Physician Shortages in the Specialties Taking a Toll
Career Resources articles posted on NEJM CareerCenter are produced by freelance health care writers as an advertising service of the publishing division of the Massachusetts Medical Society and should not be construed as coming from the New England Journal of Medicine, nor do they represent the views of the New England Journal of Medicine or the Massachusetts Medical Society.
Career Resources Editor’s Note:Finally, some good news for most physicians graduating from training — you’'re needed! The physician shortage has extended from the realm of primary care to the medical and surgical subspecialties. Even the proverbial lower-income specialties, such as pediatrics-related ones, are now in ever increasing demand due to their scarcity in non-urban settings and the impending professional retirement of the baby-boomer generation. Better compensation packages and a more financially equal playing field could mean a wider range of career choices for medical students moving into training. — John A. Fromson, MD
Effects of the increasing undersupply are palpable in recruiting, not just patient-access difficulties.
By Bonnie Darves, a Seattle-based freelance health care writer
In the persisting, sometimes heated national conversation about physician shortages, the focus and headline-grabbing reports have largely centered on the dearth of primary care physicians and attendant access problems. Shortages in the non-primary care specialties haven’t been ignored, but that undersupply has not, some claim, received the attention it warrants.
“In any specialty that cares for older adults, there will be severe, increasing shortages — and we’re already seeing some of the same recruiting issues in the academic sector that we see in the community,” said Atul Grover, MD, PhD, chief advocacy officer for the Association of American Medical Colleges (AAMC) in Washington, D.C. “The biggest concern is that over the next 10 years, as 10,000 baby boomers turn 65 every day, things will get much worse.”
The short list Dr. Grover cites includes cardiology, critical care, diagnostic radiology, oncology, and orthopedic surgery. Shortages in dermatology, general surgery, neurology, psychiatry, urology, and vascular surgery are also becoming more acute, recruiters report. Relatively narrow training pipelines are making recruiting especially challenging and costly at the other end of patient-age spectrum as well, in most pediatric subspecialties.
“If you look at the data, in some of these niche areas the packages being offered are astronomical. I’ve heard of pediatric surgeons being offered $500,000 just a year out of fellowship,” Dr. Grover said, adding that the figure represents an increase of more than $100,000 over a few years ago.
Dr. Grover cites similar stories in diagnostic radiology, where fellows are not only garnering top-dollar salaries but also calling the shots on employment terms. “Some are getting contracts with eight or nine weeks of vacation, no call, and no weekends,” he said.
In many shortage-plagued specialties, recruiters and prospective employers are reaching out to physicians very early — in some cases before they’ve even completed their second year of training. In a relatively new trend, specialists also are being “hired” more than a year before they will start, and are receiving cash stipends to make their final training year more financially comfortable. Those advances, structured as loans that must be repaid, were almost unheard of a few years ago.
In urology, that stipend — up to $2,000 a month — could be in addition to already hefty signing bonuses, reports Vivian Luce, regional director for the national recruiting firm Cejka & Co., in St. Louis, Missouri. “We’ve already got 2012 urology residents being wined and dined and put on stipends — just to confirm they’ll come. And for practicing urologists, we’re seeing offers of $500,000 to $600,000, with a $50,000 signing bonus,” Ms. Luce said.
In quantifying the demand, Ms. Luce notes that urology only produced 192 graduates in 2009, yet nearly 2,000 openings were advertised. “It’s ridiculous,” she maintained. She cites similarly tough recruiting conditions in general neurology. The specialty is filling only a third of its residency programs and seeing increasing numbers of the mere 463 residents head into subspecialties.
The trend toward avoiding subspecialization is disrupting the general surgery marketplace as well. As an increasing portion of trainees — only 1,080 annually — further subspecialize, it’s virtually creating a bidding war for the generalists, reports Joseph Cofer, MD, director of general surgery training at the University of Tennessee College of Medicine in Chattanooga.
“My chief residents joke that once they get to be chief — especially if they’re going into general surgery — they have to almost change their identity, especially if their phone number gets out,” Dr. Cofer said. “They all have multiple job offers before they finish, and many of them are already on the payroll.” The shortage is especially acute now that nearly 80 percent of general surgeons go on to “niche themselves” in colorectal, vascular, or plastic surgery, he explains, up from 50 percent five years ago.
“Everybody tells you it’s a buyer’s market, but you don’t really appreciate that until you start going on interviews and getting a flood of calls,” said trauma surgeon Gregory Huang, MD, a University of Louisville (Kentucky) fellow. He interviewed for seven positions in four different geographic areas before choosing St. Elizabeth’s Health Center in Youngstown, Ohio. “Some of the fellows went on even more interviews than I did,” Dr. Huang said.
In its June 2010 report on non-primary care specialty shortages, AAMC’s Center for Workforce Studies ventured a dire prediction for the decade ahead: a current deficit of 33 percent in surgical specialties, and an undersupply of 33,100 surgeons and other specialists by 2015, increasing to 46,100 by 2020. The AAMC expects the primary care physician shortage to top 45,000 by 2020. The forecast from the Health Resources and Services Administration (HRSA) is even more unsettling. The government agency calls for a shortage of 62,400 in the non-primary care specialties by 2020. In addition, one third of U.S. practicing physicians are expected to retire over the next decade.
Fewer Candidates, More Searches Make Recruiting Tough Work
For recruiters, hospitals, and community practices, these distressing numbers aren’t just future scape; they reflect current reality. Despite regional differences in specialist supply and the fact that in a handful of spots — San Francisco, New York, and Seattle, among them — specialist supply is adequate, that’s not the case in most areas of the country.
“My hardest search is maternal-fetal medicine; that could take me one to two years,” reported Wilf Rudert, a longtime recruiter with Intermountain Healthcare in Salt Lake City, Utah. “Psychiatry, neurosurgery, and pulmonary and critical care combined, are also tough areas, and basically any of the lower-reimbursing specialties.”
Health economist and well-known physician workforce researcher Richard “Buzz” Cooper, MD, at the University of Pennsylvania, Philadelphia, has long predicted the specialist dearth. He concurs with Dr. Grover that the shortages are playing out in more than recruitment and patient pressures. The undersupply is placing an inordinate burden on practicing physicians who cannot keep up with services demand.
“Practices have a harder time recruiting, and low-income patients have a harder time finding a doctor,” observed Dr. Cooper, an oncologist. “I know of physician [specialty] practices that have given up recruiting completely. From a big-picture perspective, I can’t understand why there’s nothing being done about the shortage. We’ve been writing about this for more than a decade.” He refers to the view that physician-training slots should be increased in areas of persisting shortage, and that the government should financially underpin graduate medical education to a greater extent than it does now — Medicare funding has effectively been frozen since 1997 — to relieve the pipeline pressures.
In oncology, the worsening shortage, predicted to top 4,000 by 2020 and fueled by retiring baby boomers, is hitting hard in rural areas, notes Justin Klamerus, MD, a medical oncologist with Northern Hematology/Oncology in Petoskey, Michigan, and immediate past chair of AAMC’s Organization of Resident Representatives. “Our group already serves 5 hospitals in 22 counties — and in the closest group, 1.5 hours away, some of the oncologists are in their mid-50s,” said Dr. Klamerus. “That’s an issue many practices are facing around the country. The oncologists are concerned about who will replace them. For example, I’ve been in practice for 18 months, and I’m still receiving 7 or 8 e-mails a week about jobs.”
Dermatology is experiencing similar woes, for much of the same reasons. The acute shortage — there are only 3.5 dermatologists per 100,000 U.S. residents — has persisted because of the cap on residency positions, according to Karen Edison, MD, chair of the department of dermatology at the University of Missouri in Columbia. “That number has remained at just over 300 for the past 40 years. We also have a maldistribution of dermatologists,” Dr. Edison said. Many parts of the country, particularly rural and frontier areas, she observed, have very little meaningful access to expert dermatological care.
Generally, wait times of up to three months are not uncommon for patients seeking care, Dr. Edison reports. “As dermatologists retire, this [situation] could get worse,” she said. On a national level, large recruiting firms are finding specialist recruiting tough going for reasons beyond the undersupply and the limited training slots. Pent-up demand is exacerbating the situation, according to Travis Singleton, vice president at Merritt Hawkins Associates (MHA) in Irving, Texas. He explains that hospitals, many of which had put the brakes on recruiting due to the economic environment, are getting desperate to fill specialty slots. Even health reform uncertainty about future reimbursement isn’t deterring prospective employers now.
“They’re in a bit of a ‘have-to’ recruiting environment now because demand is rising so fast,” Mr. Singleton maintained, “and they must have those specialist services.”
For MHA the surgical specialties, especially general surgery, are the most challenging and fast-rising search areas now. And psychiatry searches, especially those for rural practice opportunities, “are through the roof,” Mr. Singleton said, with requests for child and adolescent psychiatrists up more than 100 percent in a single year.
Gene Beresin, MD, director of the child and adolescent psychiatry training program at Massachusetts General Hospital and McLean Hospital in Boston, isn’t surprised. “It’s fair to say, if you look at the data, that at least 14 percent of kids have some sort of mental or psychiatric disorder — yet there are only 7,000 child psychiatrists in the entire country,” he said. Even in “physician-rich” Massachusetts, there are only 21 child psychiatrists per 100,000 children. In Alaska, the figure is a mere 3 per 100,000. The national average is 8.7 per 100,000.
“The good news for graduates is that they can get a job anywhere they want, in any setting they want — inpatient, outpatient, court work. And to some extent, they can negotiate their compensation,” Dr. Beresin said. Even plum academic jobs, historically hard to secure, are relatively plentiful right now, in a field that produces only 320 graduates annually. “The Council on Graduate Medical Education in 1990 said we would need 30,000 child psychiatrists by 2000, so we’re way behind the curve,” Dr. Beresin observed.
High-Demand Specialists — Wanted and Wooed
Child psychiatrist Kayla Pope, MD, JD, who will complete her fellowship at Children’s National Medical Center in Washington, D.C., this summer, found the job marketplace wide open and welcoming. “I definitely received a lot of interest from recruiting companies — mostly e-mail but also phone calls, and sometimes even pages,” she recalled.
Early on, Dr. Pope made up her mind to stay in research and to stay put, so the flurry of interest had little effect on her decision. “I really never went out and looked. But I know that my colleagues who have gone out there are finding that they can do pretty much anything they want to do because there are so few of us,” she said. A former family law attorney, Dr. Pope will work at the National Institute of Mental Health in Rockville, Maryland, focusing on effects of trauma on brain development.
Dr. Pope even has personal experience with the shortage’s effects. “I started a small private practice a month ago, and I’m already full,” she said. “But the downside of this shortage for those looking at community-based centers, is that the patient load is enormous.”
Pediatrician Trish Rafferty, MD, who will pursue her interests in childhood obesity after training, tells a similar story. She knew that she wanted to practice in Utah, but that didn’t stop her from receiving a constant flow of e-mails and phone calls — mostly about opportunities in places she didn’t want to go. That surprised her somewhat, but the bigger eye-opener was the interviewing experience.
“It was so different from medical school, when you’re one in 13 and basically begging for your spot. They treat you like they really want you — I didn’t expect to be wined and dined, I guess,” said Dr. Rafferty, who chose a position with Intermountain Healthcare. Some of Dr. Rafferty’s colleagues, especially those who weren’t certain about where they wanted to practice, related less orderly experiences. “They were flying all around the country,” she said. “One girl looking at pediatric hospitalist positions interviewed in five different areas.”
High-demand critical care physicians can also hold out for the right opportunity. For starters, only about half of the training slots fill in any given year. The recent rapid increase of intensive care units (ICUs) and a trend toward subspecialization within ICUs are exacerbating the undersupply. “It’s fair to say that there are so many jobs and so few of them that critical care fellows can go anywhere they choose,” observed Timothy Buchman, PhD, MD, director of the Emory Center for Critical Care in Atlanta, Georgia, and a past president of the Society of Critical Care Medicine. “They’re also shrewd now, when they start looking,” he said. “They realize critical care is a team sport, and that colors how the fellows look at opportunities.” Today’s trainees, Dr. Buchman concludes, want the ideal team makeup and interaction; some even insist on meeting the physicians who will admit and later receive their patients.
That’s pretty much how Krzysztof Laudanski, MD, a critical care–trained anesthesiologist who recently landed at the University of Pennsylvania in Philadelphia, approached his choice, after looking at more than a half-dozen academic positions. “When I was interviewing, each department I went to was desperately looking for a critical care doctor,” he said, rattling off the short list: Johns Hopkins, University of Maryland, University of Washington, University of Wisconsin, and both Beth Israel Deaconness and Massachusetts General Hospitals, in addition to a few private groups. “It wasn’t a question of getting a job — I was looking for a specific set of conditions.” He wanted 50 percent protected time for his NIH research in particular, instead of the more typical 80/20 clinical-administration/-research breakdown. “That’s hard to find, but I got it,” he said.
Some physician leaders don’t think the shortage-spawned marketplace madness is good for anyone, especially young physicians. Premature recruiting is not only disruptive, but potentially confusing as well, Dr. Buchman maintains. “The thought that students are being approached, recruited, and marketed to before they’ve had a chance to figure out what they want to do is a bit scary,” he said. “At the end of the day, that can lead to expectations on both sides that don’t get fulfilled.”
Dr. Cooper concurs, but voices his concerns in the larger context of physicians’ conduct and perception, and possible societal implications. He fears that the current environment is creating a climate of entitlement. “Coming into a worsening shortage, physicians can continually call the shots. It’s having a tremendous effect, I think, on the ethic of the young physician,” he says. “They came up during indulgent times and will be indulged as young physicians, and everyone is held captive. They’re in an unbelievably enviable position, but I don’t think it’s healthy for society.”