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Disruptive Remedies for the Physician Shortage

 |  By Philip Betbeze  
   October 25, 2012

This article appears in the October 2012 issue of HealthLeaders magazine.

The University of South Florida's Morsani College of Medicine in Tampa has been training physicians since its charter class enrolled in 1971, but apparently Morsani and other medical schools have not done enough. The physician shortage continues to grow, and the general media rarely misses a chance to pound the public with dire projections—as though the answer is to simply push more students through the education pipeline.

One problem with that simplistic thinking is that the pipeline is constrained by all manner of complex relationships. The Association of American Medical Colleges predicts there will be a shortage of 90,000 physicians nationwide by 2020. But that headline number obscures the complex nature of the physician shortage problem by suggesting that either there aren't enough medical schools or that the ones we have are not big enough. Add to that mix the knowledge that under existing predominant care patterns, the Patient Protection and Affordable Care Act will exacerbate the problem by making so many more people eligible for health insurance.

Additionally, some of the shortage can be attributed to other factors:

  • Physicians are changing their willingness to work long hours
  • New residencies aren't being created as quickly as new medical schools are
  • Medical schools and hospitals where impressionable physicians get their early training are doing a less-than-optimal job of preparing new doctors for a rapidly changing workplace in which teamwork with other medical professionals will be at least as important as technical proficiency

The residency problem

Stephen Klasko, MD, who is both CEO of USF Health and the dean at Morsani, says part of the problem in minting new doctors stems less from a lack of medical schools and more from a lack of creativity in developing new residencies.

"The fact is a plethora of states are building new medical schools, but they haven't created new residencies," he says. "Florida has four relatively new medical schools and almost no new residencies."

That's because new residencies are funded primarily by the Centers for Medicare & Medicaid Services—the same federal agency that's under extreme cost pressure for the provision of benefits to its millions of individual beneficiaries.

Most medical schools centralize the residencies available to their students at one or just a few local hospitals. USF traditionally has sent most of its 750 residents to the hospital across the street—the 1,000-bed Tampa General Hospital—as well as the 206-bed H. Lee Moffitt Cancer Center & Research Institute, also in Tampa and two Veterans Administration hospitals in the area.

Klasko and his leadership team are hoping to change that, however.

"Instead of centralizing our 750 residents, we'll double that number in the next four years creatively," he says, pointing to the need to distribute that larger number among more facilities.

For example, USF's Morsani is in the final stages of setting up a residency program at Lakeland (Fla.) Regional Medical Center and NCH Healthcare System in Naples, Fla.

"We brought in a CMS expert who showed them how they could get up to 200 residents and get them funded," says Klasko. "The community hospital might not have funding or infrastructure to explore this, so we're coming out to those hospitals and saying we'll provide both."

Klasko is also working on a similar residency program at a 300-bed Florida hospital that he would not name because discussions are not final, and has also embarked on an innovative residency program out of state with Lehigh Valley Health Network, an Allentown, Pa.–based system with two hospitals and $1.5 billion in revenue.

To address the physician shortage program, Klasko says, "the state does not have to build a medical school for half a billion dollars. That's wasteful."

The Lehigh Valley program attempts not only to increase residencies for USF medical students, but also to change the way physicians are trained—that is, focused more on team-based healthcare (see HealthLeaders,
June 2011).

The training problem

Klasko's objections notwithstanding, perhaps new medical schools can be part of the solution; but even those hospital and health system leaders who are heavily involved in creating new medical schools agree that doing so is only a partial solution—an extremely expensive partial solution.

In central Texas, a rapidly growing part of the state without a medical school nearby, Seton Healthcare Family is partnering with the healthcare district, known as Central Health, to build a new teaching hospital, while the University of Texas at Austin, with the approval of the University of Texas System Board of Regents, will build a new medical school in Austin. Seton, which operates more than 90 clinical locations, including five major medical centers, and is owned by Catholic healthcare giant Ascension Healthcare, says a projected shortage of 700 physicians in central Texas will result simply from the fact that the area will add more than a million in population by 2020.

Seton, for its part, will contribute $250 million to rebuild its aging University Medical Center Brackenridge as a state-of-the-art teaching hospital. UT Southwestern in Dallas will expand its residency program and the UT system will spend $25 million a year for the program—contingent on receiving contributions of an additional $35 million a year from "public sources," including Seton.

Seton already spends $45 million on residency programs each year. If everything goes right, says Jesus Garza, president and interim CEO at Seton, the school will have about 50 students initially, and the first class could begin studies in 2015.

"Austin is an attractive place to recruit physicians," says Garza, "but studies have shown that 80% of residents stay where they're trained."

He anticipates that while the medical school and closer residency programs will be part of the area's physician shortage solution, physician training will also have to undergo major changes so tomorrow's doctors will work in a more team-based atmosphere that brings other disciplines—such as nurses, pharmacists, and other allied healthcare providers—into direct responsibility for certain aspects of patient care that have traditionally fallen to physicians. The idea is to free up physicians to deal with more clinically critical tasks.

"As the healthcare system shifts to do more preventive care, that will be the area of most concern," Garza says. "Physician training needs to be multidisciplinary, needs to feature a team approach, and nurses and others will have to work at a higher level. We'll need to stretch our human resources."

Extended roles of nonphysicians is a direction toward which many hospitals and health systems are moving, says Clese Erikson, director for the Center for Workforce Studies at the Association of American Medical Colleges, a medical school trade organization.

"You can see that with the increased number of ACOs and efforts with ‘hot-spotting' [aggressive primary care intervention on the sickest patients]." Bringing nurse practitioners into the communities where the highest utilization patients
are, for example, can help prevent unnecessary utilization, she says.

Such efforts, if successful, might bring much-needed nuance into the discussion of the physician shortage, including disruptions in the types of physicians needed in the future.

Erikson says such efforts might mean healthcare in the medium-term future might be more primary care intensive and may change demand for specialists, but that such efforts—despite the fact that they appear to improve quality of care and seem to reduce downstream utilization of expensive healthcare services—are in such an early stage that it's difficult to define their workforce implications.

"It's too early to say, but I would be surprised if it could eliminate all the shortages," she says.

Changing expectations about work-life balance

Another piece of the shortage puzzle involves the importance many young medical school graduates have placed on leisure and family time. Where in the past a physician might find a 60- or 80-hour workweek common and expected, not so today's graduates.

"This generation of physicians views that person as a caricature," says USF's Klasko. "We are creating a group of physicians with more of a shift mentality, which will increase both the need for numbers and being creative."

Klasko, an OB-GYN, says for example that many in his specialty do not want to be as available to patients as their predecessors were and cites statistics that show that almost 60% of OB-GYNs are practicing part-time.

"If there is a workforce that wants to be on call once or twice a month," he says, "hospitals will not have enough doctors to cover obstetrics and we will need participation between obstetricians and nurse midwives."

He says powerful people, and hospital and health system senior executives count among that number, have to force a national dialogue about how to address the problem, because the lack of coordination between accrediting bodies and funders of physician graduate medical education means they can't seem to find common ground.

"None of these agencies talks to each other. It's like if the Orlando Magic players all practiced in different gyms and then showed up to play together for games," he says. "We haven't solved the shortage because we haven't wanted to."

Hospital and health system leaders have the power to change that dynamic. But, Klasko says, they need to decide whether they really want to solve the physician shortage or whether they want it to continue to be used as an agenda item for self-interested medical societies to lobby for more funding. He says
physicians have to get over themselves, in a way, in recognizing that ceding some responsibilities to allied medical providers doesn't have to mean a shrinking reimbursement pie for physicians.

"The knee-jerk reaction from medical societies is that this is bad, but they're thinking about it in their old guild mentality," Klasko says.

Instead, they should be having a clinical discussion about what's appropriate for physicians to do, and what others can do safely and effectively.

"Some of the medical societies are trying to block this," he says. "I've asked them, ‘What's your primary care strategy?' I'm often met with silence."

He says many hospitals that have never had a residency program could benefit by adding one, but that they face many issues in starting one, including the fact that their own physicians might not want to teach young doctors who will stay in the area to compete against them in the future. While having a residency program might differentiate a hospital, ensure a supply of future doctors, and improve its quality and safety record, establishing one is difficult, expensive, and potentially career-threatening.

"Part of the transition we're in requires that we all recognize there's a crisis and we have to transform," he says. "If you don't use residency to create a teamwork environment, don't be surprised when they get out and they don't act as a team."

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This article appears in the October 2012 issue of HealthLeaders magazine.

Philip Betbeze is the senior leadership editor at HealthLeaders.

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