In an ideal world, Lorna Dyk would have a pediatric surgeon and pediatric anesthesiologist on speed dial, no more than a local call away to treat young car accident victims or premature infants needing surgery.
But those physician specialists haven't been available for at least three years at St. Vincent Healthcare, with no relief in sight, says Dyk, service line director for women's and children's services at the 286-bed nonprofit hospital in Billings, Mont. The nearest pediatric surgeon, and, in fact the only one serving the sprawling state, practices 350 miles away in Missoula, she says.
So, like other hospitals struggling with specialty gaps around the country, St. Vincent's clinicians tap a variety of treatment expertise, both on- and off-site. In some cases, an adult surgeon with some pediatric training will feel comfortable stepping in. In others, the board-certified pediatric intensivists who staff the hospital might use telemedicine technology to consult remotely with physicians at Children's Hospital Colorado in Denver.
Sometimes, and this is frequently the case when premature infants are involved, children are flown by St. Vincent's flight team to the Denver facility for surgery. The parents might either catch a commercial flight or make the eight-hour drive, sometimes living nearby for weeks. "It's a disruption for the family," Dyk says. "If they have other children, either [only] one of them has to go or they have to make arrangements for their children."
Gaps in specialty physician coverage, long a challenge in far-flung locations, might become a more chronic and acute situation at hospitals around the country, according to a series of recently published surveys and analyses. The Association of American Medical Colleges projects that nearly 92,000 more physicians, half of them subspecialists, will be needed by 2020. The association endorsed recently proposed legislation to train more doctors, which would boost the number of Medicare-supported residency slots by 15 percent over a five-year period.
To be sure, not everyone agrees that subspecialty shortages are necessarily acute, describing the challenge more typically as one of poor distribution [see sidebar on page 31]. But hospital administrators and physician groups who are concerned cite several accumulating pressures, most notably an aging U.S. population and an expanded pool of insured patients once the health reform law goes into effect.
To offset the strain, they're stretching their existing staffs and aggressively recruiting, sometimes searching far in advance of anticipated vacancies. They're also using more nurse practitioners and physician assistants, when feasible, to assume some of the workload.
Meanwhile, hospital leaders continue to shop for doctors. For children's hospitals, an unfortunate side effect is "they cannibalize each other because there is such a shortage," says Jim Kaufman, vice president of public policy at the National Association of Children's Hospitals and Related Institutions.
For a rural facility like St. Vincent, recruiting subspecialists is essentially a chronic occupation. "Sometimes it takes two to three years to fill a position when they're recruiting for it," Dyk says. "As soon as you have one, because so many are sole providers, you have to start recruiting in case they change their mind."
Filling vacancies is complicated not only by the demand for some specialties, but also by an ongoing shift in medical practice itself, according to hospital leaders and physician recruiters.
Rapid changes in technology, along with some physicians' desires to differentiate themselves, have resulted in a tendency toward sub-subspecialization, says Travis Singleton, a senior vice president at Merritt Hawkins, a physician search firm in Irving, Texas.
As one example, fewer orthopedic surgeons handle all cases, while most specialize in one area, such as hand surgery. "There is also a huge need for the true general surgeon," Singleton says. "The jack-of-all-trades general surgeon is a really tough physician to come by." Moreover, newly hatched doctors are more likely to rank quality of life high on their list of priorities, according to findings from a Merritt Hawkins survey conducted with 302 final-year residents in mid-2011.
Across all specialties, 68 percent ranked adequate call coverage and personal time as most important in 2011, compared with 28 percent in 2008.
Mike Farrell, chief executive officer of Somerset (Pa.) Hospital, believes he's lost out on some promising subspecialist candidates because they didn't want to take call. "I think I can categorically say that many younger physicians are much more interested in quality of life than anything else," says Farrell, who leads the 150-bed nonprofit hospital located about 70 miles from Pittsburgh.
When specialists aren't available, emergency care can suffer. Nationally, three out of four emergency departments report not having access to all of the surgical specialists they require to treat incoming patients, according to a survey of 442 hospitals published in late 2010 in Academic Emergency Medicine. Their greatest reported needs: hand surgery, neurosurgery and plastic surgery.
Other specialties also report signs of strain. At some children's hospitals, it can take a year or longer to fill a subspecialist vacancy, such as in endocrinology, neurology or pulmonology, according to a 2009 survey for the NACHRI. A workforce analysis conducted for the American Society of Clinical Oncology also projected a growing shortfall, with a 36 percent increase in oncologists needed by 2020 to care for an aging population.
Still, any workforce analysis is only a snapshot in time. ASCO officials have been reevaluating their projections, after noticing that practices and hospitals haven't been hiring oncologists at the rate they were even two years ago, says Michael Kosty, M.D., a member of ASCO's Workforce Advisory Group.
Part of the hiring slowdown might stem from uncertainties surrounding the new health reform law's implementation. "But one would have to think that if [oncologists] were working their fingers to the bone, and were really having trouble keeping up with the demand, that there would be more hiring. And that's not the case," says Kosty, also a medical director of the Scripps Cancer Center in La Jolla, Calif.
Other factors might be involved. The sluggish economy may discourage patients from getting basic medical care that could lead to a cancer diagnosis. More hiring of physician assistants and nurse practitioners might have eased some of the oncologists' workload. Plus, Kosty says, some oncologists might have delayed retirement because their "401Ks are now 201Ks."
Hospitals that are the most effective at recruiting typically are led by administrators who are involved from the beginning, and are willing to move fast, says Singleton, who credits Farrell with embodying both of those skills.
Somerset Hospital's chief executive prefers to be the first one to meet with visiting subspecialists, as well as the last one before they walk out the door. "That stresses that the physician will have an open line of communication with the CEO," Farrell says.
When the feedback is positive from other doctors, including the hospital's recruiting committee, Farrell strives to send a nonbinding letter of agreement the following day, highlighting the terms of the contract. "If both sides hit it off, you've got to close on them as fast as possible because, as soon as they get back home, they're going to get three more calls from recruiters," he says.
As more women move into medicine, the emergence of physician couples also means that hospitals might need to consider two hires at the same time, says Sandra Bolton, R.N., vice president of professional services at City of Hope in Duarte, Calif. "It's much, much more common," she says.
Bolton could recall at least five physician couples in the prior year who both wanted to work at the cancer research center, or at least in the same Los Angeles region. "The stars almost have to align for it to work," she says.
One such mutually beneficial situation occurred earlier this year when City of Hope hired Sanjay and Sangeeta Awasthi, both Texas physicians. City of Hope officials were interested in Sanjay Awasthi, because they needed another melanoma specialist, and then became just as intrigued by the cutting-edge research he had conducted.
His hiring wasn't contingent on his wife also landing a job there, which sometimes occurs, Bolton says. But as it happened, the facility needed another psychiatrist.
Landing two specialists can quickly eliminate some coverage stresses, but some hospital administrators worry about the corresponding risk of a two-in-one package. "They see it as if you lose one, you lose two," Singleton says.
To temporarily fill specialty gaps, hospital administrators sometimes will turn to locum tenens services. Mary LaRowe, CEO of St. James Mercy Hospital in Hornell, N.Y., says her 297-bed rural facility relied on locum tenens for about two years until they were able to hire the additional psychiatrist that they badly needed.
The temporary physician coverage is far from ideal, she says. Not only do patients lose out, with less continuity of care, but there's "a very high cost, mind you" to pay for the coverage, she says.
In recent years, with one eye on the potential oncologist shortage, ASCO officials have promoted the practice benefits of incorporating more nurse practitioners and physician assistants. The nonphysician practitioners do have an initial learning curve, frequently needing at least six months to develop the requisite cancer treatment skills, Kosty says.
But the investment can pay off in boosted productivity, particularly if the nonphysician practitioner is given a broad role to play, according to the findings of a study commissioned for ASCO and published in September in the Journal of Oncology Practice.
When the providers work with all of the oncologists, the practice's productivity is 19 percent higher than if the nonphysician's practice is limited to a more select number of oncologists and their patients. And patients didn't seem to have any problem with the care, with overall satisfaction exceeding 90 percent.
Charlotte Huff is a freelance health writer based in Fort Worth, Texas.
It's Not How Many There Are, It's Where They Work
David C. Goodman, M.D., has no doubt that some hospital administrators struggle to recruit orthopedic surgeons, cardiologists and other subspecialists. A hospital might want to expand its roster to elevate a treatment program or to compete more effectively with another facility down the road, says Goodman, who directs the Dartmouth Institute's Center for Health Policy Research.
But a shortage, at least from a hospital administrator's perspective, doesn't necessarily mean that patient care is being shorted. "That's making the assumption that every one of those vacancies serves the population well," he says. "And we know that's not the case."
This fall, legislation was introduced in Congress that could increase the number of Medicare-supported residency slots by 15 percent over five years, following concerns in some quarters about a looming physician shortage (see graphic]. Goodman, though, is not the only researcher who is building the case that adding more doctors — and particularly, subspecialists — does not de facto translate to better patient care.
Studies indicate that increasing the pool of primary care doctors can be beneficial, says Kevin Grumbach, M.D., director of the UCSF Center for California Health Workforce Studies. Still, no such correlation has been identified to date with specialists, he says, citing as one example a 2004 Health Affairs analysis that broke down Medicare spending and quality.
In that study, researchers not only found that high-spending states had lower quality of care, but also looked at the mix of the physician workforce. Those states with a higher proportion of primary care doctors had better care. But a greater density of specialists correlated with poorer quality outcomes.
Moreover, training more doctors does not automatically assist rural and other underserved areas, according to another 2004 Health Affairs analysis that Goodman authored.
He tracked sizable increases in per capita physician supply between 1979 and 1999: a 45 percent increase in primary care doctors, 118 percent for medical specialists and 21 percent for surgical specialists. Yet four out of five of those new doctors opted to practice in regions with a high supply of physicians.
Before simply ramping up supply, other redistribution strategies should be pursued first, such as telemedicine outreach into rural communities and using more financial incentives to convince doctors to practice in underserved areas, Grumbach says. "The metaphor I tend to use is: Until we stir the sugar in the cup of tea, don't add more sugar to the cup."