A report released last spring, cialis sale which predicted that in 2025 Florida would experience a shortage of about 7,000 physicians, should not have come as a surprise.
“There have always been [physician] shortages created by changing science, which keeps leading to increasingly specialized areas of practice,” said Yank Coble, a Jacksonville endocrinologist and a former president of the American Medical Association.
Additionally, there have always been geographic shortages, areas where access to health care can be an issue. For instance, no full-time obstetrician practices in Baker County and pregnant residents of the county must travel to Jacksonville, Orange Park or Gainesville to deliver their children, said Kerry Dunlavey, administrator of the Florida Department of Health in Baker County.
As the number of new doctors being educated and trained failed to keep pace in recent years with the growth and aging of the population, alarms have been sounded.
“Florida Physician Workforce Analysis: Forecasting Supply and Demand,” a study commissioned by the Teaching Hospital Council of Florida and the Safety Net Hospital Alliance of Florida, echoed warnings that the Association of American Medical Colleges (AAMC) has been making for a decade.
The AAMC currently predicts a shortage of 46,000 to 90,000 physicians nationally in 2025. A decade ago it issued a call to increase medical school enrollment by 30 percent, a goal the group now says should achieved within the next five years.
The shortage is fueled by the lack of residencies (a hospital-based period of training following medical school graduation that must be completed to become a licensed physician), the aging of the baby boom generation, greater access to medical care for growing numbers of people under Obamacare and the fact that many physicians are retiring.
While medical school admissions have expanded and some states, including Florida, made efforts to increase the number of residencies, there aren’t enough residency openings to accommodate all medical school graduates.
Florida, for instance, will graduate about 100 more students from medical school this year than can be accommodated by available residencies in the state. Florida ranks 42nd with 19 physicians in training per 100,000 population, according to the Association of American Medical Colleges. By comparison, New York has 82 medical residents and Massachusetts 84 per 100,000 population.
DOCTORS OPT OUT EARLIER
Growing anecdotal evidence indicates physicians are beginning to retire earlier than in the past. In Florida 62 percent of physicians are 50 or older and 13.4 percent (about 5,900) plan to retire in the next five years, according to the Florida Department of Health’s 2014 Physician Work Force Annual Report.
“There are a lot of those stories out there, which would suggest that there is going to be a flight of physicians over the age of 55 earlier than they would have expected from the workforce,” said Atul Grover, chief public policy officer for the AAMC. “… It is certainly going to be a different environment and for older physicians it may be generational, that they don’t want to deal with it.”
Coble said unhappiness with government involvement in medicine, difficult dealings with insurance companies, and the demise of the individual practice, large numbers of which have been bought by hospitals and other corporate entities, led to “a feeling of discontent, almost of oppression” among many physicians.
Jack Drewninany, 64, a Jacksonville hand surgeon, made his feelings about the changes affecting his profession clear in his book “The Death of the Physician: How Power and Money Have Destroyed Our Medical Care,” published in 2012.
“It’s not attractive to be a doctor anymore,” Drewninany said. “Very few physicians I know have recommended their kids go into medicine. You are being told today how to practice medicine. It’s a controlled industry, which is not going in a good direction.”
“Burnout is a significant problem for physicians across the country,” said Gianrico Farrugia, chief executive officer of the Mayo Clinic in Jacksonville. “… You need people who are very enthusiastic about their profession. But the amount of administrative work per patient has grown substantially. Most physicians go into medical school in a highly idealistic state. Physicians don’t get into the business to do paperwork.”
The pressure created by ongoing innovation is also a factor, he said.
“The pace of change has become so rapid that it is difficult to keep up,” Farrugia said.
YOUNGER DOCTORS LESS DRIVEN
Meanwhile younger doctors seem to have made the conscious decision to be less driven than the older generation. Physicians under the age of 35 in 1980 worked more than five hours more a week then their most recent counterparts, the AAMC reports.
“This generation is probably not going to work as many hours as prior generations,” Grover said, even though most of them are saddled with more debt than previous generations.
“They are making quality-of-life decisions which my generation would have never considered,” said Mayo’s CEO Farrugia.
It’s not just doctors under 30 who make those kinds of decisions.
From 1999-2011, Jacksonville internist Louis Akra had a flourishing primary-care practice, treating as many as 5,000 patients. Treating that volume left him feeling not only overworked but frustrated that he wasn’t able to devote the time he wanted to each patient.
“I was burning the candle at both ends,” he said. “I really wasn’t enjoying the practice of medicine. I was missing personal time with my patients. I wanted a more personal relationship, and that was becoming more and more difficult because of the volume of patients.”
So in September 2011, Akra opened Akra Professional Services, a concierge practice. The patients he treats pay an annual fee of $1,800. For that they get as much time and attention as they desire and have round-the-clock access via email, text or phone call. He gets to practice medicine the way he wants while treating less than 10 percent of former patient load.
In addition to predicting an overall shortfall of 7,000 physicians in Florida in 2025, the Florida Physician Workforce Analysis: Forecasting Supply and Demand looked at which specialty areas of practice are likely to experience shortages and which will experience abundance by 2025. The largest shortages forecast are in psychiatry (55 percent), general surgery (50 percent), rheumatology (43 percent), thoracic surgery (38 percent), hematology/oncology (36 percent) and pulmonology/critical care (32 percent). Specialities forecast to have an abundance in Florida in 2025 are geriatric medicine (33 percent), pediatrics (26), dermatology (23 percent), emergency medicine (22) and plastic surgery (18 percent).
ACCESS TO DOCTORS DIMINISHES
Even in areas like Jacksonville that seem to have plenty of doctors, shortages will manifest themselves in wait times for appointments, particularly with specialists, Grover said.
“There is the demand issue of convenience where I’m not going to be able to see a physician as quickly as I may want or need to,” he said. “… Certainly, we’re already seeing it in mental health, psychiatry, we’re seeing it in neurology because of the growth in things like Parkinson’s and Alzheimer’s, we’re seeing it in oncology because of the growth in cancer rates.”
A 2014 survey of wait times for five specialties in 15 cities by Merritt Hawkins found Boston had the highest average wait time at 45 days. Dallas had the lowest average wait time of 10.2 days.
The other big problem for people in certain rural areas, like Baker County, is that wait times are compounded by travel time.
“We could really use some specialists,” said Dunlavey, mentioning dermatology and orthopedics as specialities hard to find in her county.
One potential answer to that problem is telemedicine — the delivery of health care using telecommunications technologies such as video-conferencing.
Telemedicine may well represent the future of medicine, says Sarvam P. TerKonda, who is the Mayo Clinic’s medical director for connected care in Florida. Someday, he said, physicians will see more of their patients via telemedicine than in person. But that future isn’t here yet.
No two states are alike in how telemedicine, also called telehealth, is defined and reimbursed by Medicare, Medicaid and private insurance, according to the National Telehealth Policy Resource Center.
“Rules still have to be worked out” about how and where a physician can treat a patient using a remote digital connection, TerKonda said.
Many states, including Florida, require that a physician must make a face-to-face meeting with a patient before the physician can prescribe medicine for that patient, although a physician can recommend medication from a remote location if another physician is in face-to-face contact with the patient.
TELEMEDICINE AN OPTION
That’s what happens with the Mayo Clinic’s stroke telemedicine program, which allows Mayo neurologist Kevin M. Barrett to assess patients who may be undergoing strokes at five hospitals in Florida and Georgia. Using wireless technology, Barrett can examine patients to determine if they are suffering ischemic strokes. Those strokes are caused by blood clots that can be dissolved using a tPA (tissue plasminogen activator) if it is administered in a timely fashion.
Eventually, TerKonda said, there will need to be an interstate compact like the one that exists among the states to agree to honor driver’s licenses issued by other states. That way a physician licensed in one state could remotely treat a patient in a different state that has agreed to honor the physician’s license. Such an agreement is not imminent, TerKonda said.
Once barriers are removed, telemedicine should “reduce travel time, increase access and reduce the cost” of medical treatment, TerKonda said. “It is going to change the entirety of patient care.”
But what it won’t do is relieve physician shortages, he said. Telemedicine may save time for patients. But the physician will need the same amount of time with the patient regardless of whether the patient is in the room with the physician or at a remote location.
Another possible solution to the physician shortage is the increased training of physician assistants and nurse practitioners, people who don’t have medical degrees but do have advanced training in the treatment of illness and injury. But the degree of independence these practitioners can exercise varies from state to state, with Florida still requiring them to work under the supervision of a physician.
One approach to solving physician shortages that has been used is allowing foreign-trained physicians to practice in the U.S. It’s a solution Coble doesn’t like.
“We’re stealing them from countries which have their own desperate needs for quality health care,” he said.
Charlie Patton: (904) 359-4413