Kyle Jahner/MEDILL NEWS SERVICE
The main entrance at Washington Hospital Center. With nearly 1,000 hospital beds, 1,600 physicians and over 40,000 inpatient admissions to go along with over 400,000 outpatient admissions annually, it is one of the busiest in the country, especially in the realm of cardiovascular services.
Connor O’Brien will become a doctor in a medical landscape that has already begun to change – in part, according to the American Association of Medical Colleges, because there aren’t enough like him.
With doctor shortage projections half a decade old, progress in increasing medical school enrollment has been made. But even if the number of doctors kept pace with increases in demand, skyrocketing health care costs and population trends will force major shifts in the way providers leverage doctor time, and as a result, health care dollars.
Nurse practitioners and physician assistants for example, will use their graduate degrees to shoulder some of the burden from doctors, whether in team-based care in hospitals and doctors’ offices, or providing care in whole new areas for patients.
“It’s already going on,” said O’Brien, who this fall starts his fourth year at Columbia. “People in my generation in medical school are much more alright with that.”
His generation might start to get lonely in the relatively near future. The aging of baby boomers will not merely add to demand for health care: more than a third of doctors are older than 55. That contributes to what the American Association of Medical Colleges projected in October to be a 58,000 doctor shortage by 2014. That number jumps to91,500 by 2020.
“If we wait until the situation is really serious we will be in trouble,” said Christiane Mitchell, director of federal affairs for the AAMC. “We can’t wait until that happens, because it takes 5-10 years to train a physician.”
There could be a shortage of residencies for new doctors without increases, she said, advocating for a 15 percent increase on the 1997 levels over the next decade. That would train an additional 4,000 doctors per year, she said. The money goes towards resident salaries and direct teaching costs, while also offsetting some of the additional costs of being a teaching hospital, which tend to draw sicker and costlier patients.
But with the focus on deficit reduction on Capitol Hill, it will be a hard sell; it was cut from health care reform as Congress tried to trim its costs.
“We spent almost as much time defending the current level of support as we do pushing for additional support,” Mitchell said.
The debate over health care reform, even though it was cut in an effort to push total costs of the Affordable Care Act below $1 trillion, informed a lot of members of Congress of the issue, Mitchell said. Top Democrats in particular, such as Sens. Harry Reid,Nev.,and Dick Durbin, Ill., had been particularly receptive during the process, she said.
While having the majority leader and majority whip in support will give a bill legs in the Senate, the GOP-controlled house will not be easy to convince, Mitchell said.
The caps had been introduced in 1997 as a part of the Balanced Budget Act. The 15 percent increase would merely address – not solve – the problem, and would cost $9-12 billion over 10 years, Mitchell said.
“We are pounding away, reminding Congress of this very serious issue they have to address.”
Projections rely on certain presumptions, and they can be fallible. A decade and a half ago, America’s doctors-per-person ratio had risen for decades, and managed care was supposed to take off. In 1994, the Journal of the American Medical Association projected a surplus of 165,000 doctors by 2000. When the underlying trends began to crack, so did the projections as the pendulum instead swung the other way, Mitchell said. The doctor ratio peaked in 2000 and has been in decline since.
This time, rather than causing a surplus, anticipated shifts to managed care merely temper expected shortfall.
The AAMC plans update its projections for increases in enrollment in medical schools this month. In 2006 it advocated for a 30 percent increase over 2002 enrollment, a goal it expects to reach a few years after the 2015 target date. Nine new U.S. medical schools started accepting students since 2005, pushing the number of accredited schools to 134. Nine more schools are in the pipeline, and if they become accredited the 30-percent goal could be reached in five or six years, according to Clese Erikson, director of workforce research at AAMC.
“It’s really impressive to see such growth in such a limited period of time,” Erikson said.
According to Erikson, existing schools have responded to calls to increase enrollment, but most medical schools are not money-makers for universities because of the costs of training doctors.
The biggest shortages generally affect rural areas, as well as certain underserved urban neighborhoods. O’Brien said he and other students, who trend towards major population centers, are “sheltered” from the shortage. Also, primary care physicians face particularly stark shortages as tens of millions of Americans to become newly insured under health care reform, and a decreasing number of medical students choose that route. Specialists tend to be more lucrative, appealing to graduates with hundreds of thousands of dollars in medical school debts; the percentage of medical students choosing primary care slipped by a quarter from 2002 to 2007 alone.
“I’m more of a part of the problem than a part of the solution,” quips O’Brien, who wants to return to his native Bay Area in California as a gastroenterologist.
The National Health Service Corp does offer repayment of student loans as incentive to get doctors and nurses alike into such areas. Mitchell said it is an effective program, adding that chances staying in such a high-need area increased when the doctor starts in one.
But Erikson said the shortage will include specialists as well. Major city hospitals have also already begun to make changes, if not because of acute doctor shortages, then because reducing doctor workload can prove more efficient.
Kyle Jahner/MEDILL NEWS SERVICE
Matthew Borloz, MD, Chief Resident in the Emergency Department at Washington Hospital Center, goes over some paperwork. Advocates say resident training, capped since 1997, needs to be increased.
“We are looking at these extensions with advance practice clinicians not just because of a physician shortage, but to improve clinical care and stretch our health care dollar,” said Janis Orlowski, chief of medicine for Washington Hospital Center. She said the changes aren’t going to be a panacea, but that such efforts to chip away costs can have an important effect. Shortening stays by fractions of a day can yield big savings, she said.
Erikson said the AAMC supports graduate nurse education and having all health professionals perform at the top of their abilities. But she said moving towards a team care model still means more physicians will still be needed.
Orlowski agrees, and she has worked on altering structure at her hospital. She is adding a Physician Assistant track and using nurse practitioners and nurse midwives to extend the care teams of physicians. Such professionals serve as care pathways after a patient goes home, trying to reduce readmission, she said.
O’Brien, part of a new wave of doctors more comfortable with such expanded roles, cautioned that there are some realities to face. While he agreed it was a more efficient way to administer care, he said issues can arise when less trained people take on bigger roles. As an example, he said that when he went in to a nurse with an injured shoulder, one he had separated before. The nurse practitioner ordered X-Rays for what he knew and told him he knew was a soft-tissue issue — and he was right. He said many friends had similar stories.
However he said training along those lines had improved significantly. Nursing organizations have pushed for higher levels and standards of education, and increased diagnostic and disease structure had been introduced into curriculum, particularly on the graduate level. The key, he said, rested on management, which needed to appropriately assess ability and avoid the temptation to cut costs by having personnel not properly trained diagnose patients.
On the whole, O’Brien said the increased involvement of non-doctor professionals will not negatively affect outcomes for patients, especially with physician supervision in places like hospitals and emergency rooms.
“You’re not going to kill anybody,” he said. “And there is a huge net positive to be realized from the expansion of these roles.”