The spiraling problem of doctor shortages and burnout

Anecdotal stories about exorbitant wait times and the incredibly difficult process of getting an appointment with a doctor — if you can find an available physician at all — have become a normal part of health care in the U.S. for many Americans. Data from the Health Resources and Services Administration suggests there’s already a shortage of health care workers in the U.S., and a report by the Association of American Medical Colleges said that the deficit will get much worse — with a projected shortage of up to 124,000 physicians by 2034, including shortfalls in both primary care and specialty care.

Now experts say physician burnout and stress — already a known problem in the health care community — have been compounded by the COVID-19 pandemic and add an additional layer to the physician shortage dilemma.

Dr. Jack Resneck Jr., president of the American Medical Association, told Yahoo News that there is a tempestuous relationship between the two — with burnout exacerbating the shortages and shortages exacerbating burnout.

“Because people are burnt out, many may be considering working less, so it definitely feeds the workforce shortage. And if we end up with fewer physicians working and access being even more of a problem, then those that are left working are faced with even heavier clinical burdens in terms of taking care of all of their patients, so that leaves them more burned out,” Resneck said. “So you really can get in an unfortunate spiral if we don’t do something to fix the drivers of burnout in the first place, and to make sure we’re putting enough new doctors into the system at the front end as well.”

In the U.S., more than 2 out of 5 active physicians will be 65 years old or older in the next decade, so many physicians will likely leave the workforce simply because they’re getting older and are ready to retire.

But for some, stress and burnout may also play a unique role in these decisions. A survey published last year on pandemic-related stress and work intentions found that about 1 in 3 physicians plan to reduce work hours, and 1 in 5 physicians intend to leave their practice altogether.

A recent survey by the Commonwealth Fund, which looked at the effects of the pandemic on primary care physicians in 10 high-income countries, found that half of younger physicians in the U.S. (which the survey defines as physicians under 55 years old) said they are “definitely burning out and have one or more symptoms of burnout, such as physical and emotional exhaustion.” Meanwhile, nearly half of older physicians (those over 55 years old) in the U.S. and in most other countries in the survey said they intend to stop seeing patients within the next three years — “meaning that the majority of primary care physicians in many high-income countries may soon be younger professionals grappling with burnout and stress,” the report said.

“Younger physicians are at an earlier stage of their careers; they’re working longer hours; they may have more responsibilities outside of their work, including raising young families,” Munira Gunja, a senior researcher with the Commonwealth Fund and one of the authors of the survey, told Yahoo News. “We found that most of the younger primary care physicians are female, and we know that females have been disproportionately affected by the pandemic in terms of stress and burnout, whether it’s in or outside of the workplace.”

While burnout takes a toll on the physicians themselves, it can affect their patients as well. In the Commonwealth Fund survey, primary care physicians who said they experienced stress, emotional distress or burnout were more likely to report that the quality of care they provided had worsened “somewhat” or “a lot” compared to before the COVID-19 pandemic.

What’s causing a shortage of physicians?

Michael Dill, the Association of American Medical Colleges director of workforce studies, told Yahoo News that he believes a growing physician shortage is contributing to more burnout, but burnout doesn’t appear to be deterring more people from joining the profession.

“The number of applicants to medical schools is not going down, so it doesn’t seem like there’s any sort of feedback that’s driving people to say, ‘Oh, maybe that’s not what I want to do,’” Dill said. “Clearly there’s still a calling to become a physician, and that’s not going down despite the levels of burnout — which is good, since we need to train more.”

The problem, Dill said, is supply and demand; the baby-boomer generation is aging and the population is growing, but the influx of new physicians, while steady, isn’t increasing at the rate it needs to.

A major obstacle to training more physicians that Dill and Resneck both point to is a 1997 cap on the number of Medicare-funded residency programs in the U.S., which has created a bottleneck of qualified medical students with not enough training positions. The shortage of residency spots has been decried by many in the medical community for years; when Yahoo News reported on this in 2020, 40,084 applicants submitted program choices (or ranking lists) via the National Resident Matching Program for 37,256 residency positions, leaving many graduates unmatched to a program. Without a residency, medical school graduates cannot go on to become a physician.

“We haven’t expanded our training capacity to produce the number of physicians we need to meet the demands of an aging, growing population — and that at a time when not only is the population aging, but the physician workforce itself is aging,” Dill said.

Some have argued that the U.S. doesn’t have a physician shortage — it has a distribution problem, with not enough physicians choosing to work in primary care, not enough physicians working in rural or impoverished areas, and too much of doctors’ time being spent on administrative tasks instead of seeing patients. Difficulty in accessing doctors, some say, is creating the perception of a physician shortage.

Resneck and Dill said it’s true that the U.S. needs more primary care physicians. It’s not uncommon for medical students to come out of school with over $200,000 in debt, so many gravitate toward specialities that are more lucrative, leaving gaps in crucial primary care fields.

But Resneck also said that there are holes in other specialities, too, and that geographically there are no areas that have been spared from shortages.

“I’m not really seeing any specialties where we have too many doctors, so I don’t think the distribution thing is really an issue anymore,” Resneck said.

“And some of the worst access issues and worst wait times are in places like San Francisco, Boston, New York — places with a whole lot of health care but that maybe are magnets for people to come from surrounding areas. So even those areas now have really long wait times.”

The burnout factor

A solution to physician and health care shortages in the U.S. needs to consider both the input and output of workers, Resneck said. Training more doctors is important, but the U.S. also needs to curb the number of physicians leaving the workforce — and burnout is a major contributor to that.

Work burnout frequently made headlines during the pandemic, but how it manifests itself can be complex and hard to define. In its recent survey, the Commonwealth Fund asked participants about burnout by using symptoms such as “physical and emotional exhaustion.”

“Burnout is one thing that you can experience where you’re not feeling joy in your work,” Resneck said. “Some physicians describe it as a sense of hopelessness. Some even go on to say it’s more than burnout but actual symptoms of depression.”

Dill said there are many underlying causes for burnout among physicians, but that they fall into two basic categories.

“One relates directly to the shortage, and it’s just the high volume of care that physicians have to provide and the intensity of that. The needs of the patients are overwhelming because there are not enough physicians,” Dill said. “But the other is related to just the work environment that creates burnout.”

One work area that’s a big generator of physician burnout is the plethora of time-consuming administrative tasks. One study found that primary care physicians spend more than half their workday, or nearly six hours, doing things like electronic health record inputs and billing and coding. A survey by the AMA found that on average, physicians complete 41 prior-authorizations per week (getting advance approval from a health plan before a specific service is delivered to the patient to qualify for payment coverage). Doing this can mean hours spent completing and faxing paperwork and speaking on the phone with patients’ insurance companies. Time spent completing these tasks, Dill and Resneck said, means less time available to spend with patients — which only exacerbates the physician shortage.

On top of that, looming Medicare cuts, Resneck said, can mean a reduction in staff whom physicians rely on.

“Medicare [is] threatening at year end to cut physician payment rates by about 8.5% at a time when physicians have just come through these three years of the pandemic; at a time when we have incredibly high rates of inflation and physicians are struggling to keep their nursing staff and their front-desk staff and the cost of supplies, and everything has gone up so much. I just can’t think of a worse time,” Resneck said.

Although burnout during COVID-19 has permeated many industries in the U.S., frontline workers — and physicians in particular — were hit especially hard.

“We had been making real progress in the years leading up to the pandemic and burnout numbers had been getting a little better, but they soared from 2020 to 2021. Just an unprecedented rate of increase,” Resneck said.

Burnout had been an occupational hazard for physicians pre-COVID, but the pandemic made things worse. In nearly all specialties, 62.8% of physicians had at least one manifestation of burnout in 2021, compared to 38.2% in 2020, 43.9% in 2017 and 54.4% in 2014, according to a survey published in September.

In addition to the physical toll of taking care of large numbers of COVID-19 patients, Resneck described an emotional roller coaster of highs and lows for physicians over the last three years. These include sleeping in tents and garages after shifts to keep their families from getting sick, being hailed as heroes with people “banging pots and pans and howling out their windows in honor of doctors” and all this being followed by an era of COVID-19 disinformation and conspiracy theories that have left physicians even more mentally drained.

“Physicians were having to, while they were fighting this pandemic, simultaneously work so hard to push back on disinformation where patients were not trusting of vaccines or COVID therapeutics or other things. So it’s been a really hard few years for the profession,” Resneck said.

‘Resilience really sort of blames the victim.’

The Dr. Lorna Breen Health Care Provider Protection Act, which was signed into law earlier this year, provides federal funding for mental and behavioral health programs for health care workers. It was named after an emergency room physician who died by suicide during the early days of the pandemic after working grueling hours taking care of COVID-19 patients.

The hope is that programs benefiting from this funding will break down some of the stigma tied to mental health that prevents many physicians from seeking help when they need it — which is a common problem. The Commonwealth Fund survey found that most physicians who reported experiencing emotional distress did not seek professional help for mental health needs.

“If you are on record somehow as having a mental or behavioral health issue, there’s concerns that it might affect their license status, and clearly they don’t want that to be in jeopardy,” Dill said. “But also, physicians have this professional bent to put others first. And so when there are so many demands upon them to care for other people, they tend to set taking care of themselves aside. And so we as a society and as the institutions that employ them and rely on them need to step up to help them with that.”

Resneck said small changes to questions on license renewal forms — such as asking about any current impairments that could affect ability to care for patients instead of asking about any history of mental health conditions — can have a big impact on physicians’ willingness to seek care.

Although caring for mental health is important, Resneck emphasized the need to focus on changes to systemic issues.

“I think there was a tendency a few years ago for a lot of health systems, when they realized that burnout was a problem, to focus on wellness and resilience and say, ‘OK, we’re going to offer free yoga classes for the doctors,’ or, ‘We’re going to give them gift certificates for dinner with the CEO.’ And those things are nice and wellness is important, but resilience really sort of blames the victim. Like, ‘Doctors just need to be tougher to put up with all of this.’ And we know that’s not how you fix burnout. It’s about getting those burdens out of the way and fixing the larger system issues that are getting in the way.”