Opinion: Residency programs can help ease doctor shortage

"It is essential that the public come to "It is essential that the public come to understand that the rules of supply and demand apply to the health care workforce.," write Norman H. Edelman and Evonne Kaplan-Liss. Photo Credit: Janet Hamlin

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As medical educators and physicians practicing on Long Island, we hear frequent complaints from patients about how hard it is to see a doctor -- especially doctors practicing adult primary care.

It's a nationwide problem, and it's likely to get much worse in the near future. The availability of doctors will be affected by the result of the presidential election because, if it's not repealed, the Affordable Care Act will mean an estimated 15 million to 30 million additional Americans will get health insurance. Most experts predict a shortage of physicians in the United States ranging from 50,000 to 100,000 by the end of the decade, due to this rapidly increasing demand for health care, which will come with a slowly increasing supply of physicians.

We know why demand is increasing. In addition to the impending impact of Obamacare, the elderly population is growing rapidly and will require more medical services. At the same time, medical technology is advancing just as fast -- making many new desirable services available to all.

The origin of the short supply of physicians is more complex though. As a result of the great expansion of medical education in the 1960s and 1970s -- as well as the success of managed care in reducing the use of hospitals in California -- graduate medical education planners, beginning in the 1980s, feared that we would produce too many physicians. As a result, medical school expansion was brought to a virtual halt, and the output of students graduating with MD degrees stayed constant from 1980 to 2005. The error of this near-freeze of graduating physicians has been recognized, and since 2005 there has been a rapid expansion of medical schools in both size and number. On Long Island alone, Stony Brook University expanded its medical school class by 25 percent, and Hofstra University opened a new medical school just this year.

But increasing the output of medical students will do almost nothing to increase the number of practicing physicians. And understanding this is the key to understanding the problem of physician shortages.

Although many states will license a physician with only a few years of post-medical school training, as a practical matter virtually all doctors who wish to practice in the United States must complete an accredited U.S. residency program after medical school. So the only way to increase physician supply to any significant degree is to increase the output of fully trained medical residents.

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The great majority of financial support for residency training in the United States is provided by the federal government through the Medicare program. And as a result of the worry about physician oversupply, this support was frozen in 1997. Despite strong urging by most medical education societies, there've been essentially no successful attempts in Congress to significantly increase the support of medical residency training. In fact, all current budget proposals call for reductions of support of resident training as one way to control the costs of the Medicare program.

Currently, there are about 20 percent more entry-level residency slots than graduates of U.S. medical schools each year -- the difference is made up by graduates of foreign schools. So the major effect of expanding the number of U.S. medical students will be that foreign students will be displaced in residency programs. It won't translate into more doctors.

Hospitals have increased resident training at their own expense, but these efforts have been modest and largely limited to the hospital-intensive specialties like orthopedics and radiology. A recent survey of New York State teaching hospitals conducted by Stony Brook Medicine, the medical school at Stony Brook University, found that only two of 20 hospitals without a family medicine residency program would establish one if provided additional Medicare support at current rates. Though they were interested in expanding internal medicine residencies, past research has shown that only about 30 percent of these residents go on to practice general internal medicine; instead, most sub-specialize in pursuit of greater income, prestige and better working conditions.

An increase in graduating medical students without an increase in residency slots will direct more U.S. medical school students to relatively fewer sought-after family medicine residencies. As the numbers equalize -- which is predicted by 2020 -- graduates will find they must take whatever entry-level residency spots they can get. So one approach to produce more doctors practicing adult primary care would be to provide current teaching hospitals more financial and other incentives to create residencies in family medicine over the more lucrative specialty residency programs. In the absence of new federal money, this may require a redistribution of current funds, ideally through Medicare -- clearly a contentious issue. Since virtually all teaching hospitals already have residencies in internal medicine, we might seek to establish these in current non-teaching hospitals. But it's unknown if they'd be willing or able to do this.

There is another approach. We might focus on producing more nurse practitioners and physician assistants. There's ample evidence that these clinicians can provide primary care equivalent to physicians in outpatient settings. New York should remove the demeaning restrictions to independent practice of nurse practitioners, such as the requirement that they subject themselves to superfluous "physician supervision." And, we should invest more in training them; there is ample demand for training programs, but inadequate access to them.

It is essential that the public come to understand that the rules of supply and demand apply to the health care workforce. We probably won't be able to increase the supply of primary care providers until the public realizes their importance and demands that insurance companies provide better access to them, just as patients now demand access to the technology-oriented specialists.

An adequate health care workforce -- one that is balanced with regard to physician specialists, primary care doctors and the increasingly, important non-physician clinicians -- is critical to the provision of high quality health care that we all expect and deserve.

Dr. Norman H Edelman, former medical school dean and vice president for health sciences at Stony Brook University, is professor of preventive and internal medicine at Stony Brook Medicine. Dr. Evonne Kaplan-Liss is director of advanced certificate in health communications and an assistant professor of preventive medicine at Stony Brook Medicine. The views expressed here are solely those of the authors.

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