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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  • A substantial amount of NPs receive their education ONLINE. Many NP schools have essentially little to no admission requirement, take the majority of their applicants that apply and nearly all do not require their students to have any sort of science background at all. This is highly at odds with MD and PA education. Additionally, they have no standardization of their curriculum at all- so there is substantial variance in what they’re learning. They also have to find their own preceptors during their clinicals, which may be of varying quality. It’s strange that this is seen as the ultimate answer. Clearly, this author did not do much research about the policy implications of what he is saying.

  • First off I respect that you have a passion for something and took time to write about it. That being said you should take time to fact check things that’s are referenced in the article. The US does not in any way have the best healthcare in the world … infant mortality and maternal mortality are significantly higher than other countries. Second advanced practice providers like NPs do not have the same training as physicians and in certain practices do not provide the same high quality care (example pediatrics). ZDOGGMD has a good video on everyone’s role as a health care tribe/team and how we all have things we are best at and specific roles and should be working together. There is significant (hours and years) in which the DNP and MD/DO training differ in both intensity and scope and thus is not something that can be Ignored. Our system is broken and needs fact based / patient outcome based models to fix it, putting people out there without the training will mean higher mortality.

  • This is a viable solution as soon as NPs have adequate SUPERVISED training hours, standardized curriculum- nationally and state nursing boards that actually police and discipline these folks! If you’re practicing medicine then you need to be trained to practice medicine.

  • my pcp retired and i got switched to a NP. it is easy for me to tell the difference since when I ask her a question, she just makes up a very general answer. Within 2 months, i demanded to be switched to a real doctor. I have good insurance, I should not have to settle. maybe if I didn’t have insurance, I could get something lesser. Not for me.

  • Health systems and schools rely on one another to provide a well-trained clinician workforce and until we have more clear communication between the two of them it’s difficult to make meaningful decisions.

    Each health care system’s workforce and education strategy is dependent on their state laws with regard to NP scope of practice, making it difficult to become a total U.S. health system solution.

    We are trying to solve this by improving a clinical site’s ability to asses and communicate their teaching capacity for all student types in one location. We invite anyone into our work to solve this problem through our platform called ClinicianNexus.

  • With all due respect to the authors, what you are suggesting is not education reform, it is education devaluation. Certainly the use of nurse practitioners(NP’s) increases access to care; however, do not infer that this translates to equitable quality of care.

    This argument is tiresome. If physicians and nurse practitioners were the same, it would stand to reason that we would all possess the same degrees. We do not. Each degree represents different levels of education; the highest level of proficiency being attributed to the physician. This is not happenstance, this is a fact. Do not assume because both professions practice in the same environment, their duties are equivalent. They are not. The fact that a nurse practiced for 12 years prior to becoming a nurse practitioner does not a doctor make. That experience IS NOT equitable to medical education by any means. And this is where legislators make their mistakes. They conclude that the longer one practices in a clinical setting, the more trained he is to practice medicine. Wrong. What occurs is that he APPEARS to practice medicine. Anyone can mimic the act, even a layperson. Where the deficits become evident is in the knowledge base. A fluctuating blood pressure and headache in a clinic patient may appear to a nurse practitioner to be uncontrolled hypertension; to a physician, suspicious for pheochromocytoma. A patient who presents to the ER with an increased temperature, elevated blood pressure and rapid heart rate in the middle of summer appears to the PA to have hyperthermia. A physician, noticing the moderately enlarged thyroid gland on the patients neck and the slightly bulging eyes, will immediately begin treatment for the potentially deadly thyroid storm. You see, it is our job to notice not only the obvious, but to be aware of the not so obvious. Why? Because the human body is a complex system. It is why our training is so extensive. It is because of the constant, repetitive reinforcement of the many causes of human disease/disorders and their management that one develops the ability to consider these diagnoses in their differential. Nursing is algorithmic, medicine is deduction; based on one’s depth of knowledge. One does not learn medicine by osmosis; that is, by simply being at the bedside or practicing in a specialty that appears to resemble medicine. To master the practice of medicine, one must attend medical school and complete a residency. Period. There is no shortcut. There is no online process. There is only one way. The right way. Those who are determined to circumvent that pathway by legislation rather than education must cease, for the public deserves better. And it is not about patient preference. To the public I say, quality medicine is not based on a popularity contest, it is based on skill. It is not that physicians don’t care, of course we do. Why else would we spend a significant portion of our adult lives obtaining an education and incurring thousands of dollars of debt if we didn’t give a damn? Sometimes at the expense of our own families? Somebody has to do the open heart surgery-that would be the Cardio-thoracic Surgeon. Someone has to deliver the breech birth–that would be the Obstetrician/Gynecologist. Someone has to repair the broken bones and dislocations–that would be the Orthopedic Surgeon. Somebody has to perform the multiple life-saving measures required when you present to the ER as a result of a motor vehicle accident after suffering a heart attack or stroke–that would be the Emergency Physician. Someone has to treat the most difficult “system” in the human body….the mind. It is difficult to treat what one cannot see or touch. That requires the expertise of the Psychiatrist. But you also need physicians for those diseases that are not so obvious but can kill you nevertheless. Enter the woefully under-appreciated primary care physicians; the Internal Medicine, Family Medicine and Pediatric specialists who identify those subtleties of medicine. The very same doctors Nurse Practitioners believe they can replace. No one else is trained to do what we do. What other proof do you require to show that we care? Do not minimize our commitment to you because of rhetoric. For those of you who have determined that nurse practitioners provide adequate care for the masses such that supervision is not needed, let me ask you. How many of you have NP’s as your primary provider? If not, why not? If it is not good enough for you, then it should not be good enough for anyone else.

  • If there is such a big bottle neck at graduate medical education, did the authors look into allowing the thousands of American medical school graduates who don’t match into residency to practice in the mean time? These folks have more medical training than NPs and are forced to sit out. At least 1 state, Missouri, already allows these doctors to work as “Associate Physicians” in rural primary care directly improving access care.
    There is a bedside nursing shortage too. Nurses end up getting burn out from their high work load and turn to becoming nurse practitioners to escape. Robbing Peter to pay Paul is not the solution.

  • The number of clinical practice hours an NP spends while in training doesn’t compare to that an MD has to go through just to graduate from medical school. How about allowing MDs to practice as general practitioners, as they do in other developing AND developed nations the world over! There are multitudes of MDs that don’t get into residency with a valuable education they can’t use.

    • Yes Katrina, there is a group looking into this. Physicians for Patient Protection(PPP).

      In the military, General Medical Officers(GMO’s) are physicians with one year of training. They practice as primary care physicians for approximately 4 years and then return to complete residency.

      In the last two years, 17,000 medical students did not get into a residency. That is 17,000 potential physicians working at Target or WalMart because there are not enough residencies, thanks to the cap placed on funding by the Centers for Medicare(CMS) in 1997. Medical schools are growing at a much faster rate. Some of these students are fortunate enough to get into an internship for one year, they can then apply for their medical license. But the states tend to not approve physicians who have not completed an entire residency. Back in the day they were known as General Practitioners(GP’s). If it is good enough for the military, it should be good enough for civilians. And it will help with the physician shortage. Common sense dictates that if you want to fill a physician gap, you fill it with physicians, not nurses. The nursing gap is even larger, who is filling that?

  • it was not as if we did not see this coming. This author here is confused, claiming that the “U.S has the best healthcare in the world,” a claim that is simply not true. The Statistics don’t lie. Physician Assistants are already providing care in many places, unbeknownst to the general public. They are perfectly adequate 90% of the time.
    It is rather disturbing how they spin, the obvious lessons of Remote Area Medical, into another endorsement of a broken system. People seeking care from R.A.M, many suffer for years, line up days before. They are desperate for basic medical care. Typically when articles are written promoting our broken system, they conflate the number of ‘Doctors” available, with the number actually treating the populace. Various boutique physicians are added into the total. In local newspapers, journalists go through extreme contortions finding data to inflate the numbers. The facts are not pretty, here in the US. The fact that millions of American have to rely on random charity, and wait years to treat things that in other developed nations, they would have treated immediately, should be a source of shame or embarrassment.
    The use of that old data is by design too, meant to create scarcity and drive prices up. We import a lot of our Doctors, since it is too difficult and expensive to train Physicians here in the US.
    It is really clear that we need Universal healthcare, then we would not have these manufactured “Shortages.”

  • Patients have to be educated as to the services a nurse practitioner can provide. Many will still say “I want a doctor, not a nurse” because they don’t know the scope of practice for NPs. Personally, I prefer NPs over MDs as my primary care provider. They provide this service just as well as an MD, at least in my experience as a patient.

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