Bipartisan legislation to address resident physician shortages that have only worsened during the COVID-19 pandemic.

[vm26]

I'm a physician in a sub-speciality that does not currently utilize many PAs/NPs. I am curious as to what your thoughts are on proposed legislature to expand residency spots in the next 10 years. On one hand there seems to be a trend towards PAs/NPs to improve access and cut down on costs. This new proposal seems to be an exception, unless the end result is to utterly saturate the field of medicine practiced by all of us, and substantially lower HC costs (at least the cost of reimbursement to all of us). Have any of your advocacy groups come out with a statement? Clearly most field in medicine are opposed to this. EM apparently is projected to have a surplus of 10K physicians by 2030 which will hurt both physicians and PAs/NPs in that field.

"This bipartisan legislation is crucial to expanding the physician workforce to ensure that patients across the country are able to access quality care from providers," ACR, the American Medical Association and numerous others wrote March 24. "The COVID-19 pandemic has further exposed the significant barriers to care that patients face, and has also highlighted rising concerns of clinician burnout," they added later. Rep. Terri Sewell, D-Ala., introduced the House bill last month alongside Reps. John Katko, R-N.Y., Tom Suozzi, D-N.Y., and Rodney Davis, R-Ill. Sewell noted that the proposal would support an additional 2,000 positions each year from 2023-2029 for a total of 14,000 positions. Absent any legislation action, the U.S. could face a doc shortage of upward of 121,300 by 2030, experts noted.

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[deleted6669]

I think it has been shown numerous times that we don't have physician or provider shortages, we have distribution issues. Not everyone can work in a desirable major metro area. There are plenty of rural/inner city/health provider shortage area jobs out there that go unfilled year after year. One in my state has been running the same ad for over a decade and is only filled a few months a year by locums providers. This despite loan repayment, good pay, and a generous benefits package.
I have been emergency credentialed multiple times(days instead of months) because I am willing to work in rural locations that others are not.

 

[vm26]

I think it has been shown numerous times that we don't have physician or provider shortages, we have distribution issues. Not everyone can work in a desirable major metro area. There are plenty of rural/inner city/health provider shortage area jobs out there that go unfilled year after year. One in my state has been running the same ad for over a decade and is only filled a few months a year by locums providers. This despite loan repayment, good pay, and a generous benefits package.
I have been emergency credentialed multiple times(days instead of months) because I am willing to work in rural locations that others are not.

I don't disagree. Problem is that advocacy groups/politicians can present "data" or "projections" in order to achieve their agenda. Hard to see how this agenda is not in part backed by P/E but I may be paranoid. I would spread this info to your colleagues. Apparently the govt passed a law this past Dec adding more spots already. I don't have a pulse on the market for PAs/NPs so I wonder how would most in these fields look at this proposal?

Consolidated Appropriations Act Includes GME Support Provisions

The Consolidated Appropriations Act, 2021, creates 1,000 new Medicare-funded graduate medical education (GME) residency positions, expands opportunities for rural residency training, and allows hospit

www.natlawreview.com

 

[pamac]

In 1997, physician groups lobbied for physician residency slots to be reduced.... YOU GUYS DID THAT. The market responded with PAs and NPs. But physicians still kept their role as the highly paid gold standard at the top of the food chain. Now some physicians and medical students (coughSDNtrollscough) complain about “midlevels” harshing your buzz. Well, non-physician providers aren’t going anywhere... expect us to expand and thrive. So why would physicians want to now saturate their own labor pool. I get that everyone chiming in will say “so patients get better care!” because that’s always the haymaker that critics try to land when fighting NP independent practice rights. So, ok.... if that’s the case, then live with the outcome of that, which will certainly be a hit to your wages and marketability within your specialties. Guess who will be perfectly fine with a flood of new physicians into high paid specialties? Hint: not physicians in those specialties. Anyone sitting back saying “well I’m safe because I’m in ophthalmology”.... sure you are, until 4 new ophthalmologists move into town. Or.... when your kid can’t land an ophthalmology residency because it’s the hottest thing around now that ER is saturated. How many of you guys went into match day as a shoe in for what you wanted to do?



The fact is that when something like this movement to get more residency slots comes to fruition, it means change is afoot that is difficult to control.



And if you think any of this is about delivering better care just for the sake of delivering better care, you are nuts. This is pushed by 1) corporate cost cutters, 2) government cost cutters, and 3) activists who give no heed to physicians’ bottom line WHATSOEVER.



Yes, the “shortage” really is about distribution vs bodies in the industry. That distribution disparity may change as people flee cities. Providers may find its time to flee as well. However, I dont see people wanting to flee much farther than either the suburbs, or else to other smaller cities that are more desirable... which will just set us up for another distribution issue because it will only represent a shift, rather than a move to rural locales. In other words, rural areas will still get the shaft. Besides, rural areas are dying, and nobody cares about them anyway. The rural share of the population is decreasing every year, and 51% of the country wishes them to die out already.



So enjoy your new residencies and what comes with it. When it was just NPs you guys were up against, everyone was safe because they fled to the specialties, right? Because NPs can’t do surgery and complex procedures. You could always live large and strangle the market to get your high wages. Ok, now what?



Additionally, at what price point do you think employers are going to replace me (a psyche NP) with a physician psychiatrist? Hint... not until the point where they absolutely are compelled to. If it happens, it will be at a pay rate that physicians would barely be able to stomach. And there’s no safety there because NPs can just go further down in price in response. Not every psyche NP is making >$160k like I am. Some are in situations where they are making $110k ish, and thrilled to do it because they aren’t working as bedside RNs anymore. Are physicians going to join a nurse in the race down to $110k with the same gusto that they would have in the race toward $180k? Nope. But employers will be thrilled to consider a $110k NP vs a $180k psychiatrist. So a psychiatrist might not mind taking a $180k job just to have one, even though they would rather have $250k like they expected when they were an undergrad. A job is a job. Well, Mr. Psyche NP making $170k will likewise be willing to adjust expectations down to $120k to keep food on the table so that his boss won’t replace him with the slightly more expensive psychiatrist. Would the psychiatrist then want to consider working for $150k? That’s the kind of situation that stakeholders are salivating at (NPs and physicians aren’t the stakeholders I’m referring to, BTW).



So does anyone think any of this is about patient access or quality of care anymore? I’d suggest physicians hold on to what they’ve got while they can, but this narrative is being driven by the hospitals, healthcare, and insurance companies now. If it’s not the insurance companies, it will be the government. And if you think physicians are in a position to control anything at this point by leveraging their reputation as a profession to rally the public, just wait and see what’s in store. There will be people in media, government, and activism that will paint you guys as fat cats with rich kids, and it will turn things.

 

[pamac]

EM apparently is projected to have a surplus of 10K physicians by 2030 which will hurt both physicians and PAs/NPs in that field.

No, dude.... PAs and NPs will just go find something else. ER docs are pretty well invested in that role. Next stop for the physician is urgent care, or maybe primary care? Maybe to roam the backwoods rural areas with everyone else chasing coins and short term contracts because they also don’t have a good ER job. The NPs will just go snag something else and be happy not working as a bedside nurse where they were prior to becoming an NP. Doesn’t have to pay much more than nursing, either.

That 10,000 number doesn’t account for how many NPs and PAs willing to work in that role will be added to the workforce during that time as well. The reality is much worse.

 

[pamac]

Back in 1997, physicians had the choice.... cut supply and thereby increase value, or else keep the status quo, take the financial hit, and expand their presence (thereby maintaining dominance).

NPs decided to expand presence, and a couple years ago reached the point where they produced more NPs than physicians. Add in PAs, and you have many more non physician prescribers churned out than physicians each year. We come up from the bottom to drive down price. Physicians were better off when they were just competing between themselves. But it’s too late to benefit from expanding presence at this point. It will now just provide the death blow to your wages.

Are specialties safe? Other countries get by with 2/3 of their physician workforce being general practice. In our country, 2/3 of our physician workforce are within specialties. Entities in our country are looking hard at shifting towards other models of specialization that don’t involve such heavy leverage towards specialties. They can do that by either forcing folks into general practice by offering that as the only spots opening up with new residencies, but I think they will do it by saturating your specialties. That gives the added benefit of driving down specialty costs. Everyone knows primary care is an option to go into, but nobody is seeking it. They can have that issue solved by using NPs, so they will. NPs will always be cheaper than docs. The public still wants specialists, they just want them to cost less and be more accessible. How’s 5000 new residents distributed amongst their fields sound to those folks already in the specialties? Imagine what an infusion of 1000 new cardiologists could do the the wages in that field in one year?

 

[deleted6669]

I don't disagree. Problem is that advocacy groups/politicians can present "data" or "projections" in order to achieve their agenda. Hard to see how this agenda is not in part backed by P/E but I may be paranoid. I would spread this info to your colleagues. Apparently the govt passed a law this past Dec adding more spots already. I don't have a pulse on the market for PAs/NPs so I wonder how would most in these fields look at this proposal?

Consolidated Appropriations Act Includes GME Support Provisions

The Consolidated Appropriations Act, 2021, creates 1,000 new Medicare-funded graduate medical education (GME) residency positions, expands opportunities for rural residency training, and allows hospit

www.natlawreview.com

As an EMPA working in rural areas, my competition isn't EM boarded physicians, it's FP docs without EM experience. When it comes down to it, I deliver better care at a lower cost than they do, so I feel pretty secure in my job. I make $20/hr less than an an FP doc doing exactly the same job, and as PAMAC mentioned above, I could flex down in my salary and be fine with it. I am making more than 3x what I made as a new grad PA 25 years ago. Find me a doc willing to work rural shifts for less than $100/hr. Good luck.

 

[vm26]

In 1997, physician groups lobbied for physician residency slots to be reduced.... YOU GUYS DID THAT. The market responded with PAs and NPs. But physicians still kept their role as the highly paid gold standard at the top of the food chain. Now some physicians and medical students (coughSDNtrollscough) complain about “midlevels” harshing your buzz. Well, non-physician providers aren’t going anywhere... expect us to expand and thrive. So why would physicians want to now saturate their own labor pool. I get that everyone chiming in will say “so patients get better care!” because that’s always the haymaker that critics try to land when fighting NP independent practice rights. So, ok.... if that’s the case, then live with the outcome of that, which will certainly be a hit to your wages and marketability within your specialties. Guess who will be perfectly fine with a flood of new physicians into high paid specialties? Hint: not physicians in those specialties. Anyone sitting back saying “well I’m safe because I’m in ophthalmology”.... sure you are, until 4 new ophthalmologists move into town. Or.... when your kid can’t land an ophthalmology residency because it’s the hottest thing around now that ER is saturated. How many of you guys went into match day as a shoe in for what you wanted to do?



The fact is that when something like this movement to get more residency slots comes to fruition, it means change is afoot that is difficult to control.



And if you think any of this is about delivering better care just for the sake of delivering better care, you are nuts. This is pushed by 1) corporate cost cutters, 2) government cost cutters, and 3) activists who give no heed to physicians’ bottom line WHATSOEVER.



Yes, the “shortage” really is about distribution vs bodies in the industry. That distribution disparity may change as people flee cities. Providers may find its time to flee as well. However, I dont see people wanting to flee much farther than either the suburbs, or else to other smaller cities that are more desirable... which will just set us up for another distribution issue because it will only represent a shift, rather than a move to rural locales. In other words, rural areas will still get the shaft. Besides, rural areas are dying, and nobody cares about them anyway. The rural share of the population is decreasing every year, and 51% of the country wishes them to die out already.



So enjoy your new residencies and what comes with it. When it was just NPs you guys were up against, everyone was safe because they fled to the specialties, right? Because NPs can’t do surgery and complex procedures. You could always live large and strangle the market to get your high wages. Ok, now what?



Additionally, at what price point do you think employers are going to replace me (a psyche NP) with a physician psychiatrist? Hint... not until the point where they absolutely are compelled to. If it happens, it will be at a pay rate that physicians would barely be able to stomach. And there’s no safety there because NPs can just go further down in price in response. Not every psyche NP is making >$160k like I am. Some are in situations where they are making $110k ish, and thrilled to do it because they aren’t working as bedside RNs anymore. Are physicians going to join a nurse in the race down to $110k with the same gusto that they would have in the race toward $180k? Nope. But employers will be thrilled to consider a $110k NP vs a $180k psychiatrist. So a psychiatrist might not mind taking a $180k job just to have one, even though they would rather have $250k like they expected when they were an undergrad. A job is a job. Well, Mr. Psyche NP making $170k will likewise be willing to adjust expectations down to $120k to keep food on the table so that his boss won’t replace him with the slightly more expensive psychiatrist. Would the psychiatrist then want to consider working for $150k? That’s the kind of situation that stakeholders are salivating at (NPs and physicians aren’t the stakeholders I’m referring to, BTW).



So does anyone think any of this is about patient access or quality of care anymore? I’d suggest physicians hold on to what they’ve got while they can, but this narrative is being driven by the hospitals, healthcare, and insurance companies now. If it’s not the insurance companies, it will be the government. And if you think physicians are in a position to control anything at this point by leveraging their reputation as a profession to rally the public, just wait and see what’s in store. There will be people in media, government, and activism that will paint you guys as fat cats with rich kids, and it will turn things.

I apologize if I touched a nerve here. This was not my intention so need for antagonism. I get the whole thing between physicians vs non-physicians, but I am a rad and do not have any issues w/PAs/NPs. I read studies regardless of who orders them and speak with referrers more or less the same despite their credentials or understanding of imaging. While there are some PAs/NPs that do some fluoro/light IR, this is extremely rare, and not a threat to my field. Just finding a sub-specialist rad who can do general and mammo is hard enough. We have our own threats but they are not mid-levels.

I disagree with you if you think job saturation is good for you and your colleagues, but this is just my opinion. These increases in training spots are across the board, not just for EM. On LI, CRNAs reimbursement was approaching anesthesiologists. I will let you figure out what the hiring trend is there right now. My point is the govt (?P/E) are primarily concerned with cost containment, particularly given the changing demographics. Seems they have accepted that they cannot compete against the lobby of private insurers and increasingly larger/stronger consolidated HC systems. So flooding the clinician field may be the best route to go. Again just my opinion.

 

[vm26]

As an EMPA working in rural areas, my competition isn't EM boarded physicians, it's FP docs without EM experience. When it comes down to it, I deliver better care at a lower cost than they do, so I feel pretty secure in my job. I make $20/hr less than an an FP doc doing exactly the same job, and as PAMAC mentioned above, I could flex down in my salary and be fine with it. I am making more than 3x what I made as a new grad PA 25 years ago. Find me a doc willing to work rural shifts for less than $100/hr. Good luck.

If 10K ED physicians don't have jobs which is the projection for 2030, I have to think they will go wherever needed for 3-5 years to pay down their debt and get some experience etc. But who knows I may be completely off. I do agree that FP docs w/o EM experience is sub-optimal.

 

[deleted6669]

If 10K ED physicians don't have jobs which is the projection for 2030, I have to think they will go wherever needed for 3-5 years to pay down their debt and get some experience etc. But who knows I may be completely off. I do agree that FP docs w/o EM experience is sub-optimal.

I work at 4 rural EDs. They all preferentially hire EM trained and boarded physicians first when they can get them(as they should), then experienced EMAs, then FP physicians. I will work for $50/hr if I have to in order to keep my jobs. I don't think any physicians want to get into a lowest bid war with me. My first job paid $24/hr. Now I make almost 4 times that. I have no loans. I will own my house in a few years.

 

[pamac]

I apologize if I touched a nerve here. This was not my intention so need for antagonism. I get the whole thing between physicians vs non-physicians, but I am a rad and do not have any issues w/PAs/NPs. I read studies regardless of who orders them and speak with referrers more or less the same despite their credentials or understanding of imaging. While there are some PAs/NPs that do some fluoro/light IR, this is extremely rare, and not a threat to my field. Just finding a sub-specialist rad who can do general and mammo is hard enough. We have our own threats but they are not mid-levels.

I disagree with you if you think job saturation is good for you and your colleagues, but this is just my opinion. These increases in training spots are across the board, not just for EM. On LI, CRNAs reimbursement was approaching anesthesiologists. I will let you figure out what the hiring trend is there right now. My point is the govt (?P/E) are primarily concerned with cost containment, particularly given the changing demographics. Seems they have accepted that they cannot compete against the lobby of private insurers and increasingly larger/stronger consolidated HC systems. So flooding the clinician field may be the best route to go. Again just my opinion.

No nerve touched, I just took the opportunity to give my opinion on how we got to this place. It’s a bit unconventional, I know.

Its wierd to think that saturation can be good for one field, and bad for another, but so much rests on influence and value. I came to the conclusions I did by considering PAs vs NPs. PA training is on point and robust. They are an excellent physician extender, and probably should be independent in their own right. But there are less of them. They lack the voice and reach that NPs have because there are more NPs, and they also have the backing of the nursing community as a whole, which is millions strong. Long ago, the NP world decided to go all in on churning out numbers of prescribers. It’s a bit like the waves of Soviet troops thrown at the Nazi Juggernaut. Eventually, the nazis would run out of bullets, but the Soviets weren’t going to run out of people. Nurses knew you first secure the landscape.

Being rare works for physicians because they have such value as the top of the food chain. Being rare doesn’t work well for PAs because they need to be cheap and obtainable for employers. The less of them there are, the more expensive they are, and that only works to a point. PA school is expensive too, and they often don’t have a lucrative fallback if landing a job becomes hard... NPs do.

NPs decided that they are fine with a large pool of NPs, because it expands their reach. When a job opens up, they want 5 NPs to apply alongside each PA. For long term success, NPs have to be cheaper than physicians, and more plentiful than PAs. For physicians, saturation at their level means competing with each other, because they will never compete with NPs on wages.

I agree that radiology has its own problems, with NPs and PAs NOT being any of those problems. AI and cheaper physicians (foreign) are what I’d fear most.

 

[d2305]

AI may be a bigger threat to Rad than MLPs.

 

[pamac]

AI may be a bigger threat to Rad than MLPs.

In terms of threat, I see it manifesting mostly in the form of jobs becoming more scarce. Physicians are in demand, and everyone wants them around. What tends to dry up is the notion that there is a sweet job waiting in every desirable place. Where there are changes, we will see rads having to settle more than they might have expected. You won’t see them driving taxi cabs because they aren’t getting work. I knew of a radiologist that “got replaced” by cheaper labor somehow, but it wasn’t what the rest of us would call a tragedy. The radiologist had to make a choice to move to a different place to get a job that paid as much, or else take a pay cut to stay closer to where they were at. Not benign, but not the unemployment line either. AI rolling in will probably be gradual enough to make for a smooth transition over the course of years. It could also go the other way, and allow for more services to be rendered. We always assume that the demand for services will remain at current levels vs increased productivity. I’m an optimist, and figure that maybe we will see more scans to sift through, with AI helping. Maybe they will need more radiology services as NPs come on scene to replace physicians and order frivolous testing.... who knows?

 

[DownJonesIndustrial]

In 1997, physician groups lobbied for physician residency slots to be reduced.... YOU GUYS DID THAT. The market responded with PAs and NPs. But physicians still kept their role as the highly paid gold standard at the top of the food chain. Now some physicians and medical students (coughSDNtrollscough) complain about “midlevels” harshing your buzz. Well, non-physician providers aren’t going anywhere... expect us to expand and thrive. So why would physicians want to now saturate their own labor pool. I get that everyone chiming in will say “so patients get better care!” because that’s always the haymaker that critics try to land when fighting NP independent practice rights. So, ok.... if that’s the case, then live with the outcome of that, which will certainly be a hit to your wages and marketability within your specialties. Guess who will be perfectly fine with a flood of new physicians into high paid specialties? Hint: not physicians in those specialties. Anyone sitting back saying “well I’m safe because I’m in ophthalmology”.... sure you are, until 4 new ophthalmologists move into town. Or.... when your kid can’t land an ophthalmology residency because it’s the hottest thing around now that ER is saturated. How many of you guys went into match day as a shoe in for what you wanted to do?



The fact is that when something like this movement to get more residency slots comes to fruition, it means change is afoot that is difficult to control.



And if you think any of this is about delivering better care just for the sake of delivering better care, you are nuts. This is pushed by 1) corporate cost cutters, 2) government cost cutters, and 3) activists who give no heed to physicians’ bottom line WHATSOEVER.



Yes, the “shortage” really is about distribution vs bodies in the industry. That distribution disparity may change as people flee cities. Providers may find its time to flee as well. However, I dont see people wanting to flee much farther than either the suburbs, or else to other smaller cities that are more desirable... which will just set us up for another distribution issue because it will only represent a shift, rather than a move to rural locales. In other words, rural areas will still get the shaft. Besides, rural areas are dying, and nobody cares about them anyway. The rural share of the population is decreasing every year, and 51% of the country wishes them to die out already.



So enjoy your new residencies and what comes with it. When it was just NPs you guys were up against, everyone was safe because they fled to the specialties, right? Because NPs can’t do surgery and complex procedures. You could always live large and strangle the market to get your high wages. Ok, now what?



Additionally, at what price point do you think employers are going to replace me (a psyche NP) with a physician psychiatrist? Hint... not until the point where they absolutely are compelled to. If it happens, it will be at a pay rate that physicians would barely be able to stomach. And there’s no safety there because NPs can just go further down in price in response. Not every psyche NP is making >$160k like I am. Some are in situations where they are making $110k ish, and thrilled to do it because they aren’t working as bedside RNs anymore. Are physicians going to join a nurse in the race down to $110k with the same gusto that they would have in the race toward $180k? Nope. But employers will be thrilled to consider a $110k NP vs a $180k psychiatrist. So a psychiatrist might not mind taking a $180k job just to have one, even though they would rather have $250k like they expected when they were an undergrad. A job is a job. Well, Mr. Psyche NP making $170k will likewise be willing to adjust expectations down to $120k to keep food on the table so that his boss won’t replace him with the slightly more expensive psychiatrist. Would the psychiatrist then want to consider working for $150k? That’s the kind of situation that stakeholders are salivating at (NPs and physicians aren’t the stakeholders I’m referring to, BTW).



So does anyone think any of this is about patient access or quality of care anymore? I’d suggest physicians hold on to what they’ve got while they can, but this narrative is being driven by the hospitals, healthcare, and insurance companies now. If it’s not the insurance companies, it will be the government. And if you think physicians are in a position to control anything at this point by leveraging their reputation as a profession to rally the public, just wait and see what’s in store. There will be people in media, government, and activism that will paint you guys as fat cats with rich kids, and it will turn things.

Hello, joined the forums yesterday. My first reply.

You raise some cogent points. Sharing the same specialty you do, I've had the privilege of earning over $200k/yr in communities without a high standard of living because I was willing to do the work. The problem with that was it makes most other jobs look distasteful until you're forced to move out due to consolidations/closures/etc.

I took a job making about 60% of that and within a few months made the income transition manageable, and I'll happily work it because I didn't like anything about being a RN. I'm also too old and encumbered to return to my first non-health profession. I've talked to other NPs who share the same sentiment. "I'll do anything to not go back bedside." For me, I was just looking for a stable, office job without Bill Lumberghs standing in my office. I didn't really care what I did but looked to healthcare, found nursing, found advanced practice, found psych, found that interesting, and I ran with it. I love having a job where I sit in a controlled climate chatting with people. I don't have projects to manage, people to supervise, or any actual deadlines. But because I don't have "standards" I pimped myself out doing various telehealth jobs until I made up the lost money. I'm not really satisfied with my profession (it's not my vocation), but as far as the job goes - I've got great jobs.

The question has never been about quality care. It's always been about income and standard of living. I've had the pleasure of working corporate, non-profit, government, academic/faculty, community (indigent) clinics, and I have never once seen a physician give a single iota of care about what a NP or PA was doing or not doing. If the physician oversight is focused enough on what the "midlevel" is doing then the physician's panel isn't large enough, and when they're concerned we're making too much they need to step it up and work a little harder rather than trying to apply brakes to our revenue. The entire goal of preventing independent practice has nothing to do with patients the physicians have never seen or heard of. It's quite clearly a turf war. Because the medical boards control the PAs I seriously doubt PA independence will ever happen outside conditions most extreme. As medicine becomes increasingly socialized and the glut of supply saturates the areas with a political voice we'll all see our incomes and lifestyle expectations decline. The only saving grace we have is telehealth. To work those inner city environments and remote locations no one wants to live in or drive to telehealth is the answer, and that will be the last bastion of good income.