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Is There a Doctor in the House?

Can you get an appointment with your doctor tomorrow morning? How about in a month? Do you think this is because doctors like to make...

Can you get an appointment with your doctor tomorrow morning? How about in a month? Do you think this is because doctors like to make you wait? They are booked up because there are too few physicians, particularly in some areas of the country and in some medical specialties. It is going to get worse. And nurses won't be there to fill the gap, either. It is estimated that there will be a shortage of over a quarter of a million nurses by 2025.

At least 12 states report some physician shortages now or expect shortages within the next few years. How long it takes to get an appointment to see a physician is not a bad way to get at a region's supply and demand. In a 2009 survey looking at wait times in 15 big U.S. cities, average wait times for appointments to see skin cancer, heart and knee specialists and family doctors were three to four weeks, even when medical problems were suspected or injuries had occurred.

A good way to plan for an adequate physician workforce is to design a formula that relates the numbers and types of physicians within a given geographic area and population. In this way, we would know what kinds of physicians are needed where. This is important because many Americans live in geographic regions where they lack access to physicians. A ratio of less than one physician to 3,500 persons is designated as a "health professional shortage area." These areas may be urban or rural areas. At present, over 20 percent of the U.S. population lives in an area designated as a health professional shortage area. These areas have traditionally and continue to need all types of health care practitioners, but, now, increasingly, they need physicians -- not only generalists, but also specialists.

Medical schools in the United States graduate a total of about 16,000 students a year, a number that has remained stable for more than two decades. There are approximately 23,000 post-medical school residency positions that last for three to eight years. We make up the difference between the number of U.S. medical graduates and residents by bringing into the U.S. approximately 7,000 physicians who graduate from overseas medical schools. Even so, over the past five years, the overall physician supply in the United States has grown only slightly (by eight percent), but when seen in relation to the U.S. population growth, the ratio of physicians to patients has grown half that much -- 4 percent.

What do we know of the future? More and more young physicians are telling us that they want more time to have a life outside of medicine, to be with their families. As a result, the next generation of physicians is expected to be 10 percent less productive. And many are graying and will leave practice in the near future. A third of the nation's 750,000 physicians are over the age of 55, which means that they probably will retire in 10 to 15 years. We are already seeing evidence of this trend: The most recent workforce study reported that current physicians say they are going to retire at 2 percent per year, twice the current rate, and other estimates suggest that by 2020 physicians will be retiring at a rate of 22,000 a year, up from 9,000 in 2000.

Even as we experience a decrease in the total number of hours worked by physicians we will see a rise in demand for their services. The U.S. population is aging; one in five Americans will be over the age of 65 by 2030, and seniors use more medical services. In addition, we are living longer with chronic disease; approximately 45 percent of Americans have chronic disease, which also drives the need for more physicians because it takes time to treat patients with multiple chronic diseases. Combining the aging of our population with our growing number of chronic illnesses, the demand for medical care is going to increase markedly over the next two decades. This trend will only be exacerbated if millions more uninsured Americans gain coverage under health care reform.

In recognition of these trends, the American Association of American Colleges estimates that there will be a shortage of 124,000 to 159,300 physicians of all types by 2025. What can we do? We can increase the number of medical students and build more medical schools. If we increase enrollment in existing schools by 30 percent, an AAMC recommendation, we can count on 5,000 new graduates per year over the next 10 years. Yet, even if medical schools increased and were able to boost enrollment by 30 percent, the ratio of physicians to patients would still begin to decline by 2025. To fill the gap, the United States may need to turn to international medical graduates and, just as important, leverage the abilities of other practitioners such as nurses, nurse practitioners, physician assistants and pharmacists to work at the maximum level of their licensure, or perhaps with more training, widen their licensure.

Building the nursing workforce will also require various strategies to attract and then retain a sufficient supply of qualified RNs and nurse practitioners. Having an adequate supply of nurses is important: Adequate staffing levels in hospitals are associated with 25 percent fewer adverse outcomes, and advanced-practice nurses offer a critical resource to fill the gap between primary care and chronic care management, which reduces avoidable hospitalizations. Some recent innovative programs include partnerships between community colleges and four-year nursing programs to increase the number of baccalaureate-trained RNs, as well as public-private partnerships to increase salaries at the faculty level to expand NP graduate programs and to attract nurses to community-based settings.

Increasing the supply of nurses and physicians will take time, and we need to begin to address access problems in health care right now. After all, last year in Boston it took 49 days on average to get an appointment to see a physician, and other cities are experiencing long wait times as well. To this end, community health workers can help fill the gap, working as a liaison between the patient and health professionals. Trained community workers have been providing basic care for more than 20 years with great success; examples include working with Native American populations and in Alaska through the community health aide program.

At a recent national meeting, a group of chairs of departments of family medicine said that "a significant portion of their patients could be cared for by a good grandparent." Taking their cue, we recently wrote in the journal Health Affairs about formalizing a primary care model utilizing grandparents as community health workers. While being a grandparent is not required, the characteristics that are needed: nurturing, caring, staying calm with a sick person, having taken care of others (e.g. retired teacher, nurse, physician), able to coach others, generating respect in patient and community. With proper training, grandparents can become a new and valuable tool in a new paradigm for patient care. They can improve medical and social outcomes in their communities and derive personal benefit, learning and satisfaction. Of course, such workers will not replace physicians and other health care practitioners, but they can work to fill a vital gap, especially as the recently uninsured seek care.

We need to rethink the care team and leverage every member to their fullest, beginning with patients caring for themselves -- and then with community health workers doing what a good grandparent did in the past and can do in the future -- leaving for nurses and doctors those tasks only they can do. In doing so we will find fewer shortages than we currently imagine.

Arthur Garson Jr. and Carolyn L. Engelhard are the writers of GOVERNING's Health Myths column. They are co-authors of "Health Care Half-Truths: Too Many Myths, Not Enough Reality."
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