Tragically, there is limited access to healthcare in developing countries that results in high levels of mortality in some of the most vulnerable patients and populations worldwide. However, even in a developed Western country, such as the United States, there are disparities in access to quality healthcare. While there are valid fears about worsening the already-limited access to healthcare with federal changes to mandates in insurance coverage, another major issue that will contribute to lack of quality healthcare is the increasing national shortage of physicians.
There is a growing national shortage of physicians which, although seen throughout the nation, is felt most significantly in rural areas. This shortage is predicted by the American Medical Association to drastically worsen in the upcoming decade by as much as a 90,000 physician shortage nationwide.
Various governing bodies and experts have postulated on the factors that contribute to the physician shortage, as well as the various potential solutions to this problem. A simple way of viewing this issue is due to a systems issue that stems from two major problems: 1) hurdles students experience in their medical training that prevent sufficient numbers of physicians from being trained and 2) hurdles physicians face in daily practice that result in physician burnout, in dissatisfaction and, ultimately, in the ending of their medical careers.
Hurdles in training: what factors prevent adequate numbers of physicians from being trained?
In identifying the barriers in producing a sufficient number of physicians, the first issue is the matriculation of an adequate number of people into medicine. There are incredibly stringent requirements for medical school admissions; they are so stringent, in fact, that some of the most exceptional, intelligent and capable applicants are denied admission. Once admitted, a physician takes an average of 10 years in training until she graduates and is able to practice. This training is rigorous, with an education that is so heavily focused on grades, repeated testing and fears of failing standardized exams, and ultimately results in a medical school debt that is typically around $200,000. Once a student has completed medical school and enters residency training, she will find herself competing with American and international medical students for a limited number of residency spots; these residency spots are limited due to the large amount of funding required to support each trainee.
Hurdles in practice: why can’t we keep our best and brightest doctors in practice longterm?
Dissatisfaction with clinical medicine and burnout is a growing problem, impacting up to 50% of practicing physicians today. Practicing physicians also face a number of factors that cause burnout and result in drop out of clinical practice, which contributes to the growing physician shortage. Some of these issues include dropping reimbursements, high malpractice risks and costs, and views of MOC as unnecessarily expensive and rigorous. Many physicians feel that the shift to electronic health records has been detrimental to their practices. Some of the current parameters by which compensation and practice success are often determined are the Press-Ganey scores and other metrics that may not always be consistent with smooth workflow and truly good patient care. Further, with increasing pressures and overhead costs, many solo and private practitioners that had once been available to serve their communities, including underserved or rural areas, are opting to instead sell or close their practices and take positions that are employed by larger systems and hospitals.
“…a punitive, high stress schooling system does not necessarily result in better trained physicians.”
I can understand that no system is perfect. However, in my work in London, many of the trainees seemed happier and more able to cope with some of the rigors of medical training. Of note, many of them told me that they opted to take half a day off per week to pursue their non-academic interests, such as sports, hobbies or a part time job for extra pocket money. And surprisingly, many of them seemed clinically as strong or stronger than their American medical student counterparts, which suggests that a punitive, high stress schooling system does not necessarily result in better trained physicians.
As a psychiatrist who provides therapy to many physicians who are experiencing depression, anxiety and various other symptoms of burnout, I often hear concerns from these physicians that they are afraid of the negative consequences of seeking this form of support. They also express concerns that in any future employment, they will be asked about any prior mental health treatment, to which an affirmative response might make them less likely to secure the jobs they desire. I find this curious – a system that can be high pressure and punitive, thus resulting in physicians who become burned out; however, that same system discourages these physicians from seeking support for that very burnout that it created. It’s no wonder that many physicians feel that the only way to move forward is to opt out.
So what can be done to solve the problem?
While there is no clear right answer on how to address the physician shortage, consideration of the various aspects that may be contributing to the shortage could help alleviate the issue. The first step would be increasing the number of people entering medicine by increasing the number of medical student seats as well as residency spots to accommodate all eligible American and excellent foreign medical graduates. We can continue to attract the best and the brightest students into medicine by offering a more balanced medical school education that encourages learning in an environment that is collaborative and lower stress while still allowing for creativity in analytical skills and excellence in clinical assessments. Since burnout is detrimental to physician health and to patient care, we can encourage mental health treatment amongst those physicians who need additional support. If certain metrics must be set in order to incentivize reimbursements, perhaps the best next step would be to determine how we could set these metrics in order to truly measure good, efficient, compassionate, evidence-based care. We could also continue to support physicians by recognizing and supporting their non-physician needs first; countless female physicians have complained to me about feeling discriminated against for pursuing pregnancy , breastfeeding or part-time work.
Increasing the number of physicians in the workforce must be our primary goal if we are to prevent the increasing physician deficit, which will ultimately impact the health of our nation. Increasing the number of our medical trainees and supporting their personal and professional wellness throughout their training and careers is a large first step towards this goal.
Photo credit: Dolgachov/bigstockphoto.com
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