Locums CME #2: Does the US Train Enough Docs? 7 Ways Locums Make an Impact; About the IMLC; Trends that Docs Fear Most & More

Our Top Story: America Trains Enough Doctors — Redefining Medical Supply and Demand

(Edited from KevinMD post by dermatology practice co-founder Rushi Negalla)

If the US medical system is a chessboard, and providers are the game pieces, America is playing those pieces with one column, row, and role instead of using the whole space.

Several journals, economists and medical professionals forecast physician supply to be dangerously low in 10- to 20-plus years. They’re 100% correct that supply won’t meet demand (as things stand now), but the reasons are flawed.

Alarmists have been complaining about doctor shortages for decades. Physician retirement and burnout don’t explain predicted gaps. The physician shortage everyone worries about is not a lack of new graduates but a grand misallocation of resources.

[Editor’s Note: While the debate continues–and until physician supply is increased or reallocated rather dramatically–the outlook for the locum tenens industry remains bright.]

The Numbers Don’t Tell All

In terms of raw supply, there are just over one million licensed physicians. According to a Federation of State Medical Boards census, the number of doctors grew by 20% from 2010 to 2020. Most of that growth (+168K physicians) is from new graduates.

In the same period, the US population rose ~7% to ~330M. The seemingly reassuring headline numbers are misleading.

Younger millennial doctors are seeking work-life balance; late-career doctors and burned-out providers put in fewer hours at the clinic. The number of doctors aged 60+ grew by 48%, while those aged 49 and younger grew by 16%.

In terms of fresh supply, the number of medical school graduates rose by 32% between 2011 to 2021, but in absolute terms, there were ~28K grads last year. The US population is a slow-growing mega-fountain, while medical providers are a fast-flowing sink faucet. It’s not practical to expect both to balance each other without help.

Shortage and Supply Aren’t the Same

More data gathered by the Kaiser Family Foundation indicate that one primary care doctor serves 665 people on average, while one specialist serves 584 people. The doctor-to-patient ratios appear extremely low in a vacuum, but most physicians can handle patient groups in the low thousands. There’s a critical difference between real capacity and max capacity.

If the US population doubled tomorrow, one average PCP could oversee ~1,300 patients, and one specialist ~1,100 patients. So why do both patients and economists keep worrying about doctor capacity? The answer: Shortage isn’t the same as supply.

Physicians don’t magically pop into clinics, see patients, and then poof away. Amazon.com is better at delivering packages anywhere in two days than we are at having doctors in the right place at the right time.

Hyper-urbanized regions have too many doctors chasing relatively concentrated patient populations. Meanwhile, rural areas have too few doctors to care for smaller numbers of patients who are more widely dispersed.

Most physicians in private and public settings practice during the traditional workweek, some limiting their patient appointments to just a few weekdays. Physicians have to do paperwork alongside patient care.

Even if physicians make themselves available to see thousands of people each, those doctors may still reject Medicare and Medicaid patients because such plans typically reimburse at much lower rates than private insurers do.

To remedy some of these healthcare-delivery woes, our physician supply needs to be realigned instead of rebuilt.

Realign, Rather Than Rebuild

Expanding AI office solutions, targeting more patient demographics by redefining “availability,” and carefully expanding the non-physician workforce (e.g., nurse practitioners and physician assistants) can maximize each doctor’s max patient panel enough to keep up with demand.

Fine-tuning office-visit timing while embracing technology and easing administrative hassles (i.e., vertically integrated disease/drug literature banks, chart notes, insurance claims, and payment systems) are the most appropriate supply-side adjustments. Offering additional time over weekends or after normal business makes care accessible to patients in certain demographies.

Supply must reach demand somewhere. Our country’s true medical care needs create the shortage in the first place. The Association of American Medical Colleges, or AAMC, publishes a 25-year forecast of physician supply. In their 2019 to 2034 review, the authors calculated demand based on demographic changes, the incidence of diseases affecting the related demographics, and care delivery setting.

Current U.S. medical needs suggest a lack of ~38K to 124K physicians and ~18K to 48K primary care doctors by 2034. Those are massive gaps compared to ~28K expected new medical graduates in 2021, but the AAMC lowered both top ends of those ranges by 12 to 14% year-over-year from their last report. The report highlights four nationwide scenarios for improving real medical capacity (and reducing shortage forecasts).

Total Physician Supply and Demand

Source: AAMC’s The Complexities of Physician Supply and Demand Report June 2021

Stretching Supply is Easier Than Reducing Demand

The first interesting, but impractical, shift to ease demand would have all covered patients join an HMO or ACO insurance network. In this world, medicine, doctors and money are vertically integrated like a company that owns its whole supply chain.

Unending political gridlock precedes this outcome based on current US healthcare policy and current insurance and physician trade group positioning.

The second demand scenario involves magical thinking, but remains a helpful reference point. The AAMC modeled what might happen if we all lost weight, cut glucose, quit smoking, and reduced cholesterol. Population-wide health improvements prevent shortfalls–but we’re human.

The next two possible futures in extending supply appear somewhat reasonable.

Thinking More Realistically

First, drugstore chains like CVS and Walgreens are sprouting more and more clinics. The proliferation of these retail clinics introduces alternative primary care facilities treating minor, but acute, issues. It’s efficient for patients to get basic goods, prescriptions, and routine medical exams at the same place. If referrals are necessary, patients can still get those permissions and move on to see specialists rather than wait for advice from traditional medical practices.

Second, adding more registered nurses and physician assistants under strict oversight could help plug gaps of care that doctors can’t easily reach.

Combining all these scenarios might ensure that providers can heal Americans faster while preventing the need to grow doctors on trees.

Whatever the consensus definition for the US physician shortage, cleaning up healthcare delivery, better utilizing retail clinics and advanced practitioners, and redefining availability to target broader patient-demographic segments can reduce the gap between clinician supply and patient demand. Patients who understand this situation will better handle whatever changes occur next to our fragmented healthcare system.

The late Dr. Ken Teufel quoted Harvard Business Review’s advisory board in a “Dr. Ken’s Corner” blog post for Interim Physicians dated June 23, 2020 [speaking about a predicted deficit of primary care physicians that could grow to 55,000 PCPs by 2023]: “It’s time to stop panicking about a looming ‘shortage.’ Rather, the real shortage is one of courage to disrupt the way things have been done for decades.”