GI physician shortage ‘a significant concern’ affecting both providers, patients
Click Here to Manage Email Alerts
As demand for health care providers continues to increase, the U.S. Department of Health and Human Services reported gastroenterology will be among the top fields with the highest predicted provider deficit.
“The National Center for Health Workforce Analysis’s report from December 2016 estimates the shortage of gastroenterologists to be 1,630 full-time physicians,” Peter Sinclair, public affairs specialist at the Bureau of Health Workforce in the Health Resources and Services Administration (HRSA), told Healio Gastroenterology. “Gastroenterology is among the highest of the projected shortages alongside cardiology, hematologists/oncologists and pulmonologists.”
Source: American College of Gastroenterology
HRSA estimated a supply of 15,540 providers and demand of 17,170 providers by 2025 with regional assessments indicating that the Midwest (–810), South (–690) and West (–680) will account for the greatest differences in supply and demand. The Association of American Medical Colleges (AAMC) corroborated these projections, reporting an overall shortage between 37,800 and 124,000 physicians by 2034.
“The physician shortage in GI is a significant concern as it impacts our ability to care for patients who need our expertise,” Darrell S. Pardi, MD, MS, professor of medicine and chair of gastroenterology and hepatology at Mayo Clinic Rochester, said. “Not only does the shortage impact our ability to provide current state lifechanging and lifesaving interventions, like colorectal cancer screening, it will also impact our ability to deliver new treatments, such as the myriad emerging endoscopic interventions.”
To better understand this growing problem, Healio Gastroenterology spoke with experts about how these shortages may affect the field, possible solutions and why there is a dire need to act now.
Driving Factors
While it is difficult to pinpoint one specific factor as the impetus for the provider shortage, three culprits continue to play a critical role in this deficit: demographics, retirement and limited training.
Trends in population growth and aging show that patients are living longer, creating an increased demand for age-related GI care. Data from the 2017 U.S. Census Bureau projected a 10.6% growth in the population from 2019 to 2034 and a 42.4% growth in those aged 65 years and older.
“We can’t meet the growing demand in health care services because we’re aging, we’re living much longer and we just have more people,” Joseph J. Vicari, MD, MBA, FASGE, a gastroenterologist at Rockford Gastroenterology Associates, said. “It is inevitable that more GI and health care problems will arise across all fields.”
Physician recruiter Eric Rose, MBA, group vice president of HCA Physician Services Group, noted that an increase in colonoscopy screening awareness may also be contributing to the increased demand for GI care.
“It’s this double-edged sword where the GI industry has done a great job of advertising what patients need to do,” he said. “But this has, in turn, inundated physicians with patient visits.”
Complicating these concerns is physician retirement. AAMC reported a large portion of the physician workforce is nearing traditional retirement age —more than two out of five currently active positions will be 65 years or older in the next decade — and shifting retirement patterns have indicated many physicians are opting for earlier retirement.
“If you simply look at AAMC’s prediction, where you’ve got 50% of GI providers aged 55, and in 5 years, they will be 60 and over. Depending on how the economy is doing and retirement funds, a large portion of those will actually retire,” Anne Marie Lennon, MD, PhD, FASGE, professor of medicine and director of gastroenterology and hepatology at Johns Hopkins Medicine, said. “In the past, physicians often worked into their 70s — that trend appears to be changing.”
In its 2021 Physician Compensation Report, Doximity reported the jump in cumulative physician retirement compared with the pre-pandemic rate (4% in January 2020 vs. approximately 10% in April 2021) could be an “early warning sign of larger shifts to come.” Survey results from the report further revealed that of 2,000 physicians in the U.S., 21.8% considered early retirement as a result of feeling overworked.
“The effects of the pandemic, I believe, have led to a greater number of GI physicians retiring and will cause a further accentuation of the predicted shortage,” Daniel J. Pambianco, MD, FACG, managing partner of GastroHealth in Charlottesville, Virginia, and ACG president, said. “The decrease in gastroenterologists and hepatologists — combined with the increased population — has led to and will further the demand for advanced practice providers.”
Plus, the field has not seen “commensurate growth in residency positions,” Pardi said, adding that the growth in medical student positions (AAMC reported a 37.5% increase in matriculants from 2002 to 2021) has not translated into growth in internal medicine residents or subspecialty fellows.
Further, the many years of required schooling and training has only added to existing shortages and increased the workload burden on established medical professionals.
“We don’t have enough providers coming in, and we have too many going out,” Vicari said. “If this is fixable, it doesn’t happen in a year or 3 or 5 — this is at least a 10-year project to get approval and funding for new fellowship spots then complete training. There’s a need to be creative, think outside the box and wisely use other providers.”
Downstream Effects
With no immediate fix for the shortage of GI providers, concerns are mounting about the inevitable effect on patient care and accessibility, particularly where it is needed most: rural and urban underserved populations.
“This phenomenon will lead to difficulty accessing care with greater wait times for consultative appointments and cancer screening exams. Accentuating the circumstance further has been the increased screening demand of age 45 and catching up on the backlog of pandemic-interrupted screening and surveillance exams,” Pambianco said. “These delayed screenings will lead to increases in cancer mortality, as well as noncancer mortality such as alcohol- and obesity-related liver disease.
“Unfortunately, and inevitably, the underserved areas and populations will have disproportionate deferrals in their care,” he continued. “There are models predicting widening gaps in racial cancer mortalities as a result.”
Vicari noted that the bottom line is “timely access,” especially in circumstances when waiting only a few months could lead to “devastating consequences.”
Another aspect of patient care that is likely to be affected — although not widely discussed — is cost.
“It’s interesting that this is mimicking what we’re seeing in the economy with inflation and supply chain issues — it’s exactly the same thing happening in health care, which I have never seen in my 20 years of experience,” Rose said. “Where you have supply shortages, costs are going to go up, and it goes back to the fact that somebody’s going to bear the cost and it’s most likely the consumer.
“In the battle between the ‘haves’ and the ‘have nots,’ the patients who are going to suffer are those who don’t have good insurance,” he added. “We’re going to see that play out in emergency rooms and urgent cares.”
Retention, Recruitment and Other Solutions
As Vicari previously mentioned, too many physicians are leaving practice and not enough coming in to take their place. As such, retaining physicians, attracting the younger generation and increasing fellowship opportunities are key to mitigating this growing problem.
“It’s important to retain because you’re not going to be able to replace, and replacement costs can be 12 times the monthly salary,” Rose said. “It’s growing exponentially every day, and it can take an average of 18 to 24 months, depending on where you are.”
To increase retention, Vicari recommended offering a competitive salary, a work schedule with robust vacation, a generous benefits package and ample opportunities for continuing education. He further advised physicians to “be flexible” in during staff negotiations and help employees understand the value of their entire compensation package.
“Decreasing the flow of physicians out of the system is a critical need to begin addressing the physician shortage,” Pardi said. “This can be done by making the job more meaningful and less exhausting through tactics such as expanded team-based care and the creation of novel digital solutions that make our work more efficient.”
Lennon added that it is not just about compensation packages when it comes to both retaining current employees and attracting new ones.
“For younger generations quality of life is very important,” she said. “They want to have maternity and paternity leave, as well as a greater flexibility on when they practice medicine, compared with the older generations.”
Although attracting younger physicians into practice is key, bolstering these numbers means increasing opportunities for fellowship. Despite Congress’ best effort to expand graduate medical education (GME) positions in December 2020 by way of legislation that added 1,000 new Medicare-supported GME positions, more needs to be done.
“GME shapes the physician workforce, which in turn influences the quality of and access to health care. ... However, this funding does not cover the true cost of GME, and it lacks consistency, accountability and transparency,” the Council on Graduate Medical Education wrote in a 2017 report. “A national strategic plan for GME is needed to build a dynamic and agile GME system that better addresses the nation’s physician workforce needs, evolving processes in medical education and practice and health care transformation.”
In addition to retention and recruitment efforts, solutions such as building up advanced practice provider (APP) programs and redirecting non-emergency visits to ancillary staff may provide relief.
“The only way I think that GI will continue to provide timely access to high quality care is to develop robust APP programs within their practices,” Vicari said. “Another thing is to refine communication lines where triage phone nurses take care of patients without alarming symptoms.”
As gastroenterologists continue to split their time between clinics, ambulatory endoscopy centers and hospitals, the increasing use of APPs may benefit outpatients in the clinic setting, according to a report in Gastrointestinal Endoscopy Clinics.
“In the future, gastroenterologists will spend the majority of their time performing endoscopic procedures. Their limited time spent performing cognitive services will be focused on complex inflammatory bowel disease, hepatology and pancreaticobiliary disease,” Aaron J. Shiels, MD, and colleagues wrote. “Increasing use of APPs will improve patient access, improve quality of care and improve clinic efficiency.”
When asked how the physician shortage can be improved, the consensus from experts was clear: increase fellowship positions.
“Short of that, it’s really going to be APPs,” Vicari added.
Advice From the Experts: How to Avoid Burnout
We asked our experts what could be done to support physicians who are taking on greater workloads — without sacrificing patient care or creating burnout.
According to Pambianco, there needs to be a “multidimensional approach” to practice reorganization as consolidation may be an “attractive” option for future gastroenterologists.
“This is culminating is practice shifts to where almost 60% of gastroenterologists will be employed by health care systems or consolidated groups within the next year,” Pambianco said.
Vicari added that job sharing may also become the future of keeping practices staffed and running.
“All practices have to focus on access to high quality care and right now that seems to be how we need to manage our physician population, APP population and all staff,” he said.
On an individual basis, Pardi suggested doing “something meaningful” to avoid burnout in this time of increased workload and decreased workforce.
“We know from research on the subject that one of the best ways to avoid burnout at work is to do something meaningful. In fact, it may work if one spends as little as 20% of one’s time doing something that aligns with one’s purpose,” he said. “It would be ideal if gastroenterologists could align their professional effort with things that provide them meaning, even if it is not something they do every day.
“In addition, we should try to find time outside of work to do meaningful things like volunteer work, hobbies and especially spend time with family.”
- References:
- Association of American Medical Colleges. Congress passes historic GME expansion. Available at: www.aamc.org/advocacy-policy/washington-highlights/congress-passes-historic-gme-expansion. Accessed: Oct. 13, 2022.
- Association of American Medical Colleges. Physician supply and demand — a 15-year outlook: Key findings. Available at: www.aamc.org/media/54686/download?attachment#:~:text=By%202034%2C%20demand%20for%20physicians,full%2D%20time%2Dequivalent%20physicians.&text=Total%20projected%20shortages%20by%202034,and%2048%2C000%20primary%20care%20physicians. Accessed: Oct. 13, 2022.
- Association of American Medical Colleges. The complexities of physician supply and demand: Projections from 2018 to 2033. Available at: www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf. Accessed: Oct. 13, 2022.
- Association of American Medical Colleges. 2021 Fall applicant, matriculant and enrollment data tables. Available at: www.aamc.org/media/57761/download?attachment. Accessed: Oct. 13, 2022.
- Doximity. 2021 Physician compensation report. Available at: https://c8y.doxcdn.com/image/upload/v1/Press%20Blog/Research%20Reports/Doximity-Compensation-Report-2021.pdf. Accessed: Oct. 13, 2022.
- Health Resources & Services Administration. National and regional projections of supply and demand for internal medicine subspecialty practitioners: 2013-2025. Available at: https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/internal-medicine-subspecialty-report.pdf. Available at: Oct. 13, 2022.
- Health Resources & Services Administration. Towards the development of a national strategic plan for graduate medical education. Available at: www.hrsa.gov/sites/default/files/hrsa/advisory-committees/graduate-medical-edu/reports/april-2017.pdf. Accessed: Oct. 13, 2022.
- Shiels AJ, et al. Gastrointestinal Endoscopy Clinics. 2021;doi:10.1016/j.giec. 2021.05.007.
- For more information:
- Anne Marie Lennon, MD, PhD, FASGE, can be reached at John’s Hopkins Medicine, 1800 Orleans St., Sheikh Zayed Tower, Baltimore, MD 21287; email: amlennon@jhmi.edu.
- Daniel J. Pambianco, MD, FACG, can be reached at GastroHealth, 1139 ease High St., Suite 203, Charlottesville, VA 22902; email: dpambianco@cvillegi.com.
- Darrell S. Pardi, MD, MS, can be reached at Mayo Clinic Rochester, 200 1st St. Southwest, Rochester, MN 55902; email: pardi.darrell@mayo.edu.
- Eric Rose, MBA, can be reached at HCA Physician Services Group, 1 Park Plz, Nashville, TN 37203; email: eric.rose@hcahealthcare.com.
- Peter Sinclair can be reached at the Bureau of Health Workforce in the Health Resources and Services Administration, 5600 Fishers Lane, Rockville, MD 20857; email: psinclair@hrsa.gov.
- Joseph J. Vicari, MD, MBA, FASGE, can be reached at Rockford Gastroenterology Associates, 401 Roxbury Rd., Rockford, IL 61107; email: joevicari@msn.com.
Collapse
Association of American Medical Colleges. Congress passes historic GME expansion. Available at: www.aamc.org/advocacy-policy/washington-highlights/congress-passes-historic-gme-expansion. Accessed: Oct. 13, 2022.
Association of American Medical Colleges. Physician supply and demand — a 15-year outlook: Key findings. Available at: www.aamc.org/media/54686/download. Accessed: Oct. 13, 2022.
Association of American Medical Colleges. The complexities of physician supply and demand: Projections from 2018 to 2033. Available at: www.aamc.org/system/files/2020-06/stratcomm-aamc-physician-workforce-projections-june-2020.pdf. Accessed: Oct. 13, 2022.
Association of American Medical Colleges. 2021 Fall applicant, matriculant and enrollment data tables. Available at: www.aamc.org/media/57761/download?attachment. Accessed: Oct. 13, 2022.
Doximity. 2021 Physician compensation report. Available at: https://c8y.doxcdn.com/image/upload/v1/Press%20Blog/Research%20Reports/Doximity-Compensation-Report-2021.pdf. Accessed: Oct. 13, 2022.
Health Resources & Services Administration. National and regional projections of supply and demand for internal medicine subspecialty practitioners: 2013-2025. Available at: https://bhw.hrsa.gov/sites/default/files/bureau-health-workforce/data-research/internal-medicine-subspecialty-report.pdf. Available at: Oct. 13, 2022.
Health Resources & Services Administration. Towards the development of a national strategic plan for graduate medical education. Available at: www.hrsa.gov/sites/default/files/hrsa/advisory-committees/graduate-medical-edu/reports/april-2017.pdf. Accessed: Oct. 13, 2022.
Shiels AJ, et al. Gastrointestinal Endoscopy Clinics. 2021;doi:10.1016/j.giec. 2021.05.007.
Read more about
Click Here to Manage Email Alerts