Let’s take stock on the real issue of why we don’t have enough physicians.
On March 17, 2023, nearly 43,000 medical school graduates will anxiously await the chance to continue their journey to become licensed physicians. But with just 40,375 available residency positions available, what will happen to the remaining 2,500 applicants that fail to match into a slot? While a lucky few may be able to ‘scramble’ into an open position, most will have no choice but to wait an entire year to reapply for the privilege of practicing medicine.
Although medical students will have received 6,000 hours of clinical experience by the time they graduate, they are required to complete additional postgraduate training to receive a license to practice medicine. Every state in the country requires at least one year of residency training for U.S. citizens, with some states requiring two or three years, and most states requiring three years for graduates of foreign medical schools. A lack of postgraduate residency training positions creates a bottleneck for medical students who wish to pursue any type of medicine, including primary care.
According to the National Resident Matching Program, there are more than enough residency slots to accommodate all graduating U.S. medical students, with 1.82 residency positions per graduate. However, after factoring applicants who trained at medical schools outside the country, including U.S. citizens, there are, in reality, just 0.85 positions per applicant. Every year, this leaves thousands of aspiring physicians unmatched and unable to help fill the physician shortage.
A physician surplus?
While today’s physician shortage is accepted as fact, it may come as a surprise to learn that just forty years ago the exact opposite problem was being predicted: a physician surplus. Back in 1980, reports warned that too many physicians were being trained, and organizations like the Pew Charitable Trust and the Institute of Medicine (now the National Academy of Medicine) urged a moratorium on new medical schools and a reduction of first-year residency positions to restrict the entry of foreign medical graduates. In fact, there was such urgency in the 1990s to slow the production of physicians that the government began paying hospitals not to train doctors.
In 1997, a consortium of medical organizations agreed that further steps should be taken to limit the number of physicians, recommending a decrease in funding for postgraduate medical education. That same year, the 1997 Balanced Budget Act capped residency training funds, which would remain frozen for the next twenty-five years.
One interesting twist on residency funding policy is that while Medicare funds are capped for established residencies, the program will pay for positions at new residencies, which may grow the number of residents for five years, at which point further funding is frozen. This rule has helped for-profit companies to create their own residency programs. For example, HCA Healthcare jumped into the residency market in 2015 and within the five-year Medicare funding cap time limit, the company had become the largest sponsor of residency programs in the U.S., training more than 5,000 physicians per year.
Was there ever the risk of a physician surplus? While the United States did indeed have one of the highest numbers of physicians per population in the 1960s, that ratio had already rapidly declined by the 1980s. With policies enacted to curb the predicted physician surplus, the U.S. physician supply dropped below comparable countries by 2018, with 2.6 physicians per 10,000 compared to the average of 3.6. The U.S. currently lags behind other nations in the production of physicians, with an increase of just 14% between 2000 and 2018, compared to an average of 34% in Western Europe. Canada ranks just ahead of the U.S., having followed a similar physician-reduction tactic as the United States in the 1990s.
Too many physicians, but not enough NPs and PAs?
The initial 1980 report predicting a physician surplus advised restricting training for non-physician practitioners as well as physicians. But in the next twenty years, the number of nurse practitioners quadrupled, and the number of physician assistants doubled. Ironically, at the same time as his administration was paying hospitals to stop training physicians, President Bill Clinton designated the first funding program for graduate nurse education, allocating $200 million in 1994 to train nurse practitioners. Fifteen years later, President Barack Obama signed the Affordable Care Act (2010), legislation that expanded funding to nurse practitioner and physician assistant training programs, without increasing residency training for physicians.
Groups warning of the dangers of too many physicians simultaneously advocated for the growth of non-physician practitioners. For example, the Pew Charitable Trust, which recommended cutting medical school admissions, advocated that nurse practitioners “step in where doctors are scarce” and encouraged an expansion of independent nurse practice. In 2014, the Institute of Medicine continued to insist that the U.S. was training too many physicians, and recommended redirecting physician training funds toward advanced training for nurses. In response to the Institute’s Future of Nursing (2010) report, which called for nurses to be ‘full partners’ with physicians, the U.S. Government Accountability Office recommended diverting physician residency funds toward funding nurse practitioner and physician assistant ‘residency’ programs, stating, “while increasing physician supply is one way to reduce physician shortages, some experts have also suggested increasing the number of non-physician providers.”
The physician shortage: A manufactured crisis
Instead of relying on training shortcuts, the physician shortage can be immediately alleviated by unfreezing residency funding. But Congress has failed to act, despite the introduction of multiple bills addressing the issue over the last 17 years. Legislation proposed by U.S. Senator Bill Nelson (D-FL) in 2007 and again in 2009 did not pass committee hearings, with critics arguing that the bill targeted non-primary care training. Similar bills have been reintroduced nearly every year since 2011, with the most recent legislation sponsored by Senator Robert Menendez (D-NJ) in 2021.
The current version of the bill, the Resident Physician Shortage Reduction Act of 2021, which would fund 14,000 residency positions over seven years, is the tenth attempt to lift the 1997 freeze on residency positions. Despite the bipartisan support of over two hundred House members and a third of Senators, Congress has not yet acted. While Congress did allocate funding for 1,000 residency positions (200 per year) as part of the Consolidated Appropriations Act of 2021, critics note that the slots are tied up in Medicare red tape.
As we approach Match Day 2023, I am mentally preparing myself for reports of heartbroken medical graduates who will find themselves unmatched despite spending years of their lives and hundreds of thousands of dollars to become physicians. While this crisis could be resolved by commonsense political action, what will it take for Congress to finally act to end the physician shortage?
Rebekah Bernard MD is a family physician in Fort Myers, FL, and the author of Patient at Risk: The Rise of Nurse Practitioner and Physician Assistant in Healthcare.