Physician Workforce Struggles to Meet Rising Demands Across Urban, Rural Areas

A report released Tuesday outlining US physician employment growth from 2018 to 2019 documents a 5% increase in demand among the profession’s top 10 metropolitan areas across the country.¹

Although these findings are positive for physicians hoping to enter the worforce, there is cause for concern. As more patients demand care, statistics show there aren’t enough providers to give it—particularly in rural areas, where a separate study says the lack of students coming from rural settings will exacerbate the shortage.

According to the Association of American Medical Colleges (AAMC), the US physician shortage is estimated to reach over 120,000 by 2032.

Doximity, the nation’s largest medical professional network, published the physician employment trends report using data collected from clinical job postings and network-wide compensation surveys.

Approximately 27,000 jobs were posted in total on Doximity in 2018 and 2019. The study, which focused on the top 50 metropolitan statistical areas, produced data showing rising demand for physicians over the last 3 years.

The survey conducted by Doximity found geriatrics, family medicine, allergy/immunology, and emergency medicine are the most in-demand specialties and subspecialties across the country.

Of the metropolitan areas surveyed, El Paso, Texas, ranked as the area with the highest demand for physicians. Miami, Florida, was the second highest, followed by Cleveland, Ohio.

The remaining top 10 metro areas are:

4. Phoenix, Arizona

5. Denver, Colorado

6. Portland, Maine

7. Seattle, Washington

8. Honolulu, Hawaii

9. Minneapolis, Minnesota

10. Los Angeles, California

Metropolitan areas with the largest physician pay growth increases ranked as follows:

1. New Orleans, Louisiana: 10%

2. Cincinnati, Ohio: 9%

3. Ann Arbor, Michigan: 3%

4. Hartford, Connecticut: 3%

5. Riverside, California: 3%

6. Baltimore, Maryland: 2%

7. Atlanta, Georgia: 2%

8. Rochester, New York: 2%:

9. Minneapolis, Minnesota: 1%

10. Charleston, South Carolina:1%

Additionally, physicians received the highest pay in Milwaukee, Wisconsin, New Orleans, Louisiana, and Riverside, California, with an average compensation of $383,770. Doximity’s self-reported surveys of around 70,000 full-time, licensed physicians and 7500 nurses who work at least 40 hours a week determined compensation growth.

The researchers conclude rising demand for care is attributable to the fact that more Americans have become insured in recent years, due in part to the Affordable Care Act. They caution additional access to care “needs to be married to policies that would address the current physician shortage, as well as account for the future growth in patient demand.”

An ageing population of patients and physicians, along with nationwide health initiatives aimed to increase longevity, also contribute to the shortage.

Whereas Doximity focused on increased demand for physicians in metropolitan areas, a recent study published in Health Affairs stresses the more pressing need for physicians in rural areas.²

In conjunction with the factors listed above, the study conducted by researchers from AAMC looks at how the lack of geographic diversity among medical school applicants and matriculants affects where physicians opt to practice once they graduate.

Researchers point out that the setting in which physicians grow up is largely indicative of where they chose to practice. “Growing up in a rural setting is a strong predictor of future rural practice for physicians,” they state.

The scarcity of practicing physicians in rural America is a major obstacle to providing necessary and timely care. This fact is exacerbated by the disproportionately high healthcare needs faced by rural Americans compared with their urban counterparts. Rural residents report higher rates of chronic illnesses, maternal morbidity, infant mortality, and lower rates of life expectancy.

Additionally, rural Americans are less likely to receive preventive services. These pitfalls are more keenly felt by members of racial/ethnic minority groups which make up over 15% of rural populations.

In the study, rural areas were defined by the 2013 Rural-Urban Continuum Codes which outline populations in counties across the country. Any county with a code between 6, meaning the area had an “urban population of 2500-19,999 and was adjacent to a metropolitan area,” and 9, “meaning that the county was completely rural or had an urban population of fewer than 2500 and was not adjacent to a metropolitan area,” was considered rural.

Researchers looked at each applicant’s birth and high school graduation county codes to identify if the applicant came from a rural background. Due to data limitations, US territories were not included in the study, unless applicants were born or graduated high school in one of the 50 states or Washington D.C.

Taking all of this into consideration, researchers looked at data obtained from the American Medical College Application Service from 2002 through 2017 and concluded, “the number of applicants from a rural background declined 18% during the study period from 2479 in 2002 to 2032 in 2017.” Contrarily, the number of urban applicants increased by 59%, from 27,023 to 42,894.

The number of matriculants from rural backgrounds decreased by 28% while the number of urban matriculants grew by 35%.

In 2016 and 2017, only 4.3% of the total incoming medical student body came from rural backgrounds, making it the smallest cohort of any year included in the study. Although the overall number of underrepresented racial/ethnic minority (URM) groups in medicine increased over the study period, the researchers found URM students with rural backgrounds accounted for less than 0.5% of new medical students in 2017.

“If the number of rural students entering medical school were to become proportional to the share of rural residents in the US population, the number would have to quadruple,” said the authors.

Several solutions have been proposed to curb the demand for physicians. Because medical students often graduate school with burdensome debts, they are more inclined to look for work in lucrative geographic settings. To combat this, some rural communities are offering signing bonuses of up to $100,000, according to NPR.³

AAMC researchers also emphasize the importance of creating pathways for rural children and young adults to become physicians. Another potential solution is to increase the number of clinical rotations in rural settings available to medical students.

The incorporation of telemedicine into the routine of rural practices is also a possible solution. The Doximity report ranks specialties in the telemedicine job market with the greatest demand, with internal medicine, psychiatry and radiology as the first 3 topping the list.

These 3 specialties were followed by:

4. Family Medicine

5. Pediatrics

6. Emergency Medicine

7. Neurology

8. Cardiology

9. Obstetrics & Gynecology

10. Dermatology

NPR cited telemedicine when it reported about how Bisbee, a small town in Arizona, copes with the shortage of family doctors by using real-time consultations with physicians at the Mayo Clinic.⁴

Besides a lack of pathways for rural residents to become physicians and the student debt issue, NPR reported that immigration policy changes instituted by the Trump administration contribute to the shortage. Local doctors said changes in visa policies stymie the flow of foreign-born doctors; prior to the changes, many foreign students would complete residencies in rural settings to obtain green cards.

Although solutions like telemedicine, incentives, and initiatives to encourage rural Americans to pursue medicine all aid the goal of providing care to all Americas, seemingly unrelated factors like student debt and immigration policies continue to contribute to the crisis.

References

1. Whaley C. U.S. physician employment report 2019. Doximity website. Link. Published December 2019. Accessed December 10, 2019.
2. Shipman SA, Wendling A, Jones KC, Kovar-Gough I, Orlowski JM, Phillips J. The decline in rural medical students: a growing gap in geographic diversity threatens the rural physician workforce. Health Aff (Millwood). 2019;38(12). doi: 10.1377/hlthaff.2019.00924.
3. Siegler K. The struggle to hire and keep doctors in rural areas means patients go without care. NPR. May 21, 2019. npr.org/sections/health-shots/2019/05/21/725118232/the-struggle-to-hire-and-keep-doctors-in-rural-areas-means-patients-go-without-c. Accessed December 9, 2019.
4. Siegler K. Doctor shortage in rural Arizona sparks another crisis in ‘forgotten America.’ NPR. July 14, 2017. npr.org/sections/health-shots/2017/07/14/535792864/doctor-shortage-in-rural-arizona-sparks-another-crisis-in-forgotten-america. Accessed December 9, 2019.