What is the Physician Shortage?
By: Amanda Chassuel-Mahon, M.S., Sarah Diekman, M.D., M,S., Amy Wen, Arpitha Shenoy, and Twinkle Desai
More doctors are graduating every year, and yet there are simply more doctors than there are residency program openings. The number of training positions for medical school graduates is lagging behind. Additionally, the number of doctors in the field is not in pace with the population growth. Compounding the issue is the aging population of the United States, resulting in both the need for more medical care as well as a reduction in physicians due to those aging out of the workforce. This combination of factors is leading to the dire situation of a physician shortage.
The number of students graduating from medical schools in the United States has increased by 25% over the past 14 years (Moawad, 2016). However, this does not translate into more available physicians. In order to have a medical license in the United States, a doctor must complete at least part of a residency (Association of American Medical Colleges, 2017a). Residency is depicted on the beloved shows Grey’s Anatomy, Scrubs, and ER. These shows, although exaggerated and fictional, depict an essential part of medical education which training our society relies on. Without this training medical school graduates, who are in fact actual doctors, will not be able to serve you, your family, or the public as a doctor! Last year alone, over 8,000 doctors did not get a residency spot. This means that while they are paying the student loans for medical school (the average for 2012 was $170,000) they cannot actually practice medicine (Association of American Medical Colleges, 2013). We literally have thousands of doctors who are unemployed, yet at the same time we have a doctor shortage. Keep in mind that these unemployed doctors are very intelligent, accomplished, and persistent people; the average GPA of the students admitted to a U.S. medical school in 2016 was 3.78 (Association of American Medical Colleges, 2016b). As students they achieved those scores while taking physics, organic chemistry, and calculus. Additionally, to enter medical school they had to perform as top in the nation on the MCAT, which is a test of physics, chemistry, biology, reading comprehension, and writing (Association of American Medical Colleges, 2016b). Despite this rigorous selection process, approximately 4% of United States allopathic medical students will not graduate (Caulfield, Redden, & Sondheimer, 2014). While in medical school these students compete against each other to achieve passing grades and mastery of a plethora of subjects, including anatomy, neuroanatomy, physiology, pathology, pharmacology, medical statistics, histology, microbiology, surgery, pediatrics, medicine, obstetrics, gynecology, primary care, psychiatry, and neurology.
In addition, society is facing an aging general population in need of medical coverage, as well as an aging physician population nearing retirement. The healthcare industry is facing a previously unencountered crisis: in a medical system currently dominated by baby boomers, who will care for the elderly when our older generation of doctors begin to age out of medical practice (Merritt Hawkins, 2015)?
How Many Physicians Are Needed and Will be Needed in the Next 50 Years?
Researchers have estimated that the United States will need nearly 52,000 new primary care physicians by 2025, in order to keep up with the demand for healthcare (Porter, 2012). The doctor shortage, even at the current numbers, has been called “an invisible problem,” causing difficulties and delays for patients (Lowrey & Pear, 2012). The Association of American Medical Colleges (AAMC) foresees surgery as the specialty which will suffer the most shortages, particularly those who treat diseases more prevalent in the aging population, such as cancer (Bernstein, 2015). According to SkepticalScalpel (2012), to adequately serve the public, there needs to be at least 7 surgeons per 100,000 people. At present, there are approximately 5.8 surgeons per 100,000 people, a ratio which has decreased by 26% over the last 25 years (SkepticalScalpel, 2012). Residency programs produce about 1,050 new general surgeons per year — a rate that has been stagnant for almost 20 years (SkepticalScalpel, 2012). While medical schools are expanding class sizes and new schools are opening it will take several years for the impact of these changes to be felt.
How Many Doctors Will Residency Produce?
In the U.S., approximately 18,000 medical students graduated from allopathic (M.D.) medical schools in 2016 (Association of American Medical Colleges, 2016c). These students, along with 7,500 international students, apply for residency spots in the U.S., for a total of roughly 25,500 (Eden, et al., 2014).
The National Resident Matching Program (NRMP) is a popular program that pairs students with residency programs based on their certifications (Intro to Main Residency Match, 2017). This specific program offers about 22,000 M.D.-based residency positions in the U.S. per year. But with the large number of international applicants, there is a shortage of about 3,500 positions. In 2016, 6% of M.D. students who were graduates of U.S. medical students were unmatched (Association of American Medical Colleges, 2016a). One thousand, one hundred, and forty (1,140) medical students have nowhere to practice medicine after their eight years of schooling, at a time where the physician shortage is becoming increasingly problematic (Association of American Medical Colleges, 2016a). The match system, created in 1952, was meant for a time where positions exceeded applicants; it is outdated and can no longer accommodate the growing medical field today (Ho, 2014). The medical school class of 2012 reported having at least $1.7 billion in education debt after earning their medical degree. For the 2012 school year the AAMC estimates the cost of attending medical school was $275,305 per person (Association of American Medical Colleges, 2013).
What is Limiting the Number of Residency Spots?
On October 1, 1997, the Balanced Budget Act (BBA) was enacted by Congress to limit the indirect medical education (IME) and direct graduate medical education (DGME) funding. (Association of American Medical Colleges, 2017b). This funding cap, combined with the PRA calculations [see next paragraph], limits the number of medical residency positions. If a hospital has exceeded their funding limit, they will receive no additional reimbursements for the teaching of residents (Association of American Medical Colleges, 2017b). No new residency positions have been created since the passing of the BBA (Guram, 2013).
How Are Residency Programs Funded?
Medicare provides the majority of funding for residency training, in order to help offset some of the costs associated with educating residents in exchange for their treatment of patients who require more intense and complex care. The amount distributed is calculated and dispersed as a “per resident” amount (PRA) (Eden, et al., 2014). The PRA “represents the cost incurred by a teaching hospital in a base period, divided by the number of full-time equivalent (FTE) residents during that base year” (Robert Graham Center, 2017, para. 4). Overall, in 2012 Medicare provided $9.7 billion in funding for residency programs (Eden, et al., 2014). This was divided into about $6.8 billion from IME payments and $2.8 billion from DGME payments (Eden, et al., 2014).
Additionally, pediatric residencies at children’s hospitals get funding from the Children’s Hospital Graduate Medical Education Program (CHGME) (Eden, et al., 2014). The Veterans Health Administration (VA) and the Health Resources & Service Administration (HRSA) are funders of residency programs as well, contributing $1.4 billion and $0.5 billion, respectively (Eden, et al., 2014).
What is the Result?
Our estimates calculate that the lack of match placement results in 193.8 million dollars worth of unpaid student loans, the majority of which is subsidized by the government*. That is almost 193.8 million dollars in educational debt that is not being paid back to the tax payers because these doctors cannot work! Our situation is that some of the smartest people in this country are not working as doctors and not able to pay this 193.8 million dollar debt while we are suffering from a doctor shortage.
*This total was calculated by multiplying the total of M.D. graduates of U.S. medical schools who did not place into residency (1,140) by the average rate of student debt for medical students ($170,000), with statistics provided by Association of American Medical Colleges (2016a, 2016c, 2013).
Read Real Stories Here:
“I’m a Doctor. I’m on Medicaid. I Work as a Waitress.”
“M.D., but not a Doctor.”
“Unmatched Graduate: ‘Med Schools to Blame’”
“Looming Question for Medical Students: Will They Be Shut Out of Advanced Training?”
Association of American Medical Colleges (2013). Physician education debt and the cost to attend medical school: 2012 update. Retrieved from https://members.aamc.org/eweb/upload/Physician%20Education%20Debt%20and%20the%20Cost%20to%20Attend%20Medical%20School,%202012%20Update.pdf
Association of American Medical Colleges (2016a). AAMC congrats new MDs on successful match day. Retrieved from https://www.aamc.org/newsroom/newsreleases/456876/match_day_2016_03182016.html
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Association of American Medical Colleges (2016c). Table B-2.2: Total graduates by U.S. medical school and sex, 2011-2012 through 2015-2016. Retrieved from https://www.aamc.org/download/321532/data/factstableb2-2.pdf
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Caulfield, M., Redden, G., & Sondheimer, H. (2014). Graduation rates and attrition factors for U.S. medical school students. Analysis in Brief, 14(5).
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Guram, J. (2013, June). The shortage of medical residency spots: A failure of government control. Forbes. https://www.forbes.com/sites/theapothecary/2013/06/10/the-shortage-of-medical-residency-spots-a-failure-of-government-control/#64a9a76d680f
Ho, A. (2014, April). How a Nobel economist ruined the residency matching system for newly minted M.D.’s. Forbes. Retrieved from https://www.forbes.com/sites/theapothecary/2014/04/15/how-a-nobel-economist-ruined-the-residency-matching-system-for-newly-minted-m-d-s/#741c5fc95585
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SkepticalScalpel (2012, August). A shortage of general surgeons: Coming soon? Physicians Weekly. Retrieved from https://www.physiciansweekly.com/general-surgeons-shortage/