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….