A Drop in the Bucket.

By 2030, the state of California is expected to have a shortage of roughly 32,700 physicians. (1) Yet, a 2020 survey of over 20 thousand doctors and healthcare providers finds that 20% expect to leave their practice in the next five years (from 2020-2025). (2) It’s safe to say a physician shortage is growing in the United States. While COVID-19 has pushed record numbers of providers out of the industry, there are many causes for this trend. (3) One cause is the aging American population. In my article titled “Demographic Shift. A Focus on Need-Based Policy,” I discuss how the average age in the US is currently 38.1 years but by 2040, the proportion of the population aged 65+ will double. (4) Thus, reducing this shortage is essential to safeguard the health of the American population from both an access and quality standpoint.

The cause of this shortage that I intend to focus on in this article is the limited number of spots in physician training or residency programs in the United States.

More than 83 million people in the US reside in places with limited physician access. (5) In fact, a 2017 study predicts that by 2025, the nation will have a shortage of 23,640 primary care physicians. (6) Below, I include a model of the United States with physician-patient ratios for each state. (7) While states like Maine, New York, and Massachusetts have relatively high physician-patient ratios (low shortage), states such as Texas, Utah, and Georgia suffer from large shortages.

So what structural issues does the American healthcare industry face? First, as I mentioned previously, the aging American population requires additional healthcare needs; more physicians are necessary to treat older patients with chronic conditions. However, this trend does not mean the healthcare industry must grow in all sectors; as the population ages, demand for geriatric specialists will increase and medical schools and residency programs must make adjustments so that enough geriatric clinicians are trained to keep up with the rising demand. (8) Additionally, healthcare shortages put pressure on physicians to treat more patients while maintaining quality standards; this pressure results in burnout where trained clinicians leave the industry. Finally, and as I will focus on throughout this article, training medical students is both expensive and time-consuming; thus, medical schools have very limited capacities and admissions have not kept up with the growing demand and population. (9)

This shortage has had consequences for patients, resulting in shortened and fewer visits, longer wait times, reduced access, and higher costs. (10)

The Resident Physician Shortage Reduction Act of 2021 is attempting to resolve this crisis. (11) Proposed to the Senate and House in 2023 and backed by the AAMC (American Association for Medical Colleges) and AHA (American Hospital Association), the bill calls for increasing the number of eligible residency positions for Medicare funding in specific hospitals by 14,000 over 7 years and beginning in 2025. (12) The Medicare program is responsible for covering the training costs of many residents; by expanding the number of Medicare-eligible spots, the Physician Shortage Reduction Act is effectively expanding the American resident population while providing opportunities for individuals who may need additional funding to pay for their education.

Below, I include a graph highlighting residency match statistics in Emergency Medicine. (13) “Matching” is the process by which a medical school student applies and is accepted into a residency program. Documented in this graph are the proportion of applicants who receive a residency spot (numeric), the number of applicants (blue), the number of available residency positions (green), and the shortage of positions when compared to applicants (red).

While the Physician Shortage Reduction Act will expand residency programs by 14,000 positions over 7 years, the Act may also expand medical school populations as more students are accepted into residency positions. (14) Regardless, although the Act is not explicit in increasing medical school capacities, if this bill is passed, it could signify a shift in policy focus, with the US government attempting to grow the physician workforce by increasing education opportunities.

The Resident Physician Shortage Reduction Act is a bipartisan bill that is garnering support in both Congress and the House. Yet, the Act itself still has its costs and benefits:

Starting with the pros:

• The Act will expand residency spots by 14,000 over a 7-year period. This increase in the physician workforce should help reduce the growing shortage in the United States.

• The Act should also improve access to care in rural and underserved communities as more physicians move to these regions in search of employment.

And now the cons:

• Medical training is an expensive endeavor and expanding residency programs may result in higher costs for resident-training hospitals. These costs may be paid by the federal government and then passed to consumers in the form of taxes or they may be paid by hospital patients when they receive care. (15)

• Additionally, if hospitals do not hire additional physicians to train the growing population of residents, we may see the quality of residency training decline as each student receives less time with practicing clinicians. (16)

Let’s revisit the “aging population” crisis I highlighted at the start of this article. There are many disparities that affect access to and quality of care from a physician’s perspective. One is the prevalence of larger physician shortages in specific medical specialties (including geriatrics). Another is the prevalence of larger shortages in rural and underserved communities. While the Physician Shortage Reduction Act increases the physician population, it does not guarantee that existing disparities are resolved. We cannot know for sure whether any additional residents trained by this program will actually practice in an underserved area or decide to specialize in a field with a large physician shortage.

While the physician shortage will surely decrease with the passing of this Act, we cannot make a prediction about how successful it will be at increasing healthcare access to those with greatest need. Below, I include a chart showing how competitive various medical specialties are. (17) (If you are interested in the residency match process and want to learn more, I suggest reading the article cited with the previous sentence). While thoracic surgery, plastic surgery, dermatology, and orthopedic surgery are all highly competitive (with 80%+ spots being taken up), other specialties such as internal medicine, radiation oncology, family medicine, and pathology are less so (with more open/unfilled residency positions). The specialties with many unfilled positions (to the right of the graph) are the ones with the greatest physician shortage. (note: it was brought to my attention that this analysis provides information about only MD graduates and not DO graduates. It is true however that thoracic and plastic surgery are amongst the most sought after specialties for all residency students with pathology and family medicine having the greatest physician scarcity.)

Addressing the physician shortage is important to maintain and improve access to and quality of healthcare in the United States. By meeting the growing demand for healthcare, the Resident Physician Shortage Reduction Act of 2021 attempts to expand medical residency capacities, expanding the physician workforce and improving patient care.

Yet increasing the number of physicians will not reduce structural disparities; in addition, policymakers must incentivize newly trained physicians to work in rural areas (see my article on Quality vs Quantity) or create additional spots specifically in fields with greater shortages. In this way, healthcare administrators can expand the field as a whole while targeting underserved populations and providing care to those who have the greatest need.

Ultimately, while the Resident Physician Shortage Reduction Act of 2021 is a step in the right direction in solving one of the most important problems in healthcare, it is not a complete solution. By implementing this legislation and also developing incentives for physicians to take on roles that serve especially underserved patient populations, we can create a stronger healthcare network with better access to quality care for all Americans.