With the U.S. already facing a physician shortage, is the COVID-19 pandemic making things worse?
Yes, according to Patrice Harris, MD, president of the American Medical Association (AMA). "I just heard a story this morning about a number of physicians, nurses, and other healthcare professionals becoming ill and infected, which puts them out of the workforce," Harris said in a phone interview at which a public relations person was present. "We certainly had a workforce challenge pre-pandemic, but it's exacerbated by COVID-19 disease."
Adding to the Current Shortage
How big is the shortage now? The Association of American Medical Colleges (AAMC) publishes an annual report on the physician shortage; in its 2019 report, AAMC projected a shortfall of 40,000 to 122,000 physicians over the next decade, with a shortage of 29,000 to 42,900 doctors in 2020, depending on several factors.
"The majority of that comes from the idea that the U.S. population is growing and you need so many doctors per 10,000 people," Janis Orlowski, MD, AAMC's chief healthcare officer, said in a phone interview. The second factor is that "the U.S. population is aging and as people get older than 65, they utilize more doctors. If you're 25, you only go to the doctor once or twice a year, but at 65, you may go to your primary care physician, cardiologist, and GI doctor, so you receive more services ... That's where the demand comes from."
In addition, "there's an aging of physicians and a 'bubble' of doctors -- one out of every five doctors is older than 65 and is at retirement age," she said. The question is, over the next decade, "do all of those men and women retire or do they stay in the workforce?"
In the past, "physicians have worked longer than the general population -- we get started later because we're in school for so long -- and we tend to work longer, people enjoy the work they're doing and find it fulfilling, so we see physicians tend to work a little longer. The question is, is that still going to be the case?" Orlowski said.
'All Hands on Deck'
"Before the pandemic, we were saying if people's retirement fund is looking healthy, and they economically feel like they can retire, so there's all kinds of factors about when people retire," Orlowski said. "Now what we're looking at is we're trying to expand the scope of doctors by letting them do more telehealth, bringing retired doctors back into the workforce, and having medical students graduate early -- all this kind of stuff to grow the workforce at this time."
And, she added gently, although no one likes to think about it, also factoring in is "how many healthcare workers are we going to lose during the pandemic? We hope that that's very small, but it will be another factor."
Right now, "we are in a moment where we need an 'all-hands-on-deck' approach," said Harris, a psychiatrist in Atlanta. In addition to calling back retired physicians and letting medical school students graduate early, "here in Georgia we have a medical reserve corps, which is managed by the state medical association of Georgia, so that's another strategy."
Allowing in more physicians from abroad is another way to increase the supply. The AMA recently asked Secretary of State Mike Pompeo and Acting Homeland Security Secretary Chad Wolf to open visa processing at embassies and consulates worldwide for physicians seeking to enter the U.S. to join residency programs beginning on July 1. "The AMA believes that any delay in the commencement of training programs will significantly compromise serving our nation's most vulnerable patients at hundreds of academic medical centers and safety-net facilities across the U.S.," wrote James Madara, MD, the AMA's executive vice president and CEO.
Telemedicine is another strategy being used to stretch the physician supply, Harris said. "Telemedicine is a wonderful opportunity to increase access to care and help with workforce issues," Harris said, especially since both health insurers such as Medicare and hard-hit states like New York have been relaxing their regulations to allow out-of-state physicians to deliver care in other states. Increased use of telemedicine is also helpful for doctors who have decreased the hours their outpatient practice is open in order to protect the health of patients and employees.
This increased use of out-of-state physicians raises a long-simmering question about whether the U.S. should do away with state-by-state medical licenses and have just a single national license. "Many are supportive of a national medical license, and the issue will be the monitoring, oversight, and discipline of physicians, and that will need to be sorted out," Orlowski said on a COVID-19 conference call with reporters. "It's an important national discussion we need to have, and we need a better solution than we have right now."
For its part, the AMA remains opposed to national licensure, Harris said. "We do support the interstate medical licensure compact; 29 states are participating in that," she said. "Really, that's the way to go. That allows states to continue to have the oversight but to expedite the process for processing. And in the current environment, we support laws allowing license reciprocity in disaster; that's not new for us."
Role of Nurse Practitioners
Other health professionals also are stepping forward to battle the pandemic, including nurse practitioners (NPs). Unlike physicians, NPs are in adequate supply except in certain rural and underserved parts of the country, according to Sophia Thomas, DNP, APRN, president of the American Association of Nurse Practitioners (AANP). About 65% of the country's 290,000 nurse practitioners are in primary care, with the rest in a variety of specialties such as cardiology and orthopedics, she said in a phone interview.
Despite the robust supply of NPs, however, "the pandemic is going to work on our workforce," she said. "As more NPs get sick, that's going to pull people out of the front lines in caring for this pandemic." In addition, some state laws are preventing more NPs from helping out with COVID-19 patients.
In 22 states plus the District of Columbia, as well as the Department of Veterans Affairs and the Indian Health Service, "NPs have full practice authority, full scope of practice," said Thomas. "But in other states, our hands are tied because we are bound by collaborative agreements with physicians that prevent us from going into other areas of practice." For instance, "the majority of NPs are trained to be family practice providers," including those who specialize in things like orthopedics or cardiology, "and could easily go into the front line to provide care for patients, but because their specialization is in orthopedics ... they can't provide care because their collaborative physician isn't a primary care physician."
The AANP recently called on governors to waive regulatory barriers -- such as the requirement for a collaborative agreement -- that prevent NPs from providing access to care. This requirement "needlessly restricts the number of NPs who could otherwise evaluate, diagnose, and treat patients especially in times of crisis," the organization said in a press release. "Further, it creates unnecessary geographic access challenges and delays in care."