Covid exacerbates physician shortage - Medical Economics

The United States was short on doctors before COVID-19 hit. The pandemic put massive strain on the entire health care system, pushing physicians to their limits as they try to care for patients in an environment where there already weren't enough doctors to go around. Health care organizations made changes to adapt, and not all of them were positive.

Medical Economics spoke with Alyson Maloy, MD, FAPA, member of Physicians for Patient Protection, to discuss the physician shortage and what it means for medicine in the long run.

(Editor's note: The transcript has been edited for clarity and brevity.)

Medical Economics: What has COVID taught us about the physician shortage in the US?

Alyson Maloy: What COVID has taught us is that the physician shortage in the U.S. right now is here and it's severe. There has been a lot of predictions and projections put out there about when it would be and how many physicians the shortage would consist of. And one of the most recent ones was that there will be a shortage of up to 124,000 physicians by 2034 and that would include both primary care physicians and specialty physicians. However, 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 the state of Maine and people cannot find a primary care physician and they cannot find a psychiatrist, period. They have to go out of state at this point. Because of the pandemic, about half of 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 psychiatrists weren't able to transfer all of their patients to new psychiatrists, and forget about people who for the first time are looking for a psychiatrist. And additionally, in specialty care like neurology, neurology in this town is booking out about four months. And that's just not workable, as most neurologic problems you need to be seen within weeks, not months. So COVID really brought on the shortage sooner, I think, because a lot of physicians who were maybe on the cusp of retiring, just retired sooner. And then of course, you have all the physicians being taken up dealing with COVID itself that were being taken away from their other regular positions. I will also add that 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 procedures or dental procedures or orthopedic procedures, they were just let go because the physicians were costing the system too much money. And ironically, again, those same physicians were asked to volunteer on the front line.

ME: Why have rural and underserved communities suffered even more during the shortage?

AM: Well, rural communities have suffered more historically because clinicians of all types—physicians, nurse practitioners, physician assistants—all practice in a 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. And I'll use veterans as an example. Veterans have veterans 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 that 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 have 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 in medicine?

AM: Well, I'll first answer this question from my own practice. What I can say is it is absolutely heartbreaking to get phone calls every single day from people who really, really need my expertise, and who if I have the time, I could actually help them and improve their quality of life. It is absolutely heartbreaking to have to say no, and to know that that person doesn't have anywhere else to go. I fill every single minute and more 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 absolutely 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 there to be 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 non-physician practitioner, and that includes nurse practitioners and physician assistants, and also many other allied health professionals etc. There are many claims to the contrary, but to date, there has not been one single published study that involved NP health care being provided without physician involvement somewhere somehow in the study population, because either the physicians were given the more complicated patients, or they were reviewing the stuff done by the non-physician practitioners, etc. So 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 the field of medicine. We have these organizations feeding us this lie to justify the practice models that they are setting up. And this whole existence of this lie compounds physician burnout. Number one, because we see these terrible, terrible things happening to patients that would not be happening if they were being seen by physicians. As a physician, that is just absolutely heartbreaking. You know, 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, 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 if a primary care physician had seen this, it would not have been diagnosed as a fungal infection. And as we know, melanoma is one of the most rapidly metastasizing cancers. So six months was basically a death sentence to that patient. That is demoralizing. And the other piece of this that is demoralizing to physicians is comes from this thing called the Dunning-Kruger Effect. That is a cognitive bias that is 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 the least aware of them. And so as physicians when we try to bring up this emergency in medical care in this country, and we try to have conversations with administrators or with non-physician practitioners, and we tried to coordinate and collaborate and work on efficient and safe and effective medical teams that contain a physician expert and a nurse practitioner and a physician assistant and a social worker and an RN, etc., we're told that we have this position only because we're worried about money, or we're worried about a turf war, or other nonsensical arguments that are really just a projection onto us. There's no physician I know that is approaching this crisis from that mentality. I mean, we would not have sacrificed our entire youth, and all of 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 non-physician practitioners in roles that a doctor should be leading?

AM: Don't get me started. In Maine, in March of 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 same week was the week that the state of Maine called emergency shutdown. So every physician that I know, myself included, was completely consumed in converting our practices to telemedicine making sure that we could continue to provide medical care for patients in a safe way. It was all hands on deck. And even one of my own professional organizations, the APA, when I spoke with their experts in legislative affairs, they had no idea that this law had even passed in May, and they're all over these topics. It was really pushed through in this crippling 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 was in a dire emergency and needed emergency care. The problem was that there was no end date put on this legislation. So now we have this permanent law, that physician assistants after a certain amount of clinical hours, I believe it's 4,000—I'll just say that after a certain number of clinical hours, a physician assistant can basically hang a shingle and function like a physician. And you know, this would not be a problem at all because we live in the United States of America and 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, in fact, patients knew about the differences in training between the different clinicians. And unfortunately, a lot of the lobbyists and a lot of their powerful corporate groups who stand up, make a lot of money off of 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 just lump us all into one category and call us all providers. There's no longer a physician or nurse practitioner or physician assistant, we're just providers, which is a very offensive term to physicians.

ME: Patients are often taking a very consumer mindset of just wanting to see a medical practitioner as quickly as possible. Do you think patients understand the true difference between a doctor and nurse practitioner and the level of care and training, even though they might be in a rush and want to see a nurse practitioner because they're available sooner?

AM: Because of this physician shortage and needing to wait weeks and months or maybe having to leave the state or whatnot, patients are ending up needing to see non-physician practitioners. There's no problem with seeing a non-physician practitioner and in fact, no member of Physicians for a Patient Protection disparages the importance of nurse practitioners and physician assistants. We believe that all of the clinician types that we have in the United States are important on a health care team. We advocate for a physician expert to be on each and every one of those teams. So as long as that nurse practitioner or physician assistant that our patient is going to see is part of a physician-led team where they can consult a physician if the problem is out of their scope or if they have some questions, that's fine. Or, really, in an ideal situation, a physician should be supervising closely and should be able to see these patients seen by the non-physician practitioners, right at the same visit, they may spend less time with the patient and the non-physician practitioner can see the patient, do the physical exam, create the differential diagnosis, maybe even come up with a preliminary diagnosis in the clinic preliminary treatment. But again, let me remind you of the Flexner Report, which was done in 1910 and established in the United States of America what it takes to practice medicine independently. If we would like to change those standards, then we should do another Flexner Report until those standards are changed. And until we all collectively agree that we don't need or want that level of expertise of the people seeing us and we're putting our life in their hands, then a physician needs to be intimately involved in all patient's medical care. And if a physician is not involved, I would go so far as to say the patient isn't receiving medical care, they're receiving health care. And that is another new term invented by corporations and by non-physician practitioners. Think about it: you and I are old enough to go back 20 years in our minds, and you go to a doctor's appointment, right? You get medical care. And in the book, "Patients at Risk: The rise of the nurse practitioner and physician assistant in health care," which was written by Niran Al-Agba, MD, and Rebecca Barnard, MD, this was published in 2019. And one of the frightening examples in the book involves patients who go to urgent care clinics believing they're receiving medical care, and in fact, they're not. They're being seen by a non-physician practitioner, and they have no idea they're receiving this big thing called health care. They're requesting and paying for medical care, yet there is no person with a medical license anywhere to be found.

ME: Why are so many health organizations embracing non-physician practitioners? Is it simply a matter of them trying to save money?

AM: Well, non-physician practitioners do not save money. That is another one of the terrible lies that the public has been sold. The malpractice policies on non-physician practitioners are less expensive than the malpractice policies on physicians, but the reason for this is for physicians our training is standardized. Our skill set is confirmed. And we have to do a lot of examinations and certifications and supervision to prove that we are qualified to practice medicine independently. Therefore, if we fail in any way, shape or form to meet those standards of care, we will be held responsible in a court of law. The same is not true for non-physician practitioners. If a patient sees a nurse practitioner, and that nurse practitioner fails to meet the medical standard expected of a physician, that patient has no recourse in a court of law. They go to court, the court says nurses practice nursing, physicians practice medicine, this nurse cannot be expected to perform medical decision-making, this nurse met the standard to be expected of a nurse, and case closed. Patients do not know this. And they don't understand that when they're seeing non-physician practitioners. There is no right of theirs to demand a certain level of quality. So, institutions that hire nurse practitioner save money. Sorry, they save money in the malpractice policies of the non-physician practitioners. Also, in many of those systems, non-physician practitioners make the system more money due to their lack of medical training, because they order more studies, more lab tests, more imaging studies, more referrals to specialists. And usually, all of those lab tests, imaging and referrals to other specialists are done within the medical system. So that medical system makes a ton of money off that one patient problem. So a patient can go for a simple problem, they can have one office visit with a physician who diagnosis the problem correctly, they get the right treatment, they need no lab tests or imaging studies and problem solved. If that corporation or medical system has a lot of non-physician practitioners, oftentimes that patient will have multiple visits for the same problem, they will have multiple studies done all at a higher cost for the patient. So one of the reasons that organizations are embracing non-physician practitioners is number one, they save money on malpractice policies. Number two, they make more money within the system off of those non-physician practitioners. Also, due to the differences in the culture of the different disciplines, non-physician practitioners are in fact easier to control by the administration of these corporations. Physicians take the Hippocratic oath, we have a duty to patients, we are in medicine and it is a helping profession, it's a service profession, we are obligated to put the patient's needs above our own. And there are, by the way, a lot of laws that make that standard. Non-physician practitioners are not held to those same professional standards. And so it's very easy to set up a clinical system that a physician would not accept as safe or sufficient. But other types of clinicians would just go along with it. And the final point I'll make on that question is that part of the reason that a lot of these systems are embracing non-physician practitioners, in addition to the ones I've just stated, is the actual legitimate physician shortage. I should qualify that last statement with sometimes the shortage is real, and sometimes that shortage is fabricated, such as with emergency medicine; the shortage there is no shortage of emergency medicine physicians, and I was speaking with a friend of mine who works at a high level in a medical system and he was saying you can't recruit emergency medicine physicians in rural areas and they have to hire non-physician practitioners. And when I pushed him on this, he admitted that in fact, actually that's not true, that the cost of the physician is higher. Again, this gets down to malpractice cost, not salary cost.

ME: So what needs to happen to combat the physician shortage and make sure physicians are leading patient care?

AM: The number one thing that 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. And the in that same period of time, the number of medical school positions has increased by 30%. So 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 MD or DO degree, we have about 10,000 of those people who can't practice because they weren't able to do the residency piece. So these medical school graduates are called assistant physicians. There are several states who are trying to pass legislation where these APs can have a pathway to practice at the state level, because they have far more training than any other non-physician practitioner, and it is insane to not use that incredible knowledge. So creating more medical residency positions, is the number one thing we need to do to combat the physician shortage. And as we speak right now, there is the Resident Physician Shortage Reduction Act of 2021. That was introduced by Senators Bob Menendez (D), New Jersey, and John Boozman, (R), Arkansas, and this would create 2,000 new residency positions over seven years. So 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. The other thing I will add, 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's all this 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 PhDs 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 with.

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