More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

There is no doubt that Affordable Care Act has changed the landscape of medicine in the US.  Now, private practice is becoming a thing of the past. Financial pressures, increasing regulatory requirements, electronic medical records and outrageously complex coding systems are forcing long time private physicians to enter into agreements with academic centers and large hospital systems in order to survive.  As a result, medicine today is more about increasing patient volumes, completing reams of paperwork and administrative duties than it is about interacting with patients and providing superior care.  The American Academy of Family Practice (AAFP) estimates that there will be a significant shortage of primary care physicians in the next several years unless we increase the number of primary care trainees by more than 25% over the same time period.  In fact, the AAFP suggests that the primary care workforce must increase to 260K physicians by the year 2025–which translates to an additional 52K primary care doctors.

Given the need for more physicians and the pending shortage (particularly in primary care), many analysts have suggested that the reason for the shortage is a lack of training slots in primary care.  The ACA will add an additional 32 million patients to the pool of insured and primary care doctors will be at a premium.  In the New York Times this week, the editorial board collectively penned an article discussing their thoughts concerning the doctor shortage.  The NYT editorial board suggests that the shortage is all about an imbalance between Residency training slots and medical school graduates and can be easily corrected by federal funding of a larger number of training positions.  However, I think that the issue is much more complex and the solution is far from simple.

Primary care is an incredibly challenging specialty and requires a broad knowledge of much of medicine.  Reimbursements for primary care work continue to lag and physicians are now spending more time with administrative duties than they are with patients.   I do not believe that the so called post graduate training “bottleneck” will come into play.  I would suggest that many primary care training slots will go unfilled over the next 5-10 years even without increasing the numbers of available positions.  Increasing training slots for primary care specialties may do nothing to alleviate shortages if there are no students who wish to train.  While medical school enrollments have increased over the last decade, much of this increased enrollment may be due to a lack of jobs available to recent college graduates.  Moreover, as the ACA continues to evolve, physicians are now realizing lower compensation rates, increased work hours, more administrative duties and LESS time spent caring for patients.  Many physicians are forced to double the number of patients seen in a clinic day–resulting in less than 10mins per patient–in order to meet overhead and practice expenses.  In a separate article in the New York Times, author and cardiologist Sandeep Jauhar discusses the increased patient loads and subsequent higher rates of diagnostic testing that is required in order to make sure that nothing is missed–ultimately increasing the cost of care.

For most of those who have entered medicine, the attraction to the profession is all about the doctor-patient interaction and the time spent caring for others.  I would argue that the primary care shortage (and likely specialist shortage) will worsen in the future.  Many bright minds will likely forego medicine in order to pursue other less government-regulated careers.  In addition, many qualified primary care physicians will opt out of the ACA system and enter into the rapidly growing concierge care practice model.  The answer to the physician shortage may be more political than not–politicians must realize that laws and mandates only work if you have citizens willing to devote their time, energy and talents to the practice of medicine.  Going forward, more consideration must be given to physician quality of life and autonomy must be maintained.  In order to make healthcare reform sustainable, those in power must work with those of us “in the trenches” and create policies that are in the best interest of the patient, physician and the nation as a whole.  Cutting costs must be approached from multiple angles–not simply reducing the size of the physician paycheck.

Medicine remains a noble profession.  Those of us that do continue to practice medicine are privileged to serve others and provide outstanding care.  In order to continue to advance, we must continue to attract bright young minds who are willing to put patients and their needs above their own–at all costs.  I think that there is still HOPE to save medicine in the US.  It is my HOPE that our government will soon realize that in order to continue to propagate a workforce of competent, caring physicians we must provide time for physicians to do what they do best–bond with patients and treat disease.  (as opposed to typing into a computer screen and filling out endless reams of electronic paperwork).  It is my HOPE that those physicians in training  that will follow in my generation’s footsteps will realize the satisfaction that comes from impacting the health and lives of patients over time.  It is my HOPE that the ART of medicine can be saved before it is too late….



4 responses to “More (or less) Hope and Change (for the worse) In Healthcare: Are Doctor Shortages Really All Due To Training Bottlenecks?

  1. Thanks so much for reading my blog and submitting a reply. I certainly agree with you that PREVENTION is critical. However, I do believe that the key to prevention is developing a strong doctor-patient bond. It is very clear that when there is a strong doctor-patient bond that patients become engaged and invested in their own healthcare. Engaged patients have improved outcomes. I do believe that we must continue to focus on seeing patients as an integral part of PREVENTION.

    • Thank you for clarifying the issues: Time spent in accounting detracts from time treating patients. The doctor in charge of England’s NHS estimated their administrative costs at ~6% in 1997 over cocktails in Philadelphia; Drs. Woolhandler and Himmelstein have estimated Canada’s administrative costs at ~14%, and ours at ~34%. Senator Charles Grassley (R., Iowa) cited a “not for profit” hospital in Missouri for suing indigent patients for whose hospital costs the tax-exemption exists; similarly, on 6 December 2010 reporter Michael Mather (Norfolk, Virginia) cited Sentara Hospital for suing an indigent minority mother earning $16/hour in his local newspaper article (“Charity Profiting Millions”) and paying its “nonprofit hospital’s” administrator (David Berndt) millions of dollars per year. Applicants to medical school have a choice of choosing an ethical teaching hospital.
      Virginia offers doctors, dentists, and lawyers a tax-credit for treating indigent patients. Congress could adopt such a law, and even extend it to all citizens who pay for someone’s care.
      H.E.Butler III M.D., F.A.C.S.

  2. I enjoyed reading your article Dr. Campbell, it inspired my to look up a myriad of healthcare issues that are on the debate plate regarding the future of healthcare in the U.S. I certainly went off on many tangents, but after reading your blog, I think you would agree that all these issues come to play when one is looking how to resolve even a specific issue like the ones you characterized.

    I too like most all Americans have my ear to the ground, trying to predict the future of healthcare, and particularly what my future costs and availability of access will be. The bottom line as I see it, is that we (most Americans) cannot afford a healthcare system that has grown in costs continually for the last 4 decades, always greater that the rate of inflation. Even after the recent downturn in the economy and the ACA has slowed down growth, we cannot sustain a continual increase of healthcare costs above the inflation rate for very long. In the U.S., we now spend 17 % of our GDP on healthcare, and in less than 5 years it is predicted to be 20% or more by a 2009 Social Security report. We as a nation will have to find a better way to “do business.” I agree with you, we need to have a multiple-prong approach to solving the issues you mentioned and the answers most definitely will be politically spawned.

    I would prefer to see a healthcare system like we had after WWII, where doctors were paid directly by their patients for routine visits, and medical insurance kicked in for catastrophic events or long hospital stays. This could only be done if we have major legal/tort reform in the U.S. It’s a shame that the Common Sense Legal Reform Act was vetoed by President Clinton in the 1990’s. If he had signed this into law, our country would not have a healthcare cost crisis because it would drive down costs in many areas of healthcare delivery. Malpractice suits would have been transformed to the loser pays the entire costs of litigation, like the “English Rule.” Also, there would be no “Sweepstakes payouts” to frivolous lawsuits. In addition it would help to eliminate many of the diagnostic tests and excessive documentation due to the threat of a frivolous lawsuits combined with Sweepstakes payouts. Legal reform of this nature would have not only transformed healthcare but would have created a legal reform tsunami throughout all sectors of our lives. Being a retired educator, I can see how education in the U.S. could be transformed too.

    Thank you for taking the time to inspire people like me to wake up and start looking for greater knowledge and answers.

  3. Hans Crumpler MD

    KEVIN!!! SO good to hear you have not lost your analytical mind and your forthright communication skills! BRAVO!!! I find myself ever so pushed away from what my clinical training has taught me is best for the patient by someone who knows nothing of their clinical care, all for administrative decisions! Yes, I have to stare at a computer screen for the majority of the time I am seeing a patient in the room and lose the ability to truly CARE for them wholistically. I fear that very soon, we will be forced into vending machine medicine and patients won’t be interacting with a live person. Also, I see the tide of “minute clinics” in retail locations replacing the true experience of seeing a comprehensively trained physician to account for the major facets of their illness and lifestyle. I fear we are another profession that will be relegated to higher cost of living and inability to recoup the cost of our education only to be replaced by lower cost in training medical providers. Family medicine has lost its valuable role and has been underutilized for what impact we should have on the population. Those that have raced to the trough of healthcare and garner the most in revenue are the ones who provide the LEAST face-to-face care. Thank you for giving us a voice again!

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