A Doctor Shortage Is Looming, and a Clinton-Era Policy Is Partly to Blame

Antiquated funding restrictions for medical apprenticeships could worsen an already devastating burnout crisis.

  • The U.S. is projected to experience a shortage of 46,900 to 121,900 physicians by 2032.

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In 1997, President Bill Clinton was coming off a convincing reelection effort and presiding over a booming economy. Tax revenues were surging, and the federal budget deficit was falling. During the preceding two years, the annual deficit had shrunk from $164 billion to just $22 billion. For the first time in a generation, a federal budget surplus seemed like a real possibility.

Against this backdrop, Clinton and a Republican-controlled Congress negotiated the Balanced Budget Act of 1997, which aimed to balance the federal ledgers by 2002. The act created the State Children’s Health Insurance Program, which provided health insurance to children from low income families, and enacted a number of reforms aimed at squeezing cost savings from Medicare.

One of these provisions sought to cap the number of medical school graduates apprenticing as residents in U.S. teaching hospitals. Then as now, Medicare reimbursed hospitals for a significant share of residents’ salaries. The Balanced Budget Act established limits on those reimbursements, effectively fixing the number of funded residents at 1996 levels. (In 1999 Congress amended the limit for rural hospitals only, increasing the numbers of funded residents at those hospitals to 130 percent of 1996 levels.) Essentially, the law stipulated that if a hospital wanted to expand its pool of residents, Medicare would not pay for it.

How could such a provision make it through Congress? Lawmakers received cover from the American Medical Association (AMA), the Association of American Medical Colleges, and other major stakeholders in American medicine who endorsed caps on funding for residents and other graduate medical education programs. In March 1997, months before the Balanced Budget Act was enacted, the AMA even suggested reducing the number of U.S. residency positions by approximately 25 percent — from 25,000 to fewer than 19,000. “The United States is on the verge of a serious oversupply of physicians,” said the AMA and other physicians’ groups in a joint statement. Since most states require at least some residency training for medical licensure, reducing the number of residency positions would curtail the supply of doctors in the U.S.

Fast forward two decades, and what once seemed like a glut now looks like a shortage. The growth in the number of residency positions — and thus the number of doctors — slowed after the passage of the Balanced Budget Act. From 1997 to 2002, the number of residents in the U.S. increased by just 0.1 percent. Although the number of positions has increased since then, each year thousands of residency applicants fail to secure a position. Factor in an aging population and a projected increase in demand for health care services, and the U.S. is now forecasted to experience a shortage of 46,900 to 121,900 physicians by 2032. Absent a meaningful response from Congress, it will be doctors — particularly residents — and their patients who pay the price.

American medicine is already experiencing a devastating crisis within its workforce. In a recent Medscape survey, 44 percent of American physicians reported feeling burned out, 15 percent reported feeling depressed, and 14 percent reported thoughts of suicide. Between 300 and 400 doctors kill themselves every year, a rate more than double that of the general population. And the crisis may be getting worse.

Physician burnout has serious consequences for patients, providers, and the medical system at-large. A 2018 study found that physicians who reported at least one symptom of burnout were more than twice as likely to report having committed a serious medical error within the preceding three months. Burned out physicians are more likely to suffer from anxiety, depression, and exhaustion. A recent study estimated that burnout costs the American health care system $4.6 billion annually.

Residents are most vulnerable to burnout. They work brutal hours, get insufficient sleep, and lack control over their schedules. It’s little surprise that nearly 30 percent of residents experience depression or depressive symptoms.

Many causes underlie the physician burnout crisis. For instance, the increasing corporatization of American medicine has burdened physicians with excessive non-medical tasks, or “scut work,” and diminished the power of their voices. Also, excessive paperwork requirements and the proliferation of electronic medical records have forced physicians to spend more time in front of computers and less meaningful time with their patients. And long work hours, historically a hallmark of an American medical career, leave them little time to wind down and maintain crucial relationships outside of the clinic or hospital. The outdated funding caps established by the Balanced Budget Act now threaten to exacerbate the crisis.

This augurs poorly for the welfare of American physicians. My worst days as a medical intern came when I was carrying a full patient load. During a day shift, that meant managing 10 patients at a time: spending time with them, examining them, entering all necessary medical orders, and filling out dozens of associated medical documents. During night shifts, sometimes as many as 40 patients were under my care. These shifts were often challenging, chaotic, and stressful; if even a single patient developed complications, the shifts could quickly become unbearable.

To prevent these nightmare scenarios from becoming the new norms, Congress must, at the minimum, lift the graduate medical education funding caps implemented by Mr. Clinton’s 1997 law. An even better response would be to increase Medicare funding to create more residency positions.

Time is of the essence: It takes four years to complete medical school and an additional three to seven years to complete residency in the U.S. With a physician shortage looming, Congress must act as soon as possible. Bills to create more residency positions have been introduced in both the House and Senate in 2019, but they’ve stalled. They deserve a vote.

Increasing federal funding for medical residents will not solve the burnout crisis in America. But it would go a long way toward mitigating the effects of impending demographic changes. After two decades of inaction on this issue, it’s time for legislators to act.

Kunal Sindhu is a resident physician in New York City. You can follow him on Twitter @sindhu_kunal.

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21 comments / Join the Discussion

    Spend 10 minutes during a day shift in the hospital as a nurse. At a nurse’s wage. Your complaining would stop immediately.

    In 2003 I wrote a letter, as a Board of Directors with San Francisco Medical Society,to the leadership for CMS. I Pinpointed the CMS speaker did not know of primary care shortages and attention is needed. Despite the letter co-signed by an ex-President of SFMS, the letter never reached the addressee. To date, I don’t know what happened to the letter, since there was no reply. My point is, our paid leadership needs to share responsibility in where physicians are performing in real time. Progress can be hindered by politics, our paid employees will only perform for those who sign their cheque. Most of us are by standers only periodically contribute to the cause, NOT KNOWING the details in each problem.

    Production has fallen, thanks to time-consuming documentation requirements. Becoming more difficult to find Family Med or IM docs seeing 30 patients per day. So it takes more doctors just to see a fixed number of patients. But population has grown..it isn’t fixed!

    hutcher1@comcast.net I am CMO of a global patient safety organization with a footprint in 36 countries many emerging markets. The US is falling behind their best. Other countries know little of the call system. They have enough doctors so hospitals are staffed 24/7 in house.
    Almost every ED has a general surgeon and cardiologist. Almost every ICU has on site critical care doc 24/7.
    One of biggest overlooked looming factors in the shortage numbers game is the changing gender ratio of med school grads (I’m not a sexist just a realist). There are now >50% female grads. For many valid reasons, they do not work the same number of hours as their male colleagues. This will require adjustment in the blinded numbers game.
    More physicians will also bring down costs. We must get the business of medicine under control!!!! No other business sends a bill not knowing if they will be paid, when paid or even how much. With no control on overhead(tort reform), insurance interference or the EMR; no wonder there are burnout and depression.
    Private practice as I knew it is DEAD!!! It is a complex situation that must be addressed sooner not latter.

    There was not a surplus of physicians and there is not now a shortage of physicians. Just too many physicians doing unnecessary procedures and providing unnecessary care. Looking at cardiologists, how many echocardiograms, nuclear stress tests and carotid ultrasounds are necessary.
    Answer: as many as insurance will pay for.

    As usual the AMA was on the wrong side on this,as it has been on every issue that concerns the welfare of practicing working physicians.

    Funding for residencies should be based on need for that specialty. Yes the ceiling should be raised on funding for primary care along with debt repayment for residents who stay in primary care for a decade post training. Office overhead assistance and IT assistance as well should be offered to attract students to primary care. Five year manpower reassessments could readjust specialty residency funding using ten year census data as a guide.

    The real problem is not physician shortage as is maldistribution of physicians. There is a disproportionate amount of docs in trendy citys and its suburbs compared to rural areas. More residency graduates will not fix this problem.

    2 problems, 1, Is there a looming doctor shortage or is our present funding scheme the problem, there are more physicians/1000 than ever & 2, hospitals make $$ on each resident

    Looming? Its already here! And the solution?
    Artificial intelligence. Billions of dollars are being spent on AI research “to bridge the shortage”.
    I think that there should be a cap on politicians, and that they stop fighting with each other and begin to fight for the citizens that elected them.

    most GPs and emergency physicians could be replaced by PAs and NPs

    The decrease in physicians is intentional. The country will be cared for in large part by PAss and NPs. Do not doubt it, this is intentional.

    Dear Doctor C: your hospital administrator knows not just what toilet paper you use, but how many sheets or inches of paper, and how many times you flush the toilet! He doesn’t give a tinker’s damn about how you benefit your patients as he is only interested in how much money your patients bring in!!! I believe there is a new rings in Hell for hospital administrators!

    Sorry, but the Federal gov’t (taxpayers) shouldn’t be paying for any of this. Hospitals making mountains of money every day and you’re asking for Medicare to increase residency funding and positions? Hospitals should be cover those wages and hiring whomever they need. My insurance, Medicare, and Medicaid ensure that.

    You are so wrong. Government’s job is to help society. Graduate Medical Education gets physicians out there helping society at places that have nothing to do with hospitals and insures. Their shortage will be devastating. The cost of training should be borne by all of us and there is no other wat than through government

    Medicaid doesn’t ensure squat. They reimbursement from Medicaid is so poor that typically only physicians in FQHCs accept it. Every time I see a patient with Medicaid in my Emergency Department (often for a problem that ought to be dealt with in the office, but waits to see the few Medicaid physicians are >2 months), I’m essentially seeing them for free. And in an urban setting, that’s about 30% if my work that I give away. That’s not including any of the 8-12 hours I spend at home doing charts. Do you do 2/3 or your job for free? Or work for free on your days off?
    Completely apart from that, the role of government is to ensure the most good for the most people. That includes healthcare. Timely medical care is not something that should be reserved for the rich.

    My wife had kids just before residency (she graduated from a top-3 medical school). She had to take a break but there’s no real maternity leave for students. She ended up dropping out to watch our kids for a few years. Will she go back? How can she? Not only would she have a hard time getting into a different specialty, she used the appropriated funding that the system had allocated to her first year of education and now she’d have to convince a system to essentially fund her for an entire year while she catches back up. It’s almost impossible. Our medical system lost out on a smart, capable, and incredibly compassionate doctor due to absurd funding restrictions and a lack of care for the wellness of students. Residency should not be so ridiculous.

    Much as I despise the corporatize goin af medicine -essentially the arbitrage of human life – I also see how the answer is not more doctors. It is better teamwork. Doctors (and all other professional health caregivers)could get their jobs done without all the “scut work” if managers and administrators would provide the tools and work environment that enhanced their talents instead of suppressing it.

    It should not be health caregivers jobs to map their work so administrators can squeeze out more profits or lower costs. If the IOT can know what toilet paper I use, they should know what benefit I achieved for my patients, and how much I saved them.

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