A REFRESHER ON WHY THERE IS A PHYSICIAN SHORTAGE
A refresher on why there is a shortage of physicians…
Congress sets the number of physicians that will be trained in residency per year. The Centers for Medicare and Medicaid Services(CMS), pays for these residencies. In the ’80s, the American Medical Association , the Association of American Medical Colleges(AAMC) and other medical groups predicted and ultimately convinced Congress there would be a glut of physicians in the upcoming years. Subsequently, the American College of Graduate Medical Education(ACGME) froze residency slots and and the Council on Graduate Medical Education(COGME) reduced the number of international medical graduates(IMGs), which was 25-30% of U.S. medical school graduates, to less than 10%. Then in 1997, the Balanced Budget Act was passed by Congress to cut back on Medicare spending, including the funding needed for residencies. Congress capped the number of residency spots at 1996 levels. They have never lifted that cap. And the predicted glut never happened.
In fact, over the years, the opposite occurred-a manufactured physician shortage due to the cap. To address this “shortage”, more medical schools opened. No one had the forethought to concomitantly expand residencies to accommodate the expected increase in the number of medical school graduates. This invariably led to a bottleneck in which many qualified residency candidates were unable to match. On average, there are approximately 8000+ unmatched medical school graduates per year. That 8000 would go a long way in addressing the shortage AND improving access to physicians. But instead of lifting the cap, the most obviously responsible solution, our inefficient, corporatized, ho’ish hellcare system and clueless government decided that the over-utilization of non-physician practitioners(NPPs) would be a cheaper and preferable option than using actual physicians.
However, one individual recognized how absurd it was that so many potential physicians were left rotting on the proverbial shelf and believed that valuable education should not go to waste. Enter orthopedic surgeon and former Missouri state representative, Dr. Keith Frederick. In 2014, he proposed legislation for the first Assistant Physician(AP) program in the U.S(not to be confused with Physician Assistant). This program enabled unmatched graduates to work in primary care, with limited supervision by a physician with whom they have a collaborative agreement, in underserved and/or rural areas of Missouri. This model permitted these assistant physicians to maintain their clinical skills and didactic knowledge until they could re-apply to residency.
As of Feb 2023, 292 APs are licensed to practice in Missouri and have expanded Primary Care in rural areas by 3%(https://www.statnews.com/2023/05/18/assistant-physicians-missouri-law/). Since the introduction of this program, six more states(Arkansas, Kansas, Utah, Arizona, Louisiana, and Idaho) have enacted the same legislation. Tennessee has AP legislation pending. Additionally, in May of 2023, Tennessee Governor Bill Lee signed legislation that grants provisional licenses to international medical graduates who possess full licenses, in good standing in their country, thus increasing the number of physicians in Tennessee. My hope is what Governor Lee has accomplished will set a precedent for other states to follow, if they are serious about addressing the manufactured physician shortage. Last but not least, anyone and everyone who wishes to increase the number of physicians in the United States should support the Resident Physician Shortage Reduction Act of 2023. A mind is a terrible thing to waste. Indeed.
“A mind is a terrible thing to waste, but a wonderful thing to invest in.” –United Negro College Fund slogan
Thank you for this piece, which a physician friend forwarded to me. I appreciate the information and the update on the more recent history of this issue. I want to draw to your attention, and to your readers’, a book which presents an authoritative academic history of “health care” in America, commencing in the first decade of the 20th century. It is thick, a little tedious, and laconic as far as pointing salient issues and drawing conclusions, but it is also rock solid, thoroughly documented, tremendously informing and provocative. On its showing (among much much else) the AMA’s conspiracy (an accurate word in the context) to limit the number of medical school graduates in America dates back now 80 years and more.
Christy Ford Chapin, Ensuring America’s Health: The Public Creation of the Corporate Health Care System (Cambridge University Press, 2015).
Thank you again for your article. Keep on keepin’ on.
I appreciate your response.
It took me several years to recognize that the shortage was manufactured, not happenstance. I began to suspect a conspiracy when it became evident after several years that no glut was on the horizon, but a shortage. Yet no lift of the cap occurred. It made no sense that new medical schools were consistently being approved for accreditation in a supposed effort to increase the number of physicians, with no concomitant expansion of residencies. So how were these graduates expected to practice with no residency? They weren’t. While med schools were making buck off students with no guaranteed internships, competition for residency slots became fierce, creating a scenario ripe for exploitation. Providing unpaid “opportunities” for unmatched grads to supposedly strengthen their applications. The powers that be all the while knowing that these grads weren’t being accepted not because of a weak application, but because there were no positions available. Giving them false hope. But hospital unpaid “fellowships” and research opportunities abounded. And within the resident medical educational complex there was a witnessed increase in the number of unnecessary fellowships. Both of these events not only effectively extended the pool of indentured servants, but increased the time they were expected to “serve”. Saved the corporate run hospitals gads of money. Many fellows believed that these added on educational opportunities would enhance the ability for them to get top jobs. Sometimes it did, sometimes it didn’t.
The strategy was brilliant. Create an influx of multiple revenue streams within the medical complex while limiting the number of physicians. Why? To corporatize health care. Completely. For profit. On the surface, it defies logic that since there is a shortage, the pay to physicians will increase and we know corporations consider physicians to be their highest expenditures. A good solution would be to then force physicians to become employees who had little to no say over their salaries. They would either accept the inevitable whittling down of the reimbursement or benefits…or quit. Docs willing to take the cuts would then be hired or even better, corporate employers would begin replacing physicians with non-physician practitioners(NPPs), who are cheaper and less likely to rebel, while ensuring the remaining docs retained liability for those NPPs. Everybody wins except the physicians–and patients. And all this s**t would occur under the fake altruistic guise of “filling” the shortage that the AMA and Congress created in the first place. It begs the question, since the AMA influenced Congress to place the cap, why haven’t they, in almost 30 years, persuaded them to lift the cap? Because it would undue exactly what was intended to happen. Make medicine a cash cow.
I don’t know…call me paranoid. But that’s my take.
Thanks for this, Natalie. Read Christy Chapin’s book. It will open your understanding of the problem — and of possible solutions — into many new dimensions. The plot is deeper and thicker, and the players more numerous and more networked, than we can possibly realize by extrapolating from present effects. This has been going on since before the First World War.
I’m not surprised to hear that the process began even before I was born and that insurance companies are at the center of it. Diabolical. I will order the book. I’m very interested in reading her info. Thank you.
There is no physician shortage.
There is only a shortage of physicians willing to be screwed.
Not sure where you got the 8000+ figure. According to the match website, only 254 applicants went unfulfilled in 2023. Nevertheless less, your points are valid, and well stated.
First of all there was NO need for Congress to have to FUND residency slots. Prior to the residency hour reduction, and the increased supervision and resulting lack of independent management (and loss of skills) the average resident made money for the program. We functioned as senior level residents at a current attending level. The amount of additional basic work (scut) alone covered my salary with inner city hospitals understaffing or hiring staff that existed to pay party dues. My senior years I easily was generating a million dollars in billing with a salary of 25k.
This money has gone into further bureaucracies and wasted costs. Each specialty should determine the needs (we dont want unemployed people with 300k in debt and 15 years of education either) and allocate the spaces. It can be up to the programs to budget .
The surgery program I attended had 4 staff and 6 residents it now has 20 attendings and 18 residents although it is now integrated and 6 years rather than the 2.
It seems that without market signals, the number of physicians needed is pure guesswork. The way physicians are treated today those that can are retiring as soon as possible, the shortage will get worse, not better. This will especially become acute in the surgical sub-specialties.
The ARNP pipeline is wide open, applicants can simply get online degrees, and the sick patients have someone in a white coat to see them. Of course you can count on the bureaucrats to screw things up. Honestly I do not understand why someone would want to enter our profession in this day and age unless it was for a specific non-employed and non-insurance related subspecialty….like plastic surgery. The insurance companies have squeezed us, physician management companies have squeezed us, we are unable to unionize and are treated like rats that can be put on treadmill, in order to spit out RVU’s. The patients do not like it, we do not like it, and the healthcare CEO’s are making millions off of our work.