Doctor Shortage...How Do We Fill the Prescription?

Medical Author: Benjamin C. Wedro, MD, FAAEM
Medical Editor: William C. Shiel, Jr., MD, FACP, FACR

The recent health care insurance reform passed by Congress gave hope to the millions of people who could not afford to insure themselves or their loved ones; but the forgotten part of the equation is that there might not be doctors to provide that care. The problem is that there aren't enough primary care physicians in the United States and the supply isn't going to catch up with demand any time soon. According to the Association of American Medical Colleges, there may be a shortage of 150,000 doctors in the next 15 years.

The numbers game begins with the length and expense of training a doctor. Usually a four year undergraduate degree is the entry requirement to four years of medical school, which is followed by three or more years of residency training to become a primary care provider like a family doctor, pediatrician, or internist. If all 18,000 students who entered medical school this year decided to practice primary care, it would take 11 years for them to see their first patient. If we kept that rate up for a decade, perhaps the physician manpower needs would be met. But what would the country do without the surgeons, cardiologists, obstetricians, psychiatrists, and other medical specialists whose ranks would be depleted?

The need to provide basic medical care, to have a place for a patient to call home, has been lost in the ever more specialized world of Western medicine. Primary providers spend much of their time coordinating the care recommended by other specialists and trying to prevent fragmented advice that is confusing to the patient. Often patients are uncertain as to whose advice to listen to, who their "regular" doctor might be, and whom to call with questions. With more pressure on doctors to expand their practice to add the newly insured, even less time will be available to spend with each office visit.

In the past years, physician extenders have developed their scope of practice to help ease the shortage of doctors and to allow more patients access to care. Physician assistants and nurse practitioners routinely assume the role of "family doctor". Some states require physician supervision of these practitioners, while others don't. The line of who can do what becomes blurred when a rural community just wants somebody, anybody, to care for their citizens.

Within the new health care laws are clues to whom the government would like to train. Medicare did not increase the funding for physician residency training programs but did add $50 million to train nurse practitioners. There were payment increases to entice physicians to choose primary care as a specialty, and some medical schools are expanding their focus or rural medicine, hoping to train doctors for smaller communities.

The physician manpower shortfall is not news. Medical school tuition averages more than $40,000 per year, and may lead to large student loan debts that can drive newly minted doctors into specialties that are higher paying. The debt also influences where these doctors practice; poor neighborhoods and small towns may not be able to entice new grads. The shorter length of training for nurses and physician assistants means that their financial burdens may be less.

Ultimately, the question of who will provide primary care will not be as important as asking if there will be enough care providers to service the needs of the population. Most patients don't care whether the letters after the name are MD, RN, or PA. All they want is a caring person who smiles and says welcome.

REFERENCE: Tuition and Student Fees Reports: U.S. Medical Schools Tuition and Student Fees - First Year Students 2009-2010 and 2008-2009.

Last Editorial Review: 4/15/2010