The Physician Specialty Shortage
Over the last decade there has been increasing concern about an impending shortage of primary-care physicians. The most cited study projecting a shortage of these doctors (whose specialties include internal medicine, family medicine, and pediatrics) was published by the Association of American Medical Colleges Center for Workforce Studies in 2008, and its projections were updated in 2010 to take account of the Affordable Care Act. Lost in the dire warnings is an equally alarming shortage of non-primary-care physicians: The same organization puts the numbers at 33,100 this year; 46,109 by 2020; and 64,600 by 2025.
Some have suggested using non-physician clinicians, which include nurse practitioners (NPs) and physician assistants (PAs), to address the primary-care shortage. This is an option for the specialty shortage as well, but it will be more challenging.
NPs have an expanded scope of practice; they hold a master's or doctoral degree and have advanced specialty training. Their specialties include acute care, adult gerontology acute care, adult gerontology primary care, psychiatric mental health, family, pediatric primary care, and emergency. While their numbers are projected to increase from 192,000 to 244,000 over the coming decade, as of 2013, 87.2 percent of all NPs practiced in specialties considered primary care.
Physician assistants, meanwhile, practice medicine under the direct supervision of a physician. The average length of a PA program is 27 months, although it can range from two to three years, and students must have completed at least two years of undergraduate courses in basic sciences and behavioral science and some health-care work experience beforehand. They also must complete at least 2,000 hours of clinical practice before they graduate and pass an exam before they are certified.
Physician assistants, unlike NPs, are confronted by harmonization issues in educational requirements; PA programs vary in their length, and some don't require a formal post-graduate specialty education. The basic PA curriculum should be standardized to two years, followed by one year for post-graduate didactic and clinical training in a certificate-awarded specialty, with the National Commission on Certification of Physician Assistants overseeing the process.
When it comes to addressing the specialty shortage with these non-physician clinicians, one area in particular stands out: psychiatry. The field is suffering from a chronic shortage of physicians. Yet in 2013, according to the American Association of Nurse Practitioners, only 3.2 percent of all nurse practitioners were certified in psychiatric mental health.
Currently, there are 31 states that have yet to legislatively authorize "full [scope of] practice" status for all NPs, which restricts the full set of practice skills that psychiatric mental health nurse practitioners can offer. But even in "Restricted Practice" or "Reduced Practice" states, psychiatric mental health NPs can successfully work in a team with supervising psychiatrists. An expansion in the number of NP programs nationwide, along with other financial incentives, could increase interest and the number of students favoring this specialty. Incentives in this specialty are also needed for PAs, as there is only one post-graduate certificate program offered in psychiatry in the U.S.
Team-based health care, involving both physicians and non-physician clinicians, remains a viable model for relieving physician shortages. All disciplines, including physician and non-physician training programs, need to incorporate this model into their curricula. The growing shortage physicians in specialty areas can be addressed with a common understanding of the complementary roles of physician and non-physician clinicians.
Thomas A. Hemphill is an associate professor of strategy, innovation, and public policy in the School of Management, University of Michigan-Flint, and a Senior Fellow at the National Center for Policy Analysis. Gerald Knesek is an instructor of management in the School of Management, University of Michigan-Flint.