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Doctors face increased burnout rates, loss of autonomy and greater financial threats from nonphysician practitioners
The United States was short on doctors before COVID-19. The pandemic put massive strain on the entire health care system, pushing physicians to their limits as they try to care for patients. Health care organizations made changes in response, and not all were positive. Medical Economics® spoke with Alyson Maloy, M.D., FAPA, a member of Physicians for Patient Protection, a physician advocacy group, about the physician shortage and what it means for medicine in the long run. The transcript has been edited for length and clarity.
Medical Economics® (ME): What has COVID-19 taught us about the physician shortage in the U.S.?
Alyson Maloy, M.D. (AM): What COVID-19 has taught us is that the physician shortage in the U.S. right now is here and it’s severe. There (have) been a lot of predictions and projections … about when it would be and how many physicians the shortage would consist of. One of the most recent was that there will be a shortage of up to 124,000 physicians by 2034 and that would include primary care and specialty physicians. I don’t know what the shortage is as of this moment, but it’s here.
For example, I practice in Portland, Maine. This is the most urban area in Maine and people cannot find a primary care physician (or) a psychiatrist. They have to go out of state. Because of the pandemic, about half the psychiatrists in my state retired this year and we knew it was coming. It was an older population of psychiatrists, but it happened in one fell swoop and (they) weren’t able to transfer all their patients to new psychiatrists — and forget about people who for the first time are looking for a psychiatrist. Additionally, specialty care like neurology in this town is booking out about four months. That’s just not workable; most neurologic problems need to be seen within weeks, not months. COVID-19 really brought on the shortage sooner, because a lot of physicians who were maybe on the cusp of retiring just retired sooner.
Then of course, you have all the physicians …dealing with COVID-19 (who) were being taken away from their other, regular positions. Ironically, a lot of physicians were let go from their positions in the pandemic because hospitals needed to shut down elective surgeries. So those surgeons who were doing maybe ENT (ear, nose and throat), dental or orthopedic procedures were just let go because the physicians were costing the system too much money. Ironically, those same physicians were asked to volunteer on the front line (of the pandemic).
ME: Why have rural and underserved communities suffered even more during the shortage?
AM: Rural communities have suffered more historically because clinicians of all types — physicians, nurse practitioners, physician assistants — all practice in higher-
density urban areas. In terms of underserved communities, they are being hit more severely due to the physician shortage because patients may not be fluent or do not have the freedom of choice to go where they want to be treated.
I’ll use veterans as an example. Veterans have Department of Veterans Affairs, or VA, insurance, they are treated in the government health system and the VA has decided that all nurse practitioners can work independently from physician involvement, which is called full practice authority. So now the VA does not need physicians to accomplish seeing patients. A veteran who wants to use their VA insurance goes to the VA to get medical care and instead they’re provided with what’s called health care by someone who does not have a license to practice medicine independently but (has) been put in the position to practice health care independently — and the veteran has no option to get physician-led care.
ME: How has this shortage exacerbated the burnout problem
AM: I’ll first answer this question from my own practice. It is heartbreaking to get phone calls every day from people who really need my expertise and who, if I have the time, I could help and improve their quality of life. It is heartbreaking to have to say no and to know that person doesn’t have anywhere else to go. I fill every minute … of my day with patient care. If I block off a day that I would like to catch up on administrative tasks or take a day off, forget about it — I end up booking a patient just because my profession demands that we take care of people. It is just unimaginable to me that we live in a first-world country and people are suffering under this artificial physician shortage. There’s absolutely no reason for a physician shortage.
Another piece of the problem is that corporations and big lobbying groups have fed us the lie that it’s completely legitimate to fill a physician position with a nonphysician practitioner (NP), and that includes nurse practitioners, physician assistants and many other allied health professionals. There are many claims to the contrary but, to date, there has not been one published study that involved NP health care being provided without physician involvement somewhere in the study population, because either the physicians were given the more complicated patients or were reviewing the stuff done by the NP.
Corporations and big lobbying groups whose interest is to make money, their interest is not in providing quality patient care. This has happened because of the private equity takeover (of) the field of medicine. We have these organizations feeding us this lie to justify the practice models they are setting up.
Existence of this lie compounds physician burnout … because we see these terrible things happening to patients that would not be happening if they were being seen by physicians. That is just heartbreaking. I’ll give one simple example. A patient goes to see a nurse practitioner with a lesion on their finger. It’s diagnosed as a fungal infection (and) they’re treated with antifungals and other medications for six months. Lo and behold, it’s a melanoma and if a dermatologist had seen this, or a primary care physician, it would not have been diagnosed as a fungal infection. Melanoma is one of the most rapidly metastasizing cancers. Six months was basically a death sentence to that patient. That is demoralizing. The other piece of this that is demoralizing to physicians comes from the Dunning-Kruger Effect. That is a cognitive bias created by lack of knowledge, and it argues that people who have the most training are the most aware of their knowledge deficit. The people who have the least training are the least humble about their knowledge deficits and are least aware of them. As physicians, when we try to bring up this emergency in medical care in this country…with administrators or NPs, and we try to work on efficient, safe, effective medical teams that contain a physician expert, a nurse practitioner, a physician assistant, a social worker and an RN, we’re told we have this position only because we’re worried about money or about a turf war, or other nonsensical arguments that are really just a projection onto us.
There’s no physician I know (who) is approaching this crisis from that mentality. We would not have sacrificed our entire youth and all our finances for 15 years of working for less than minimum wage if we didn’t care about the profession. If you want to make a lot of money today, don’t become a physician. Like that’s no secret, right?
ME: Do you see health care organizations using the shortage as an excuse to install NPs in roles that a doctor should be leading?
AM: Don’t get me started. In Maine, in March 2020, the legislature pushed through in a matter of five days a physician assistant independence bill that had been languishing in committee for two years. That was the week that the state of Maine called (for) emergency shutdown. Every physician I know, myself included, was consumed in converting our practices to telemedicine, making sure we could continue to provide medical care for patients in a safe way. It was all hands on deck. Even one of my own professional organizations — when I spoke with their experts in legislative affairs, they had no idea that this law had even passed, and they’re all over these topics. It was really pushed through in this moment of crippling fear, when the state just wanted to make sure that physician assistants didn’t have to have some silly administrative form signed if a patient … needed emergency care. The problem was that there was no end date put on this legislation. So now we have this permanent law, that … after a certain number of clinical hours, a physician assistant can basically hang a shingle and function like a physician. ...People have freedom of choice, they have a right to go to whatever health care person they choose. This would not be a problem if patients knew about the differences in training between the different clinicians. Unfortunately, a lot of the lobbyists and their powerful corporate groups who make a lot of money (from) the confusion do everything they can to help patients not know who is seeing them, and the biggest way they’ve done this is to lump us all into one category and call us providers. There’s no longer a physician, nurse practitioner or physician assistant — we’re just providers, which is a very offensive term to physicians.
ME: What needs to happen to combat the physician shortage and make sure physicians are leading patient care?
AM: What needs to happen is creating more medical residency positions. The United States right now is 24th out of 28 countries studied in the number of primary care physicians we are producing; there is literally no reason for us to have a physician shortage. This is an artifact from the Balanced Budget Act of 1997. We have not grown the number of medical residency positions since the late ’90s. No other industry in the country has held steady at staffing numbers except medicine. In that same period, the number of medical school positions has increased by 30%. We have 10,000 medical school graduates right now. These are physicians who would be able to work in a physician position if not for the fact that we do not have enough medical residency positions, and they have been unable to complete their medical training. Someone who has about eight years invested in the process of becoming a physician and has their M.D. or D.O. degree — we have about 10,000 of those people who can’t practice because they weren’t able to do the residency piece. These medical school graduates are called assistant physicians. There are several states trying to pass legislation where these (assistant physicians) can have a pathway to practice at the state level because they have far more training than any other nonphysician provider, and it is insane to not use that incredible knowledge. Creating more medical residency positions is the No. 1 thing we need to do to combat the physician shortage.
As we speak, there is the Resident Physician Shortage Reduction Act of 2021. That was introduced by Sens. Bob Menendez, D-N.J., and John Boozman, R-Ark., and this would create 2,000 new residency positions over seven years. It will produce 14,000 more physicians over the course of those seven years — that’s not going to be sufficient. But that bill is in Congress right now and we absolutely need to get that bill passed. One thing we can do to reduce the physician shortage is to stop forcing physicians to spend what would otherwise be clinical time embroiled in ridiculous, nonsensical documentation and form filling. We could be so much more productive if all of us had scribes to do the office notes for us; if we had the right support staff. There (are) all these catchphrases out there about letting clinicians work to the top of their licenses. This is an argument for nurse practitioners to get full practice authority. This is an argument for Ph.D.s to get optimal team practice.
I say let physicians work to the top of our license; we do not need to be spending 20 hours a week hitting buttons on a computer to enter information into these archaic, electronic medical record systems. It is absolutely a waste of our talent. And that alone would free up a lot of physician hours to take care of patients.