Running dry

By Ruth Carol, Contributing Writer, December 1, 2021

For years, there has been concern that a physician workforce shortage is looming. The United States could see a shortfall of 37,800 to 124,000 physicians by 2034, according to projections released by the Association of American Medical Colleges (AAMC) this past June. Medical specialties, such as dermatology, are expected to see a shortage ranging from 3,800 to 13,400 physicians. These recent figures are consistent with the AAMC’s previous physician workforce reports.

Why is a shortfall imminent? Simply put, the physician workforce shortage is a classic case of supply and demand. The number of doctors is not keeping pace with the growing demand for their services. While the shortage remains on the horizon, some actions taken now could lessen the shortage’s impact on dermatologists and their patients in the future.  

Fewer physicians

Physician numbers are not keeping pace for myriad reasons. For starters, physicians are aging with the rest of country’s population. The AAMC projects that in the next 10 years, two out of every five physicians in the U.S. will be age 65 or older. “We anticipate that as much as one-third of the physician workforce could be retiring in the next 10 years,” stated Michael Dill, AAMC’s director of Workforce Studies. 

Burnout is also taking its toll on the physician workforce. About 42% of all physicians, and 29% of dermatologists, reported burnout in a 2021 Medscape report. A 2015 study in the Mayo Clinical Proceedings found that burnout among dermatologists from 2011 to 2014 rose from 32% to 57%, which happened to coincide with the height of electronic health record (EHR) implementation (2015; 90(12): 1600-1613). 

Today, EHR remains high on the list of contributors to physician burnout, noted Suephy Chen, MD, MS, FAAD, chair of the department of dermatology at Duke University School of Medicine. Tasks associated with the EHR used to be handled by the administrative or nursing staff, but they increasingly require the physician to address them. “Physicians go to medical school to learn how to deliver medicine, but instead they’re doing a bunch of administrative tasks,” she said. While 58% of respondents to the Medscape report cited too many bureaucratic tasks as the No. 1 reason for burnout, 28% cited increasing computerization of the practice.

“The longer the COVID-19 pandemic drags on, the more burnt out physicians are getting.”

How significantly the COVID-19 pandemic has contributed to physician burnout has yet to be determined. Physicians were already experiencing high levels of job-related burnout as well as depression before the COVID-19 pandemic hit, Dill said. Those feelings were exacerbated by the pandemic, possibly swaying older physicians to reduce their hours or retire early. A physician survey conducted in 2020 by Merritt Hawkins on behalf of The Physicians Foundation seems to support that notion. About 20% of physicians said they plan to change practices, stop providing care, or work locum tenens due to COVID-19; 37% said they would like to retire in the next year. Finally, COVID-19 took the ultimate toll on the health care workforce. According to data from Kaiser Health News and the Guardian, more than 3,500 health care workers have died during the pandemic; nearly 17% of those deaths were physicians. “The longer the COVID-19 pandemic drags on, the more burnt out physicians are getting,” Dr. Chen said. 

More patients

In a 2016 analysis of the dermatology workforce, Dr. Chen and her colleagues predicted a substantial shortage of dermatologists in the next 30 years that could negatively impact 25% of anticipated demand. Since then, the demand has only gone up and is expected to continue to rise.

More people are reaching the age of Medicare eligibility in this country. Currently, there are 44 million beneficiaries, which translates to approximately 15% of the U.S. population enrolled in the Medicare program, according to the AARP. Medicare enrollment is expected to reach 79 million by 2030.

An aging population requires more complex care, resulting in a greater reliance on specialized care. Currently, people 65 and older account for 34% of the demand for physicians, the AAMC reports. But by 2034, they will account for 42% of the demand. As people get older, they get more skin issues, contributing to a growing demand for dermatologists, Dr. Chen said. 

An estimated 41% of U.S. adults delayed or avoided medical care because of concerns about COVID-19, the Centers for Disease Control and Prevention reported in June 2020. Those delays included routine care (32%) as well as urgent or emergency care (12%). If those delays cause more severe health issues down the line, they will result in greater increased demand for care, Dill said. 

Similarly, delays in diagnoses of skin cancers because of people postponing dermatology visits or temporary practice closings due to COVID-19 have been documented in the literature. Despite rebounding numbers, some experts estimate this will result in a nearly two-month diagnostic delay. Delays in skin cancer diagnoses could lead to advanced-stage melanoma or other skin cancer diagnoses in the future. That’s already playing out in the data for other types of cancer, Dr. Chen noted.

It is too soon to tell, but COVID long haulers may contribute to greater increased demand for care, Dill said. He hopes to gain more insight about the impact of COVID-19 on the physician workforce shortage after the AAMC completes a new national survey of physicians in early 2022.

Glitch in physician pipeline

While medical school enrollment is on the rise, graduate medical education (GME) slots are not keeping pace. Enrollment in U.S. MD-granting schools has grown 33% since 2002-2003, according to a recent AAMC survey of medical school deans. Enrollment at DO-granting schools rose by 54% between 2002-2003 and 2018-2019. First-year enrollment at accredited MD-granting schools is projected to increase by an additional 7% by 2024-2025. However, more than 60% of the deans reported concerns about GME in their state and 67% had concerns about GME at the national level.

In contrast, the number of positions accredited by the Accreditation Council for Graduate Medical Education (ACGME) had been growing at a rate of about 1% per year. After the single accreditation system was implemented in 2020 by the ACGME, American Osteopathic Association, and Association of American Colleges of Osteopathic Medicine, ACGME slots have grown about 4% per year, said John Combes, MD, chief communications and policy officer for the ACGME.

Federal caps on Medicare-funded residency training positions have a lot to do with the slow growth in GME slots, Dill noted. Those caps were put into place in the late 1990s when it was believed there would be a surplus of physicians jumping on the managed care bandwagon, he explained. “That never panned out, but we’ve been stymied by it ever since,” Dill said. 

Dermatology took a real hit when the caps were imposed, Dr. Chen added. While primary care is essential, it should not be at the expense of specialty care, she said, adding, “Slots aren’t the whole story. It’s how you use them and where people end up.” 

Funding fixes to address the shortage

As part of the $900 billion COVID-19 relief package, Congress ended the nearly 25-year freeze on federal support for GME by adding 1,000 new Medicare-supported GME positions, or 200 per year for five years. Priority will be given to training programs in rural areas, hospitals that are training residents over their caps, states with new medical schools, and facilities that provide care for underserved communities. 

Another piece of federal legislation, the Resident Physician Shortage Reduction Act of 2021, is currently under discussion on Capitol Hill. If passed by Congress, it would add 14,000 GME slots or 2,000 annually for seven years. In the study, Dr. Chen and her colleagues called for an increase of first-year dermatology resident positions by 50 annually over the previous year’s total to help gradually eliminate the shortage. 

There have been some discussions about extending the timeframe for hospitals to establish their GME programs before their caps are set, according to a recent Government Accountability Office report. Medicare currently gives hospitals five years to establish and grow their programs before the caps are set. Once set, hospitals’ resident caps are generally permanent. Extending this timeframe could result in larger caps and more residents trained at some hospitals because they would have more time to recruit additional faculty and residents or start programs in more complex specialties. These extensions could be granted to under-resourced hospitals. 

Other federal programs that could help include the Conrad 30 Waiver Program for foreign medical graduates, the National Health Service Corps and Public Service Loan Repayment Program, and Title VII and VIII Health Professions Training Programs, all of which help recruit a diverse workforce and encourage physicians to practice in specialties impacted by shortages and underserved communities. The Opioid Workforce Act of 2021 and Substance Use Disorder Workforce Act would provide Medicare support for an additional 1,000 GME positions over the next five years in hospitals that currently have, or are establishing, accredited residency programs in addiction medicine, addiction psychiatry, or pain medicine.

States are increasingly funding GME slots for Medicaid programs, Dr. Combes said. In 2018, 43 states, including the District of Columbia, provided $5.58 billion in funding for Medicaid, according to the AAMC. That is up from 2015, when 42 states, including the District of Columbia, contributed an estimated $4.26 billion for Medicaid GME payments. Often states are funding programs that grant money to new GME positions, he added. It appears that strategy does pay off as most physicians don’t move far away after completing their residencies, the AAMC reports. Most residents (55.5%) who completed training from 2010 through 2019 continued to practice medicine in the states where they did their residencies. 

While Medicare funds the bulk of resident positions, teaching hospitals can fund GME slots that go above the caps set by Medicare. Medicare data show that in 2018, 70% of hospitals were over one or both caps on Medicare-funded residents; only 20% of hospitals were under one or both caps. Hospitals funded significantly more slots over the cap than they left unfilled. 

The Department of Veterans Affairs has expanded its funding in the last couple of years, Dr. Combes noted. The Department of Defense supports its own in-house residencies and fellowships to provide health care for individuals who serve in the Army, Navy, and Air Force. Other sources that have contributed to GME funding include the Children’s Health Insurance Program, Health Resources and Services Administration, and National Institutes of Health.

Other fixes to ease the shortage

“Fifteen thousand new GME slots need to be created,” Dill said, “but that’s not the complete solution.” Fixing the physician shortage will also require innovations in team-based care and better use of technology, which will make care more effective and efficient.

Dr. Chen recommends engaging with different support staff to find creative ways to remove tasks from the dermatologists’ responsibilities. At her institution, they are looking at utilizing pharmacy technicians or clinical pharmacists to help with pre-authorizations and handling medication issues.  

Technology can be used to better connect patients to physicians, but also physicians to physicians, Dill said. For example, remote patient monitoring can be used to check blood pressure or blood glucose. Patients could phone in or email the results, eliminating the need for an in-person visit. 

Teledermatology can be an effective way to conduct patient visits, as well. When Dr. Chen worked at a Veterans Affairs facility, they were able to perform 500 consults a month, all completed in one business day. About half of the patients didn’t need an in-person appointment, she said. Payers could facilitate these efforts by continuing to pay physicians for telemedicine visits on parity with in-person visits like they did in the early days of the COVID-19 pandemic. “Now that we have found safe ways to see patients, certain states are starting to cut back on payment for telemedicine,” Dr. Chen said. “One thing we have learned from COVID-19, and store-and-forward telemedicine before the pandemic, is that we can do this, but we can’t do it for free or at a loss.” 

In 2015, the first Dermatology Extension for Community Healthcare Outcomes (ECHO) Project was started at the University of Missouri. During biweekly virtual clinics, a multidisciplinary team of dermatologists and pediatric dermatologists as well as a dermatopathologist, clinical nurse specialist, and health literacy expert consult with rural clinicians about patient cases. The sessions include providing primary care physicians with evidence-based knowledge for treating common dermatologic conditions that they are most likely to encounter. In 2016 and 2017, 223 total cases were presented through the Dermatology ECHO Project. Nearly half of the adult cases were incorrectly diagnosed by a primary care provider. While 28% of pediatric cases were incorrectly diagnosed, another 28% were partially correctly diagnosed. Expert treatment recommendations benefited 84% of adult cases and 73% of pediatric cases. In addition to improving patient care, the Dermatology ECHO Project helped equip primary care physicians with more dermatology training, increasing dermatologists’ availability for more serious or complex cases. The Dermatology ECHO Project enables the University of New Mexico School of Medicine to ease access to patient care where there are only about 33 board-certified dermatologists serving a population of more than two million people. 

Clearly, fixing the physician shortage will take more than just adding GME slots; it will require a multi-pronged approach. Luckily, there is still time to fix it if stakeholders act now.

Additional DermWorld Resources