Cleveland Plain Dealer...
Doctor shortage threatens U.S. and Ohio: The Changing Face of Medicine
By Ellen Kleinerman 
August  30, 2011 

CLEVELAND, Ohio -- Northeast Ohio is beginning to feel the pinch of the looming nationwide doctor shortage. 

Major medical centers, including the Cleveland Clinic, MetroHealth System and University Hospitals, are looking for neurosurgeons, urologists, pediatric oncologists and other specialists to fill the gaps. 

But the largest and most immediate need in this region and nationwide remains primary care doctors -- an umbrella term for family medicine, internal medicine, pediatrics, gynecology and general surgery. 

The Association of American Medical Colleges estimates there is a shortage of 13,700 doctors nationwide in all specialties. That number is predicted to hit 63,000 by 2015, and more than double, reaching 130,000, by 2025. 

Right now, there are 954,000 physicians practicing in the United States, including 30,000 in Ohio. Ohio is ranked 21st among states in the number per capita of physicians in active patient care, according to the medical colleges association’s most recent work-force data book. 

Across our region, especially in urban and rural areas, there are pockets that desperately could use more primary care doctors, said Dr. Alfred Connors, MetroHealth Medical Center’s chief medical officer. The need will spread, he said. 

“Our population is going to age,” he said. “If we put off trying to find a fix for the doctor shortage, it will end up being a bigger problem.” 

Dr. Atul Grover, chief advocacy officer of the medical colleges association, pointed to several reasons for the current and anticipated problem: 

• There has been a cap on slots in medical schools and residency training programs for the last 34 years as the U.S. population grew by 31 percent. Federal money now helping to pay for graduate medical education could be slashed by Congress. 

• The elderly population nationwide is expected to double in the next decade. Adults in this age group use health services more than twice as much as younger folks. 

• One-third of physicians now in practice nationwide are expected to retire in the next 10 years. About 21 percent of Ohio’s doctors are now 60 years or older.

• As many as 30 million people currently without insurance are expected to be pulled into the system as federal health care reform rolls out in 2014. 

Grover emphasized that the nation is in need of doctors in every specialty from family medicine to heart surgery. 

Educating more doctors 

Medical schools in the United States have agreed to grow enrollment 30 percent by 2015. Between 2006 and 2010, the number of medical students rose by just 7.5 percent. 

But increasing class size takes time. 

Dr. Pamela Davis, dean of the Case Western Reserve School of Medicine, said classrooms and labs hold a set number of students. Additionally, schools must abide by state infrastructure standards and student-to-faculty ratios to maintain accreditation. 

CWRU and Ohio’s other six medical schools have gradually been finding more classroom space each year and increasing faculty to accommodate additional students. 

Across the nation, four new M.D. medical schools opened in 2009 and 13 new osteopathic medical school programs opened in the past decade. None of them is in Ohio. 

To get doctors where they are needed most, admissions committees are going beyond grades and standardized test scores. 

“We’re looking at the total person, students who would go back to their rural or urban community to practice medicine,” said Dr. Andrew Filak Jr., interim dean of the University of Cincinnati College of Medicine. 

Studies show that a substantial number of students return to their hometowns or similar communities when their training is complete, said Dr. Catherine Lucey, vice dean of education at the Ohio State University College of Medicine. 

About 41 percent of Ohio medical school graduates stay in the state, compared to 38.8 percent nationwide. 

Medical schools in Ohio and across the United States have created family medicine tracks to expose students to the immediate need for doctors in rural and urban areas. 

“Primary care doctors are on the front lines in a demanding job where they’re highly responsible for coordinating care,” Lucey said. “They’re paid less to do more and end up being under more scrutiny.” 

Another deterrent: The median annual income of a practicing family physician is $173,000, compared with $292,000 for a urologist or $400,000 for a cardiothoracic surgeon. 

That can make pay an issue for even the most altruistic student, who may have to borrow $200,000 to $300,000 to cover four years of medical school tuition and living expenses. 

“I was scared to death to consider having that much debt,” said Sarah Sweeney, 26, of Bay Village, who just started her third year at CWRU medical school. She plans to pursue primary care medicine by participating in the National Health Service Corp, which offers full-tuition scholarships and loan repayment in exchange for years of service in a geographic area where doctors are needed. 

Dr. George Kikano, chairman of the family medicine department at University Hospitals Case Medical Center, said competition to attract residents to his program is stiff, but he manages to recruit a committed group. 

“They are mission-driven kids who want to change the world,” Kikano said. 

Dr. Evan Howe, 30, who graduated from CWRU medical school this spring, figures that even in family medicine he will earn enough to slowly pay off his loans, support his wife and two children, and fulfill his career goals. 

“I see myself as a teacher and a community worker,” said Howe, who just embarked on a family practice residency at Fairview Hospital. 

Young doctors in training are feeling the demand. “I have friends in their third year [of a five-year general surgery residency] already being bombarded with solid job offers,” said Dr. Linden Karas, 26, of Pepper Pike. 

Karas graduated last year from Boonshoft School of Medicine at Wright State University and now is in a general surgery residency program at Mercy Fitzgerald Hospital in Philadelphia. 

Congress’ actions affect the numbers 

In the control room of the Mt. Sinai Skills & Simulation Center at Case Western Reserve University Medical School is Jamie Janos. Sessions where medical students conduct practice exams on actors called “simulated patients” are recorded. Students can later view the exams with their instructors for critiques.

Despite shortages in primary care specialties, Karas said that several of her classmates vying for spots in general surgery and other popular residency training programs were shut out. 

To accommodate more medical school graduates, Grover said that Congress must increase the number of residencies -- specialized training that lasts between three and eight years -- necessary before young doctors can take medical exam boards and go into practice. He advocates a 15 percent growth nationwide, or 4,000 new slots annually. 

In 1977, when officials feared there would be a glut of doctors, Congress froze the number of residencies at 110,000 nationwide. 

But, residency slots could be reduced as Congress haggles over debt issues and considers slashing current funding to graduate medical education by between 20 percent and 60 percent. Cuts could come from Medicare, which now pays $9.1 billion each year to teaching hospitals that use the money for resident and fellow salaries and other costs to run training programs. Salaries for training in just about every specialty are $45,000 annually. 

The funding battle in Washington could prove to be important for Northeast Ohio, with teaching hospitals such as UH, the Cleveland Clinic, MetroHealth, Akron’s Summa Health System and others. 

Ohio currently has 5,384 training positions for residents and fellows (advanced training after a residency), placing it sixth per capita among all other states. New York is first with 15,679 slots and Montana last with just 20, according to the Association of American Medical Colleges. 

“We are training the next generation of physicians from pediatricians to endocrinologists,” said Heidi Gartland, vice president of government relations at University Hospitals. “It’s a huge contribution. Our doctors are recruited here in Ohio and all over the country.” 

Dr. James Stoller, chairman of the Cleveland Clinic Education Institute, said threatened funding cuts are coming at a time when the demand for doctors is rising.

Officials from teaching hospitals point out that federal money does not cover the entire cost of graduate medical education. 

Even in the face of budget battles, Grover said, U.S. medical schools still need to turn out more graduates since they only fill about 75 percent of the current residency slots. The rest are taken up by graduates of foreign medical schools, he said. 

About 54 percent of doctors completing residency or fellowship programs in all specialties at Ohio medical centers remain in the state, according to the association. That compares to 47 percent nationwide. 

Pediatric residencies, unlike most others, are not funded by Medicare, Gartland pointed out, but rather by the federal Children’s Hospitals Graduate Medical Education program created in 1999. 

Ohio has the second-largest pediatric training program behind California, and about 60 percent of the trainees remain in Ohio. 

The six free-standing pediatric hospitals in Ohio, including Rainbow Babies & Children’s, Cleveland Clinic Children’s and Akron Children’s, have received about $32 million annually to fund residencies. 

Gartland said Rainbow’s funding was slashed 15 percent earlier this year, and more cuts are possible as the U.S. Department of Health and Human Services looks to follow a congressional mandate to shrink its 2011 fiscal budget. 

Other answers 

Doctors won’t be the only solution to keeping up with patient demand and more accessible care, Ohio State’s Lucey said. “We need to think creatively and work with our colleagues in nursing, pharmacy and business.” 

Cleveland Clinic CEO Dr. Toby Cosgrove said he sees more midlevel practitioners, such as physician assistants and surgical technicians, used to improve efficiency in hospitals. 

Changes already are occurring in Northeast Ohio. 

Some doctors are using a group approach in which they direct care and focus on complicated cases while their team -- consisting of nurse practitioners, physician assistants, dietitians, social workers and pharmacists -- covers preliminary exams, patient counseling and follow-up care. 

Another approach is corporate health care. University Hospitals, for example, has been expanding its program by working with companies like Lincoln Electric to provide employees with on-site nurse practitioners to provide easy access to care for minor illnesses and to manage chronic conditions such as high blood pressure and diabetes. 

Both the Cleveland Clinic and UH are staffing health clinics in grocery stores and drugstores with nurse practitioners in an effort to make primary care more accessible to the public. 

The Clinic, MetroHealth and UH have established medical homes and community centers that blend services of doctors, nurse practitioners, nurse educators and case managers. 

Such wellness efforts -- growing in Ohio and across the country -- reduce the burden on doctors and the need for expensive care down the road. 

“If you get someone in a state of good maintenance,” Connors said, “then they are less likely to get severely sick and less likely to end up in the emergency room.” 

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