The State of the Physician Workforce - AAMC · 2019. 7. 3. · Number of clinical sites. Supply of primary care preceptors. Supply specialty preceptors. Percent of programs very concerned

The State of the Physician Workforce

Michael J. DillDirector, Workforce Studies

AAMC

November 4, 2017

1

Projections

PopulationDiversity

Projections

2

Projections

Supply, demand, specialty groups

3

4

What’s new?

• Updated data

• Refined hospitalists estimates

• Updated PA & APRN supply projections

• Population health scenario

• Metro/non-metro location data for demand and

utilization equity

5

• Physician demand continues to grow faster than supply

• Projected total physician shortfall of between 40,800 and 104,900 physicians by 2030

• Shortages in both primary and specialty care – with a particularly large shortage in surgical specialties

• Consistent with 2015 & 2016 projections reports

Key takeaways from the updated projections

6

Supply scenarios include retirement, work hours, GME expansion

750,000 800,000 850,000 900,000 950,000

Projected FTE physician supply, 2030

Retire Earlier (-2)

Millennial Hours

Status Quo

GME Expansion

Retire Later (+2)

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.7

750,000 800,000 850,000 900,000 950,000 1,000,000 1,050,000 1,100,000

Projected FTE physician demand, 2030

ACA + APRN/PA High

ACA + APRN/PA Moderate

ACA + Population Health

ACA + Retail Clinics

Status Quo

ACA

ACA + MC

Demand scenarios include ACA, APRNs/PAs, population health, retail clinics, managed care

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.8

An increasing overall shortage of physicians is projected through 2030

0

30,000

60,000

90,000

120,000

2015 2020 2025 2030

Proj

ecte

d sh

orta

ge, F

TE p

hysi

cian

s

Total projected physician shortfall range, 2015-2030 104,900

40,800

2030 range

Source: AAMC, 2017 Update: Complexities of Physician Supply and Demand: Projections from 2015 to 2030.

9

The size and range of projected physician shortages varies by specialty group

7,300

33,500

1,300

19,800

18,600

43,100

61,800

12,000

29,000

31,8000 10,000 20,000 30,000 40,000 50,000 60,000 70,000

Primary CareSpecialties

Non-Primary Care

Medical Specialties

Surgical Specialties

Other Specialties

Projected physician specialty group shortfall ranges, 2030


10

Projections

Health care utilization equity & population health

11

We model Health Care Utilization Equity to better understand magnitude of unmet need

• What if barriers disappeared? How much more utilization (in 2015)?

• People without medical insurance and people living in non-metropolitan areas => utilization patterns equivalent to their insured peers living in metropolitan areas

• Everyone => utilization patterns equivalent to white insured populations residing in metropolitan areas

Scenario 1:Insurance &

Metro/Non-metro

Scenario 2:Insurance, Metro/Non-

metro, & Race/Ethnicity

12

Estimated Additional Physicians Needed if U.S. Had Achieved Health Care Utilization Equity in 2015

Scenario 1:Insurance &

Metro/Non-metro

34,800 Additional Physicians

Scenario 2:Insurance, Metro/Non-

metro, & Race/Ethnicity

96,800Additional Physicians


13

Estimated Additional Physicians Needed if U.S. Had Achieved Health Care Utilization Equity in 2015

Scenario 1(Insurance,

Metro)Primary

CareScenario 2(Insurance, metro, race)

Scenario 1(Insurance,

metro)

Scenario 2(Insurance, metro, race)

Specialty Care


10,300

21,800

24,500

75,00014

We model population health measures to better understand their long term workforce implications

• Scenario models the workforce implications of achieving selected Healthy People 2020 goals

• Sustained 5% body weight loss for overweight and obese adults

• Improved blood pressure, cholesterol, and blood glucose levels for adults with elevated levels

• Smoking cessation

15

Achieving population health goals would have different short- and long-term effects on demand

• Short-term: 1% decline in physician demand• Long-term: 2% increase in physician demand (by 2030)

• Shifts in demand for select physician specialties• Shifts in utilization across delivery settings

16

Effect of achieving population health goals would differ across specialty groups

0 1,000 2,000 3,000 4,000 5,000 6,000Net change in projected FTE physician demand by 2030

Medical Specialties

Other

Surgery

Primary Care


17

Projections

Underlying trends: UME18

19

US MD enrollment expected to exceed 30% increase

15,000

16,000

17,000

18,000

19,000

20,000

21,000

22,000

23,000

2002 2005 2008 2011 2014 2017 2020 2023

US

MD

FIR

ST Y

EAR

EN

RO

LLM

ENT

Original schools (n=125)

All Schools (n=145)

30% over 2002

Historical Data Survey Data Projections

Source: AAMC 2016 Medical School Enrollment Survey Report20

Overall MD & DO first year enrollment is projected to grow 59% between 2002 and 2021

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021

Firs

t yea

r enr

ollm

ent

Projected MD and DO first year enrollment through 2021

DO

MD

196%

35%


Admissions/UME Match/GME

22

Clerkships

Medical schools are increasingly concerned about clinical training opportunities for their students

72.6%77.4%

54.0%

79.6%87.1%

73.5%

0%

20%

40%

60%

80%

100%

Number of clinical training sites Supply of qualified primary care preceptors Supply of qualified specialty preceptors

Perc

enta

ge o

f sch

ools

con

cern

ed a

bout

clin

ical

tra

inin

g op

portu

nitie

s

2010 2016


Medical schools experiencing more difficulties with existing clinical training sites

11.1%17.0%

26.0%

17.0%23.8%

32.0%26.5% 28.0%

53.0%

34.9%

62.1%59.1%

0%

10%

20%

30%

40%

50%

60%

70%

High turnover amongvolunteer physicians

Difficulty in replacingretired physician

volunteers

Competition fromosteopathic medicalschools for clinical

training sites

Competition fromoffshore medical

schools for clinicaltraining sites

Competition from otherhealth care

professionals (e.g.,NPs, PAs)

Pressure from existingclinical training sites

regarding payment(s)for student rotations

Perc

enta

ge o

f sch

ools

exp

erie

ncin

g di

fficu

lties

with

ex

istin

g cl

inic

al tr

aini

ng s

ites

2009 2016Source: AAMC 2016 Medical School Enrollment Survey Report

24

25

Adequacy of clinical opportunities for students an across-the-board concern

0%

10%

20%

30%

40%

50%

60%

70%

Number of clinical sites Supply of primary care preceptors Supply specialty preceptors

Percent of programs very concerned

M.D. D.O. N.P. P.A.

Source: Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/ClinicalTraining Site Survey.

26

Clerkship/clinical training sites were getting harder to develop & maintain 4 years ago

0%

10%

20%

30%

40%

50%

60%

Identify and develop new core or required training sites Maintain and preserve existing core or required training sites

Percent of programs reporting much more difficult than two years prior

M.D. D.O. N.P. P.A.

Source: Recruiting and Maintaining U.S. Clinical Training Sites: Joint Report of the 2013 Multi-Discipline Clerkship/ClinicalTraining Site Survey.

27

Projections

Underlying trends: GME28

Percentage of schools concerned about graduate medical education, 2012–2016

35%

67%

84%

47%

76%

91%

48%

71%

86%

50%

62%

77%

39%

62%

80%

FOR MY INCOMING STUDENTS IN MY STATE NATIONALLY

PERCENT OF SCHOOLS REPORTING MAJOR OR MODERATE CONCERN

2012 2013 2014 2015 2016


10,000

12,500

15,000

17,500

20,000

23,000

28,000

33,000

38,000

43,000

48,000

53,000

58,000

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Phys

icia

ns tu

rnin

g 65

Res

iden

ts/P

op. 6

5+ in

thou

sand

s

Residents entering ACGME Pop 65+ Physicians turning 65

Production of new physicians not keeping up with aging workforce and population

Source: ACGME, Census, AMA Physician Masterfile; US Census Bureau

+ 19%

+ 36%

+ 97%

30

Projections

Underlying trends: Physician practice

31

Numbers of new PAs and NPs still growing rapidly

Source: NCCPA; AACN.

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

NP Graduates Newly Licensed PAs

UPDATE32

The shift in physician work hours has varied by age group

30

35

40

45

50

55

60

26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs Total age 66 or older

Average physician work hours per week

1980 1990 2000 2009-2011 2012-2014

Source: Census (Decennial/ACS).33

The shift in physician work hours has varied by age group and sex

-5.8

-1.1-0.4

+0.8

+2.1

-6

-3

0

3

6

26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs 66 + yrs

Change in average male physician work hours, 1980 to 2012-2014

Source: Census (Decennial/ACS).

-3.9

+3.8

+2.5

+5.8

+3.5

-6

-3

0

3

6

26 to 35 yrs 36 to 45 yrs 46 to 55 yrs 56 to 65 yrs 66 + yrs

Change in average female physician work hours, 1980 to 2012-2014

MALE FEMALE

34

The US physician workforce is getting older

0

50,000

100,000

150,000

200,000

250,000

Age 26 to 35 Age 36 to 45 Age 46 to 55 Age 56 to 65 Age 66 or older

Number of Physicians Who Worked in Prior Year

1980 1990 2000 2010

Source: United States Census Bureau. Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys. *In 2000 and 2010, “Other” includes two or more races

35

Retirement scenarios remain the most extreme physician supply projections

780,000

830,000

880,000

2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030

Projected FTE Physician Supply: All Physicians

Retire Later +2

GME Expansion

Status Quo

Millennial Hours

Retire Earlier -2


36

From a patient perspective, we ask about:• Viewing lab results online• Making appointments online• Telephone communication• Email communication• Video communication

Technology can improve access to a wide array of services

37

Consumers report overall increases in most types of technology use

38

Largest divergence in consumers’ use of technology reported for video communication

39

Workforce

Diversity

40

0

200,000

400,000

600,000

800,000

1980 1990 2000 2010


Male Female

454,539

612,549709,382

Source: United States Census BureauNote: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys

Physician workforce in the US continues to grow and to include more female physicians

346,660

41

Physician workforce is slowly becoming more racially and ethnically diverse

Source: United States Census Bureau. Note: Data for 2010 are a combination of 2009, 2010, 2011 American Community Surveys. *In 2000 and 2010, “Other” includes two or more races

42

0

250,000

500,000

750,000

1,000,000

2000 2005 2010 2015


White Black American Indian or Alaska Native

Asian or Pacific Islander Two or more major races Hispanic, any race

North Carolina makes a good case study in the need to understand workforce diversity in context

Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data

43

Black or African American population and physician distributions dissimilar

Population

Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data44

American Indian / Alaska Native population and physician distributions somewhat similar

Population

Data Source: 2015 American Community Survey 5-year Estimates; 2014 North Carolina Physician Licensure Data45

IMGs comprise a significant part of the nation’s physician workforce

12017 State Physician Workforce Data Report, AAMC Workforce Studies.2 2016 AAMC Report on Residents, December 2016

of 2016 active physicians were International Medical Graduates (IMGs).124.5%of 2015-2016 active residents were International Medical Graduates (IMGs).224.9%

46

Deferred Action for Childhood Arrivals (DACA) program uncertainty could impact workforce diversity

1 https://www.forbes.com/sites/brucejapsen/2017/09/05/how-trumps-move-to-end-daca-worsens-the-doctor-shortage/#738df05d5b06.

Students with DACA status:

AAMC expects increased enrollment of DACA Dreamers in 2017-2018 since most with confirmed DACA status have not yet finished their undergraduate degrees.

65 Enrolled in U.S. medical schools in the 2016-2017 year

113 Applied to U.S. medical schools for the 2016-2017 year

47

Education pipeline

Diversity

48

Small but important gains from medical school expansion

• Most expansion - highest proportions in primary care and practicing in underserved and rural areas.

• Racial and ethnic diversity of matriculants increased modestly - new schools contributed disproportionately.

Shipman, Jones, Erikson, & Sandberg. 2013. “Exploring the Workforce Implications of a Decade of Medical School Expansion: Variations in Medical School Growth and Changes in Student Characteristics and Career Plans”. Academic Medicine 88(12): 1904–1912.

49

Percentage of U.S. medical school graduates by sex, 1980-2015

Source: AAMC Data Warehouse: Student file, as of 1/7/2016.

0%

10%

20%

30%

40%

50%

60%

70%

80%

1980 1985 1990 1995 2000 2005 2010 2015

Female

Male

50

Percentage of U.S. medical school white graduates by sex, 1986-2015

Source: AAMC Data Warehouse: Student data and Applicant and Matriculant file, as of 7/11/2016.

0%

10%

20%

30%

40%

50%

60%

70%

80%

1986 1990 1995 2000 2005 2010 2015

Female

Male

51

Percentage of U.S. medical school Hispanic graduates by sex, 1986-2015


0%

10%

20%

30%

40%

50%

60%

70%

80%

1986 1990 1995 2000 2005 2010 2015

Female

Male

52

Percentage of U.S. medical school Asian graduates by sex, 1986-2015


0%

10%

20%

30%

40%

50%

60%

70%

80%

1986 1990 1995 2000 2005 2010 2015

Female

Male

53

Percentage of U.S. medical school American Indian/Alaska Native graduates by sex, 1986-2015


0%

10%

20%

30%

40%

50%

60%

70%

80%

1986 1990 1995 2000 2005 2010 2015

Female

Male

54

Percentage of U.S. medical school Black or African American graduates by sex, 1986-2015


0%

10%

20%

30%

40%

50%

60%

70%

80%

1986 1990 1995 2000 2005 2010 2015

Female

Male

55

Percentage of U.S. medical school female, 1986-2015


0%

10%

20%

30%

40%

50%

60%

70%

80%

1986 1990 1995 2000 2005 2010 2015

Hispanic Black or African American Asian White

56

After 30+ years, Black male matriculation is slowly increasing above 1980 levels

0

100

200

300

400

500

600

700

80019

8019

8119

8219

8319

8419

8519

8619

8719

8819

8919

9019

9119

9219

9319

9419

9519

9619

9719

9819

9920

0020

0120

0220

0320

0420

0520

0620

0720

0820

0920

1020

1120

1220

1320

1420

1520

1620

17

Mal

e m

atric

ulan

ts to

US

med

ical

sch

ools

, 198

0 to

201

7

Black/African American

Black Alone

Black Alone or in Combination with Another Race

Source: AAMC AMCAS APP_BIO tables. Race is only available for permanent residents. 57

Most USMD schools have programs or policies designed to recruit a diverse student body

90%

88%

60%

61%

70%

0% 25% 50% 75% 100%

Minori ty groups current ly underrepresented in medicine

Students with disadvantaged backgrounds

Students from rural communit ies

Students from underserved communit ies

Students from local underserved communit ies

Percentage of programs


Recruitment programs begin in elementary school

86%

59%

42%

8%

91%

59%

23%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Four-year-university students--local

Four-year-university students--nationwide

Community college students--local

Community college students--nationwide

High school students

Middle school students

Elementary school students

Percentage of schools with specific admissions programs or policies


Demand

Population

60

More absolute future growth in utilization projected from whites than other groups

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

White Black Asians, Pacific Islanders,Native Americans, and

Alaskan Natives

Hispanic

Proj

ecte

d G

row

th in

Phy

sici

an D

eman

d by

Pa

tient

Rac

e an

d Et

hnic

ity

Projected growth in FTE physician demand, 2015 to 2030


61

Much faster utilization growth rates projected for other groups than for whites

10%

25%

45%49%

0%

10%

20%

30%

40%

50%

60%

White Black Asians, Pacific Islanders,Native Americans, and

Alaskan Natives

Hispanic

Proj

ecte

d G

row

th in

Phy

sici

an D

eman

d by

Pat

ient

R

ace

and

Ethn

icity

Projected percentage growth in FTE physician demand, 2015 to 2030


62

The vast majority of physician demand –current and projected – is in metropolitan areas

0

50,000

100,000

150,000

200,000

250,000

300,000

PrimaryCare

MedicalSpecialties

Surgery Other

FTE physician demandMetro, 2015 Metro, 2015-2030

0

50,000

100,000

150,000

200,000

250,000

300,000

PrimaryCare

MedicalSpecialties

Surgery Other

FTE physician demandNon-metro, 2015 Non metro, 2015-2030


63

Access to care

Population

64

AAMC collects data on health care access from consumers

Source: AAMC Consumer Survey of Health Care Access (June, 2017)

7% of U.S. adults (>17

million people) could not

always get careDid not need care,

43%

Needed care last 12 months-always able to

get it, 50%Could not afford, 3%

Could not get appointment soon

enough, 1%

Could not find provider, 2%

Other, 0%Transportation problems, 1%

65

LGB individuals consistently face greater challenges accessing care

66

23

29

17

25

1412

22

14

Source: AAMC Consumer Survey of Healthcare Access.

Gay, lesbian, or bisexual

Heterosexual or straight

Access to care appears to be improving, though racial/ethnic disparities persist

0

5

10

15

20

25

30

35

White Black/AfricanAmerican

Hispanic and Other Asian Hispanic/Latino Multi-race (non-Hispanic)

AmericanIndian/Alaska

Native

Percent of respondents not always able to get care

2011 2017

Source: AAMC Consumer Survey of Health Care Access Native Hawaiian/Other Pacific Islander & Other excluded due to sample size.67

The nation’s rural population is not homogenous

68

Rural access varies by race/ethnicity

69

“The diversity of American medicine — and the conversations, ideas and breakthroughs this diversity sparks — may be one reason for our competitiveness as a global leader in biomedical research and innovation.”

- Dhruv Khullar, MD

Aaron Carroll, “Why America Needs Foreign Medical Graduates”. https://www.nytimes.com/2017/10/06/upshot/america-is-surprisingly-reliant-on-foreign-medical-graduates.html70

• Da’Shia Davis, BS• Kara Fisher, MPH• Sarah Hampton, BA• Karen Jones, MApStat• Scott Shipman, MD• Imam Xierali, PhD

• Preeti Iyer, BSE (in progress)• Michelle Ogunwole, MD

The AAMC Workforce Studies Team

71

Data Snapshots

72

Physician data reports

State and specialty rankings and data on:

• Physician Supply• UME/GME• In-State Retention

73

[email protected] www.aamc.org/workforce

2018 Health Workforce Research ConferenceTysons, VAMay 9-11, 2018

74

10,000

12,500

15,000

17,500

20,000

23,000

28,000

33,000

38,000

43,000

48,000

53,000

58,000

2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Phys

icia

ns tu

rnin

g 65

Res

iden

ts/P

op. 6

5+ in

thou

sand

s

Residents entering ACGME Pop 65+ Physicians turning 65

Production of new physicians not keeping up with aging workforce and population

Source: ACGME, Census, AMA Physician Masterfile; US Census Bureau

+ 19%

+ 36%

+ 97%

75

Projections

PopulationDiversity Population

Projections

Diversity

Pulling it all together

76

PROJECTIONS• SHORTAGES• NOT KEEPING UP

WITH AGING

DIVERSITY• A GOOD THING• PROGRESS• NEED MORE

PROGRESS

POPULATION• AGING• DIVERSE• DEALING WITH

DISPARITIES

Where do we go from here?

• Extent of current shortages• Work hours and retirement• PAs and APRNs• Clinical training/clerkships• Distribution solutions• Pipeline programs• Keep tracking access

77

Questions?

78

Documents

The State of the Physician Workforce - AAMC · 2019. 7. 3. · Number of clinical sites. Supply of primary care preceptors. Supply specialty preceptors. Percent of programs very concerned