In a medical mecca like Boston, which is home to three medical schools and many world-class hospitals, you’d think that getting a timely appointment with a primary care physician or specialist would be a breeze. It isn’t. Finding a doctor is even harder in rural and underserved areas. Yet the public debate on health care remains focused on insurance and funding, and largely ignores the undersupply of health care professionals. Access to care means more than adequate insurance.
Many factors influence projections about the size of the health provider workforce, which have swung widely over past decades. How best to assess it, from average wait times for appointments to number of physicians per population (both of which vary geographically and by specialty), is still an open question.
That said, it is clear that the growth and aging of the U.S. population combined with an aging physician workforce translates into a need for more providers. The Association of American Medical Colleges has recently predicted a nationwide shortage of somewhere between 40,800 and 104,900 physicians by 2030.
Ironically, one of the biggest obstacles to improving access to health care providers is the profession itself, enabled by a plethora of public and private agencies that control licensing and certification. These often inadvertently limit access to care rather than enhance it.
The current system for training doctors dates to the early 20th century, when medicine transitioned from a largely ineffective and amateurish enterprise to one rooted in science. Physician training and licensing have certainly evolved since then, but at a disappointingly slow pace. Physician shortages are increasing as the population ages, while many enthusiastic and capable students and trained foreign-born caregivers are shut out of the profession.
Why has so little attention been paid to the number and quality of health care providers? Physician education, licensing, and credentialing are determined by an alphabet soup of organizations that change at a glacial pace. Their roles and interactions are difficult to delineate, even for a former dean of Harvard Medical School, and this complexity makes change difficult.
Worse, while the mission statements of these licensing organizations stress public health, they also serve the interests of incumbent professionals, who may be wary of new competitors. Tension between these conflicting interests produces a less innovative, less diverse, and less accessible workforce than could be the case.
Accreditation is regulated by the Liaison Committee on Medical Education, a body sponsored by the Association of American Medical Colleges and the American Medical Association and recognized by the Department of Education for accrediting programs leading to the M.D. degree. It manages a rigorous process that, despite many benefits, raises the bar too high for creating new medical schools and slows the rate of educational innovation.
After completing medical school, graduates must pass a three-part exam and complete a one-year internship to become eligible for state licensing. Most physicians undertake further clinical training and specialization in hospitals, overseen by other certifying organizations. Hospital committees conduct evaluations before granting admitting privileges to carry out specific procedures or tasks.
Medical standards are essential. Can we develop more efficient approaches to ensuring them?
As my colleague Jared Rhoads and I argue in a white paper on the U.S. health provider workforce, the key is to substitute competency-based assessments for the process-driven approaches used today. Some costly exams and recertification processes have little or no evidence to support their use. Which schools a doctor has attended or exams she has passed matter far less than her competence. And please don’t misconstrue finding new ways to train and certify competent providers as lowering standards or expectations for quality — it’s quite the opposite.
The number of U.S. medical schools and the size of each year’s class have increased over the past decade, but not enough to solve the pressing workforce issue. Nearly a quarter of currently licensed physicians — well over 200,000 — are foreign trained, and the care they provide equals that of graduates of U.S. medical schools. They disproportionately practice in rural and underserved communities. Why not increase their numbers?
The Educational Commission for Foreign Medical Graduates certifies international medical graduates from legitimate medical schools, regulates access to the same exams that U.S. grads must pass, and authorizes the residencies required for licensing. But many more foreign medical graduates are eligible for residency positions in U.S. hospitals than there are available slots for them.
If training slots are limited, why not allow fully trained foreign physicians to fill the void? Under current rules, to secure a license they must repeat in U.S. hospitals the residencies and fellowships they already completed in their home countries. Many outstanding doctors will not do this. It would not be difficult to design a system through which hospitals and other health organizations facilitate and take responsibility for physician relocation.
Another indicator of the medical profession’s inadequate response to consumer demand is the rapid growth of nonphysician health providers. Nurse practitioners undertake advanced training that enables them to diagnose and treat disease, write prescriptions, and bill for services. They can practice independent of physician oversight in 21 states and the District of Columbia.
Today’s 234,000 licensed nurse practitioners can’t provide every health service. But for those they are able to perform, the quality of the care they deliver and patient satisfaction are equivalent to that provided by physicians. They fill major unmet needs, such as primary care. Yet some states still seek to limit the activity and independence of nurse providers.
Increased use of computers, artificial intelligence, telehealth, sensor technology, and health apps will someday transform the practice of health care. The only questions are when, and how training and licensing will adapt to these new realities. Consumers are now more actively involved in their own care, and are likely to support such innovations. Organized medicine should do the same. Perhaps, as has occurred in other industries, new entrants like Amazon, Apple, and Walmart will more aggressively seize opportunities to transform health care and how we train future professionals to deliver it.
While insurance and health expenditures continue to grab the headlines, let’s not ignore the vital role of health providers in the health care equation. We need more providers who are better suited to the challenges and opportunities of tomorrow’s world, and there is no legitimate reason why we shouldn’t start getting them today.
Jeffrey S. Flier, M.D., was dean of Harvard Medical School from 2009 to 2016. He is the co-author of the new Mercatus Center at George Mason University white paper “The U.S. Health Provider Workforce: Determinants and Potential Paths to Enhancement.”
I love medicine and this information above helped to stay focused and be passionate about my studies. And I’m searching for a bursary for the next 3 years
Massachusetts is the state with the highest concentrations of health care workforce and Boston is the peak of Massachusetts. Rural and underserved areas are just a small portion of those left behind totaling over 50% and increasing due to system design. It is the Triple Threat that defines and shapes shortages – worsening revenue, worsening costs of delivery, worsening complexity. JAMAnetwork has an article demonstrating the high costs of administration and numerous articles demonstrate Triple Threat.
Please stop spreading the insanity of massive expansion or new types of workforce or innovative types of practice. It is the foundation of the system that is broken. No training intervention is more powerful than the financial design which prevents shortages from being addressed.
Expansions of NP PA DO and MD graduates have proceeded at 6 to 12 times the annual growth rate of the US population at 0.7% for the past 12 years and even longer than that for NP PA and DO. The market is being flooded by excessive graduates, often by those who profit from training more and more. This profits those who profit most also. The excessive graduates keep costs of personnel down and prevent professionals from policies that pad corporate or institution profits. Also the basic workforce such as primary care is flat while the excess graduates go to more subspecialties with more added in each – MD DO NP and PA. This leads to more profits and higher health care costs as well as more cost for little gain in outcomes – the True American health care design.
Shortages are entirely about the financial designs specific to the shortage areas – generalists and general specialties, primary care, women’s health, mental health, small practices, small hospitals, 75% of rural American (not 25% doing well), 2621 counties lowest in concentrations of MD DO NP and PA (75% of rural pop and 32% of the urban pop) because of 15% lower payments, worst collections, and most penalties – by design. This does not include the populations in higher concentration counties that cannot access care due to worst public and private insurance plans (10 – 20% of the US).
Triple Threat is the cause of disparities in workforce – revenue too low where needed, costs of delivery accelerated especially where workforce is most needed, complexity increasing in multiple dimensions specific to the places and populations and practices most left behind.
By 2010 we needed a better financial design to maintain until 2040 to result in sufficient basic services by 2040. Instead we lost ground. For example the 2621 counties lowest in primary care with half enough (50 per 100,000) had 38 billion invested in primary care practices but HITECH to MACRA to Primary Care Medical Home has extracted 8 billion leaving only 30 billion. Turnover cost have increased and have subtracted another 3 billion not counting administration of various programs to decrease turnover. These counties need over 80 billion for sufficient primary care plus whatever is forced on them in higher costs and even then the complexity would not be fully addressed in these counties with 40% of the population and higher concentrations (over 45%) of diabetics, smokers, COPD, obesity, Veterans, poor children, mentally ill, premature deaths, and more. They have the worst social determinants, local supports, turnover frequency, and turnover costs. MACRA added $40,000, PCMH added $80,000, EHR added $60,000 and turnover is $100,000 per primary care physician each year). This is why fewer participate in MACRA or PCMH. The dollars add up to system failure.
The NHS of Scotland has a program that enables foreign trained physicians to practice in the NHS after demonstrating competence in medical knowledge , cultural sensitivity, and language proficiency without requiring costly retraining programs. Realizing that the world is not prepared for the changing demographics of an aging population and physician workforce I introduced a resolution, currently under study, at the interim meeting of the Massachusetts Medical Society urging them to work with any appropriate agency to introduce such a program in the US.
Contrary to popular belief nearly 20% of immigrants to the US since 2010 have advanced degrees according to census data. Most of these individuals cannot practice in the discipline in which they were trained, whether accounting or medicine, because of our currently restrictive policies.
Physician shortages have to be addressed by increasing funding for residency spots not by training midlevels.
A NP can never be a physician . They just do not have the basic scientific knowledge. Their role is in assisting physicians . Independent practice should never be allowed for them . They have 3% clinical training compared to medical grads.
Do you replace lawyers with Paralegals?
Plus taking nurses away from bedside does not address the physician shortage at all. It just augments the issue.
Foreign physicians do not have the same legal and cultural standards as practiced here in the U.S. It is naïve to assume that there would be a quick, smooth and flawless transition from one country to another. Instead, why not open more residency programs and train more U.S. students (both U.S. grads and off shore graduates), many of who are unable to get into a residency program and end up with enormous student loans that are impossible to repay. The number of Americans enrolled in income-driven repayment plans increased by more than 600% between 2011 and 2015. More than 40 million Americans owe the government $1.4 Trillion in federal student debt, making student debt second only to mortgages as the highest form of debt in the country. Seems illogical to try to solve the problem by grabbing foreign physicians when we have so many Americans not getting the chance to train. Of course it doesn’t help that many residency spots reserved for foreign students with no student debts (since most come from countries with socialized educational system). For the sake of this country let’s rethink what’s happening and assist our own students.
Some good thoughts here, but NPs do not serve in rural areas in any greater numbers than physicians do. Giving them autonomy to practice medicine independently does not solve any access problems, but does create a group of providers that order more lab, more imaging studies, and which makes more unnecessary referrals to specialists. Don’t believe me? Arizona NPs have had independent practice since 2001. Fewer than 11% of them practice in rural areas, and they serve less than 15% of Arizona’s rural population. The NP push for independence is nothing more than an attempt to advance their careers by legislation, rather than education. Today, an NP can graduate without ever working as an RN, can do their school 100% online (these are accredited schools, by the way), and can practice independently in 23 states plus DC after completing as little as 500 clinical shadowing hours! SHADOWING, as in following someone else around the office, not doing any assessment, diagnosis, or management. Just shadowing. Contrast that with the 17-20,000 hands-on clinical hours that primary care physicians have. NPs have less than 3% of the training and education of physicians. Even if an NP worked first as an RN, working as an RN is not practicing medicine, which is what these NPs are really trying to do, while calling it “advanced nursing”. Let’s not create a two-tiered health system. Let’s incentivize physicians to go to rural areas–more loan repayment, more tax breaks, telemedicine, rural residencies.
Great article. I would like to see more NPs take on a leadership role in primary care to free up physicians to move to the more complex areas of healthcare. I’m sure I’ll get blowback for this statement, but I’ve never quite understood specialty NPs (surgery, neurology) and I say this as a nurse. If everyone should be working at the top of their license then primary care should be the domain of NPs and led by them, but pull them out of specialties.
Primary care will eventually be a nursing profession for people with average insurance, and only people with high class insurance will see a real doctor for primary care. I think that trend is obvious, desirable, and inevitable. I would prefer nurse practitioners stay out of specialties such as psychiatry. The brain is the most complex organ.
NPs order more tests and make more unnecessary referrals than primary care physicians. It’s likely because they act more like glorified triage nurses than actual primary care providers. Primary care physicians can manage complex multi-system problems in patients, while NPs cannot. They do not know what they do not know.