I was sad to read 2 articles this week about 2 separate physicians who took their own lives. One was an overwhelmed practicing Emergency Physician and the second was a physician in training, who had failed to obtain a residency position. I did not intend for this week’s post to be about physician suicide and mental health, but was surprised by what I found on researching the topic. We lose about 1 physician per day to suicide or 300-400 per year which is 28-40 per 100,000 and more than double the general population. Doctor’s rates of suicide is the highest of any profession and is attributed, in part, to the stress, sleep deprivation, high demands and competitiveness that begin with Medical School. And our rates of successfully completing the act of suicide, like everything else that us highly motivated physicians do, is alarmingly high. It is also disheartening that so many troubled physicians don’t seek help when they need it for a variety of reasons. If either you or a colleague you know needs help, please seek that help or encourage them to do the same.
Writer’s Note:
I am certainly not intending to seem crass about the topic of physician suicide, but as I came across the (above) two articles in my research this week, I realized that this represents yet another source of the physician shortage and wanted to include this important topic in the post.
For the most part, no practicing physician needs to be told that there is a shortage of physicians. They experience it every day in their practice through any number of ways. This could be the constant onslaught of requests for appointments from new or existing patients. Otherwise, it can become evident when you require the assistance of a colleague in an alternate specialty and you realize the wait time for your patient is longer than you had expected or hoped. Additionally, the shortage problem may involve a particular specialty, location, or even a specific population. I have spent the past 2 decades practicing medicine in a rural town that is economically dying (and technically has been for several decades) and that is populated by a largely elderly retired blue collar population. This is the trifecta of factors creating a physician shortage; rural location, economic decline, and a population that is made up of predominantly complicated elderly patients.
As of the March 2019 data from the Kaiser Family Foundation, there were about 1 million actively practicing physicians in the U.S. (479,000 Primary Care Physicians and 525,000 Specialists which includes surgery). These numbers do not, of course, account for full-time or part-time status. Based on the April 2019 update from the Association of American Medical Colleges (AAMC), there is expected to be a total physician shortfall between 46,900 and 121,900 physicians by 2032 (21,000-55,000 in primary care and 25,000-66,000 in non-primary care). These may be underestimates based on the following factors:
- Continued aging of the population.
- Achieving population health goals will further raise demand.
- Achieving improved healthcare utilization by underserved populations will further raise demand.
- More than two out of five currently active physicians will be 65 or older within the next decade and changes in physician retirement decisions could have the greatest impact on supply.
- The trend toward fewer weekly hours worked is reducing Full-Time Employment Physician supply.
How can this expected shortage of physicians be corrected? Is the answer not as simple as increasing the number of Medical School positions? The answer is complicated including the fact that the delay in training of 4 years for Medical School and 3-7 years for Residency/Fellowship training for each physician will certainly prevent the U.S. from reaching the required numbers of practicing physicians in time (sadly right about the time when I expect to be reaching that point in my life when I will require more medical services). But the more complicated aspect of this scenario is that the U.S. would likewise need to expand the number of Residency/Fellowship positions for the increased number of Medical School graduates.
Currently, the AAMC 2019 figures are as follows:
# of 1st year Medical Students in U.S. (2019) 21,622 (Allopathic), 8124 (Osteopathic)
# of 1st year Residency Positions in U.S. (2019) 35,185
# of 1st year Fellowship Positions in U.S. (2020) 11,545
These positions are funded under the Medicare Graduate Medical Education Program based on legislation originating in 1965 when it was determined to be an important investment in the future of Medicare to fund the education of health care providers. Through a series of formulas based on the law, Medicare pays each training hospital approximately $150,000-$170,000 per resident per year for a total of about $10-15 billion per year. Therefore, in order to increase the number of residency positions, laws would need to be changed and the increased costs would need to be funded.
It is true that writing new laws and increasing government spending are significant challenges. However, I think the greater challenge would be to increase medical school enrollment to the numbers needed to correct the shortfall for a variety of reasons including the length of time and incurred debt involved in medical training (median medical school debt of about $200,000 which does not include debt from premedical education). Dare I mention delayed gratification, physician lifestyle concerns, uncertainties in the future of healthcare, and decreased physician satisfaction associated with medicine’s bureaucracy as additional impediments to increasing Medical School enrollment?
I have not addressed the fact that further compounding the shortage of physicians is early retirement and career change to non-clinical positions due to dissatisfaction in medicine. I am always surprised by the number of articles, blogs and websites devoted to physicians who left the practice of medicine to pursue an alternate career after coming to the conclusion that they just weren’t fulfilled in medicine, were suffering from burnout, or felt like the actual practice of medicine in today’s environment was not what they had been “promised” it would be. A good friend and colleague often jokes that he would like to sue his Medical School for the inaccuracies they told him about pursuing a career in primary care including “you will be the boss/gatekeeper and truly in charge of patient care” (with the reality being that he feels as if he is in charge of nothing other than completing forms for insurance companies, employers, government entities, etc.). Furthermore, I believe that with the increasing complexities in medicine, smaller patient panel sizes will be required, especially for primary care, thus increasing the need for more physicians in this field.
Unfortunately, the fix for this problem will not be easy and is likely to create its own set of problems including increasing the number of Advanced Practice Providers (CRNP’s, PA’s) and increasing their ability to work independently (without physician oversight), as we are seeing in many parts of the country without any real way of measuring outcomes. Some have proposed shortening Medical School to 2 years, thus reducing basic science education in favor of more of the clinical training. There have been suggestions that changes in the compensation system to favor primary care could improve this shortage with a greater focus on wellness care, thus leading to less lifestyle-related disease costs (e.g., less need for joint replacements from obesity-related osteoarthritis).
I believe the true solution will require a focus on correcting all that leads to physician unhappiness, including complicated insurance and government regulations, reimbursement model inequalities, and the public’s unrealistic expectations for healthcare. It is clear (from the data above) that there is a significant individual and public investment in the training of physicians. Our society must be willing to make the changes necessary for a solution and physicians need to be the driver for these changes.