June 4, 2006

An aging America needs more doctors, but supply isn't keeping up. Experts fear worsening quality and dangerously long waits for appointments.

A looming doctor shortage threatens to create a national healthcare crisis by further limiting access to physicians, jeopardizing quality and accelerating cost increases.

Twelve states — including California, Texas and Florida — report some physician shortages now or expect them within a few years. Across the country, patients are experiencing or soon will face shortages in at least a dozen physician specialties, including cardiology and radiology and several pediatric and surgical subspecialties.
The shortages are putting pressure on medical schools to boost enrollment, and on lawmakers to lift a cap on funding for physician training and to ease limits on immigration of foreign physicians, who already constitute 25% of the white-coated workforce.

But it may be too late to head off havoc for at least the next decade, experts say, given the long lead time to train surgeons and other specialists.

"People are waiting weeks for appointments; emergency departments have lines out the door," said Phil Miller, a spokesman for Merritt, Hawkins & Associates, a national physician search firm. "Doctors are working longer hours than they want. They are having a hard time taking vacations, a hard time getting their patients into specialists."

North Hollywood resident Anneliese Ohler, who had a cancerous lesion removed from her face several years ago, had to wait two months recently to see a dermatologist after her hairdresser — and then her primary doctor — told her they saw worrisome spots on the top of her head.

"I was lucky it was not cancer," said Ohler, 83. "But what if it had been?"

Experts say her wait was a symptom of a wider problem: Demand for doctors is accelerating more rapidly than supply.

The number of medical school graduates has remained virtually flat for a quarter century, because the schools limited enrollment out of concern that the nation was producing too many doctors. But demand has exploded, driven by population gains, a healthy economy and a technology-driven boom in physicians' repertoires, which now include such procedures as joint replacement and liposuction.

Over the next 15 years, aging baby boomers will push urologists, geriatricians and other physicians into overdrive. Their cloudy eyes alone, one study found, could boost the demand for cataract surgery by 47%.

Yet, much of the nation's physician workforce also is graying and headed for the door. A third of the nation's 750,000 active, post-residency physicians are older than 55 and likely to retire just as the boomer generation moves into its time of greatest medical need.

By 2020, physicians are expected to hang up their stethoscopes at a rate of 22,000 a year, up from 9,000 in 2000. That is only slightly less than the number of doctors who completed their training last year.

At the same time, younger male physicians and women — who constitute half of all medical students — are less inclined to work the slavish hours that long typified the profession. As a result, the next generation of physicians is expected to be 10% less productive, Edward Salsberg, director of the Assn. of American Medical Colleges' Center for Workforce Studies, told a congressional committee in May.

Although some communities still enjoy a glut of physicians, shortages have arrived in many places. One in five U.S. residents lives in a rural or urban area that has so few physicians that the federal government considers it to be medically underserved.

The scarcity hit home for Dr. Robert Werra three years ago when he tried to find a family practitioner to fill his shoes before he retired from a medical group that he helped found in the Northern California city of Ukiah.

Despite nibbles from physicians in the Midwest, Werra couldn't persuade a single one to pay a visit. In the end, his patients were added to his colleagues' caseloads, extending wait times in a practice that is now closed to newcomers.

"We can't get any family doctors to come here," said Werra, 75.

Experts worry that Werra's experience is becoming more common, and not just in rural communities. The nation's physician workforce is approaching a tipping point, beyond which patients face dangerously long wait times and distances to see physicians. Or they get more care from nurses, physician assistants and other substitutes, whose ranks also are stretched thin. Or they go without.

Wait times for appointments are a sign of the emerging strain. The wait to see a dermatologist for a routine skin cancer examination in 15 big cities including Los Angeles averaged 24 days, according to a 2004 survey by Merritt Hawkins.

For a routine gynecological checkup, women faced an average wait of 23 days, the survey showed. To see a cardiologist for a heart checkup, the wait was 19 days. And to have an orthopedic surgeon check out a knee injury, the average wait was 17 days.

Hospitals, practices and academic medical centers in places such as Los Angeles not considered healthcare backwaters report more difficulty recruiting physicians — primary care doctors and specialists alike. Headhunters charging as much as $30,000 per placement now count some of the nation's most prestigious medical centers as their clients.

It's even gotten more challenging for medical groups in resort communities from the Florida Keys to the Coachella Valley, places where it was once easier to recruit a doctor than it was to get a tee time.

"I can remember five, six years ago, I had general surgeons calling me, asking, 'Do I have a job?' " said Dr. Marc Hoffing, medical director of the Desert Medical Group in Palm Springs.

Pay offers have been rising steadily in places where practices and hospitals are competing most vigorously for available physicians.

With a greater premium on physicians, some experts fear an acceleration of a trend among some doctors to limit their practices to wealthy patients who can afford to pay cash. These so-called concierge practices further exacerbate the disparity in care between the rich and everyone else.

If nothing changes, experts say, the prognosis for the quality of healthcare is poor.

"People are going to really hurt," said Dr. Richard Cooper, a professor of medicine and economics at the University of Pennsylvania. "Right now we have well-trained nurse practitioners to pick up a lot of the work, but when even they are overwhelmed, the whole thing really falls apart. We're at the cusp, and it's a little worrisome."

How did so many smart people and groups —including the American Medical Assn. — predict a doctor glut not too long ago?

They say they bought into a notion that health maintenance organizations would ratchet down physician demand by promoting preventive care and reducing tests and procedures. Tightly managed care was expected to become so widespread and effective that it would put many physicians out of work.

"They said we'd all be driving taxicabs," recalled Dr. Neil Parker, an associate dean at UCLA's Geffen School of Medicine.

The HMO juggernaut didn't materialize. That's largely because of a backlash against precisely the type of gate-keeping that was supposed to reduce the use of physicians. Accusations that HMOs were denying care to boost their profits led to their decline.

Preferred provider organizations proliferated instead. They give patients more of a choice of physicians and make it easier to get care. And the demand for physician services has never been greater.

Another idea that didn't pan out was that technology would reduce the use of physicians. Minimally invasive surgical techniques and other advances, however, actually have expanded demand for physicians by making it possible to perform operations on patients who are older and sicker than those who got surgery in the past, said Dr. David Etzioni, a surgical resident who studied future surgeon needs for the UCLA Center for Surgical Outcomes and Quality.

What's more, older people generally are healthier today than in the past, Etzioni said. "Operating on a 70-year-old now is much different than 30 years ago. So surgeons are more aggressive about patients they would do procedures on."

The AMA changed its position on the physician workforce a year ago, acknowledging that a shortage was indeed emerging. The consensus has shifted so quickly that experts who view the physician workforce as adequate — though poorly distributed, inefficient or wasteful — now are seen as contrarians.

Momentum for change is building. This month, the executive council of the Assn. of American Medical Colleges will consider calling for a 30% boost in enrollment, double the increase it called for last year.

The University of California built its last three medical schools — Davis, Irvine and San Diego — in the 1960s. Administrators are considering raising UC medical school enrollment by as much as 25% by expanding existing schools, building new ones or both. UC Riverside and UC Merced are eager to host new medical schools. A handful of states, including Florida and New Jersey, also are considering new schools.

Yet even if the schools quickly boosted enrollment by 30%, the ratio of physicians to patients would begin to decline by 2025, said Dr. Jordan Cohen, president of the Assn. of American Medical Colleges.

"The population is growing at a faster clip than any reasonable increase in the workforce could be accomplished," Cohen said. "That alerted us to the fact that we may need to be more aggressive in our recommendation."

AMA trustee Dr. Edward Langston has experienced the problem himself. His Lafayette, Ind., practice is getting a new family practitioner this month, but only after a difficult search that took three years.

"There is a shortage," said Langston, who, at 61, is thinking about retirement. "We need more physicians."