Physician Shortage Spreads Across Specialty Lines
—By Scott Harris
It is widely known that the nation is in the grips of a physician shortage. When doctors, patients, and advocates discuss the effects of that shortage, the conversation typically centers on primary care. And while primary care providers and patients undoubtedly feel the effects, physicians in a range of other specialties also are struggling to meet patient needs.
As with family and internal medicine, specialist shortages can overburden practices and departments, cause longer patient wait times, and severely hamper or altogether prevent access for those living in areas where shortages are most acute.
According to statistics from the federal Health Resources and Services Administration (HRSA), by 2020, demand is set to outstrip supply in several specialties, with nonprimary care specialties in general projected to experience a shortage of 62,400 doctors. General surgery is predicted to be among the hardest hit, with a shortage of 21,400 surgeons. The number of practicing general surgeons is expected to fall to 30,800 by 2020 from 39,100 in 2000. Ophthalmology and orthopedic surgery are each expected to need more than 6,000 additional physicians over current levels. Urology, psychiatry, and radiology all are expected to see shortfalls of more than 4,000 physicians, according to the HRSA figures.
"These shortages are driven by the demographics of the population," said AAMC Chief Advocacy Officer Atul Grover, M.D., Ph.D. "If you look at how the population has changed, it is not only growing in size but also getting older. The boomers are starting to retire. When you look at the older individuals, they use far more health care services than younger adults do. Individual specialists need to be consulted on systems-based illness. Primary care doctors can do a lot of this, but not all of it."
The aging population in and of itself will also have a direct impact on specialties. Medical advances mean that once fatal diseases are now treated as chronic conditions. This is great news for patients, but at the same time, specialties such as geriatrics, oncology, and endocrinology (which handles diabetic patients), are becoming more important—and more thinly spread—among the population. A 2007 study conducted for the American Society of Clinical Oncology (ASCO) by the AAMC's Center for Workforce Studies found that demand for oncology services is expected to rise 48 percent between 2005 and 2020. During the same period, the supply of oncologist services is expected to grow only by 14 percent, translating to a shortage of between 2,550 and 4,080 oncologists.
"One of the big diseases that stands out is cancer," Grover said. "Older adults are much more likely to get cancer than younger people, increasing demand for oncologists, surgeons, and postoperative cancer care."
Another severe shortage lies in the relatively small field of dermatology. According to a recent study that analyzed data from the American Medical Association Masterfile of doctors, only 3.5 dermatologists currently are available for every 100,000 Americans. Lead study author Jack Resneck, Jr., M.D., associate professor of dermatology at the University of California, San Francisco, School of Medicine and chair of government affairs for the American Academy of Dermatology (AAD), said the shortage is caused largely by the cap on the number of residency training slots supported by Medicare funding; since 1970, the number of dermatology residencies has hovered at around 300 per year. According to AAD figures, as of September 2009, there were 9,179 practicing dermatologists in the United States. Patient wait times average about 34 days for new patients, and in some cases can run as long as three months.
"It's an unquenchable thirst in a lot of ways," Resneck said. "Long wait times are common. You never feel caught up. It's frustrating. We try to triage patients who need to get in sooner, but we spend a lot of our day dealing with phone calls from people who feel their problems are urgent. And for dermatologists who want to retire or add another physician to their practice, it's a challenging environment. About a third of dermatologists are looking to hire an associate in their practice at any given time."
Dermatology practices are trying telemedicine to work in remote areas, and are testing different pilot programs designed to fund new residency slots without Medicare support, as well as "hybrid" residency programs that partner teaching hospitals and health systems with programs in underserved areas.
In general surgery, sea changes in training models are a major reason for the shortage. Anthony G. Charles, M.D., M.P.H., an assistant professor in the department of surgery at the University of North Carolina at Chapel Hill School of Medicine, said the issue is only getting worse. "We have a problem," Charles said. "Over the past 25 or 30 years, the number of surgeons has been pretty static as the population increases. If you get in a car crash, your primary care doctor will be a surgeon. So we can't ignore this." Charles said residency programs need to be created or expanded to address the shortage, but added that expansion alone would not be enough. "The traditional role was that everyone trained in general surgery and then broke off into subspecialties," Charles said. "But now, early subspecialization exists in some areas, such as plastic surgery and vascular surgery. Good, oldfashioned general surgery now does not exist as much.
The surgeon who can deliver a breadth of care essentially is no more." Specifically, the phenomenon known as progressive specialization, in which surgeons bypass general surgery training and enter fellowships in subspecialities like laproscopy, oncology, and trauma, is steering physicians away from general surgery, Charles said. Charles proposes shorter training periods for general surgery, as well as more streamlined and standardized expectations for what general surgeons will learn. "Training a general surgeon currently takes five years. Early and progressive specialization are here to stay," Charles said. "We could reduce the length of training from five years to four, knowing people will subspecialize.
You can increase the pool because you have reduced the training time. There is a natural evolution of narrowing the general surgery practice anyway. So if you train in 15 common procedures very well, you do not need five years to train on that. Other cases can be referred to specialists." He also said a culture change may be in order. "People also think there are two tiers of surgeons, with general surgeons being surgeon light. We have to change that mindset." Interestingly, the relentless advance of medical knowledge can also exacerbate shortages. This is particularly true in pediatrics, where, contrary to other specialties, generalists are plentiful but many subspecialists are scarce. "We've learned in recent years that kids are more than just small adults," Grover said. "They are physiologically different.
The knowledge base in pediatrics has expanded rapidly and we now need a broader range of pediatric specialties, which spreads the workforce more thinly." Another factor behind the shortages in some specialties is work-life balance. According to Resneck, this has been a problem in dermatology for years. "We've been dealing with the reality that women and younger physicians in general tend to work a little less, and the younger generation just has a different expectation for work-life balance, "Resneck said.
Resneck said he understood why primary care was the main target of attention on Capitol Hill and in the general public, but said other specialties should be included in the discussion, particularly when it comes to lifting the current cap on the number of residency slots that can be supported by Medicare. "We would love to see the cap lifted," Resneck said. "A lot of the dialogue in Washington has emphasized primary care. Dermatologists very much understand that we need to do something about our primary care shortage. We just want people to be aware that there are patient care implications from shortages in other specialties, too."