In a recent article in MedPage Today, David Nash, MD, MBA spoke about physician burnout – a serious issue facing a growing number of physicians.
The statistics are alarming – more than 50% of all doctors claim they have experienced burnout with approximately 1 in 5 reporting they plan on working less in the new year. In the past two years, 1 in 50 physicians have quit practicing medicine altogether.
Dr. Nash notes that burnout can lead to a variety of serious problems including decreased safety, malpractice claims, substance abuse and even an increased risk of suicide. His solution — a multi-pronged approach that includes “many dimensions of wellness, from the occupational, emotional, spiritual, intellectual, and social.”
“Factors known to contribute to burnout in the workplace including loss of control and flexibility, inefficient processes like over-reliance on the electronic medical record, poor work life integration, frustration with insurance-related issues, and of course, declining reimbursement for clinical care,” said Dr. Nash.
What can be done to address this growing problem? According to Dr. Nash, “… we can start by monitoring physician well-being with a big focus on prevention.” This includes a focus on things like:
• Paying attention to sleep, exercise, nutrition
• Taking appropriate vacations
• Getting reconnected with the community
• Promoting self-awareness and resilience activities with mindfulness training
• A proactive annual check-up
• Appropriate counseling
• Minimizing the stigma and barriers for those who are seeking help
Dr. Nash also notes that the physician community should pay special attention to the work environment because a workforce facing burnout could mean the healthcare system is causing harm.
According to Nash, “We should look at models of health system science that make our daily work more efficient without burning out staff. We should support research that looks into promoting clinician well-being, and we should educate the leadership of health systems. After all, that’s where most doctors work. We should educate the leaders about physician burnout to make sure that they support workplace wellness for clinicians at all levels.”
Physician Retraining and Reentry (PRR)provides a solution for physicians experiencing burnout by providing an opportunity to switch their current focus to full or part-time positions in adult outpatient primary care. Since 2013, PRR has helped a wide variety of medically licensed physicians in good standing either return to the clinic, switch focuses or add primary care to their current practices. To learn more, schedule a consultation by calling (858) 240-4878or emailing firstname.lastname@example.org.
Since 2002, U.S. medical school enrollment has increased by 25 percent, according to a new report.
The country is facing a physician shortage, and 10 years ago the Association of American Medical Colleges called for a 30 percent increase in enrollment by 2015.
Now, the AAMC’s new report shows that medical schools are responding: 20 new M.D.-granting medical schools have been established since 2002, and the country should reach the 30 percent benchmark by the 2017-18 academic year.
Across the country, medical schools are also more focused on serving diverse health needs. Last year, 84 percent of medical schools had — or planned to establish — policies focused on recruiting diverse students who want to work with underserved populations. Another 49 percent are focusing on students from rural communities.
Colleges of osteopathic medicine are also expanding particularly quickly. Using 2002 as a baseline, first-year enrollment in these institutions is expected to grow by 55 percent by 2020.
Primary-care physicians will account for as much as one-third of that shortage, meaning the doctor you likely interact with most often is also becoming much more difficult to see.
Tasked with checkups and referring more complicated health problems to specialists, these doctors have the most consistent contact with a patient. But 65 million people live in what’s “essentially a primary-care Desert,” said Phil Miller of the physician search firm Merritt Hawkins.
Without those doctors, our medical system is “putting out Forest Fires — just treating the patients when they get really sick,” said Dr. Richard Olds, the chief executive officer of the Caribbean medical school St. George’s University, who is attempting to use his institution’s resources to help alleviate the shortage.
Dr. Ramanathan Raju, CEO of public hospital system NYC Health + Hospitals, goes even further, saying the U.S. lacks a basic primary-care system. “I think we really killed primary care in this country,” said Raju. “It needs to be addressed yesterday.”
The primary-care gap is particularly acute in about one-third of states, which have only half or less of their primary-care needs being met. Connecticut is a standout among the group, at about 15%, with Missouri, at 30%; Rhode Island, at 33%; Alaska, with 35%; and North Dakota, at 37%, next on the list, according to government statistics.
“The real problem is we don’t have enough doctors In the Right places and In the Right specialties,” Olds said, noting that doctors tend to cluster in big cities, and are Far more scarce in rural areas and in other small communities as well as certain parts of some big cities.
But how did this shortage come about, and how has the problem gotten so acute?
Here’s what’s involved:
• How doctors get paid: Choosing to go into primary care is also a choice of lesser pay.
Starting salaries in high-paying specialties can range from $354,000 (general surgery) to $488,000 (orthopedic surgery), while primary-care fields tend to bring a sub-$200,000 starting salary, from$188,000 (pediatrics) to $199,000 (family medicine), according to a Merritt Hawkins report.
The pay disparities reflect America’s “fee for service” health-care model, which compensates providers based on the number and type of services they complete, and which inherently favors specialists.
Reform-minded critics say compensation should instead be based on the period of time a patient is cared for. They argue that this structure would incentivize preventative care and prevent unnecessary (and often costly) medical procedures. The Centers for Medicare and Medicaid Services is in the very early stages of considering this global payment model.
Experts say it’s not just that primary-care doctors are paid less; they also typically work longer hours and have to be well-versed in a wide array of medical issues, to refer patients to the appropriate specialists.
Our culture is also part of the problem, Raju said, since “it’s not very glamorous to [say] that I went to some primary-care doctor. It’s glamorous to say, ‘I went to a cardiologist.’ ”
Paired with hundreds of thousands of dollars of debt, it’s a recipe for a shortage, Olds said.
“From the patient standpoint, the most important doctor you have is the primary-care doctor, who’s paid the least,” Olds said. “We pay for procedures, drugs and expensive tests, but we don’t pay doctors to think and care and manage patients’ health-care problems.”
• More Demand: People are living longer and thus need more medical care, accelerating doctor Demand; AAMC’s 2015 report calculates an 11% to 17% growth in total Demand, of which a growing and aging population is a significant component.
The shortage is one that’s been stewing for decades but of late was exacerbated by passage of the Affordable Care Act, which increased the number of insured people and along with that the Demand for doctor access, experts say.
• Medical schools themselves: Few medical schools consider a community-service background or an expressed interest in primary care when admitting applicants, though these are factors that would be easy to screen for. Past service in programs such as the Peace Corps and Teach for America are good predictors of students taking an interest in primary care, Olds said.
Diversity also plays a role. Olds said he’s found that students from a range of socioeconomic backgrounds tend to go into a diversity of medical fields, too.
Then there’s the structure of the programs themselves. A majority of med-school faculty members tends to be composed of specialists (a more research-oriented bunch, aiding the school’s federal funding), which influences their students’ choices, and use of university hospitals as teaching sites doesn’t immerse students as much in the outside community, inhibiting growth of community Roots.
Osteopathic schools — which have the same educational requirements as an M.D. degree institution but with a focus on holistic medicine and a more hands-on approach — tend to have more luck sending students into primary care, with over half of graduates going into nonspecialized fields, said Dr. Barbara Ross-Lee, dean of the New York Institute of Technology’s new osteopathic medical campus at Arkansas State University.
The NYIT ASU campus was founded to alleviate Arkansas’s physician shortage and will enroll its first class of 115 students in August.
Like other osteopathic schools, the NYIT ASU degree program will focus on patients’ overall wellness, an approach that dovetails with the philosophy and role of a primary-care doctor.
But osteopathic programs are also designed to expose students to general medicine, with generalists making up much of the teaching faculty and clinical training opportunities in settings where primary care is Delivered. The school also asks students in entrance interviews about their interest in primary care, Ross-Lee said.
• Geography: It doesn’t take more than a quick scan of a map of medical schools in the U.S to note that they’re heavily concentrated in the northeastern U.S. Graduates tend to stay in the areas where they went to school, so this contributes to a geographic skew among doctors.
Prospective doctors must complete a residency in order to practice medicine, but those programs — funded in part by federal dollars — aren’t located in areas with great need nor do they geographically calibrate with that factor in mind.
Pay figures in, too. Suburban areas typically offer a perceived higher quality of life to doctors and their families, along with, often, better compensation than a public, urban system, said Raju, resulting in shortages even in places such as his own hospital system in New York City.
• The government’s role (or lack thereof): In the U.S., though government dollars sponsor aspects of medical education, especially residencies, there’s no oversight in how doctors are sorted into various specialties.
But fingers aren’t just pointing at medical schools. Fear of a doctor surplus prompted a 1997 payment cap on Medicare funding for residencies, which has served as a “stumbling block” for doctor training ever since, John Iglehart wrote in the New England Journal of Medicine in 2013.
So as medical-school enrollment has swelled — medical schools planned to increase their enrollment classes by almost 30% between 2002 and 2016, according to Iglehart — residency-slot expansion has slumped.
• A numbers game: Only about one in four medical-school graduates is heading into a primary-care career, according to Olds, a ratio that’s half what it should be.
But doctors also want to practice differently today than their predecessors did, placing a higher premium on regular, 9-to-5 hours, Miller said. So “we find it takes more than one doctor coming out today to replace an old-style, baby boomer doctor [of 25 years ago],” he said.
Then there’s the seven years it takes to train a doctor — a lag time that’s built into any program or effort to address the shortage.
In this article, Forbes reporter Bruce Japsen reports on the American Academy of Medical Colleges annual physician workplace report, which notes the growing decline of primary care physicians in the United States year-over-year.
Forbes: Doctor Shortage Worsens, Particularly In Southern States
There are 91 active primary care physicians per 100,000 population in the United States, but there needs to be more if Americans are going to get the right care, In the Right place and at the right time, a group representing the nation’s medical schools and teaching hospitals says in a new report.
The Association of American Medical Colleges (AAMC) this week released its annual physician workforce report, which looks at the Supply and makeup of U.S. physicians, as well as the general expanding state of graduate medical education in the U.S. The report drew on data that includes information from AAMC researchers as well as the American Medical Association’s “Masterfile.”
While it’s been well documented that the U.S. needs more doctors, the report shows much of the country is in need of primary care physicians and their numbers aren’t on the Rise despite increasing emphasis on outpatient care and wellness. The flat to falling number of primary care doctors comes as more Americans can pay for treatment and are flocking to healthcare providers thanks to the Affordable Care Act.
Primary care doctors, which include internists, family physicians and pediatricians, are critical to managing chronic conditions to ensure Americans are getting the care they need to avoid bad health outcomes and higher costs that go when patients get sick and end up in the hospital. The median number of “active primary care physicians” has steadily fallen to 90.4 per 100,000 from 91 in 2010.
“We do have concerns when the numbers get below 100 primary care physicians per 100,000 people,” Dr. Atul Grover, AAMC’s chief public policy officer, said in an interview. “I’m worried people aren’t going to have access to primary care.”
Medicare and private health insurers like Aetna AET -1.85%, Anthem ANTM -0.71% and UnitedHealth Group UNH -0.85% are pushing value-based care models that emphasize primary care, wellness and outreach to populations.
But across the country, there is one primary care doctor for every 1,100 people and Grover said anything below a doctor per 1,000 Americans isn’t good. Most U.S. states except those in the northeast and certain states in the upper Midwest like Minnesota and Michigan have fewer than 100 primary care doctors per 100,000 people.
By comparison, southern states are severely lacking and tend to have a greater need. Texas, Oklahoma, Georgia, Arkansas, Alabama and Mississippi not only have low numbers of primary care doctors, but analysts say these areas tend to have high rates of obesity and chronic conditions like hypertension and other risk factors for heart disease.
There were 11 states with 64 to 78 primary care physicians per 100,000 people with Mississippi scoring the worst with just 64.5 physicians per 100,000 Americans. By comparison, Massachusetts was at the top, with 133.9 primary care physicians per 100,000 people.
In this piece, The Wall Street Journal interviews our President & Founder, Dr. Leonard Glass, about the Physician Retraining & Reentry program and his efforts to positively impact the growing physician shortage.
Wall Street Journal: “A Retired Surgeon Takes on a New Medical Mission”
Former surgeon forms an organization that retrains retired specialists to be generalists
The U.S. is facing a looming doctor shortage. With a surge of baby boomers enrolling in Medicare and millions of newly insured citizens seeking physicians under the Affordable Care Act, there simply aren’t enough general practitioners to go around. The Association of American Medical Colleges estimates the U.S. will be short by as many as 31,000 primary-care doctors by 2025.
Leonard Glass, a retired surgeon, had an idea about who could help fill these much-needed shoes: older medical specialists. For example, many surgeons retire due to diminishing eyesight or fine-motor problems, while obstetricians often burn out in their 60s after decades of Sleepless Nights. Yet these doctors are still capable of providing general medical care. Dr. Glass himself retired from practicing surgery in 2005 when a neck injury began limiting his dexterity.
“I kept reading about this impending doctor shortage, and I looked around at many of my retired colleagues and thought, why not get some of these doctors back to work?” says Dr. Glass, now 80.
So in 2013, he Launched Physician Retraining & Reentry, or PRR, to help retrain medical specialists in adult outpatient primary care. He funded the startup with his own savings and investments from friends and family, and didn’t primarily set out to make a Profit. “I just had to do something to ensure my kids and grandkids would have access to good medical care,” Dr. Glass says. “It became my obsession to help fix the doctor shortage.”
PRR is essentially an online training program, helping medical specialists get up to speed on the latest primary-care techniques. Specialists are already licensed in general medicine, but most haven’t practiced it since their residencies, so they want a “refresher course,” says Dr. Glass.
The self-paced program includes interactive tests and live role-playing, with actors posing as patients. It takes four months to a year to complete. “We teach everything from the latest diagnostic techniques to medical record-keeping,” says Dr. Glass, who works about 30 hours a week at PRR.
Doctors who complete the program receive 180 hours of continuing-education credit and help finding jobs. PRR has only four full-time paid employees (Dr. Glass and his brother-in-law, who Serves as CFO, don’t receive salaries), and one works solely on job placement.
“Many doctors want to work part time, and some want to give back by working at public clinics, while others want full-time posts,” says Dr. Glass. Only 30 doctors out of the 130 who have entered the PRR program have completed it so Far, but Dr. Glass is hopeful hundreds more will. “We built the technology platform so up to 3,000 doctors could take it per year,” says Dr. Glass. If doctors can’t afford the $9,750 course fee, PRR offers no-interest financing.
“Being a primary-care doctor is medicine at its finest, but many doctors lose sight of that purpose after practicing a specialty for decades,” Dr. Glass says. “We help doctors get back to the root of why they went to medical school in the first place: to take care of people.”
In this story, written by Chicago Tribune’s Sheryl Kraft, the reporter takes a deep look at the many ways the country’s healthcare system will be impacted by the physician shortage.
Chicago Tribune: “How health care will look with a physician shortage”
The Association of American Medical Colleges projects that the nation will face a shortage of 12,000 to 31,000 primary-care physicians by 2025. So it’s no wonder you may be finding it harder to find a doctor or to schedule an appointment with the one you have.
What’s fueling this problem? The baby Boom generation pouring into older age, an aging physician workforce preparing to retire and an estimated 30 million Americans joining the ranks of the insured since enactment of the Affordable Care Act in 2010.
What that means is that you may not be seeing a doctor at all the next time you go for health care.
“The impending physician shortage is an Opportunity to move to a health care model where the physician can be more of a quarterback on a team of health care providers, rather than being on the front lines,” said Dr. David Gorstein, managing director of Health Innovations, a health care consulting firm in Charleston, S.C., focusing on new models of health care. It’s time to look to other, more affordable and accessible settings, he said.
Maybe you have a scratchy throat and suspect another cold, but there’s a two-week wait to see your doctor. Or you’re out of town on business or are self-employed without health insurance.
Typically located in pharmacies, groceries and “big box” stores, these walk-in clinics began cropping up in 2000 and served more than 20 million patients in 2014, according to their trade association, the Convenient Care Association. To date, they number over 1,800 in 40 states and Washington, D.C., offering lower-cost options for health services with transparent pricing, so consumers know what they are paying for.
Visits typically range from $40 to $75 and address acute conditions, such as bronchitis and ear infections, as well as provide immunizations and physicals. Usually staffed by nurse practitioners, who are highly trained registered nurses, some incorporate pharmacists into ongoing care (which is particularly valuable in medication counseling for chronic diseases like diabetes or asthma). The clinics generally accept health insurance and can send a record of your visit to your primary-care physician.
“While the care can be excellent and the wait times and cost to the patient much less than emergency rooms, it’s important to understand that walk-in clinics only treat a limited list of problems,” said Dr. John W. Rowe, professor of health policy and aging at the Columbia University Mailman School of Public Health. They should not be relied on as a source of ongoing care, he cautioned. Yet Dr. Don Goldmann, chief medical and scientific officer at the Institute for Healthcare Improvement in Cambridge, Mass., sees their growth as proof that they fill important needs, providing “easier access to providers and quick, convenient care.”
Although they’ve been around for decades, the more than 6,400 urgent-care centers in the U.S are seeing an upswing in growth (from 8,000 to 9,300 since 2008), fueled by consumer frustration with long waits in emergency rooms and for appointments with primary-care physicians. These same-day walk-in clinics focus primarily on emergency medicine for acute (but less severe) medical problems. Typically staffed by trained and licensed physicians and medical assistants, registered nurses and X-ray technicians, nearly one-third of them are hospital owned and operated.
Many offer evening and weekend hours, perform X-rays and some on-site lab tests (like urinalysis and pregnancy and strep tests) and provide procedures like suturing and casting, usually more economically and with less wait time than hospital emergency rooms. In some communities, they function as primary-care practices for some patients. One study estimated that up to 27 percent of emergency room visits could be handled appropriately at retail clinics and urgent-care centers, offering cost savings of $4.4 billion per year.
Nurse practitioners, nurse anesthetists, nurse midwives: You find them in every setting where patients receive care, including doctor’s offices (where they often treat patients with more routine complaints, thus freeing up doctors), retail clinics, hospitals, nursing-care facilities, schools, clinics, free-standing practices and hospices. Known as advanced-practice registered nurses, or APRNs, they are nationally certified registered nurses who have completed master’s or doctoral programs and have advanced clinical training in patient-centered primary care. They can practice independently in 19 states and the District of Columbia.
Nurse practitioners, a subgroup of APRNs, perform a range of duties, from diagnosing and treating conditions like diabetes, high blood pressure, infections and injuries to prescribing medications, promoting disease prevention, and providing health education and counseling.
Although U.S. nurse practitioners have been providing health care for half a century, the health care system now is seeing the benefits of patient access to nurse practitioner-provided health services, said Tay Kopanos, vice president, state government affairs for the American Association of Nurse Practitioners, who added that many patients are choosing NPs as their primary-care providers. The Bureau of Labor Statistics estimates job growth for APRNs to Rise by 31 percent between the years 2012 and 2022.
Could physicians want to “protect their turf” by limiting the practice of nurse practitioners? “I would think they’d welcome this arrangement,” Gorstein said. “The doctor would see the interesting patients — the ones who have more than a minor ear infection or sore throat — and also would be getting referrals and income from a network of NPs. This is the Walgreens and CVS clinic model; while not perfect yet, it’s on the right track.”
The average length of a health care visit is less than 15 minutes, hardly enough time to address all of a patient’s needs. That’s why many practices are creating physician-led teams. Nurses, doctors, community health workers and other health care providers work together so the patient receives comprehensive care.
This approach can be more efficient and effective, allowing more time with the professional who has the right expertise, said Dr. Andrew Morris-Singer, president of Primary Care Progress, a grass-roots organization working to revitalize the primary-care system.
“We’re seeing team-based care in large groups, solo practices, hospital-based clinics and community-based settings,” he said. For instance, for some patients with diabetes, a pharmacist can set up a medication plan, while a registered dietitian can advise on proper nutrition guidelines, eliminating the need for physician visits. The American Medical Association supports this approach to help meet the surge in Demands on health care.
The need for them emerged out of a shortage of primary-care physicians in the mid-1960s. Their training was based on the accelerated training doctors got during World War II. Now, nearly six decades later, physician assistants are part of team-based care and are found in doctor’s offices, hospitals and other health care settings. Though they don’t practice independently like nurse practitioners (most states require the presence of a supervising physician), they typically undergo 26 months of medical training, including about 2,000 hours of supervised clinical practice.
Applicants to an accredited PA program must have a two-year minimum of college education, with a basic focus on science and behavioral science. Many students have worked as paramedics or registered nurses before pursuing their degrees. PA duties typically include performing physicals, taking patient histories, ordering/interpreting tests, developing treatment plans, prescribing medication and assisting in surgery.
General internist Dr. Jane Orient, a member of the American Association of Physicians and Surgeons, recommends looking for a PA “who has experience and has been practicing for a while, rather than someone fresh out of school.”
In some states, constant on-site presence of a doctor is not always necessary; in many rural and underserved areas, a PA may be the only primary-care provider for miles. As the need for health care increases, the Bureau of Labor Statistics estimates, the number of PA jobs will increase by 39 percent between 2008 and 2018.
Once a way to connect rural or disabled residents with licensed physicians, this year about 800,000 remote visits will take place in urban areas as well, according to the American Telemedicine Association. “Patients increasingly will want to take advantage of advances in mobile technology via their smartphones and remote monitoring,” said Goldmann, who thinks that they have the potential to change the traditional face-to-face physician visits.
For patients, telemedicine offers convenience and time and money saved on travel. Many physicians favor this approach as a way to cut down on overhead and allow more time with patients. Remotely, they can diagnose a condition and prescribe medication or advise patients to visit a specialist or an emergency room.
While some office-based physicians add these consultations to their offerings, it’s more common for providers to practice telemedicine exclusively, either at call centers or telecommuting from their video-equipped home offices. Retail clinics are getting into the game too: Rite Aid, the first to enter telemedicine, offers it at some of its stores in 22 states with its NowClinic program, allowing patients a 10-minute, $45 virtual visit with a physician from OptumHealth. (Walgreens and CVS have gotten into the telemedicine business, including mobile apps too.) Some experts caution that this cannot and should not replace regular office visits, especially for more complex medical issues.
Dr. Ronald Weinstein, co-founder and director of the Arizona Telemedicine Program, said telemedicine state parity laws require private insurers to cover telemedicine-provided services that are comparable to in-person visits. Considering that the number of states with those laws has doubled in the last three years, there may be a lot more physician-patient online chatter in the future.
Sheryl Kraft is a freelance writer.
When you don’t have a doctor
It’s good to have an established relationship with a physician before you need one in an emergency situation, said Dr. Robert Wergin, president of the American Academy of Family Physicians, but if you seek care beyond your own physician, or you don’t have one, here are some tips:
•Make the provider aware of your medical background and history.
•Be prepared to describe your symptoms, their severity and duration.
•Get a treatment plan at the end of your visit. Ask: What do I do if I don’t get better? Are there other health concerns I should have?
•Get a list of qualified physicians or specialists in your area.
•Request that the report of your visit be sent to your personal physician (if you have one) to ensure coordination of care. You don’t want important information to fall through the cracks.
Created by educators at the medical school and primary care physicians who are renowned experts in physician training and assessment, Physician Retraining and Reentry (PRR) provides physicians of all backgrounds, retired and otherwise, the tools needed to offer adult outpatient primary care in their current practices or at understaffed clinics across the country.
America faces a significant physician shortage by 2025, according to a physician workforce projectionreport(www.aamc.org) released by the Association of American Medical Colleges (AAMC) today titled “The Complexities of Physician Supply and Demand: Projections from 2013 to 2025.”
The analysis, compiled for the AAMC by IHS Inc., a global information company headquartered in Englewood, Colo., estimates a primary care shortage of 12,500 to 31,100 primary care physicians and a shortfall of 28,200 to 63,700 non-primary care physicians, “most notably among surgical specialists.
Two state legislative committees are taking on problems of health care in Georgia, and neither has to do, at least not directly, with the high-profile national debates on the subject.
As described by columnist Charlie Harper elsewhere on this page, and reported in considerable detail over the past few years, there’s a health care crisis in rural Georgia, and it’s getting worse with each passing year. Small rural hospitals are endangered, and their numbers are shrinking toward extinction. That means rural Georgia’s largely poor and often indigent population is left with limited — at best — access even to emergency care, much less maintenance care.