Why does AAMC advocate more residency slots when it hurts physicians?

[voxveritatisetlucis]

Got an email earlier from the AAMC saying

“Specifically, AAMC Action advocates on behalf of increased support for:

• New Medicare-supported graduate medical education (GME) positions to improve patient access to care by training more physicians to address primary care and specialty shortages in high-need areas, such as mental and behavioral health.”

Have they looked at radonc and EM? Why would they advocate for this?

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[Karlington]

Got an email earlier from the AAMC saying

“Specifically, AAMC Action advocates on behalf of increased support for:

• New Medicare-supported graduate medical education (GME) positions to improve patient access to care by training more physicians to address primary care and specialty shortages in high-need areas, such as mental and behavioral health.”

Have they looked at radonc and EM? Why would they advocate for this?

It's right in there: "to address primary care and specialty shortages in high-need areas, such as mental and behavioral health."

 

[voxveritatisetlucis]

There’s not a primary care shortage. It’s a misallocation problem. Unless the residency contracts will specify that residents must remain in the area for x number of years upon completion, it won’t help the problem

 

[GoSpursGo]

There’s not a primary care shortage. It’s a misallocation problem. Unless the residency contracts will specify that residents must remain in the area for x number of years upon completion, it won’t help the problem

Yes, there is a primary care shortage. There just is not a primary care shortage in major metropolitan areas, which is what I think you’re getting at. The idea is that eventually if you saturate the metropolitan areas and drive down earning in metropolitan areas, some physicians will be more open to serving the rural areas in greater need.

Whether this is “bad” because this drives down long term earning or “good” because it means more grads can receive residency training probably depends on your perspective. In the short term this would benefit US-IMGs who are currently getting squeezed out of residency programs. In the long term, if US based med schools continue to expand and increase class sizes, it may help students from “lower tier” schools. If you are already attending a name brand school, then this is probably slightly bad, but it is unlikely you will be out of a job.

 

[VA Hopeful Dr]

There’s not a primary care shortage. It’s a misallocation problem. Unless the residency contracts will specify that residents must remain in the area for x number of years upon completion, it won’t help the problem

The quote was: to address primary care and specialty shortages in high-need areas

So yes on a nationwide basis its an allocation problem, but on a smaller scale in high-need areas its a shortage.

 

[voxveritatisetlucis]

The quote was: to address primary care and specialty shortages in high-need areas

So yes on a nationwide basis its an allocation problem, but on a smaller scale in high-need areas its a shortage.

I guess but what’s to stop people from training in Fargo, North Dakota and then moving to NYC, only to further saturate an already saturated market

 

[VA Hopeful Dr]

I guess but what’s to stop people from training in Fargo, North Dakota and then moving to NYC, only to further saturate an already saturated market

Years of evidence that a sizeable number of graduates stay fairly local to their residency programs.

 

[Goro]

There’s not a primary care shortage. It’s a misallocation problem. Unless the residency contracts will specify that residents must remain in the area for x number of years upon completion, it won’t help the problem

At least a quarter of All American doctors are over the age of 50, and they're going to be retiring soon, especially the baby boom docs who are going to be either retiring or dying off!

So while there may be a maldistribution of doctors now, there is a physician crunch coming.

 

[collegestud2013]

Got an email earlier from the AAMC saying

“Specifically, AAMC Action advocates on behalf of increased support for:

• New Medicare-supported graduate medical education (GME) positions to improve patient access to care by training more physicians to address primary care and specialty shortages in high-need areas, such as mental and behavioral health.”

Have they looked at radonc and EM? Why would they advocate for this?

It's more of a distribution/allocation problem across the board than not having enough physicians overall. At the medical school/residency level, a lot more trainees want to go into high-paying specialties like derm or ortho than primary care specialties like FM or peds. At the attending level, a lot more want to work in a major city or desirable coastal areas than rural or remote areas.

When it comes to choosing patients, most will want to care for patients who are cooperative and with the financial means who have good commercial insurance or able to pay cash for concierge services, while a lot less want do deal with difficult patients who are at the socioeconomic bottom who have no insurance or Medicaid at best and have a complex host of social problems and likely severe mental health problems. Obviously the it's latter group that will have difficulty accessing care in a free market, and requires significant government subsidies/interventions for them to even get basic care.

They're also looking 10-20 years in the future when the population in the US is expected to shift significantly toward older ages as the baby boomers retire and live longer and with lower birth rates. These combined means there be a much greater need for geriatricians and specialties serving the geriatric population than pediatric specialties

 

[NotAProgDirector]

My usual solution to questions like this is to follow the $$$ and self interest. It is very rare for an organization to have purely altruistic motives, and the AAMC is likely no exception.

The AAMC is funded by and hence represents the interests of US MD medical schools. So even if we think that increasing the number of docs in primary care is a good thing (which is an interesting question), I find it unlikely that the AAMC would make this part of its platform unless 1) it had at least some secondary benefit, or 2) it was a hot button issue that taking a stand was expected (and even in that case, see #1).

So what benefit does the AAMC get from more residency spots? US MD schools main selling point are their match lists. Anything that makes those better is good for the AAMC. Both MD and DO schools have been increasing their class sizes, DO much more so than MD. The AAMC can't make COCA stop this expansion. They are worried that there will be a match crunch. It's many years off -- if it happens at all. But more residency spots = more chances for US MD students to match. It also means bigger / more residency programs for students to rotate in.

But I'm a pessimist.

Years of evidence that a sizeable number of graduates stay fairly local to their residency programs.

Hinted at above, I wonder if this is true for programs in underserved areas, or if it's mainly true in urban / oversubscribed areas which won't help anything.

At least a quarter of All American doctors are over the age of 50, and they're going to be retiring soon, especially the baby boom docs who are going to be either retiring or dying off!

So while there may be a maldistribution of doctors now, there is a physician crunch coming.

This is often mentioned as a talking point about a possible physician shortage in the future. But why would this be? If a quarter of all docs are >50, is that a new phenomenon? It would only be true if residencies some time in the recent past were much bigger, creating a bubble of physicians whom will all retire at the same time. Otherwise, residency spots have been slowly growing over time and you'd expect an increasing proportion of younger physicians. If we assume that most graduate HS at 18, college at 22, a gap year (on average, some more some less) is 23. Four years of medical school is 27. Three years of residency is 30. (Ignoring specialists, non-primarry care fields)

So the "real work" starts at 30. If we assume that physicians retire at 60, and keep the number of residency spots even over time, then 1/3 of physicians would be over 50, by definition. So I don't think this is a real concern. Unless we think that lots of docs are goinng to take early reritment (more than in previous years).

 

[NotAProgDirector]

Also, there's these repeated calls for "more training spots". Not mentioned is that the training spot cap only applies to established programs. If you start a brand new program, you get new funding for that. No legislation needed. Especially in underserved areas. So basically this is mainly an attempt for urban programs which are capped to get more trainees.

 

[Mr.Smile12]

Got an email earlier from the AAMC saying

“Specifically, AAMC Action advocates on behalf of increased support for:

• New Medicare-supported graduate medical education (GME) positions to improve patient access to care by training more physicians to address primary care and specialty shortages in high-need areas, such as mental and behavioral health.”

Have they looked at radonc and EM? Why would they advocate for this?

AAMC represents Medical Schools and Academic Medical Centers where residency training occurs. It's in their vested interest to have more residency spots funded and available. .... EDIT: What @NotAProgDirector said.

 

[Med Ed]

There’s not a primary care shortage. It’s a misallocation problem.

Citation?

 

[voxveritatisetlucis]

Citation?

Doesn’t the fact that PCPs in NYC make 160k while those in Nebraska make 280k despite the higher COL in the former kind of imply an allocation problem

 

[Med Ed]

Doesn’t the fact that PCPs in NYC make 160k while those in Nebraska make 280k despite the higher COL in the former kind of imply an allocation problem

I'm not looking for an implication, and the two problems aren't mutually exclusive. This is a complicated subject, and while I've heard the refrain of "it's not a shortage problem, it's an allocation problem" many times over the years, I've yet to see any real data to support that assertion.

 

[Mr.Smile12]

I'm not looking for an implication, and the two problems aren't mutually exclusive. This is a complicated subject, and while I've heard the refrain of "it's not a shortage problem, it's an allocation problem" many times over the years, I've yet to see any real data to support that assertion.

I agree this is a complex problem, and real data have to be reviewed rather critically, but offices of rural health have definitely pushed the fact health care providers are not coming to rural areas. I don't think "allocation" is as easy as it sounds since we don't really assign people to places where they choose to work. I think there are more residency spots set up in more rural areas as more medical schools have opened up in rural areas in the past decade.

Interview that features ACGME president with COVID-19 context (April 12, 2021)


Citing article on ACGME website Medically Underserved Areas and Populations

 

[annoyedpsychiatrist]

There is a huge shortage of psychiatrists, in most areas of the country. Even the states with the most psychiatrists still have rather large shortages

 

[cj_cregg]

There IS a primary care shortage, it is not just an allocation problem. Yes, areas with more competitive markets can pay less. But it is still ridiculously easy to find a job in those markets...they're still hiring, aren't they? The PCPs in those areas are still booked solid, aren't they? I have yet to come across a health system that isn't looking to hire more family docs. There is an allocation issue in addition in the sense that docs are less likely to go to less desirable areas, but it is still also true that there are just not enough PCPs. (And I'd argue we also need to do a better job of supporting and recruiting folks who are from rural/underserved communities to help address that allocation issue, not just increase residency slots.)

This is also an anticipated demographic issue as mentioned above with an anticipated shortage of literally tens of thousands of PCPs in the next few decades as the baby boomers age. This is a twofold issue - we have an enormously disproportionate population of elderly patients who require more care, and a large percentage of the physician workforce retiring as well.

To overcome doctor shortage, get rid of obstacles to primary care

For patients in some communities, a pressing question is whether their primary care doctor will retire—because a replacement may be hard to come by.

www.ama-assn.org

 

[voxveritatisetlucis]

There is a huge shortage of psychiatrists, in most areas of the country. Even the states with the most psychiatrists still have rather large shortages

Do you think that expansion is the answer? Look at rad onc and EM (estimated 10,000+ excess EM physicians by 2030). The problem with expansion is that it tends to overshoot.

 

[ChordaEpiphany]

I think the problem is severe enough that the AAMC is not out of their minds saying we need more docs, especially as boomers age out of the workforce and become superheavy users of the healthcare system, likely for another 40 years. The problem will solve itself with either more doctors or more mid-levels.

We'll see if any of these organizations are worth anything at all to the profession from how well they fight for physician reimbursement if supply and demand become less favorable.

And I'd argue we also need to do a better job of supporting and recruiting folks who are from rural/underserved communities to help address that allocation issue, not just increase residency slots.

I hope the next generation starts to see this, but I don't have much hope. I think we've done a decent job of beginning to correct representation for metropolitan areas. Med schools see the problem daily (poor black patients, rich white doctors). They can see these patients need doctors who relate to them and can relate their struggles to their colleagues.

However, poor white folks from rural areas are forgotten and washed out in the diversity statistics. They're so underserved the policy movers in the cities barely even notice their presence. They often live and die nearly completely out of the medical system. To add to that, the last decade of political discourse has created undue disdain for rural whites, who are really just products of the system like any other disadvantaged group. This disdain is especially poignant among Millennials and Gen Z. Send rural folks to low tier, rural med schools and they'll flock to similar communities. Continue training people (like me) who have gotten used to city life with college, work, and med school in the city and doctors will continue to take massive pay cuts to avoid rural areas.

 

[GoSpursGo]

Do you think that expansion is the answer? Look at rad onc and EM (estimated 10,000+ excess EM physicians by 2030). The problem with expansion is that it tends to overshoot.

I don't think those specialties are analogous to primary care. Rad onc is very obviously highly specialized, and as an aside radiation is also being used less frequently in oncology if you can avoid the toxicity. EM doesn't seem like it, but I'd argue it is also a pretty specialized field. While ERs are overutilized, a lot of the urgent care nonsense can be handled by an APP which is contributing to their job crunch. In general someone REALLY only needs an ER and see a real EM physician for a true medical emergency which are relatively rare events that probably happen less than once every 10 years for most people.

Everyone over the age of 30-35ish really needs a PCP. Even if primary care also can use APPs to see more patients, the number of patient encounters are log fold higher than for EM (let alone rad onc). There are problems in those two field specifically (and other fields where jobs are tight, like path) that simply don't apply to primary care.

However, poor white folks from rural areas are forgotten and washed out in the diversity statistics. They're so underserved the policy movers in the cities barely even notice their presence. They often live and die nearly completely out of the medical system. To add to that, the last decade of political discourse has created undue disdain for rural whites, who are really just products of the system like any other disadvantaged group. This disdain is especially poignant among Millennials and Gen Z. Send rural folks to low tier, rural med schools and they'll flock to similar communities.

FWIW, I do think this is a problem which is becoming recognized; I know in my institution when we talk about underserved populations, I think we probably talk about "rurality" even moreso than racial or ethnic minorities, just because that is a significant percentage of the population that our institution cares for. I think the problem that you're alluding to is that it is much harder to measure "success" when it comes to caring for rural communities, whereas when addressing diversity a school or residency program can just recruit more URMs, draw up a demographics table and call it a day. A few schools are at least TRYING through some rural medicine tracks, but there is a lot more work that needs to be done in this area.

 

[Future_Bone_Docta]

Got an email earlier from the AAMC saying

“Specifically, AAMC Action advocates on behalf of increased support for:

• New Medicare-supported graduate medical education (GME) positions to improve patient access to care by training more physicians to address primary care and specialty shortages in high-need areas, such as mental and behavioral health.”

Have they looked at radonc and EM? Why would they advocate for this?

Because currently the alternative is independent practice for midlevels to address the concern.

Also I believe I read an article that stated post covid some wild number of physicians (20%) or something planned on retiring within the next two years.

Edit: found the article

Did COVID Really Send Doctors Fleeing Toward Retirement?

As the pandemic went from bad to worse, an emerging storyline was that frustrated and overwhelmed doctors and nurses were quitting the profession in large numbers. But did they really?

www.medscape.com

Mayo clinic survery: 20k healthcare physicians were surveyed and 1 in 5 said they planned on "leaving their current practice" within the next two years (not sure to what capacity that means)

Medscape: 18% of 500 physicians said they planned on retiring within the next 12 months.

 

[ChordaEpiphany]

FWIW, I do think this is a problem which is becoming recognized; I know in my institution when we talk about underserved populations, I think we probably talk about "rurality" even moreso than racial or ethnic minorities, just because that is a significant percentage of the population that our institution cares for. I think the problem that you're alluding to is that it is much harder to measure "success" when it comes to caring for rural communities, whereas when addressing diversity a school or residency program can just recruit more URMs, draw up a demographics table and call it a day. A few schools are at least TRYING through some rural medicine tracks, but there is a lot more work that needs to be done in this area.

Yeah, I think the rural medicine tracks are nice, but I still think there's a major recruitment problem. Granted I go to a very academics-focused MD school in a major city, but the rural medicine track is small, poorly funded, and barely recognized or advertised, and most students in it aren't planning to actually do rural medicine. They tend to fit the normal med student stereotype, and the university doesn't really want to sway from that. Right now priorities in admissions are, 1) recruit talented URMs, 2) recruit white/asian students that keep the stats high. Recruiting low stats, rural, mission-driven white people from North Carolina doesn't serve these schools in any way. Right now I'm seeing mostly lip service, and I don't think you're ever going to get suburbanites to go rural.

I also think the normalization of dual income households means that even if you're willing to go rural, you won't if you live/train in the city and marry another city dweller. I grew up rural and wouldn't mind going rural at all, but my SO is in biotech, and you can't really build a worthwhile career in that field outside of a few major cities. To fix the allocation problem you need to train folks who are born and bred rural, train them rural, and keep them rural.

 

[VA Hopeful Dr]

There IS a primary care shortage, it is not just an allocation problem. Yes, areas with more competitive markets can pay less. But it is still ridiculously easy to find a job in those markets...they're still hiring, aren't they? The PCPs in those areas are still booked solid, aren't they? I have yet to come across a health system that isn't looking to hire more family docs. There is an allocation issue in addition in the sense that docs are less likely to go to less desirable areas, but it is still also true that there are just not enough PCPs. (And I'd argue we also need to do a better job of supporting and recruiting folks who are from rural/underserved communities to help address that allocation issue, not just increase residency slots.)

This is also an anticipated demographic issue as mentioned above with an anticipated shortage of literally tens of thousands of PCPs in the next few decades as the baby boomers age. This is a twofold issue - we have an enormously disproportionate population of elderly patients who require more care, and a large percentage of the physician workforce retiring as well.

To overcome doctor shortage, get rid of obstacles to primary care

For patients in some communities, a pressing question is whether their primary care doctor will retire—because a replacement may be hard to come by.

www.ama-assn.org

22% of FPs are 60 and over, 50% are 50 and over.

 

[voxveritatisetlucis]

Because currently the alternative is independent practice for midlevels to address the concern.

Also I believe I read an article that stated post covid some wild number of physicians (20%) or something planned on retiring within the next two years.

Edit: found the article

Did COVID Really Send Doctors Fleeing Toward Retirement?

As the pandemic went from bad to worse, an emerging storyline was that frustrated and overwhelmed doctors and nurses were quitting the profession in large numbers. But did they really?

www.medscape.com

Mayo clinic survery: 20k healthcare physicians were surveyed and 1 in 5 said they planned on "leaving their current practice" within the next two years (not sure to what capacity that means)

Medscape: 18% of 500 physicians said they planned on retiring within the next 12 months.

20% won’t be retiring when Amazon is down 20% on a random weekday in after hours trading. Most physicians nearing retirement are probably losing hundreds of thousands if not millions of dollars.

This was probably when they were flush with cash and investment growth

 

[NotAProgDirector]

As already mentioned on this thread, it's a very complicated question with no real answer. You can argue both for and against a current shortage, or a future shortage, or no shortage at all. It's much like asking what we should do about the current economy and inflation. We can try to predict what's going to happen, make best guess moves to try to address the issue, and never know whether what was done made things better or worse.

We could look at it from a purely numbers perspective. How many patients can a full time PCP manage? 2000-2500 is probably a reasonable number, potentially more if you have a very efficient practice. Let's use 2500 for this example. Next, what's the population of the US? That's easy - 330 million. 330 million / 2500 = 132,000. So with perfect distribution, we would need 132K PCP's to manage everyone. This oversimplifies things -- I'm lumping kids in with adults, and the census may be undercounting people, etc. But it's at least a number to start with.

So how many PCP's are there? That's not so easy to measure, interestingly. Google reports all sorts of numbers. The AMA Masterfile in 2010 reported 200K. Some estimates are higher, some are lower. AAMC has some data, (reading more about this, it's actually all just a report of the same AMA Masterfile) suggesting 120K each of both IM and FP, so 240K together + another 60K in peds. Whether we should count NP/PA's is also complicated. And any counting system usually does not adjust for how much FTE / clinical activity they have. And whether Hospitalists count as primary care or not is also complicated. But we can see that we might actually have enough PCP's based on the raw numbers.

Distribution is often mentioned as a big problem, and it almost certainly is. Also hard to measure. The common counterargument is that PCP's are being hired everywhere, so there must be a shortage everywhere. But there's an interesting problem with that argument -- there's good evidence that healthcare is supply sensitive - adding more supply drives more demand. Nobody wants an open schedule - that's just lost income. So when a doc opens a new PCP practice and sees their first patients, their schedule is wide open. They are very likely to recommend closer follow up. Why see that pt with HTN trying to lose weight in 6 months when you can see them in 2 and try to encourage this good behavior? The same is true for MRI machines, cath labs, and any other healthcare resource -- if you build it they will come. And studies that have looked at this usually show no improved outcomes -- more MRI's just costs more money without making anything any better. So just because everyone's schedule is full and practices are hiring doesn't necessarily mean that we really need more PCP (or any other) resource.

The Baby Boomers are often portrayed as a disaster on the horizon. And they may be - a bubble of people all of similar age. But if we "staff up" to deal with them, then what happens after they all die off? Then we won't need all of those docs any more - yet if we open more residency programs we will have them in the pipeline for 30+ years. And closing residency programs rarely happens.

I've already commented on the oft quoted figure about physician ages. The AAMC data above breaks it down between over/under 55. Overall, 55% are under 55 and 45% are over. That data makes me worry that the database is not capturing when physicians actually retire -- which doesn't surprise me greatly. If I were to retire this year, how would the AMA know that? I'm certainly not updating them, and I'd likely keep my medical license -- cost is small, CME is easy, and it's nice to have. So I expect their data is too high, they are including some retired docs. Even with that, there may not be a huge shortage once we include NP/PA's. And sure people may threaten to retire early, but unclear if that will really happen or not.

Some fields have big age skews. New fields trend towards more young physicians - ED is a great example. Didn't exist as a separate field when I was a resident, so not surprising there are less older physicians in it. Other fields swing the other way and may be a sign of impending collapse - Pathology.

And then there's the question of specialization. As more fellowships open and more residents leave IM for a subspecialty, that leaves less for PCP. Is the number of specialists right? Too low? Too high? There's no central management of this -- any program can open a fellowship.

And last is asking whether just pumping out more doctors is the right answer, or thinking about the whole "system". A good example is colonoscopy. Do we really need to train a zillion gastroenterologists to do screening colonoscopies? Or should we train techs to do them, leave the GI folks to do the complicated endoscopies? But screening colo's are the bread and butter for a GI practice, mention "taking them away" and you'll get lots of screaming of how unsafe it would be.

So, complicated.

 

[Future_Bone_Docta]

As already mentioned on this thread, it's a very complicated question with no real answer. You can argue both for and against a current shortage, or a future shortage, or no shortage at all. It's much like asking what we should do about the current economy and inflation. We can try to predict what's going to happen, make best guess moves to try to address the issue, and never know whether what was done made things better or worse.

We could look at it from a purely numbers perspective. How many patients can a full time PCP manage? 2000-2500 is probably a reasonable number, potentially more if you have a very efficient practice. Let's use 2500 for this example. Next, what's the population of the US? That's easy - 330 million. 330 million / 2500 = 132,000. So with perfect distribution, we would need 132K PCP's to manage everyone. This oversimplifies things -- I'm lumping kids in with adults, and the census may be undercounting people, etc. But it's at least a number to start with.

So how many PCP's are there? That's not so easy to measure, interestingly. Google reports all sorts of numbers. The AMA Masterfile in 2010 reported 200K. Some estimates are higher, some are lower. AAMC has some data, (reading more about this, it's actually all just a report of the same AMA Masterfile) suggesting 120K each of both IM and FP, so 240K together + another 60K in peds. Whether we should count NP/PA's is also complicated. And any counting system usually does not adjust for how much FTE / clinical activity they have. And whether Hospitalists count as primary care or not is also complicated. But we can see that we might actually have enough PCP's based on the raw numbers.

Distribution is often mentioned as a big problem, and it almost certainly is. Also hard to measure. The common counterargument is that PCP's are being hired everywhere, so there must be a shortage everywhere. But there's an interesting problem with that argument -- there's good evidence that healthcare is supply sensitive - adding more supply drives more demand. Nobody wants an open schedule - that's just lost income. So when a doc opens a new PCP practice and sees their first patients, their schedule is wide open. They are very likely to recommend closer follow up. Why see that pt with HTN trying to lose weight in 6 months when you can see them in 2 and try to encourage this good behavior? The same is true for MRI machines, cath labs, and any other healthcare resource -- if you build it they will come. And studies that have looked at this usually show no improved outcomes -- more MRI's just costs more money without making anything any better. So just because everyone's schedule is full and practices are hiring doesn't necessarily mean that we really need more PCP (or any other) resource.

The Baby Boomers are often portrayed as a disaster on the horizon. And they may be - a bubble of people all of similar age. But if we "staff up" to deal with them, then what happens after they all die off? Then we won't need all of those docs any more - yet if we open more residency programs we will have them in the pipeline for 30+ years. And closing residency programs rarely happens.

I've already commented on the oft quoted figure about physician ages. The AAMC data above breaks it down between over/under 55. Overall, 55% are under 55 and 45% are over. That data makes me worry that the database is not capturing when physicians actually retire -- which doesn't surprise me greatly. If I were to retire this year, how would the AMA know that? I'm certainly not updating them, and I'd likely keep my medical license -- cost is small, CME is easy, and it's nice to have. So I expect their data is too high, they are including some retired docs. Even with that, there may not be a huge shortage once we include NP/PA's. And sure people may threaten to retire early, but unclear if that will really happen or not.

Some fields have big age skews. New fields trend towards more young physicians - ED is a great example. Didn't exist as a separate field when I was a resident, so not surprising there are less older physicians in it. Other fields swing the other way and may be a sign of impending collapse - Pathology.

And then there's the question of specialization. As more fellowships open and more residents leave IM for a subspecialty, that leaves less for PCP. Is the number of specialists right? Too low? Too high? There's no central management of this -- any program can open a fellowship.

And last is asking whether just pumping out more doctors is the right answer, or thinking about the whole "system". A good example is colonoscopy. Do we really need to train a zillion gastroenterologists to do screening colonoscopies? Or should we train techs to do them, leave the GI folks to do the complicated endoscopies? But screening colo's are the bread and butter for a GI practice, mention "taking them away" and you'll get lots of screaming of how unsafe it would be.

So, complicated.

Do you think they should let EM docs (or maybe give them some sort of shorter residency) to practice primary care given the job outlook?

 

[Future_Bone_Docta]

EM docs don't have the training to practice primary care as their residencies currently are. Acute stuff - fractures/injuries, infections, etc. - absolutely. But they are not trained in long-term management of chronic diseases or preventive care which is the bread and butter of family practice, and increasingly so in the era of value-based care and aging baby boomers. I would certainly not expect an ER doc to know when a patient needs a pap smear, what fourth blood pressure medication and third diabetes medication should be added in a medically complex patient, how to diagnose or treat osteoporosis, what unique preventive care needs a kid with Down's syndrome has, etc. Yes, these things can be learned...but they do need to be learned. (and FWIW, I would also say the reverse is true- most family docs don't have the training to work in an ER these days unless they get additional training in certain areas, particularly trauma care)

I totally agree, FM is its own beast. but they would be better equipped than a fresh PA/NP, no?

 

[Neopolymath]

The theme of any bureaucracy is to find a flashy solution that is easier than fixing the actual problem. People don't want to move to these places, much less physicians, for so many reasons. Better not actually fix/address some of those reasons and just indirectly force them there due to a terrible job market, pay, and corporate medicine in nice suburbs and cities. God forbid we take some time to actively promote even a 5 second thought about moving to these places.

Make a bunch of crappy training programs and the market will force these people into underserved locations eventually. The rest of the profession be damned.

The devil's advocate answer is that if we do nothing then midlevels take over and their currently completely BS lies about taking care of underserved (currently from rich suburban derm clinics lol) will actually become true. Radiology is in an interesting position, for example. Crazy imaging demands across the nation. We are looking great... But that means we also have an easy target on our back for CMS cuts and some program/groups pushing midlevels hard to "help out" (read: get rich).

You need a healthy need of physicians in each specialty ideally. Radiology is about to go too far and might suffer some consequences if our specialty isn't careful.

 

[JP2740]

The AAMC does not work for physicians.

 

[JP2740]

As already mentioned on this thread, it's a very complicated question with no real answer. You can argue both for and against a current shortage, or a future shortage, or no shortage at all. It's much like asking what we should do about the current economy and inflation. We can try to predict what's going to happen, make best guess moves to try to address the issue, and never know whether what was done made things better or worse.

We could look at it from a purely numbers perspective. How many patients can a full time PCP manage? 2000-2500 is probably a reasonable number, potentially more if you have a very efficient practice. Let's use 2500 for this example. Next, what's the population of the US? That's easy - 330 million. 330 million / 2500 = 132,000. So with perfect distribution, we would need 132K PCP's to manage everyone. This oversimplifies things -- I'm lumping kids in with adults, and the census may be undercounting people, etc. But it's at least a number to start with.

So how many PCP's are there? That's not so easy to measure, interestingly. Google reports all sorts of numbers. The AMA Masterfile in 2010 reported 200K. Some estimates are higher, some are lower. AAMC has some data, (reading more about this, it's actually all just a report of the same AMA Masterfile) suggesting 120K each of both IM and FP, so 240K together + another 60K in peds. Whether we should count NP/PA's is also complicated. And any counting system usually does not adjust for how much FTE / clinical activity they have. And whether Hospitalists count as primary care or not is also complicated. But we can see that we might actually have enough PCP's based on the raw numbers.

Distribution is often mentioned as a big problem, and it almost certainly is. Also hard to measure. The common counterargument is that PCP's are being hired everywhere, so there must be a shortage everywhere. But there's an interesting problem with that argument -- there's good evidence that healthcare is supply sensitive - adding more supply drives more demand. Nobody wants an open schedule - that's just lost income. So when a doc opens a new PCP practice and sees their first patients, their schedule is wide open. They are very likely to recommend closer follow up. Why see that pt with HTN trying to lose weight in 6 months when you can see them in 2 and try to encourage this good behavior? The same is true for MRI machines, cath labs, and any other healthcare resource -- if you build it they will come. And studies that have looked at this usually show no improved outcomes -- more MRI's just costs more money without making anything any better. So just because everyone's schedule is full and practices are hiring doesn't necessarily mean that we really need more PCP (or any other) resource.

The Baby Boomers are often portrayed as a disaster on the horizon. And they may be - a bubble of people all of similar age. But if we "staff up" to deal with them, then what happens after they all die off? Then we won't need all of those docs any more - yet if we open more residency programs we will have them in the pipeline for 30+ years. And closing residency programs rarely happens.

I've already commented on the oft quoted figure about physician ages. The AAMC data above breaks it down between over/under 55. Overall, 55% are under 55 and 45% are over. That data makes me worry that the database is not capturing when physicians actually retire -- which doesn't surprise me greatly. If I were to retire this year, how would the AMA know that? I'm certainly not updating them, and I'd likely keep my medical license -- cost is small, CME is easy, and it's nice to have. So I expect their data is too high, they are including some retired docs. Even with that, there may not be a huge shortage once we include NP/PA's. And sure people may threaten to retire early, but unclear if that will really happen or not.

Some fields have big age skews. New fields trend towards more young physicians - ED is a great example. Didn't exist as a separate field when I was a resident, so not surprising there are less older physicians in it. Other fields swing the other way and may be a sign of impending collapse - Pathology.

And then there's the question of specialization. As more fellowships open and more residents leave IM for a subspecialty, that leaves less for PCP. Is the number of specialists right? Too low? Too high? There's no central management of this -- any program can open a fellowship.

And last is asking whether just pumping out more doctors is the right answer, or thinking about the whole "system". A good example is colonoscopy. Do we really need to train a zillion gastroenterologists to do screening colonoscopies? Or should we train techs to do them, leave the GI folks to do the complicated endoscopies? But screening colo's are the bread and butter for a GI practice, mention "taking them away" and you'll get lots of screaming of how unsafe it would be.

So, complicated.

Train techs to do scopes? What techs are you referring to? What are you specialized in?

 

[voxveritatisetlucis]

Train techs to do scopes? What techs are you referring to? What are you specialized in?

There is already a significant push in some states to allow NPs/PAs to do colonoscopies and what not

That would pretty much be the end of GI docs working 3 days a week, making 600k

NPs and PAs Performing Colonoscopies: Why Not?

Even though gastroenterologists oppose the practice, nurse practitioners were trained to perform colonoscopies through programs set up at several major US hospitals. Yet, most have now been discontinued. Why?

www.medscape.com

The GI doc quoted in the article is exactly what is wrong with medicine and why midlevels have made such great strides.


Highly trained nurse practitioners (NPs) and physician assistants (PAs) are just as capable of performing screening colonoscopies as gastroenterologists: this is the conclusion from a number of studies conducted across both the United States and Europe.


So, why aren't more NPs and PAs doing them?

"We wanted it to take off, but we haven't been able to do it," said San Diego gastroenterologist Daniel "Stony" Anderson, MD. He spent decades working to expand access to colorectal cancer screening at Kaiser Permanente and other healthcare organizations, and has now been doing the same as president of the California Colorectal Cancer Coalition.

 

[jstwannagraduaaate!!!]

At least a quarter of All American doctors are over the age of 50, and they're going to be retiring soon, especially the baby boom docs who are going to be either retiring or dying off!

So while there may be a maldistribution of doctors now, there is a physician crunch coming.

And that older demographic makes up the majority of the us population, once they're gone there will be an oversaturation of docs due to the eagerness of some to over correct

 

[Goro]

And that older demographic makes up the majority of the us population, once they're gone there will be an oversaturation of docs due to the eagerness of some to over correct

We don't know that yet, do we????

 

[aldol16]

The AAMC represents medical colleges, not physicians. It would make sense for medical schools to increase residency slots because that means they can enroll more medical students without seeing a detrimental impact on their overall match rate. This will then increase their revenue from medical school tuition (economy of scale).

Additionally, even if CMS increases the number of funded residency positions, the distribution will be heavily skewed towards primary care specialties where there is a distributional if not numerical issue with the number of primary care physicians.

 

[aldol16]

I don't think fresh PAs/NPs should be practicing family medicine without appropriate additional training either.

Pretty sure that primary care doesn't require much additional training. It's a generalist position and that's the point - you just need general knowledge and the ability to look algorithms up. When you're in doubt, you can always refer out or get the patient to the right person to make the decision on whether a finding should be worked up more. Does this create more bloat in the healthcare system and inappropriate referrals? Yes. But it also provides many patients who lack care with some form of healthcare (we can argue over whether outcomes are inferior).

 

[NotAProgDirector]

Train techs to do scopes? What techs are you referring to? What are you specialized in?

I'm not specialized. I'm a hospitalist.

We train techs to do vein harvests in the OR. If techs can learn to do vein harvests, they can learn to do colonoscopies. If that's all they do, every day, they will get very good at it.

We're only talking about routine screening colos. Anyone with high risk would be seen by GI.

 

[cj_cregg]

Pretty sure that primary care doesn't require much additional training. It's a generalist position and that's the point - you just need general knowledge and the ability to look algorithms up. When you're in doubt, you can always refer out or get the patient to the right person to make the decision on whether a finding should be worked up more. Does this create more bloat in the healthcare system and inappropriate referrals? Yes. But it also provides many patients who lack care with some form of healthcare (we can argue over whether outcomes are inferior).

Hi, I am a primary care physician.

I strongly, strongly disagree with you. I'd argue that in some ways generalist fields like primary care, EM, and hospitalist are more challenging than specialized fields because you actually have an undifferentiated patient in front of you. Sure, the kid with the sore throat could have another viral URI...or a peritonsillar abscess or epiglottitis. The diabetic 50 year old coming in with a hot red hand could have cellulitis or gout...or nec fasc or pyogenic flexor tenosynovitis. The hallmark of a terrible PCP is that they don't know what they don't know, and that kills patients. Literally anything could walk through your door and you need to be able to know when to be worried about something serious/time-sensitive, and no, you can't always "refer out or get the patient to the right person to make the decision" when my patients are waiting at least 2, sometimes 6+ months to see a specialist, or in some cases can't see one at all because they're on Medicaid or uninsured (which accounts for 70-80% of my patient population). Maybe generalist medicine didn't require much additional training 40 years ago when the treatment for an MI was morphine and a prayer, but that's no longer the case.

And you also point out another major logistical challenge - PCPs who can't figure out how to manage reasonable things on their own are going to do unnecessary referrals and testing. This adds expense to a healthcare system that is already by far the most expensive in the world. It adds cost and barriers for our patients to receive appropriate care. It leads to poorer health outcomes when there is not someone who is adequately coordinating care between multiple specialists...like a PCP. And it adds an enormous burden to specialists who in my neck of the woods, are already hugely overbooked. If we all sent a bunch of patients to cardiology because we couldn't figure out what to do about a fib that's controllable with a beta blocker or anybody with abnormal LFTs to GI for workup, they would NEVER be able to keep up with the patient load, which hurts patients as well. Plenty of data out there on the benefits of good PCPs in a community both with health-related and cost-related outcomes if you care to look.

In summary, primary care is only easy if you're doing it poorly.

 

[jstwannagraduaaate!!!]

I'm not specialized. I'm a hospitalist.

We train techs to do vein harvests in the OR. If techs can learn to do vein harvests, they can learn to do colonoscopies. If that's all they do, every day, they will get very good at it.

We're only talking about routine screening colos. Anyone with high risk would be seen by GI.

Slippery slope. Also much different to teach a vein harvest than a procedure where you need medical knowledge to interpret your findings and make decisions on the fly. I don't think GIs just stick a tube up and 5 min later say "all good!" like mid-levels would likely do

 

[NotAProgDirector]

Slippery slope. Also much different to teach a vein harvest than a procedure where you need medical knowledge to interpret your findings and make decisions on the fly. I don't think GIs just stick a tube up and 5 min later say "all good!" like mid-levels would likely do

Well we're going to agree to disagree then. I think that dissecting a vein, tying off branches, keeping it healthy, all while staying sterile sounds like hard, complicated work. And I bet they make clinical decisions all the time. So is doing a colonoscopy. The primary factor that has been associated with quality colonoscopy? Volume. People who do more, find more. And do it better. I have no idea why you think a mid level would do a colonoscopy in 5 minutes. If you trained someone to do it, and at our shop GI folks get penalized if they finish them too quickly (since scope withdrawal time is also associated with polyp pick up rate). Anyone can do a crappy colonoscopy -- whether mid level or MD. SHould there be an doc available to step in when something atypical is found? Of course. Would this lead to some small number of people getting two procedures? Probably. But it would be much more affordable, scalable, and likely do more good.

I guess it's all about the execution. Could end up with Colo-R-Us shops with 50 techs and a single GI doc overseeing them cranking out colos every 10 minutes. reasonable regulations should prevent that -- minimum time per colo, max supervision ratios.

 

[jstwannagraduaaate!!!]

Well we're going to agree to disagree then. I think that dissecting a vein, tying off branches, keeping it healthy, all while staying sterile sounds like hard, complicated work. And I bet they make clinical decisions all the time. So is doing a colonoscopy. The primary factor that has been associated with quality colonoscopy? Volume. People who do more, find more. And do it better. I have no idea why you think a mid level would do a colonoscopy in 5 minutes. If you trained someone to do it, and at our shop GI folks get penalized if they finish them too quickly (since scope withdrawal time is also associated with polyp pick up rate). Anyone can do a crappy colonoscopy -- whether mid level or MD. SHould there be an doc available to step in when something atypical is found? Of course. Would this lead to some small number of people getting two procedures? Probably. But it would be much more affordable, scalable, and likely do more good.

I guess it's all about the execution. Could end up with Colo-R-Us shops with 50 techs and a single GI doc overseeing them cranking out colos every 10 minutes. reasonable regulations should prevent that -- minimum time per colo, max supervision ratios.

I'm sorry but this view is just not it, and it is takes like this that will lead to the downfall and eventual brain drain in medicine. I can't imagine going through 4 years of med school, getting into a good IM residency, clawing your way into GI all to be replaced/having a key piece of your livelihood taken by a midlevel who can just switch around to different specialties. And it's not going to make them any cheaper for the patient, they will still charge the same rates, if anything it'll be more expensive because it would consolidate more power to the hospitals as they could crank out a ton of scopes with their midlevel army

 

[Future_Bone_Docta]

I'm sorry but this view is just not it, and it is takes like this that will lead to the downfall and eventual brain drain in medicine. I can't imagine going through 4 years of med school, getting into a good IM residency, clawing your way into GI all to be replaced/having a key piece of your livelihood taken by a midlevel who can just switch around to different specialties. And it's not going to make them any cheaper for the patient, they will still charge the same rates, if anything it'll be more expensive because it would consolidate more power to the hospitals as they could crank out a ton of scopes with their midlevel army

Only problem is hospitals don't care about the patients.

And you murky the waters enough the patients won't know gastroenterologist from "Dr. xyz Nurse Gastroenterologist RN, BSN, NP, DNP, CGRN, CPT, LOL, ABC"

But a do agree the take from a moral perspective ain't it.

Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients

Background and study aims  The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, ...

www.ncbi.nlm.nih.gov

 

[cj_cregg]

Only problem is hospitals don't care about the patients.

And you murky the waters enough the patients won't know gastroenterologist from "Dr. xyz Nurse Gastroenterologist RN, BSN, NP, DNP, CGRN, CPT, LOL, ABC"

But a do agree the take from a moral perspective ain't it.

Experience of nurse practitioners performing colonoscopy after endoscopic training in more than 1,000 patients

Background and study aims  The demand for screening colonoscopy has continued to rise over the past two decades. As a result, the current workforce of gastroenterologists is unable to meet the needs for colorectal cancer (CRC) screening. Therefore, ...

www.ncbi.nlm.nih.gov

Gen surg and family docs also do scopes in some communities with adequate training, particularly rural areas where there are many more FM docs and surgeons than GI docs. This can offload some of the lower risk screening scopes from GIs (and offer a nice revenue source for family docs as well). It's not necessarily ideal but I feel like it's preferable to NPs/PAs. GIs have historically been hesitant to train anyone outside their specialty in scopes however.

 

[jstwannagraduaaate!!!]

Gen surg and family docs also do scopes in some communities with adequate training, particularly rural areas where there are many more FM docs and surgeons than GI docs. This can offload some of the lower risk screening scopes from GIs (and offer a nice revenue source for family docs as well). It's not necessarily ideal but I feel like it's preferable to NPs/PAs. GIs have historically been hesitant to train anyone outside their specialty in scopes however.

As they should be, I don't see ents teaching fm docs ear tubes, urologists teaching others how to do vasectomies, or opthos teaching cataract removals

 

[VA Hopeful Dr]

As they should be, I don't see ents teaching fm docs ear tubes, urologists teaching others how to do vasectomies, or opthos teaching cataract removals

I know several FPs who learned to do vasectomies from urologists.

 

[cj_cregg]

As they should be, I don't see ents teaching fm docs ear tubes, urologists teaching others how to do vasectomies, or opthos teaching cataract removals

Some FM docs do actually do vasectomies. I didn't have any ENTs teach me to put in ear tubes or ophthos teach me to do cataracts, but in residency they did teach me to diagnose and manage plenty of other problems and minor procedures that could theoretically otherwise be referred out. OBGYNs taught me to place IUDs and do EMBs and deliver babies. Dermatologists taught me to do cyst excisions and biopsies. Orthos taught me to do joint injections and casting. (Family docs who are experienced in these procedures also helped me learn these things, but I never came across a specialist who said "ugh no thanks I'm not teaching a family medicine resident to do this")

Most of these are relatively straightforward procedures that can be done in an appropriately equipped office, as are vasectomies and scopes for low risk patients. The same issues mentioned above related to demographic changes in patient population and physician workforce are going to put a squeeze on access to these procedures - somebody needs to do them. I see no reason why an FM doc with appropriate training should not be able to perform any of these, and while I did not choose to make scopes part of my practice, I don't see a reason they should be any different. The GI docs in my town are booked out WAY in advance for new patients.

 

[voxveritatisetlucis]

I know several FPs who learned to do vasectomies from urologists.

Y tho

I feel like even if I live 12 hours from the nearest urologist, I’m finding a way to get to that airport to see a urologist for a vasectomy

 

[VA Hopeful Dr]

Y tho

I feel like even if I live 12 hours from the nearest urologist, I’m finding a way to get to that airport to see a urologist for a vasectomy

Meh, from my understanding it's not difficult. And hyperbole aside, no one is driving 12 hours for a vasectomy in America.

 

[Future_Bone_Docta]

Some FM docs do actually do vasectomies. I didn't have any ENTs teach me to put in ear tubes or ophthos teach me to do cataracts, but in residency they did teach me to diagnose and manage plenty of other problems and minor procedures that could theoretically otherwise be referred out. OBGYNs taught me to place IUDs and do EMBs and deliver babies. Dermatologists taught me to do cyst excisions and biopsies. Orthos taught me to do joint injections and casting. (Family docs who are experienced in these procedures also helped me learn these things, but I never came across a specialist who said "ugh no thanks I'm not teaching a family medicine resident to do this")

Most of these are relatively straightforward procedures that can be done in an appropriately equipped office, as are vasectomies and scopes for low risk patients. The same issues mentioned above related to demographic changes in patient population and physician workforce are going to put a squeeze on access to these procedures - somebody needs to do them. I see no reason why an FM doc with appropriate training should not be able to perform any of these, and while I did not choose to make scopes part of my practice, I don't see a reason they should be any different. The GI docs in my town are booked out WAY in advance for new patients (I am often waiting ~3 months for an appointment with my own GI as an established patient, even for urgent concerns).

I do agree FM docs are qualified enough to do these more basic procedures and such, and I do agree FM >NP/PA.

But at that point why even make a gastroenterologist fellowship a thing? Why not just have internist attendings practice colonoscopies with a "seasoned internist" to become a "GI doc". Then you don't have to eat a fellowship salary (~65k) for 3 years and can just make internist money.

 

[cj_cregg]

I do agree FM docs are qualified enough to do these more basic procedures and such, and I do agree FM >NP/PA.

But at that point why even make a gastroenterologist fellowship a thing? Why not just have internist attendings practice colonoscopies with a "seasoned internist" to become a "GI doc". Then you don't have to eat a fellowship salary (~65k) for 3 years and can just make internist money.

Because the specialty of gastroenterology encompasses a lot more than doing colonoscopies