Physician shortage in the U.S.

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Tune into this episode of PwC's Next in Health to hear PwC Health Research Institute's Trine Tsouderos, and Strategy& Principal, Igor Belokrinitsky, in discussion with PwC’s Consulting Solutions Director, Aparna Kumar, on how the U.S. can overcome the shortage of healthcare workers, including:

  • Physician workforce projections released in The Association of American Medical Colleges’ (AAMC) annual report
  • The pandemic’s impact on the physician shortages
  • Decreasing regulatory barriers for internationally educated physicians could ease the burden of physician shortages
  • Short-term strategies to address physician workforce shortages

Topics: physician shortages, clinician shortages, healthcare workers, physicians, COVID-19, health

Episode transcript

Find episode transcript below.

Trine Tsouderos (00:04):
Welcome to HRI's Next in Health podcast. I'm Trine Tsouderos and I lead PwC's Health Research Institute. I also lead the firm's Business Insight sectors team, which produces thought leadership on everything from financial services to energy, to technology.

Igor Belokrinitsky (00:19):
And I'm Igor Belokrinitsky. A principal with PwC Strategy&.Trine and I are here with Aparna Kumar. Who's a director in our firm's Consulting Solutions practice. She works extensively with organizations that train physicians both nationally as well as internationally.

Trine Tsouderos (00:35):
Great, welcome Aparna.

Aparna Kumar (00:37):
Thanks, It's great to be here.

Trine Tsouderos (00:39):
Sure. So we've been hearing about a clinician shortage for years now. I feel like this is something that we hear about every couple of years and there's a steady drum beat of warnings that we are either in a clinician shortage or shortly we will be in one, but we happen to have some fresh statistics handy. Thanks to a new report from The Association of American Medical Colleges, also known as the AAMC. And so this new report it's called the Complexities of Physician Supply and Demand Projections from 2019 to 2034. And they took a look at the physician supply situation and made some calculations about where this issue is headed. And here are some of the fresh projections from the AAMC. They said that the U.S. Is facing a primary care physician shortage of between 17,800 physicians and 48,000 by 2034, a shortage of non-primary care specialty positions of between 21,000 and 77,100 positions by 2034, including a shortage of up to 30,000 for surgical specialties and up to 13,000 or so for medical specialties and up to 35,600 for other specialties.

Trine Tsouderos (01:56):
So clearly quite a gap. A lot of this demand, the report says is because of the aging American population, which includes doctors. The retirement of physicians is part of the issue 2 0f 5 physicians will be 65 or older within the next decade. The report says. And so what we have is this issue of who is going to be delivering all the care that we will need. I think we know due to the pandemic that access to care is not evenly spread across the country. So we might need even more clinicians than we currently have per 100,000 population. And so I think this is one of the reasons that this topic is so timely right now. And so Aparna, it's so great to have you here to talk about it. This is just the right time for this kind of conversation.

Igor Belokrinitsky (02:50):
So Aparna it really sounds like AAMC has climbed up on the roof and turned on the bat signal and sounded the warning about this coming physician shortage. What's going on here?

Aparna Kumar (03:01):
Yeah, absolutely. It's interesting. So there has been this warning sort of coming in the past few years. This is not a new problem that we're facing, but I think the pandemic has really exacerbated how loud and how wide reaching this message is right now. Primarily. It's really the perfect storm, right? Your population is aging. That includes physicians. The shortage of physicians is also exacerbated by the fact that there's a lot of retention issues in the current cohort of physicians that we already have. And the average age of physicians now is I think 51 years and growing with every new study that comes out. So we need more physicians per capita. And now with the pandemic, the whole issue of health equities has come to the forefront where you find that there is a significant shortage, even more so than in urban areas, in underserved communities, rural areas, et cetera.

Aparna Kumar (03:59):
So what the AAMC has done is really brought this issue to the forefront and like the reason that you categorized it as a bat signal, shouting the rooftops, because if we found ourselves caught on our back foot during this pandemic, if this current situation continues, I think it's going to have a significant impact on the health of the overall population. As we see it currently.

Trine Tsouderos (04:25):
Aparna, can you talk a little bit about how the pandemic in particular, you mentioned that the pandemic has sort of exacerbated the situation, put a highlight on the need for access. How has that sort of manifesting with the clinician shortage?

Aparna Kumar (04:41):
The pandemic at its very core it kind of exposed the deep disparities in the healthcare system. I don't think anybody was prepared to respond to a crisis of this scale, but the lack of resources, not just physicians, but healthcare workers in general, medical services, especially in communities of color, racial, ethnic minority groups and rural and underserved areas, they were disproportionately affected by the pandemic and access to just basic healthcare.

Aparna Kumar (05:11):
We also know that, of course the majority of the essential workers come from minority groups. So they're inherently at higher risk of exposure to especially the COVID-19, but acute infectious diseases in general. And so when you put that together with the shortage of healthcare access and especially physician access amongst this population, you can really see the data weave a story around increased transmission, low vaccination rates, disproportionate hospitalization deaths in these communities. So I don't think we can completely decouple the shortage of physicians nationally with the health disparities and the health equity issue that we've been talking about all these years. But in addition to these long-term effected access to health care, et cetera, there are a number of short term effects of the pandemic as well, directly on the absolute numbers within the physician workforce. So there's positions of course, leaving the workforce for various reasons, which I won't go into in great detail, but there's disruption to the training of students, undergraduate students and residents, and coupled with an increased demand for healthcare. And so we'll see some of these consequences play out over the next few years as data emergers, but suddenly there are macro level events that sort of accelerated over the past 16 or so months during the pandemic

Igor Belokrinitsky (06:40):
It seems like an impossible equation to solve because it takes a long time to train a highly qualified clinician. And we don't have that time. So how do we solve this equation? How do we begin at least to start addressing some of this shortage in the near term?

Aparna Kumar (06:57):
So fortunately the supply exists, there's been about 29 new medical schools since the turn of the century, Maura coming on board Congress has passed the first major expansion to residency program slots in 25 years, it's been a long time coming down has happened. And these new medical schools have had no problems filling their slots. Students are interested in doing medicine and one bright, shiny star going out of the pandemic is that there's a particular increase in health care careers amongst students. There are places like California that have also shown decreased high school dropout rates amongst the seen Caldwell or the students that expressed an interest in healthcare couriers. So there's supply on the admission to medical school side of things. And then there is a supply from international medical graduates as well. I think the rate limiting factor here there is infrastructure. So assuming you have a pipeline of interested students, are there enough medical schools to educate them and then are there enough residency program slots to help them complete their clinical training.

Aparna Kumar (08:06):
That's a solvable problem to have, you can think of organic and inorganic ways of trying to solve that problem, but we'd be in greater trouble if there was no supply.

Trine Tsouderos (08:18):
So Aparna, you talked about or mentioned the internationally educated physicians coming to the U.S. Can you talk a little bit more about that? What's the trend been? Where are we headed with that? And is that kind of the stop gap as we have these students start to work their way through the medical schools and become trained clinicians?

Aparna Kumar (08:39):
Yep, absolutely. It's not a silver bullet by any means, but there's precedent. So if I draw a parallel, it has been done before, nurses trained in the Philippines were admitted to the U.S. In large numbers in the 60's and 70's, and they helped, alleviate a major nursing shortage of healthcare crisis at that time. I mean, certainly there are policy implications to it beyond just a pure supply of physicians, but currently about 25% of licensed physicians in the U.S. are international medical graduates.

Aparna Kumar (09:13):
It's a significant amount, it's a quarter and for an international medical graduate to be licensed to practice in the U.S. They need to go through residency training. They need to train in the U.S. system. So certainly an increased availability of slots is a major consideration, which Congress has acted on not in the recent past. So there are a number of U.S. students who also currently studying medicine in the Caribbean and do their clinical rotations and match for residency training in the U.S. so the supply of international medical graduates actually currently outpaces the availability of training opportunities in the U.S. so that causes a little bit of a bottleneck in terms of who's trained to provide the service. And then what do they need to do to get licensed to actually work in that capacity? I think though beyond that, certainly it's a complex situation that will require a multi-pronged approach. So the question isn't just about, can we supply the absolute number of physicians need to serve the per capita health needs of the population? I think the question is how can we get creative and inventive now with the disruption that this has caused to traditional medical delivery around the use of advanced practice providers around the use of telehealth and virtual health to triage through needs to physicians and also access those underserved areas and underserved communities so that they can then be brought into the medical system from a need standpoint.

Igor Belokrinitsky (10:49):
Aparna, you've come to challenge us today about this looming shortage but you are also giving us hope that there might be some solutions out there, through whether it's bringing in more international practitioners to changing the way we think about the delivery of care and supporting and extending the reach of a clinician. And obviously this is a highly regulated space, everything from immigration rules and guest worker rules to the scope of practice rules. So for an organization that's looking to come up with a plan, what kinds of pieces of legislation do they need to be keeping an eye on what do they need to be watching to get an indication of where we're moving in the right direction?

Aparna Kumar (11:31):
Yup. And that's where it starts getting a little more complex. So when we talk about purely just physicians shortage and organic and inorganic ways to solve that problem, you're looking at a few pieces of legislation in the recent past that have provided some hope. So certainly there doesn't see slots. It's a big step. It's one, the most direct way of addressing the physician shortage issue that 2000 positions annually over the next 10 years brings us from about 14,000 more slots, which is great, but digging into a deeper, I think it's really the diversification of the healthcare workforce, as well as thinking about ways to attract a broader contingent of people who are willing to work as physicians in rural and underserved areas. And there's been a good amount of published research, actually that international medical graduates in particular have a creative propensity to primary care specialties in rural and underserved areas to a certain degree that is also supported by government incentive programs, such as the G1 visa waiver program.

Aparna Kumar (12:43):
And some others that kind of allow them entry into the U.S. But those are limited stock gaps. So from a quality standpoint, there is certainly some ways to go to incentivize physicians, to practice in rural areas and stay in rural areas over longer periods of time. And then of course, as we discussed the care models that could also help alleviate some of this burden.

Trine Tsouderos (13:09):
So a few years ago, HRI published a report looking at primary care in particular. And one of the questions we had was if you take a look at primary care and kind of break it up into its component parts and say, put together a team of nutritionists and mental health workers and physical therapists, and all of these others are ancillary services, could you extend the reach of the primary care physician and thus alleviate the shortage? So I wonder if there's that kind of team thinking where you can alleviate the shortage in part, by using a more holistic multi-faceted team approach to delivering primary care or other services as well. What do you think about that? Are we seeing that in our healthcare providers and other organizations?

Aparna Kumar (13:55):
Yes, there has been a specific emphasis in physician education on interprofessional education. So it's a required part of the curriculum for the medical education program that physicians are trained to work in these diversified care team, the multifaceted care teams, working with physicians assistants and mental health counselors, physical therapists, et cetera. And so the emphasis is being put on the medical schools themselves to train physicians, to work in these collaborative care models. So that it's at the grassroots level training physicians to perform in these sorts of teams. I think from a provider standpoint, certainly it's an evolving situation. We're still trying to figure out a workable business model for a number of institutions around how such a care model group work. There's certainly implications to payout and reimbursement and so on and so forth, but it is happening.

Aparna Kumar (15:03):
And I think that's definitely something to hang some hope on.

Trine Tsouderos (15:06):
Yeah. I think one of the findings that we had with that particular report was that if you ask physicians who they want to have on the team to treat their patients, there's this huge number of these kinds of folks. So they want to have nutritionists at their fingertips. They want mental health counselors at their fingertips. They want all these different pieces, but then if you ask them, if they have those pieces at their fingertips, the percentages were much lower. I think we have seen some strides, like you said toward that, but it's more complicated than it might seem on first blush.

Igor Belokrinitsky (15:37):
Aparna can you think of a near term example of a disruptive change or something innovative that somebody's trying to address this issue in the near term and deal with the shortage?

Aparna Kumar (15:50):
Sure. There's a health system in the Southeast that recently moved to a midwives model for prenatal care instead of the patient, seeing the doctor every month and every couple of weeks in advanced pregnancy, they saw the midwife and they would check into the hospital and have care provided by the physician during the labor and delivery process. And this model has worked extremely well. The patient outcomes have been great. Patient satisfaction has been great. There's been an increased uptake of patient volume as well, because, you know, you just have the leverage to provide more care, more personal care, to a broader set of patients throughout the pregnancy, and then bring the medical professional, the doctor in rather towards the end stages when such characters born injured and needed. This is just a little example that there's similar models cropping up all over the country and suddenly shows that innovation is taking these. It's just more from a crossroad standpoint.

Igor Belokrinitsky (16:51):
Fantastic example. And that's also of course, an area where we see some of the greatest disparities in health is around maternal health. So glad to hear that there's an intervention that's targeting it.

Trine Tsouderos (17:02):
I think this has been a fascinating discussion about the needs, where we're headed and some of the solutions to the physician shortage that is on its way in a significant way. Thank you so much Aparna for sharing that with us and talking with us about that today.

Aparna Kumar (17:19):
Thank you for having me.

Igor Belokrinitsky (17:21):
For more on these topics, and other health industry insights, driven by policy, innovation and care delivery changes. Please visit our website at Until next time, this has been Next in Health.

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Igor Belokrinitsky

Principal, PwC US

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