October 13, 2017
Area(s) of Interest: Physician Workforce
By Ruth Haskins, M.D., President of the California Medical Association
David Lazarus’ latest column in the Los Angeles Times was right about one thing: California doesn’t have enough physicians (“California doesn’t have enough doctors, and this bad law isn’t helping,” October 10, 2017).
California is projected to have 5,000 fewer physicians than the population needs by 2025. Because physicians are the most highly trained medical practitioners, with over a decade of training, a 2025 physician shortage is a problem that California needs to address today.
California’s workforce issues can only be solved if the state invests in common-sense solutions to recruit, train and retain more physicians and other health care specialists.
Over the last decade, the California Medical Association (CMA) has worked to establish new medical schools, secure and expand graduate medical education opportunities in underserved areas, and expand scholarship and loan repayment programs for medical students and residents.
Lazarus claims that allowing nurse practitioners (NPs) independent practice is a cure-all, but his strategy doesn’t address the real problem: California’s medical workforce shortage. Even the University of California San Francisco’s (UCSF) study acknowledges that simply expanding the scope of NPs would not solve the medical work force shortage — and the number of graduating NPs would also need to grow by 3–7 percent annually just to keep pace with the population.
Currently, the foundation of California’s health care system is physician-led, team-based care. Team-based care means that every patient has the benefit of a fully trained physician reviewing their case — while allowing other health practitioners, such as NPs and physicians assistants to practice to the full extent of their training.
This ensures a physician is ready to take the lead when a patient experiences an unexpected complication during a visit with an NP. Whenever the situation goes beyond another team member’s training and experience, you must meet a patient’s need promptly — without waiting for a lengthy referral. Otherwise, care will be delayed, costs will go up or the prognosis may needlessly worsen.
Team-based care is particularly essential with previously undiagnosed conditions. Physicians are the only medical practitioners with broad-based training on diagnostics. Medical students are required to spend 5,000–6,000 hours of front-line patient care before they graduate to a supervised residency where they receive an additional 4,000 hours in training. In contrast, NPs are required to undergo a few hundred hours of clinical experience, in total.
It is also naïve to believe removing physicians will cure the systemic problems with Medi-Cal access, which serves one-third of Californians, including half of all children. In fact, California passed AB 1591 in 2006, allowing NPs to sign up as independent Medi-Cal providers to be directly reimbursed by the state. In the eleven years since that bill was signed into law, there has been no significant increase in the number of NPs working in rural and underserved areas.
Establishing more medical schools and residency programs is vital to curing the Golden State’s physician shortage so patients can access care promptly. Inadequate funding for residency programs exacerbates the problem because it means that hundreds of graduating medical students don’t find a residency slot to continue their training — forcing talented young doctors who want to stay and practice in California to other states and communities.
In 2017, CMA fought to restore more than $40 million per year in Proposition 56 funds to expand for graduate medical education (GME) slots, as well as reallocate $33 million back into the Song-Brown Workforce training program. Every dollar of investment is significant considering one primary care resident can conduct approximately 600 patients visit per year.
Six of California’s nine regions lack the number of primary care providers recommended by national health experts. The state’s move to restore and stabilize some of the funding for these programs was an important first step, but we need more leadership and investment. CMA will continue to fight for common-sense solutions to reverse our physician and health care workforce shortage — without sacrificing access or quality in care.