerbated by passage of the Affordable Care Act, which increased the number of insured people and with it the demand for doctors, experts say.

• Medical schools themselves: Few medical schools consider a community service background or an expressed interest in primary care when admitting applicants, though there are factors that would be easy to look for. Service in programs such as the Peace Corps and Teach for America are good predictors for students taking an interest in primary care, Olds said.

Diversity also plays a role. Olds said he’s found that students from a range of socioeconomic backgrounds tend to go into a diversity of medical fields, too.

Then there’s the structure of the programs themselves: a majority of faculty tends to be specialists (a more research-oriented bunch, aiding the school’s federal funding), which influences their students’ choices, and use of university hospitals as teaching sites doesn’t immerse students as much in the outside community, inhibiting growth of community roots.

Osteopathic schools — which have the same educational requirements as an MD degree but the focus is on holistic medicine with a more hands-on approach — tend to have more luck sending students into primary care, with over half of graduates going into non-specialized fields, said Dr. Barbara Ross-Lee, dean of the New York Institute of Technology’s new osteopathic medical campus at Arizona State University.

The NYIT ASU campus was founded to alleviate the state’s physician shortage, and will start its first class of 115 students in August.

Like other osteopathic schools, the degree program will focus on patients’ overall wellness, an approach that dovetails with the philosophy and role of a primary care doctor.

But osteopathic programs are also designed to expose students to general medicine, with generalists making up much of the teaching faculty and clinical training opportunities in settings where primary care is delivered. The school also asks students in entrance interviews about their interest in primary care, Ross-Lee said.

Geography: It doesn’t take longer than a quick scan of a map of medical schools in the U.S. to see that they’re heavily concentrated in the northeastern U.S. Graduates tend to stay in the areas they went to school, so this contributes to the geographic skew among doctors.

Prospective doctors must complete a residency in order to practice medicine, but those programs — funded in part by federal dollars — aren’t located in areas with great need or being geographically recalibrated with it in mind.

Pay figures in, too. Suburban areas typically offer a perceived higher quality of live to doctors along with better compensation than a public, city system, said Raju, resulting in shortages even in places such as his own hospital system in New York City.

The government’s role (or lack thereof): In the U.S., though government dollars sponsor aspects of medical education, especially residencies, there’s no government oversight over how doctors sort into their various specialties.

But fingers aren’t just pointing at medical schools. Fear of a doctor surplus prompted a 1997 payment cap on Medicare funding for residencies, which has served as a “stumbling block” for doctor training ever since, John Iglehart wrote in the New England Journal of Medicine in 2013.

So as medical school enrollment has swelled — medical schools planned to increase their enrollment classes by almost 30% between 2002 and 2016, according to Iglehart — residency slot expansion has slumped.

A numbers game: Only about one in four medical school graduates are heading into primary care careers, according to Olds, a ratio that’s half what it should be.

But doctors also want to practice differently today than their predecessors, placing a higher premium on regular, 9-to-5, hours, Miller said. So “we find it takes more than one doctor coming out today to replace an old-style, baby boomer doctor” from 25 years ago, he said.

Then there’s the seven years it takes to train a doctor, a lag time that’s built into anything that attempts to address the shortage.

That means there’s little wiggle room. “The time is now,” said Ross-Lee.

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