According to the Association of American Medical Colleges (AAMC), our doctor shortage will exceed 90,000 physicians by 2020. America’s medical schools are increasing their enrollments to meet this demand, but medical school graduates must also complete a residency training program in order to complete their training. Unfortunately, the residency programs have limited slots and don’t seem to be keeping pace with enrollments. Why is this occurring? The number of federally funded residency training positions was capped by Congress in 1997 by the Balanced Budget Act, resulting in an inadequate number of positions available for medical school graduates. Congress has continued the cap on the number of federally supported residency training positions to this day. The physician shortage has resulted in long waits for patient appointments, fewer primary care providers, and grossly underserved communities. These unfortunate outcomes are evidenced by the recent Veterans Administration saga.
The physician shortage has resulted in long waits for patient appointments, fewer primary care providers, and grossly underserved communities.
So, what are the solutions? There is the problematic “Missouri solution.” I am referring to a bill that was endorsed by the Missouri State Medical Association and was signed into law by Governor Jay Nixon. The law permits medical school graduates who haven't yet passed their final exam to treat patients in primary care settings. The new law requires these physicians to be directly supervised on site by a "collaborative" physician for 30 days, after which the “assistant physician” could treat patients provided the supervising physician is within 50 miles. The law requires the collaborative physician to review a sampling of the assistant physician’s medical records every two weeks. The assistant physicians, who will be licensed by the state, are graduates of medical schools who were not accepted into a residency program. They will be asked to be astute diagnosticians and manage complex diseases in both adults and children. They simply don’t have the requisite training or practical patient exposure, and, as a result, patient safety will be compromised. Additionally, the assistant physicians will have difficulties obtaining medical liability insurance coverage since their risk of medical liability is also significant. Another question is whether the assistant physicians meet the current Medicare and Medicaid participation and billing requirements.
The pressure that Missouri is experiencing, as one of the most medically underserved states, is understood. The American public, however, does not want physicians who have not completed their training to practice medicine. This is a bad precedent because no one deserves second-class care. Beyond the Missouri solution or the hope that Congress will increase the funding for residency openings, there are several options that should be considered. We could move away from the current physician-centric paradigm. For example, we could increase the number of physician extenders like advanced practice registered nurses (APRNs), also known as nurse practitioners, and physician assistants who can ameliorate the problem by providing much needed primary care to these patients. The first stage of this has already occurred vis-à-vis CVS and Walgreens on-site clinics staffed by physician extenders.
It has also been suggested that we should reduce the number of years of medical school training. Four years of premedical training can perhaps be reduced to three years, and the fourth year of medical school may also be reduced. In fact, there are medical schools who are now offering three-year programs. Along with this, we could provide physicians some relief for the student loan debt they incur during their training, which presumably would improve the number and quality of the applicant pool.
Lastly, physicians today are spending less time with patients. We must reduce the clerical tasks that don’t require physician-level expertise and can be handled by other healthcare professionals like, for example, scribes. All of these solutions have potential pitfalls that could trigger waste, fraud, and abuse issues let alone impact the quality of care.
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