America has a real problem with its health care system. And in a time of true health reform, one big problem isn’t being addressed.

We don’t have enough doctors.

"This is a very real problem,” says Mitchell Best, COO and vice president of business development at Physician Wellness Services, an organization that helps physicians manage day-to-day stress and work and life issues. “There’s an inevitable shortage.”

“Physicians are switching jobs, they’re switching practices, they’re retiring early—they are leaving the practice of medicine entirely,” he says.

Then, factor in the changes health reform will bring. When the Patient Protection and Affordable Care Act’s individual mandate takes effect in 2014, 30 million newly covered patients—people generally treated in emergency rooms now—will be shopping for doctors.

Where does that leave us? In more trouble. The Association of American Medical Colleges predicts there will be a shortage of 90,000 doctors by 2020. Half of those are primary care physicians.

Access crisis

The Physicians Foundation, a nonprofit, conducted the biggest survey of its kind back in September. The survey of 13,575 U.S. doctors found that physicians are working fewer hours, seeing fewer patients and limiting access to their practices in light of significant changes to the medical-practice environment.

If those patterns continue, the medical landscape will change dramatically—and patients will be the ones who pay.

Over the next one to three years, the survey finds, more than half of physicians surveyed will cut back on patients seen, work part-time, switch to concierge medicine, retire or take other steps likely to reduce patient access. And should 100,000 physicians transition from practice-owner to employed status (such as working in a hospital setting) over the next four years, this will lead to 91 million fewer patient encounters.

“It’s clear the introduction of nearly 30 million new patients into the U.S. health care system through health care reform, added to the already growing physician shortage, will have profound implications for patient access to medical care,” says Walker Ray, vice president of The Physicians Foundation and chair of its research committee. “The rate of private practice physicians leaving the medical field—as well as changes in practice patterns that reduce the number of hours spent seeing and treating patients—is alarming. When these lost hours are added up, we get a much fuller and more ominous picture of the kind of access crisis that patients may soon face.”

More than half of physicians (52 percent) have limited the access of Medicare patients to their practices or are planning to do so, while one out of four physicians (26 percent) already have closed their practices to Medicaid patients altogether, the survey shows. Physicians cited rising operating costs, time constraints and diminishing reimbursement as the primary reasons why they’re unable to accept additional Medicare and Medicaid patients.

Perhaps even more concerning is this fact: An overwhelming majority of physicians (77 percent) are pessimistic about the future of medicine, and 82 percent believe they have little ability to change the health care system. Additionally, 92 percent of physicians are unsure where the health system will be or how they will fit into it three to five years from now.

So what’s causing the doctor shortage? Reasons are plentiful.

An aging population

There’s a simple supply vs. demand problem, doctor groups say.

There’s an aging population of retiring doctors that’s not being replaced by new recruits. Baby boomers make up about a third of the doctor population. Best also notes more physicians are working part time.

And at the same time, consumer demand for medical services keeps increasing. The population of older Americans keeps growing, and older people require more health care. That means we’ll need more doctors to handle the same number of patients.

Burnout and stress

The big problem is that doctors are simply tired of their jobs.

According to Mayo Clinic research, nearly half of all doctors say they’re experiencing either emotional exhaustion, depersonalization or a low sense of personal accomplishment. A third show signs of depression and 6 percent say they’ve considered suicide in the past year.

Burnt-out doctors put patients at risk. Job-related fatigue can compromise medical care, increase medical errors and translate to doctors leaving the medical field.

Doctors suffer a higher rate of stress and burnout than workers in other careers, due in part to the fact that doctors work longer hours. Almost 40 percent of doctors report working at least 60 hours a week, compared to only 10 percent of the general population.

Docs also aren’t happy about their work-life balance, saying their jobs don’t leave enough time for a personal life or family. That’s an important note, considering most individuals entering the primary care field are women.

Health reform

Though feelings are mixed depending on who you talk to, for the most part the medical field hasn’t been too excited about the Patient Protection and Affordable Care Act. That’s because, according to the Doctor Patient Medical Association, doctors say the act will have little impact on patients’ access to medical care and will only create bureaucratic hoops.

“Doctors on the front lines clearly understand what Washington does not,” says Kathryn Serkes, DPMA chair. “Government-mandated coverage is not the same thing as actual medical care. We’ll still have millions who need medical care.”

“What PPACA does is increase patients’ access to a piece of paper that says they are covered by insurance or enrolled in Medicaid or Medicare,” she says. “But paper promises don’t translate to actual medical care when doctors can’t afford to see patients at the lowball payments, and patients have to jump through bureaucratic hoops set up by the government.”

Health reform also is a major cause of stress and burnout for physicians, Best says. Not only that—it’s causing them to leave the field of medicine.

“It’s a huge adjustment for these mid- and later-careered physicians,” he says. “They’re not comfortable; they aren’t equipped with the life skills to change from working more autonomously. This is a huge, huge issue that organizations need to get their arms around, both at a team dynamic level to address the conflict and the change, but also to have resources at a peer to peer level.”

The expansion of Medicaid accounts for more than one-third of the overall growth in coverage under President Obama’s health law. But across the country, fewer than half of primary care clinicians were accepting new Medicaid patients as of 2008, making it hard for the poor to find care even when they are eligible for Medicaid.

Other issues

Of course, liability/defensive medicine pressures, as related to potential malpractice lawsuits, continue to be a big issue with doctors, as does new technology. Those issues tend to distract or interfere with the time physicians spend with their patients.

Money issues—including physician compensation—also come into play. As doctors enter the field, many are trying to pay back the record-high debts they incurred as med students. When considering fields, med students are forced into choosing those that make the most money. Specialists often make twice as much as primary care doctors.

Additionally, an increasing number of U.S. doctors are leaving private practice because of the high cost and expense of running a business.

Doctors also are discouraging others from entering the practice of medicine. One survey suggests a whopping nine out of 10 physicians say they wouldn’t recommend—and in fact would discourage—health care as a profession.

Solutions to the crisis

Though not directly a fix, some organizations say educating the public about the shortage is one of the ultimate priorities. The Association of American Medical Colleges recently launched a new ad campaign that aims to do just that.

Their campaign has another goal—to encourage people “to tell Congress to lift the cap on doctor training.” It began 15 years ago when Congress capped the number of federally supported residency training positions for new doctors.

Increased medical school enrollment is part of the solution to addressing the doctor shortage. The AAMC has called for U.S. medical schools to increase enrollment by 30 percent, and institutions are currently on track to meet that goal by 2016, according to an AAMC survey on medical school enrollment.

Other suggested solutions include building more walk-in clinics, increasing compensation, and allowing nurses and physicians assistants to provide more care to consumers, though experts don’t always agree on if these will do much to help. Best and his colleagues at the Physician Wellness Services say doctors need more of a support staff who can handle (and worry about) administrative tasks so that doctors can focus purely on patient work. That’s one way to help alleviate some of the pressures.

But whatever the solutions might be, something needs to get done—and quickly.

“For doctors, there is little reward in this era of high costs, high regulation,” says Richard Jackson, chairman and CEO of Jackson Healthcare. “The future of medicine is not what it used to be.”

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Where have all the doctors gone?

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