MD News: About Physicians - From Physicians - For Physicians

How to Deal with the Physician Shortage

By: Laura Trude, HWIC Information Specialist
Tuesday, September 07, 2010

Filed under:  Practice Management

The physician shortage is not going away any time soon, so what can be done in the meantime? Here is what the literature has to say.

The Association of American Medical Colleges (AAMC) Center for Workforce Studies recently updated their projections of physician supply and demand to account for the impact of 30 million new patients under health care reform. According to their June 2010 report, the nation is currently short almost 14,000 physicians, and by 2025, that gap may reach 130,600 physicians.[1] With many practice panels full and others scrambling to recruit physicians (especially in primary care), imagine what things might be like 15 years from now, with a tenfold increase in the shortage of physicians. Unless something is done, such a supply/demand imbalance within the American health care system may be catastrophic.

Current Efforts to Increase the Number of Physicians

Medical schools and policymakers are working to increase the number of physicians. Thanks in large part to efforts by the AAMC and the American Association of Colleges of Osteopathic Medicine, medical school enrollment has increased 23 percent since 2002.[2] Unfortunately, the number of residency positions has not expanded accordingly. While 9,100 accredited graduate medical education positions were added in the last decade, primary care lost more than 1,300 residency positions.[3]

The Affordable Care Act implements a few provisions to help. Residency slots that were not used in the last three years will be redistributed with a preference for primary care, resulting in about 900 more residency positions.[4] Another 500 new primary care physicians are expected by 2015 thanks to a $168 million allocation to expand primary care residencies.[5] Yet even this is unlikely to compensate for the exacerbated physician shortages likely to arise as a result of the legislation. Without an adequate increase in physician supply, what can health care facilities do to prepare for a further increase in demand?

Compete to Recruit and Retain Physicians

The Health Workforce Information Center, a free online library of health workforce resources, lists a number of documents that offer best practices for recruitment and retention. A New England Journal of Medicine-sponsored presentation found that most physicians prefer to be contacted by a recruiter early in their last year of a residency or fellowship.[6] A report produced by several state primary care associations highlights effective communication as the most important factor for retaining physicians.[7] A review of promising workforce strategies supported by the Agency for Healthcare Research and Quality recommends involving physicians in key decisions, investing in training, supporting their freedom to speak up about quality and safety concerns, tracking and rewarding performance, and other strategies.[8]

Innovative care models can also attract physicians, if done well. According to a recent article in Health Affairs, the medical home model helped the Group Health Cooperative recruit 40 primary care doctors in 2009, partially by reducing physician panels from 2,300 patients to 1,800, which allowed physicians to spend more time with their patients.[9] The Primary Care Development Corporation and the New York Community Trust offer a how-to manual for helping practices obtain recognition as a medical home by the National Committee for Quality Assurance (NCQA) Physician Practice Connections Patient-Centered Medical Home (PPC-PCMH) program.[10]

Hire Physician Assistants and Advance Practice Registered Nurses

Rather than competing for the same pool of physicians, practices can hire non-physician clinicians to supplement their workforce. An American Medical Association study found that hiring an nurse practitioner (NP) or physician assistant (PA) boosted solo physician income, increased the number of patients seen every week, and decreased the number of weeks the physician spent at the office.[11] According to a study led by Robert Graham Center director Robert L. Phillips, Jr., M.D., a ratio of 0.83-1.17 non-physician clinicians per primary care physician results in lower costs and utilization rates.[12]

Physicians thinking about adding a NP or PA to their practice should consider “the needs of the patients, the needs of the practice, and the needs of the physician,” according to Nancy Hughes from the American Academy of Physician Assistants.[13] Many dermatology practices meet patient demand by using non-physician clinicians to see new and established patients with indirect supervision.[14] Nurse practitioners in outpatient clinics can reduce hospital readmissions by providing follow-ups and planning for people discharged from the hospital.[15] In rural areas, nurse-led clinics manage patients with chronic disease, offer wellness tips, screen for diseases, monitor patients, and provide information.[16]

While non-physician clinicians can be part of the solution, state licensure laws, third-party reimbursement policies, patient preference for physicians, and other complicating factors indicate that they are not likely to resolve the physician shortage alone.

Make Use of Medical Assistants and Community Health Workers

Health care systems are exploring new staffing models. In the Annals of Family Medicine, Bodenheimer and Laing recommend “The Teamlet Model of Primary Care,” which extends a 15-minute physician visit using two health coaches.[17] Medical assistants or other personnel can spend time before the physician visit to “negotiate the visit agenda, elicit a basic history, check on medication use, and perform indicated tests.” After the visit, this person can solicit patient concerns, recap the physician’s advice, help the patient set realistic goals, and help the patient navigate the health system. If the patient requires management of a chronic disease, the health coach can also follow-up between visits via phone calls or e-mails.

Similarly, community health workers can free up time for physicians and nurses, serving as liaisons by visiting patients’ homes while supervised remotely by a physician or nurse. A 2009 Health Affairs article suggests a model in which senior citizens recruited to serve as community health workers counsel people on preventative care, health insurance programs, health literacy, basic health care, and chronic disease management.[18]

Redesign Workflow

Dubois and Singh report in their 2009 literature review “that between 25 percent and 70 percent of physicians’ (most often generalists’) tasks could be delegated to other health care professionals.” The authors highlight the importance of providing training to support new roles, clearly identifying role distinctions between professions, and addressing disagreements and confusions. Cross-training people in basic patient-care skills improved care coordination and had a positive impact on health care workers, with the exception of overworked nurses.[19]

Task analysis is one of many strategies implemented by the Optimizing Primary Care Collaborative, a one-year project launched in 2007 by the California Primary Care Association. Similar to the teamlet model, physicians’ time is freed by training medical assistants to educate patients.  Mapping a flowchart of processes allowed the clinics to create smarter models, decreasing the amount of time it took to complete various activities. Those who participated in the project found that provider satisfaction increased, turnover decreased, and patients’ access to care improved.[20]

Implementing workflow changes carries its own challenges. Children’s Hospital of Wisconsin used a “one-doctor-at-a-time approach” starting with a physician champion to increase capacity in their orthopedic program. A small physician-led team test-piloted changes before offering a series of workshops to teach others what worked. As only successful changes were promoted and other physicians could see the positive results of the first group of trainees, soon they wanted to be part of the transformation. The orthopedic program reduced patient wait times by 70 percent and increased both staff and patient satisfaction. AneeshSuneja of FlowOne Lean Consulting LLC offers advice for others seeking to do the same: find a starting point, pick a physician champion, use data to paint a picture, and map the care process.[21]

Electronic medical records can also help increase efficiency.  Since an entire patient’s history, X-rays, and other information are in the EMR, physicians don’t have to spend time tracking down charts from other locations. EMRs can also allow physicians to e-mail prescriptions and receive instant notification of lab results.  However, typing information into the EMR can take time and focus the physician on the computer rather than the patient: enter the medical scribe. Practices are experimenting with using a scribe during an exam to type up a physician’s oral statements of findings. The scribe works for several physicians, helps with administrative functions like scheduling and referrals, and increases the number of patients physicians can see, more than covering the extra cost of hiring the scribe.[22]

Design the Scheduling System to Balance Capacity and Demand

Improved scheduling practices can improve retention rates by preventing physicians from getting behind and feeling rushed, reducing the time it takes a patient to get in to see their physician, and increasing care continuity. The Optimizing Primary Care Collaborative implemented several scheduling strategies to balance appointment supply and demand, reducing appointment types, creating a more flexible schedule rather than having a set number of appointments each day, and leaving slots open after vacations for physicians to see patients who had been waiting for their return.[23]

The Primary Care Development Corporation suggests five things clinics can do to increase patient access: decrease patient no-show rates by making confirmation calls one or two days before, add one visit per hour to the schedule for same-day appointments only, allow walk-ins to be seen by their regular provider, have patients call to book return visits rather than booking them automatically, and decrease unnecessary visits. Facilities implementing these strategies eliminated two-thirds of no-shows and reduced backlog by at least a week.[24]

While medical schools, policymakers, and practices cannot alleviate the effects of the physician shortage on their own, they can work together to increase the likelihood of patients enjoying the privilege of seeing their doctor in an era of health system transformation.

Interested in learning more about shortages, policy issues, or best practices related to the health workforce? Contact the Health Workforce Information Center (HWIC) for free customized assistance at 888-332-4942 / info@healthworkforceinfo.org or visit their online library at www.hwic.org. HWIC is located at the University of North Dakota School of Medicine and Health Sciences, Center for Rural Health, and is funded by the Health Resources and Services Administration (HRSA).