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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  • Interestingly I know farrrrr more NPs that are working with specialist than those doing primary care. I think as a doc I’m not afraid to say I DO disagree with a system where someone with FAR less training can see the same patients that I do with no supervision. They can see the types of patients I decide are straightforward enough. Not even in primary care are all patients just physicals and vaccines and not all physicals and vaccines are straightforward. Physicians are happy to have help in our busy practices. Working under us does NOT preclude them from serving patients. Working under us still allows them to expand the number of patients a clinic catchment area can see. Working under us does not stop any of the positives alleged in this and all the other propaganda articles. It’s a non sequiter to ASSUME independence does Anything more than increase errors because of lack of education and Oversight. Working independently does not stop complex patients from still needing to see a physician except now the onus is on the NP to recognize something complex when they aren’t trained and if it is the NP has to refer to patient to another primary care person doubling the burden to patients who now have to be seen twice or more. If the system want to safely improve overall care 1: train all doctors who graduate to provide care 2: let midlevels be mid levels and see patients at their level as decided and supervised by physicians 3: if we really want them to address primary care shortage mandate them to primary care and stop “wasting them” in specialty practices 4: reimburse docs better for complex patients 5: hire more regular nurses so they aren’t burned out and we have a well balanced team of nurses and physicians before we go discussing having even fewer nurses because they are shifting to NP.

    • Don’t mandate them to primary care, please. That’s mandating to the most complex practice in medicine. That’s how this problem began.

  • With so many graduate medical students in deep debt if they were offered help of reducing there debt by paying them for spending two years practicing in areas that are suffering from Doctor shortage we may be able to kill twobirds with one stone.

  • “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.”
    You mean laws designed to protect patients from under trained ‘providers’. Its not laws that hinder NP’s, its the complete paucity of training they have relative to Physicians. The idea that ‘bad care’ is better than no care is completely unacceptable to me. Bad care creates the illusion that one is receiving care and therefore allows patients to continue on till their disease process becomes so critical that they are forced into the hospital. Same on this publication for perpetuating these myths.

  • Please state all the facts: 1). Nurse practitioners are not physicians, and no study has ever come close to showing the two groups of professionals have the same level of overall clinical knowledge and skills. 2). Nurse practitioners do not overwhelmingly choose primary care and underserved areas; these talking points have been used to get state laws passed. If policy makers really want to do something about the shortage of generalist physicians and other health care professionals in the USA, then they should lower barriers to the growth of Direct Primary Care. This is a relatively new payment/delivery model for primary care that minimizes bureaucracy and red tape for practices by bypassing third party payers. It is the best answer I have ever heard for preventing physician burnout. When physicians, nurse practitioners, and other health professionals can focus on patients and have control over and pride in their work product, it is a wonderful thing. Many more doctors would choose to be generalists naturally, and patients would get much better care. Costs would be drastically lowered as well, as there would be far less downstream costs like ER visits, hospitalizations, etc., and there would be much more transparency (consumers would demand it as they would be spending their own money – ie, their HSA’s or FSA’s). This is already being proven, primarily by self insured businesses that use DPC as part of their healthcare benefits packages. There’s no reason it couldn’t be used in Medicare/Medicaid/TriCare, and other government plans, as long as the beneficiary has control of their own decisions. Grabbing and running with the idea that benefits packages shouldn’t be behemoth managed care/government developed products that harm patients, medical professionals, and taxpayersand will lead us to creative combinations of affordable insurance, health spending accounts, and Direct Care which, along with the clarity of transparent pricing, will solve the healthcare dilemma our country faces.

  • Focusing (for the sake of brevity, as you stated) distorts the issue of competence. Physician assistants are trained in medical schools in the medical model, along with med students. Nurse practitioners are trained in the nursing model, primarily by long distance (computer classroom) training.
    Both are of great benefit to patients, but where and what they practice, should not be confused and/or sold as the same level of competence.

    • No distortion here. Neither PAs nor NPs come within miles of the training received by MDs.

      Saying you are “trained in the medical model, along with med students” is a weak attempt at conflating your training with that of a doctor. False equivalence anyone?

      Let’s see how 100 PA grads and 100 NP grads do on the USMLE step exams. Neither degree has any business pretending their training can even come close in allowing competent independent practice.

      You are cheaper though

    • I would be interested to see those results, but only after 10 years of practice by both. Especially in psychiatry.

  • Doctors aren’t needed anymore. They use to treat and stand by their patients, because they knew what was best. Government agencies are dictating how patients are treated now.

    • This comment should be removed. It’s inflammatory and provides no useful interaction. I would call it trolling

  • Dear Author(s): Hard to imagine you are public policy analyst and can’t answer your own question:
    What’s odd about the shortage is that the number of students graduating
    from medical school keeps increasing.
    There is nothing odd here. Most in medicine know the number of residencies have been reduced through government cuts to create this shortage and replace doctors with NP. No, this was not a conclusion from a double blind study. Just observation and common sense, occurring to many intelligent, professionally trained people at once.
    I could say more, like how this info-merical, has been courageously transplanted to an online magazine for physicians. But courage aside, you are writing for an audience that lives this truth every day. Do you really think those in health care are so ignorant that they will put aside what they know first-hand to accept a “re-purposed reality?”
    Peggy Finston MD
    http://www.Acu-Psychiatry.com

  • Really? NPs=MDs? Then why bother with the extra 20,000 hours of training for MDs?
    This is a false equivalency. In specialized practices with specific protocols AND years of supervised experience, I have seen NPs in my specialty (rheumatology) provide better care than a non-specialist (family practioner or FP.) But the FP still has the advantages of breadth of training and experience. The sous chef does not replace the primary chef.
    I agree that NPs will play a major role in the future of American healthcare, and they should. But don’t confuse their role.

  • The best solution for the shortage of doctors, especially coming from a MPH, should be healthier population!

    Funny, that’s the last thing we ever think of. We can’t afford the care we have now, because there are too many sick people. There will always be ever increasing numbers of interventions for them!

    Illness is not random. It is related to public policy, environmental policy, agricultural policy, employment policy, and so on.

    • I totally agree that the increase demand for clinicians is because our American society has become sicker in the last 30 years. Children here in Texas have started school and their breakfast at school is pop tarts, cinnamon rolls,waffles and pancakes. If a child has 2 meals of the 3 a day in school this is what is a big factor in the establishment of illness. The schools are made larger and farther and the grocery stores are no longer neighborhood grocery stores ,they are megaplus size stores. Children are constantly bombarded with
      Advertisement to eat more and more processed foods, food stamps allow families to purchase unhealthy foods as part of the food stamp allowances.
      Simple eat well, sleeps well and exercise from point A to point B like they do in other countries. Asthma has increased in the last 30 years from pollution.
      I think if the government would spend the money to have school have more fresh unprocessed foods and cook (not warm up frozen French fries),teach families to cook fresh foods and less processed foods our American Children would be given the best step to a healthier life. Right now the great grand parents are healthier than the great grand children.
      Also if you want to increase the availability of primary care clinicians allow medical doctors to cross state lines and work in different states if they are already have a medical license in one state as nurse practitioners are able to do and medical doctors in the military bases . Remove the non compete clauses in employment of doctors that restricts the ability of doctors to practice. Mid levels that I know do not have this clause in their employment. All the health care team should be appreciated for the hard work we do and not devalue by what metric non medical person implements. Humans are not cars. I feel the government and big corporations have not allowed the most important 2 people to participate in the decision making. These are the patient and the clinician.
      If there are articles addressing this please let me know. Prevention is the best medicine!

  • From the comments, it seems clear that what we want N-Ps to be able to do needs to be better defined, so that we can then properly determine what training they should have, in mostly standardized programs. Perhaps with some options for specializations (geriatric, pediatric, obstet., CV, etc)?

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