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.

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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 am a psychiatrist nurse practitioner that graduated in 2009. As such, my comments will focus on nurse practitioners (NP) and to field of psychiatry. I believe, however, that the issues being created by the physician shortage extend to all specialties.

    I don’t believe that the requirement of needing a collaborative practice agreement (CPA) with a physician (actually, two physicians because a backup collaborative physician is also required) ensures safer practice by NPs. I consider myself to be a competent NP and can manage the majority of concerns with my patients independently. There have been times that I’ve consulted with my collaborative physician (CP) and can say that I would have consulted someone, even if a formal collaborative agreement wasn’t in place. Similarly, irresponsible NPs (I don’t know any personally but I know they exist) probably don’t collaborate with CPs when collaborating might be necessary for them. The shortage of physicians is a growing concern for obvious reasons, that have been discussed in this article. Another concern, which was not addressed, is that if CPAs continue to mandated for NPs to practice this will further restrict access to healthcare because there are fewer physicians to enter into CPAs. In addition, CPs must specialize in the same field the NP practices, which only shrinks the availability of appropriate CPs for NPs even further.

    The epidemics (substance abuse, suicide, mass shootings) must be addressed in a comprehensive manner and action must be swiftly. I have my opinions (which I will not address in this response) why AAMC and other organizations take such extensive efforts to block independent practice (IP)of NPs. It has already been shown that NPs not only provide comparable care to physicians, NPs provide less expensive—as well as more holistic care. Regardless of the reasons these organizations fight IP of NPs, the end result is the same; less access to care for patients that are needing them at only greater need for care.

    I end this response on a more personal note. If people would put others’ (in this context, patients’) well-being ahead of their own agendas (personal, political, etc) the world would be a much better place.

    • Competency is not based upon what you feel. It is based on standardized exams which tests both didactic and clinical knowledge. It is based on the extensive training(4 year residency) psychiatrists are mandated, at minimum, to obtain in order to practice psychiatry competently. Then they take board exams to prove that competency. And it doesn’t stop there. They are required to maintain their competency by their respective state medical boards by continuing medical education, maintenance of certification requirements and repeat board exams. A physician cannot walk into a hospital stating, “I believe I am a competent physician because I’ve been trained well.” He would be laughed out of the hospital. He has to demonstrate proof of his competency.

      Unlike medical education, NP education and training is non-standardized. Some programs are brick and mortar, some online. Some 3-4 years, some 18 months. Some require experience in bedside nursing, some don’t. Some programs have strict acceptance requirements and others will accept anyone with a pulse and a checkbook. With this lack of standardization, it is absolutely irresponsible to even discuss allowing NP’s to practice unsupervised. Then any NP with any level of training is free to take care of patients with no supervision. That is ludicrous. The fact that supervision is inconvenient for the NP establishment is not a reason to discontinue it. Nor is increasing access. Increased access does not equate to quality care–that is an assumption. Those studies you quote have been debunked by meta-analyses by the Mayo clinic and the VA. But NP’s keep quoting them anyway. Because if you say it often enough people begin to believe it. Let me explain to anyone in the public reading this. The fact that an article or study has been published does not indicate that it is a good study. For this reason, physicians are taught in residency to critically review studies on methodology, variability(ie: demographics of a population, socio-economic status, location of setting(ie: urban, community, rural, etc.), treatment location(ie: inpatient vs outpatient), volume of patients studied and so on. To put it bluntly, most studies are crap in both nursing and medical journals. But it allows authors to add it to their resume.

      Supervision exists for a reason. To protect the public. Because physicians have the most training in medicine, it only stands to reason that anyone attempting to practice some form of medicine be supervised by those well trained in it. This is not to suggest that physicians cannot make mistakes, of course we can. We are human. And if those with the most education and expertise can make mistakes, why would one believe those with less or no training in medicine are less risky? It makes no sense. And if it doesn’t make sense, it should not happen. Medical expertise does not guarantee perfect outcomes; however, it ensures less errors occur. NP’s will tell the public that they have less lawsuits. Yep, because the lawyers go after the ones with the deeper pockets. That would be physicians. We are held to a higher standard, as we should be. NP’s will tell the public they have less complaints and patients like them more. Nursing has a strong history of compassion at the bedside; hence, the term “bedside” nurses was born. But somebody has to do the work of obtaining the information required to evaluate, diagnose and treat a patient. Both the body and mind. Medicine is deduction. It requires a depth of thinking that is not taught in nursing for one simple reason. Because nursing is not medicine. The two fields complement each other; they cannot replace each other. NP’s have master’s degrees in advanced nursing. Now they have doctorates in advanced nursing that they obtain online which they suggest equates to the medical degree. It does not. How can it when they did not attend medical school? There is no medical degree that exists in the U.S. that is obtained online. It would not be practical. To learn medicine, one has to lay hands on the patient. Medicine is repetition. The more you see of a particular disease or disorder, the more likely you are to remember it. Medicine is pattern recognition. Even if the pattern deviates a bit, we see it. This kind of training is not something that should be truncated. Your lives depend on it.

      You want to increase the number of physicians in the workforce? Push your legislators to support the bipartisan Residency Physician Reduction Act(H.R. 2267) which would increase funding for more medical residencies. Residencies have not increased since the Centers for Medicare placed a cap on them in 1997. Yet, medical schools continue to proliferate. Now we have a bottleneck of students who cannot find residencies because their aren’t any. In the last two years, 17,000 graduated medical students(physicians) could not find a residency because none existed. 17,000 docs would go a long way in this shortage. NP’s are taking advantage of this unfortunate circumstance to further their own agenda. It is unconscionable.

  • I agree with preceding comments that more technology can create more problems and NPs/PAs have much less training compared to physicians, but neither of these truths changes the fact that there is a physician shortage in rural areas and the status quo is not effectively addressing that. Does anyone have a more workable and pragmatic alternative to using telemedicine and NPs/PAs in areas where there aren’t enough physicians? NPs/PAs are adequately trained for simple primary care issues and minor acute complaints, such as ear infections. It’s when the patient or illness is complex that we can run into problems. It would make sense to staff rural clinics with primary care NPs/PAs but have an agreement for a physician to be available by phone/video for cases that are beyond the NP/PA’s expertise. Independent practice by NPs should be limited to primary care (and maybe rural emergency medicine in some instances where the NP can demonstrate competence after a period of additional training). Telemedicine could be incorporated in limited cases where a patient may need to speak with a physician specialist where no specialists are available within 100 miles. These may not be ideal solutions for everyone, but they’re quicker and cheaper solutions than trying to get new physicians into rural areas, and they’re better than no health care access at all.

    • They have been hyping Tele-Medecine for a while now. It is doubtful it will do much to address the shortage. We were all aware there was a shortage 30 years ago, yet nothing was done. Changes should have been made, but the For Profit System only allows changes that increase profits. The universities failed to ensure there were enough people to become Physicians. Other countries made sure enough people were educated, to become physicians. Here in Post Fact America, the Industries ration healthcare while people die, but at least profits continue to rise. the public is still being misinformed on all of this. Not much ever gets discussed on major media, unless it is to stigmatize the people who lose everything to access marginal healthcare.

  • As a practicing Hospitalists I have direct contact with CRNP and like everything, there’s good and bad, but the “bad” ones demonstrate significantly poor clinical judgement with strong tendency towards robotic, cookbook approach.
    I believe that if these individuals had more clinical training they could overcome this significant handicap.

  • Nothing beats the training and experience of a physician. Period. If we only had one surgeon for 100,000 patients, we wouldn’t ever let that person touch a computer or piece of paper. They would be only touching patients, passing catheters, performing interventions, etc. Our system puts the burden of too many non-clinical and clerical tasks on the physician instead. The whole system needs to reworked to provide the best use of the most valuable member of the team – the physician. Until then, we can bring on all kinds of mid level providers – none of whom are as qualified as a trained physician.

    • Agree with you on all but administration. They are the problem not the answer. Who do you think create all the policies and procedures that don’t translate in efficient practical application at the point of care?

  • Physicians can open a general practice without a residency as in the “old days.” The military has a GMO approach that could be utilized. Mexico obligates graduates to work two years in rural areas. Medical education is subsidized so society should expect some “payback.” I would not have minded doing it as long as protected from being sued by being a federal employee via a program like the NHSC.

  • How can technology not be part of this equation? Issues of scale, particularly in screening and general triage are well-within the the scope of technology from the 1990’s. More recent advances in machine learning, block chain security, etc. can easily address many of the challenges identified above at a fraction of the cost.

    • Spoken like a someone who makes a living “selling” these solutions. Not trying to offend but pragmatically and analytically a second generation EMR’s that didn’t produce as promised. Lets throw good money after bad. What’s another $30,000,000 million down the drain how ridiculous is that. Common sense should prevail? If computers are the solution to not using paper whY do we still have copiers, printers, and inefficiency galore. Research for cancer treatment & cures are complex but there are some things in healthcare that we’ve made complex and costly. Sadly with very little show for it. 🤔
      Except to many forced to merge to maintain profitability but no one analyzes why, how, and what drove the car in the ditch.

  • It has been shown that midlevels are more likely to prescribe inappropriate medications, which may not ultimately change an “outcome,” but is wrong nonetheless. I suppose it depends on what you choose to look at and how you interpret the results.
    https://www.ncbi.nlm.nih.gov/pubmed/27707916

    Also, interestingly, surveyed newly minted NPs/PAs report feeling inadequately prepared once they enter into medical practice
    http://www.tafp.org/Media/Default/Downloads/advocacy/scope-education.pdf

    I also find problematic that inadequately trained midlevels are then training future midlevel providers. If i had a nickle for everytime I overheard inaccurate statements being passed along…

    • Yup. Totally true and on target. Apprenticeship learning is only as good as the teacher. Differential thinking is non-existant in my experience.

    • The two studies cited compare NPs and Physicians. If you are going to take time to cite research, then do so correctly and don’t lump PAs in with the NPs who are fighting Physicians for independence instead of a team approach. While on the subject, PAs do receive more education than NPs. The amount of clinical rotation hours and curriculum is more – that is fact. But PAs and NPs are lumped in same category of mid level. Which is fine because they are not equal to, nor superior to, the education/experience of a physician. Wait for it…here comes the roar of “we have bedside nursing experience!” But most new NPs nowadays don’t have that experience. They are graduates of strictly online programs where the students themselves have to line up their own clinical time and rotations. And now adding on the DNP so some, not all, call themselves “doctor” in a medical setting which CLEARLY misleads uninformed patients that they are being treated by a physician. I’ve known some great NPs, just as I have known some great MDs, DOs, and PAs. In my own experience, which is admittedly & incredibly short sided, I see more NPs that struggle than I do PAs. I do believe that new grad PAs are better equipped in general than new grad NPs. The argument that there is a shortcoming of Physicians is a point the nursing lobbyists are pouncing on to push forward independence for NPs in all fields of medicine except surgery. And Physicians are letting them do it. To be certain, PAs are pushing the limits of a supervising/collaborative relationship with Physicians. But, the PAs are moving at glacial speed when compared to NPs who have chosen wise lobbyists to spearhead the nursing agenda. My $0.02

  • Bring back the National Health Service Corps, which placed physicians in health manpower shortage areas in exchange for paying for medical school. The absence of rural health care is a true crisis, as is care for urban poor. APN’s doe not have adequate training (e.g., 90-120 hours of pediatrics) to practice without physician collaboration. The iPad physician is also an inadequate substitute. We really need to build a health care system from the bottom-up, based upon needs, prevention, and relationships with families.

    • Easy for academic bean counters and non MD’s to state they can provide equivalent care. {{ I love to read articles by MPH and PhD’s!}} It is another thing to provide the evidence for this and make sure it has this been scrutinized for author bias and quality of analysis. If nurse practitioners are equivalent, then perhaps we do not need physicians at all. Would be logical, no?? Many NP’ s unlike PA’s do not need MD supervision and that is scary and depends on state law. It already irks me and should all MD’s that NP get paid only 15% less than doctors. Did you guys know that??

      IMHO, but not without an article to support it, I would suggest that NP’s can provide good care 85% of the time but it is the 15% when they do not pick up your cancer or lupus, or CAD until it is more overt but also more advanced. This is not what I would call good care. I would call it economical care.

      I have had one NP in our community tell me she was clearing a noncompliant diabetic with heart disease who was on blood thinners and had bad CHF and renal failure. She got upset when I would not move forward with her clearance for surgery and was upset when I told her I needed cardiac clearance from a cardiologist and she insisted she was giving me “cardiac clearance”. That pt actually was admitted 2 weeks after my conversation and was throwing clots and pt never made it to surgery as they died.

      In my opinion, there are excellent NP’s and bright and I have worked side by side with them at VA hospitals, but many do not know what they do not know and others have this inferiority complex that fuels that defensiveness/defiance I shared above.

      We do have a real doctor shortage problem in this country but with the way the govt and insurers treat doctors financially and the underappreciated burdensome hours we serve in our training and then even more in the workplace make being a doctor much less attractive for the ‘ best and the brightest’ even when their main desire is to help their fellow man.

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