Less than 5 percent of OB-GYNs practicing in Sacramento, Calif., are under age 40. West Texas can’t recruit enough psychiatrists to meet the region’s needs. All but two of Alabama’s rural counties need more primary care physicians.

For most Americans, the physician shortage feels familiar: months to get an appointment, hours in the waiting room, and a visit so quick you barely scratch the surface. But it’s only going to get worse.

The Association of American Medical Colleges (AAMC) suggests that the country could see a shortage of up to 120,000 physicians by 2030. It’s already begun: The federal Health Resources and Services Administration calculated that 29 states already had shortages of primary care physicians in 2013.

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Some argue that there are plenty of doctors, but they are just poorly distributed throughout the country. Although this may be true, the end result is the same: reduced access to care.

Rural areas will likely bear the brunt of reduced access. Rural populations tend to be sicker and in higher need of medical care. But that care is often unavailable because medical centers and health care providers are concentrated in urban areas. Fewer providers overall will only exacerbate the disparity.

What’s odd about the shortage is that the number of students graduating from medical school keeps increasing. It’s up 27.5 percent from 2002 to 2016. But the number of available residency slots isn’t keeping up, increasing only 8 percent in the same period. If new medical school graduates can’t place into residencies, they can’t practice, offering no relief to the shortage.

The number of non-physician providers has been growing steadily. For example, almost 28,000 nurse practitioners graduated in 2017 alone. But the potential of non-physician providers to deliver care is hindered by laws that limit their ability to diagnose and treat patients on their own.

Reforming graduate medical education

After medical school, all new doctors are required to complete several years of post-graduate training before they can practice independently. This includes residency, sometimes called graduate medical education. Hospitals receive funds for providing this education based on the number of residents they train.

Most of the money comes mainly from the federal government, which spends somewhere between $14 billion and $16 billion per year on graduate medical education, mostly through Medicare. Many states contribute funds as well. Hospitals are paid through two distinct financing streams, and funding caps were implemented in 1996.

The AAMC supports increased funding for graduate medical education, saying it will result in more resident physicians. But as Amitabh Chandra and co-authors have argued in the New England Journal of Medicine, graduate medical education may not be the most effective way to train new physicians. Previous funding cuts, for example, didn’t negatively affect residency training: salaries for residents weren’t reduced and the number of residency slots still increased. This suggests funding changes may not be the best way to reform the current program.

Further, economists like Chandra argue that residents pay for their own training anyway. They accept lower wages regardless of how much funding for graduate medical education their training hospital receives.

While the impact of funding for graduate medical education on the capacity for physician training is murky, it is still central to sustaining training programs in hospitals. Thus, several medical associations recommend the evaluation of current policies in an effort to move toward a performance-based system. They argue that the current cost of training needs to be determined — per-resident funding is still based on 1980s data — and the two funding streams need to be consolidated into one. Then the system should be structured to respond to physician workforce demands, including specialty-specific shortages, and payments should be tied to its ability to do exactly that.

Reforming graduate medical education will likely have minimal effect on alleviating the physician shortage and thus access to care. The data suggest that other interventions, such as utilizing nurse practitioners and other non-physician providers, may be more effective. But at the very least, such reform will modernize a system that is rife with inefficiency and complexity.

Effective utilization of nurse practitioners

While the effect of reforming graduate medical education on the physician shortage is still theoretical, using non-physician providers more effectively already shows considerable promise. To be clear, all types of non-physician providers — nurse practitioners, physician assistants, and the like — have the potential to mitigate the impact of a physician shortage on access to care. For the sake of brevity, we focus here on nurse practitioners.

These clinicians have master’s and/or doctoral degrees and are licensed to provide direct patient care and case management, usually with physician supervision or collaboration. Both the quality and effectiveness of the care provided by nurse practitioners are on par with physician care, often at lower cost.

Even so, allowing nurse practitioners to work independently is met with resistance in America’s physician-dominated system. But doing just that, along with standardizing scope of practice laws nationwide, could increase access to care in the midst of a physician shortage.

Scope of practice laws fall into three categories: full practice, reduced practice, and restricted practice. Full practice laws, which allow nurse practitioners to independently care for patients without supervision by or collaboration with a physician, are recommended by multiple medical organizations. Yet only half of U.S. states have them.

The use of nurse practitioners is increasing nationwide, and has been for years, but license restrictions diminish the true potential of their care. As expected, states with the least-restrictive scope of practice laws have the highest utilization of nurse practitioners. State-by-state variations in these laws lead some nurse practitioners to leave more restrictive states in favor of full-practice states, which likely worsens existing provider shortages.

The Brookings Institution argues that restrictive scope of practice laws are used as anticompetitive barriers, legally separating physicians from non-physician providers. The end result is reduced efficiency, productivity, and access to care. Independent nurse practitioners offer the opposite: cost savings and increased access to quality care.

When the AAMC predicted the physician shortage, it also looked at how various policy interventions could alleviate the impact. Maximum use of non-physician providers was the only intervention for which predicted provider supply was greater than demand, most significantly for primary care. Effectively employing non-physician providers could mitigate the effects of a physician shortage on provider accessibility.

The U.S. has the best health care in the world but access to it is fading fast. Reforming graduate medical education may be needed to prepare for future workforce demands, but independent practice for non-physician practitioners is likely at the crux of an immediate solution.

Elsa Pearson, M.P.H, is a policy analyst at Boston University School of Public Health. Austin Frakt, Ph.D., is the director of the Partnered Evidence-Based Policy Resource Center at VA Boston Healthcare System; an associate professor at Boston University School of Public Health; and an adjunct associate professor at Harvard T.H. Chan School of Public Health.

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  • I see comments recommending a residency for NPs. Most NPs have had experience in nursing then as NPs with additional hours and education. I do think NPs should have req of 2 years practice – and not obtaining clinical practice while in NP school and working as a nurse part time. There should be a year of mentoring by a mentor in the NPs specialty. I don’t think we can gauge all NPs by a few. We are adequately trained but I see inadequate mentoring frequently, as well as nurses having little nursing experience being accepted in to Advanced programs. There needs to be a standard of care for all programs and NPs to insure appropriate education and training across the board. This will definitely change perceptions.

  • Thank you for acknowledging the part the non-md folks play. We have a great need in this country for better access to care and we can help.

    I would love to see APRNs and PAs be given residency trainings as well. Great article

  • Good article however misses a key point. If there are fewer residences then perhaps it needs rethinking. There should be a way for APP’s whether NP’s or PA’s to complete something like a residency if they have met didactic criteria. There should be a way to ‘train up’ instead of leaving a large talent pool of experienced clinicians untapped, unfulfilled, underutilized and essentially dead ended in medicine. We can do better, however even if such a program were to see the light of day it would likely be smothered in the cradle by doc’s protecting their piece of the pie.

  • Why can’t we all be on the same side? MDs need to govern their own practice and advanced practice nurses need to govern theirs. There are plenty of patients to go around and we all know that there are excellent doctors and advanced practice nurses and there are those doctors and advanced practice nurses that I wouldn’t send my enemy to. Advanced practice nurses have extensive training. I don’t think any of you know how hard it is to get through nursing school these days and then pass the licensing exam.
    Graduate and doctorate nurse practitioner programs may have the didactic portion online but require a high level of performance & face-to-face hours in clinical. Nurse practitioners specialize in their advanced degrees and don’t do all the rotations like doctors in training do. We spent all of our face-to-face training hours in our specialty. Well respective institutions like the University of Florida produce high-quality advanced practice nurses. I think there is enough room for both MDs and advanced practice nurses in this world. Stop arguing with each other and start thinking about the patients out there that need us!

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