Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
By Bonnie Darves
Physicians wrapping up their training might be a bit anxious about whether they’ll land a position, but these days, in nearly all specialties, that just isn’t a valid concern. The U.S. physician shortage — perennial, if lessening in primary care and becoming more acute by the year in several specialties — pretty much assures that most graduates will have ample practice opportunities.
In the physician workforce, the shortage comes down to the intersection of not just supply and demand, but increasingly, changing demographics as well — notably the aging population. From the standpoint of the projected need for medical services, that particular demand driver is being called, not so jokingly anymore, the “silver tsunami.”
Somewhat ironically, the supply situation will be exacerbated by the aging of the physician workforce: in 2015, 43.2% of active U.S. physicians were age 55 or older. In addition, the number of Medicare-funded training spots has been effectively frozen for two decades, squeezing the pipeline.
This is what the overall shortage looks like, based on the Association of American Medical Colleges’ recently updated projections: By 2025, the country will have a shortfall of between 61,700 and 94,700 physicians. The shortage range AAMC predicts is 14,900 to 35,600 in primary care, and between 37,400 and 60,300 in non–primary care specialties.
That latter category worries a lot of people in academic medicine, health care delivery organizations, and the health policy sector. Janis Orlowski, MD, MACP, the AAMC’s chief health care officer, said that while primary care and psychiatry are two sectors designated federal Health Professional Shortage Areas by the U.S. Health Resources and Services Administration (HRSA), there are growing shortages in many specialties, especially surgical ones, that are less well tracked.
Psychiatry remains a persisting shortage specialty, research suggests, and there is no solution in sight, particularly in child and adolescent psychiatry. A recent study conducted for the Department of Health and Human Services found that the specialty’s workforce — now numbering approximately 45,580 — would need 2,800 more psychiatrists just to meet current care demands. In addition, large areas of the country have no psychiatrists.
The shortage is almost palpable to psychiatry residents, even early in their training. Rashad Hardaway, MD, who finished his fellowship at Seattle Children’s Hospital in June 2017, remembers being “casually recruited” before he completed his first year of residency.
“It started as soon as I began my training,” said Dr. Hardaway, who is an attending at Zucker Hillside Hospital in Glen Oaks, New York, and practices in the Northwell Behavioral Health College Partnership Program. “My family members knew people working in community health centers, and they would say, ‘Have Rashad let me know when he gets ready to finish training, because we have a job for him.’ It puts a little pressure on you, just knowing that there is such a need everywhere — that you won’t be able to serve those populations.”
Kali Cyrus, MD, an assistant professor of psychiatry at Yale University who practices at the Connecticut Mental Health Center in New Haven, started receiving a steady influx of recruitment email inquiries even before her chief year, and then it intensified noticeably. “It really escalated then. I tended not to unsubscribe because it’s nice to know what is out there, even though I planned to stay in the East. It was a little overwhelming,” said Dr. Cyrus, who recently completed a public psychiatry fellowship and now also heads Yale’s Social Justice and Health Equity Curriculum Design.
Surgical specialties’ supply threatened
The AAMC’s 2016 update on physician supply and demand identified several non–primary care specialties where shortages are becoming acute. “We are hearing a lot about an increasing shortage in the surgical specialties, particularly vascular surgery and neurosurgery, but also general surgery, urology, and ophthalmology. And these shortages are severe in some rural areas,” Dr. Orlowski said.
The AAMC report indicates that under even conservative scenarios, the surgical specialties shortfall will reach at least 25,200 by 2025 but might hit 33,200. Although that prediction is cause enough for concern, the maldistribution of physicians — higher concentrations in urban areas and a relative dearth in rural ones — makes shortages particularly acute in some specialties. A recently published HRSA report developed by the firm IHS, which conducts research on the physician workforce, projected a 41% shortfall in urology by 2025. The report also predicted a deficit of 2,970 general surgeons, 6,180 ophthalmologists, and 5,050 orthopedic surgeons by 2025. By far, the most severe surgeon shortfalls will occur in the South, a deficit of 10,210 FTEs, according to IHS research.
There are inherent challenges in predicting the effect of shortfalls in surgical specialties, Patrick V. Bailey, MD, medical director of advocacy for the American College of Surgeons, points out. “Unlike primary care, there has been no objective definition established by HRSA as to what constitutes a surgical shortage area for general surgeons,” he said. What that means is that when projections are made, primary care’s baseline is in the deficit range, Dr. Bailey explained, while “the baseline for surgery is assumed to be zero because no definition has been objectively established. This puts surgery at an unfair disadvantage despite its importance as a necessary component of a community-based health system.”
Neurosurgery, vascular surgery sound alarm
The worst-case scenario in AAMC’s surgeon-shortage predictions is top of mind in vascular surgery. Michel Makaroun, MD, president-elect of the Society for Vascular Surgery and chief of vascular surgery at the University of Pittsburgh, states the case in simple terms. “We’re bringing in 150 new vascular surgeons each year, but we really need closer to 200 to meet future services demand,” Dr. Makaroun said, “because we have one of the highest mean ages among the surgical specialties. Probably one-third of practicing vascular surgeons are over 55 today.”
A research report published in Health Affairs in November 2013 (Dall, T. et al.) supports Dr. Makaroun’s point, predicting demand growth of 31% by 2025 — the highest for any specialty. It’s a distressing number for a small specialty, which has only an estimated 3,800 board-certified physicians.
The vascular surgery shortage translates in to more than ample practice opportunities for graduates. “Our trainees are getting a lot of job offers — and it’s estimated that for every graduating vascular surgeon, there are two or three jobs waiting out there,” Dr. Makaroun said. “And search firms tell us that one of the biggest needs for locum tenens is in vascular surgery. Some of our members use their vacation time to help fill that need.”
Niten Singh, MD, FACS, who directs the vascular surgery training program at the University of Washington, echoed Dr. Makaroun’s observation about the job market for graduates. “I think at first our trainees are nervous they won’t find a job. But we reassure them that they have a lot of options — that it’s a great time to be in vascular surgery,” Dr. Singh said. He and other faculty encourage residents to make some decisions early on, about “what they’re looking for and where their family will be happiest,” he said, to help ensure they choose the right job. Dr. Singh cites one recent case of a trainee who had lined up seven interviews for highly desirable opportunities within weeks of starting his search.
“I also remind our residents that there are many great places to practice in this country where there’s a need,” Dr. Singh said. “But if they want to live in New York City, they’ll obviously have to compete with the volume of surgeons there.”
Neurosurgery is another small specialty — there are only approximately 3,800 board-certified U.S. neurosurgeons — that is struggling mightily to address not only the current shortfall but the expected worsening shortage as the population ages. Today, there is only one practicing neurosurgeon for every 60,000 Americans, but that number takes trainees into account, according to Robert Harbaugh, MD, director of the Institute of the Neurosciences and chair of neurosurgery at Penn State University in State College.
“There really is a shortage, and it will only get worse for a lot of reasons,” said Dr. Harbaugh, a former president of the American Association of Neurological Surgeons. Many of the common things that neurosurgeons deal with — spine, stroke, and tumor, for example — all occur at much higher rates, he observed, as the population ages. And like vascular surgery, neurosurgery is also an “aging” specialty; 45% of all practicing neurosurgeons, including trainees, are over age 55.
In addition, the number of training spots has been essentially flat for more than a decade, increasingly only 1%, and a mere 200 physicians enter neurosurgery training each year. “That is essentially just replacement level,” Dr. Harbaugh points out.
“The other thing feeding into the shortage is we’re simply doing a lot more now in neurosurgery. Using deep brain stimulation for Parkinson’s or tremor is common today, and it wasn’t even around 15 years ago,” Dr. Harbaugh said.
The upshot, he added, is that all practicing neurosurgeons are “enormously busy. At the same time, it’s hard for patients to find a neurosurgeon outside the urban area. People talk about the shortage of primary care physicians, but the shortage of neurosurgeons is every bit as acute,” he said, considering the specialty’s crucial role in trauma and stroke services.
The worrisome news for the specialty as a whole is a boon of sorts to new neurosurgery graduates. Residents all get plenty of job offers, training program directors report. “Right now, there are many more positions than there are people to fill them, and neurosurgeons are being contacted about positions long before they start their chief year,” Dr. Harbaugh said.
Emily Sieg, MD, MS, a Pennsylvania neurosurgeon who is completing a fellowship in critical care at Penn State, knows that her dual training — a relatively new services approach in the neuro-ICU setting — puts her in especially high demand. “At every place where I have interviewed or looked at, people are very interested in and excited about bringing in a neurosurgeon on the critical care faculty,” she said. “This [combination] is opening a lot of doors for me — it’s something that a lot of hospitals don’t have but are interested in offering.”
On a related note, the shortage is neurology is posing challenges for dedicated neuroscience programs and health systems, and by extension, for recruiters. According to a 2016 HRSA report, the supply of neurologists will grow by 11% between now and 2025, while demand is projected to grow by 16%.
“Neurology is a big one where I’ve having trouble filling positions, and where many of us recruiters have been struggling for quite a while,” said Wanda Parker, president of the National Association of Physician Recruiters (NAPR) and a principal with the Healthfield Alliance in Danbury, Connecticut. “I think that in primary care, practices are able to deal with some of the shortage by bringing in physician assistants and nurse practitioners, but you really can’t do that in specialties like neurology.”
Other specialties feel the pinch
In some of the other non–primary care specialties, the shortage is hard to quantify but readily discernible to those in the field and to recruiters who struggle to help organizations fill positions. Patrice Streicher, associate director of the search division for Vista Staffing Solutions, cites her top-five shortage-fueled recruiting challenges: psychiatry, emergency medicine, hospitalist medicine, endocrinology, and rheumatology. “As an industry globally, both in-house and agency recruiters are all struggling with these specialties,” said Ms. Streicher, a NAPR board member.
Ms. Streicher pointed to another specialty, this one a relative newcomer, where rising demand is eclipsing supply: urgent care. “We hear so much about the primary care shortage, but we’re also seeing a worsening shortage in urgent care, perhaps because of consumer trends,” she said. “People want to be able to see a physician when it’s convenient, even if that’s a Saturday afternoon, for medical issues that don’t require going to the emergency room.”
Cardiology, like neurosurgery and vascular surgery, is a specialty that is already coping with the growing influx of baby boomer patients and increasing rates of cardiovascular disease while simultaneously dealing with an aging workforce (more than 40% of general cardiologists were over 55 in 2013). The shortage persists despite brisk enrollment in training programs — there were 2,598 general cardiology fellows in 2014, a 20% increase from 2005; and applications to interventional cardiology training programs increased by over 30% from 2011 to 2015, according to an October 2016 report in the American Journal of Cardiology (Narang, A. et al.).
Other significant contributors to the shortage in cardiology — the aforementioned Health Affairs report predicted a 20% increase in services demand by 2025 — are the aging workforce and maldistribution, according to George Rodgers, MD, an assistant professor at the University of Texas at Austin, who led a landmark 2009 American College of Cardiology workforce report.
“Yes, there’s a sense that we have a shortage of cardiologists because there’s been little difference in the number of new cardiologists being minted since 2009. But our biggest issue is the maldistribution,” Dr. Rodgers said. “We’ve got a high concentration in urban areas and a low concentration in rural areas — and that’s throughout the United States.” Many practices that have struggled to recruit cardiologists have implemented care teams incorporating advance practice clinicians such as nurse practitioners, Dr. Rodgers noted, but that isn’t a solution to the imminent demand surge, given that more than 40% of the population is expected to have cardiovascular disease by 2030.
For now, Dr. Rodgers observed, the skewed supply-and-demand picture “means that 100% of physicians finishing a cardiology fellowship get a job, but many areas of our country will remain underserved,” he said. “I have no trouble attracting cardiologists to Austin, but if I were in McAllen, Texas, it would be much harder.”
Seeking remedies for the shortage
A debate about the severity of the physician shortage is ongoing, but there is consensus that addressing the shortfall will require a multifaceted approach. It’s also accepted that simply creating team-based care models incorporating nonphysician providers won’t suffice. Likewise, the fast-track training pathways, such as the integrated residencies in some surgical and non–primary care specialties, will help alleviate the shortage — but not anytime soon.
“We’re making inroads into addressing the shortage, but the numbers are going to be impressive, so we have to continue to work on this,” Dr. Singh said.
The approach that holds the greatest potential for reducing the shortage, many physician organizations, training program leaders, and policymakers maintain, is to increase the number of government-funded graduate medical education (GME) training spots to better reflect the increasing and aging U.S. population. Recently crafted legislation, the Resident Physician Shortage Reduction Act of 2017, calls for an additional 15,000 Medicare-supported residency positions over the next five years.
“There will be a significant workforce shortage under all likely projections, and the most effective solution will be to train more physicians,” Dr. Orlowski said.
The American Medical Association, a longtime proponent of increasing the number of medical residency slots, is intensifying its efforts. The AMA’s SaveGME campaign, an initiative urging Congress to protect federal funding for GME, encourages residents to get involved by writing to their elected officials and educating patients on the role that trainees play in care access.
The AMA also recently urged the Centers for Medicare and Medicaid Services (CMS) to modify requirements that new residency programs meet stringent criteria within five years to continue qualifying for an appropriate GME funding level, to allow programs in underserved or economically depressed areas more time to get established.
Omar Maniya, MD, MBA, an AMA board member and emergency medicine resident in New York City, said that the five-year period is unrealistic in some cases. “The current five-year deadline for developing new residency programs in underserved areas before a cap is placed on the amount of Medicare funding they can receive is not effective,” he said. “We will urge CMS to give institutions the time they need to identify qualified, willing teaching partners to create residency programs … to meet the needs of patients in underserved areas.”