Questions Answered with Janis Orlowski, MD, MACP

March 2015, Vol 3, No 3 - Inside Patient Care

In a recent interview with Inside Patient Care: Pharmacy & Clinics, Dr Orlowski, Chief Health Care Officer of the Association of American Medical Colleges, discussed the physician workforce shortage, measures set in place to address the shortage, and its impact on community pharmacists and clinicians.

What is your background at AAMC?

A: I am the Chief Health Care Officer at the Association of American Medical Colleges (AAMC). I have been with AAMC for about 15 months.

I previously worked as a senior administrator at 2 academic medical centers and was a senior director at AAMC before becoming the Chief Health Care Officer. I spent many years as a senior executive dean at an institution in Chicago, and then was recruited here to Washington, DC, where, again, I had a senior leadership role in an academic medical center.

I joined AAMC to work on some of the national policy issues—for example, the Affordable Care Act—and a number of the other pressing matters that were coming to the floor. They were looking for someone with significant experience in healthcare administration. That’s what initially brought me to AAMC. The position of Chief Health Care Officer became available a couple of months after I was there, and I was so named at the end of November 2014.

AAMC has 3 mission areas; it’s looking at medical education (education platform), scientific affairs (research platform), and healthcare affairs, (clinical platform). I oversee AAMC’s work, policy work, and constituent work in the clinical environment. It can range from how academic medical centers are making changes in clinical care delivery, to how you integrate medical students and residents into your clinical care system effectively and with high quality, to interprofessional education and key development.

Within my division, we also have the AAMC Center for Workforce Studies. We have a large policy group, and I have a group that works on some of the new alternative payment mechanisms.

Could you provide an overview of the recent physician workforce shortage report?

A: Since early 2000, AAMC has had concerns regarding the accuracy of the physician workforce projections. At that time there were 2 very disparate studies available, one saying that there was an oversupply, and one saying that there’s a big undersupply. Also at that time, AAMC’s board made a commitment to set up a workforce center to evaluate the issue. For about 15 years or so, we’ve had a center for workforce.

We contracted with a group called IHS Inc, a global economic analytic corporation. They helped us with microsimulation studies, which is a new way for us to take a look at the many scenarios for demand for physician services. Then we looked at many, many scenarios of physician supply based on publicly available data.

We used US Census data to look at overall growth in the decade’s population, and growth in different sectors. I think this study was a very good, very scientific way to address workforce scenar­ios. We decided to demonstrate the shortage with a range rather than with a specific number. That’s because there are a couple of changes in healthcare delivery that are new, and we are looking at what their effect may be on healthcare delivery.

The bottom line is that we are projecting, by the year 2025, a physician short­age of between 46,000 and 90,000. That range is based on how we see the different scenarios playing out. Rather than having a report come out every 3 to 5 years, we are now committed to coming out with annual updates, because there is too much movement in today’s healthcare staffing models.

Looking at that 46,000 to 90,000 shortage, we asked, “Where is the shortage?” It looks like there’s a shortage of somewhere around 12,000 to 31,000 in primary care. Then the larger shortage, up to about 63,000 or 65,000, is in specialty care.

We then asked the question, “Why are we seeing a decrease, still a shortage but a decreased one, in the shortage of primary care?” I think that there are 2 answers for that. One is that with an aging population—and the decade census shows a significant increase in those individuals >65 years—they tend to see more specialists. The second thing that we’re seeing is the integration of other health professionals into the primary care workforce. I think that is one of the other reasons we see the shortage in the primary care specialty still being present, but not as severe as what we had noted in the past.

What is the implication of the data as it relates to community pharmacists and retail clinicians?

A: We just modeled what the change in demand would be for the retail clinics scenario.

For example, in one of the scenarios, we actually look at the retail clinic efforts that we see under way, the change in having more retail clinics. We took a look at the scenario and asked, “What if the 10 most common low intensity, low severity, illnesses were completely handled by retail clinics? What would be the demand for the physician workforce in that scenario?” That’s an example of one of the many different scenarios that we took a look at and supplied.

Between now and 2025 there is a continued demand for the physician workforce, but not as much as in other scenarios because the pharmacy and retail clinics tend not to be staffed by physicians. There is a preponderance of other health professionals in addition to physicians contributing to the demand for medical care.

What is the role of community pharmacists and clinicians in the healthcare team?

A: We are working with interprofessional groups to take a look at the appropriate development of an interprofessional team. What roles do the pharmacists play? What roles do the nurse practitioner, physician assistant, physician, social worker, and the in-hospital pharmacist play? This work is carried out by the Interprofessional Education Consortium (IPEC).

We are carrying out significant, ongoing work at the AAMC and with other professional organizations in regard to interprofessional teams.

How can retail pharmacists and clinicians help alleviate challenges associated with workforce shortages?

A: I think that we have seen—with the retail pharmacists as well as with the retail clinics—that there is an appropriate use of these 2 forms of healthcare delivery for a number of different healthcare situations.

They tend to be the lower acuity (for example, look at vaccination rates). I think from a public health standpoint, pharmacists have been very helpful in the wider distribution of vaccines to the population. I also think that if you take a look at some of the clinics, there is good, immediate availability of healthcare personnel for low-acuity illnesses.

I think that their role, and the scope of their role, continues to be defined as we see the remodeling of healthcare delivery.

What other questions have the physician workforce shortage raised?

A: One has to do with physician hours or physician retirement. Since 2008 we’ve seen a delay in physician retirement just as there has been a delay in other professions. We are taking a look at that and asking, “Is this going to be an ongoing trend?” Physician retirement has always been at an age that is older than most other professions, but it’s been stable for decades and decades. Since 2008 we’ve seen a shift of 2 additional years. We don’t know if that’s going to reverse itself now that the financial difficulties seem to be improving, or if this is a new trend related to people living longer and finding satisfaction in their jobs and working longer. That’s one of the many trends that we’re looking at.

We are also looking at the trend of the total number of advanced practice clinicians, nurse practitioners, and physician assistants. There are a tremendous number of these other health professionals who are in the pipeline and will be graduating in the next couple of years. The question is, “Will all of them be integrated into the workforce, or will any of these professions reach a natural cap?” Let me give you an example. We see nurse practitioners involved in primary care, but we also see nurse practitioners involved in specialty care. If we take a look at the ratio of nurse practitioners in specialty care, the question is, “Do you reach a certain saturation point at which you know that the advanced practice clinician will not be doing surgery so that there’s only so much work that can be done as a ratio to the number of surgeons?”

That’s a workforce issue that we are looking at right now: is there a cap on the number of advanced practice clinicians, or can we continue integrating as many advanced practice clinicians as are graduating to.

What are some misconceptions about the physician workforce shortage?

A: People have really liked the idea that we have taken a look at many different scenarios for demand and supply; we’re getting significant positive feedback on that.

However, one of the concerns being raised is that this is a national study, and a national number. You have to be aware that there are local maldistribution issues that can make this shortage worse, or can make the shortage less severe in certain areas.

What measures are being set in place to address the projected physician workforce shortage?

A: We think that there needs to be a multi-pronged effort. I would say we need to take a look at care delivery teams and improving the efficiency of care delivery. We need to take a look at the integration of technology into care delivery.

We are also recommending a modest increase in the number of resident physicians paid for and trained, increasing it by 3000 per year. However, that number will not close the gap on any of the projections that we have.

That’s why we say it’s a modest increase; but we think that there should be this multipronged approach of transformation in healthcare delivery, increased efficiency, use of technology, and then a slight increase in the number of physicians who are graduating and entering a residency.

Do you have any concluding remarks?

A: I appreciate the ability to talk about this study, and, as I mentioned, we will be having annual updates. We look forward to monitoring differing models of high-quality care staffing and would appreciate support in advocating for a modest increase in training positions for physicians.

We are asking individuals to put forward any questions or thoughts that we might be able to utilize in an annual update. If your community has any additional recommendations that you want to forward to this study, we would be happy to take those into consideration.

See "The Physician Workforce Shortage and What It Means for Team-Based Care."

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