If you don't already have a family doctor, don't count on seeing one in the next two months. That's the average wait time to get an appointment with a primary-care physician in some U.S. cities, and it's likely to get longer over the next decade as the supply of doctors shrinks while demand for them grows.
Within 10 years, the nation will be short nearly 95,000 doctors, the Association of American Medical Colleges predicts in a new report. Primary-care physicians — which include family doctors, general internists and pediatricians — will be especially hard hit and could account for more than one-third of the shortfall, the AAMC says.
This will make it harder for parents to get an appointment with a pediatrician for a child with an ear infection, or to schedule tests for themselves or an aging parent. In areas of acute need, like some parts of California and the South, primary-care physicians will be reduced to practicing as if they were urgent-care providers, some doctors say.
“This crisis was predicted well before Obamacare came into existence, but as health-care reform progresses, more people are going to be insured, and we’re going to have an increased need for all types of physicians, but particularly primary care,” said Dr. Richard Feldman, director of the Franciscan St. Francis Health Family Medicine Resident Program in Indianapolis.
Those newly insured under the Affordable Care Act, however, are only a small part of a multifaceted problem, medical professionals say. The biggest factors are predicted population growth, an aging population, and an aging physician workforce. There is also the allure of specialties that pay more than family practice, as well as the bureaucratic behemoth that determines how American physicians are paid.
“Procedures. That’s where the money is,” Feldman said. “The more you do, the more you make.”
Family doctors and pediatricians starting out earn the least of all physicians, making an average of $199,000 and $188,000 respectively, according to Merritt Hawkins, a healthcare search and consulting firm.
In contrast, the average starting salary for an orthopedic surgeon is more than double that, an important consideration for young doctors groaning with medical-school debt. More than half begin their careers with more than $100,000 in student loans. More than one-third have more than $200,000 in debt.
A problem unique to the U.S.
The AAMC report, released April 5, analyzed not just future supply and demand, but also examined how health care in America is currently distributed. It concludes that the shortage is already here.
For people in rural areas (and people who remain uninsured), to see doctors at the same rates as insured people in cities, the nation would need 40,000 more doctors right now, said Dr. Janis Orlowski, the AAMC’s chief health care officer.
“That’s not in 10 years; that’s today. These numbers are shocking,” she said.
Medical schools, Orlowski says, are doing their part. New schools are opening, and existing ones have increased their class sizes. “We anticipate graduating 26 percent more medical students than we did in 2001,” Orlowski said.
But simply having more medical students doesn’t solve the problem if they don’t choose primary care as a specialty — and increasingly they’re not.
This year, the National Resident Matching Program, which places third-year medical students into residencies, filled every slot in dermatology, radiation-oncology, vascular surgery and orthopedic surgery — but not primary care and family medicine.
In those categories, “If you look at the overall fill rates, they’re high — above 90 percent,” said Mona Signor, president and CEO of the National Resident Matching Program.
Most of the slots, however, are not filled by American medical students trained in the U.S.; those students represent just 45 percent of matches this year.
The rest of the slots went to graduates of medical schools in other countries, “some of whom are U.S. citizens and some of whom are not,” Signor said.
In other words, the dearth of primary-care physicians in America would be even greater if it weren’t for graduates of international medical schools, called IMGs.
One-quarter of America’s practicing physicians went to medical school in other countries. And they're more likely than U.S.-trained doctors to work in parts of the country that don't have enough primary care physicians.
This is, in part, because family doctors are more valued — and better compensated — in other countries, said Dr. Richard Olds, president of St. George’s University in Grenada.
“We are unique in the world with this problem,” Olds said. “You look at England or Japan or Germany; they not only have plenty of primary-care doctors, but they turn out the right balance of primary-care doctors and specialists.”
One reason is that many other countries control the number of training slots to keep the numbers balanced. Also, "The primary care job is easier in other countries and more rewarding since they don't force their doctors to do as much paperwork as we do, and in other countries doctors get paid to keep a fixed number of patients well and happy rather than see as many patients as they can," Olds said.
In most other countries, 70 percent of physicians are primary-care doctors. Fifty years ago, 70 percent of physicians in the U.S. were too. Now, only one-third are — and a third of them are 55 or older.
‘The heart and soul of medicine’
By 2025, the nation’s population is projected to increase from 319 to 346 million, an increase of nearly 9 percent. Meanwhile, the number of people 65 or older is expected to grow by 41 percent, disproportionately increasing demand for physicians because seniors consume the most health care.
But as the population ages, so do America’s doctors. Their average age is 54, and up to one-third of them will be at retirement age within a decade. Some may choose to work longer, as many Americans in other professions increasingly do, but many may not, as professional dissatisfaction among doctors is high.
One study found that only 6 percent are happy with their jobs. Another showed that nearly one-third of primary-care doctors between the ages of 35 and 49 planned to leave their practices within five years. The jump-ship rate climbed to 52 percent for those over 50.
While physicians have always worked long hours, the unhappy doctor is a relatively new phenomenon. For much of the 20th century, family doctors enjoyed wealth and prestige unattainable in many other professions.
The heyday of the family physician was prior to World War II, said Feldman, a second-generation family physician and a former Indiana state health commissioner. After the war, there was an influx of medical students whose tuition was paid by the G.I. bill, new money for research and technology, and an explosion of medical knowledge, allowing the proliferation of specialties.
In his 2013 book “Family Practice Stories,” Feldman and other Indiana physicians share anecdotes about what Feldman calls “the golden age of generalism” and rue the depersonalization of medicine, which Feldman says can turn patients into “widgets.”
“Family physicians do not have a monopoly on what is good in the medical profession. Family physicians are not better than other doctors, but they are different. They continue to be the heart and soul of medicine. More than any other specialty, family doctors humanize the health-care experience,” Feldman wrote.
The need for a 'medical home'
Although the future of family doctors appears even bleaker with the advent of telemedicine and retail health clinics, there is some evidence of a renewed interest among medical students.
There are also efforts to attract more people to family medicine with financial incentives. Tulane University in Louisiana, for example, offers a free medical education to any Louisiana resident who promises to practice in rural parts of the state.
And there’s a similar program offered through the U.S. government. The National Health Service Corps will pay up to $120,000 toward medical school debt of students who will commit to serving at least three years in an area designated as a Health Professional Shortage Area.
Such efforts help address the shortage of medical professionals in rural areas, a problem exacerbated by the lifestyle preferences of many American physicians. In Merritt Hawkins’ 2014 survey of medical residents, 93 percent said they would prefer to practice in communities with 50,000 or more people, and 69 percent said geographic location was the most important factor in where they would practice.
“We have a shortage of primary care doctors, but the more critical problem is that we have a maldistribution of doctors, both in specialty and geography,” Olds said.
Shortages are especially acute in the South, but even states like California have widely disparate access to physicians, with doctors clustering in more affluent and populated areas. Inland southern California, for example, has only one-third of the doctors it needs, Olds said.
The states with the best access to doctors, according to Merritt Hawkins research, are Massachusetts, New Hampshire, Vermont, Delaware and Maryland. The states with the worst: Mississippi, Texas, New Mexico, Nevada and Oklahoma.
Unless the problem is addressed, health care in America will not improve for the patients, regardless of their insurance status.
“You can really take care of people so much better when you know them and have continuity over time,” Olds said. “The cornerstone of quality, cost-effective care is having a family doctor. Everyone deserves a medical home.”