The Future of the US Physician Workforce—Challenges and Opportunities

The aging of the US population, along with the aging of its physician workforce, poses serious workforce challenges. Over the next 15 years, the proportion of persons aged 65 years and older is projected to grow by 42%, and the proportion of those older than 75 years is expected to grow by 74%.¹ A report prepared for the American Association of Medical Colleges¹ estimates that within the next decade more than 2 of every 5 physicians will be older than 65 years. These demographic trends portend worrisome physician workforce shortages, some of which are already occurring and are projected to worsen, particularly in primary care and psychiatry.¹ Less appreciated are current and pending shortages in the surgical specialties. Nam and colleagues² present their projections for the urology physician workforce in the US over the next 4 decades.

By conducting a population-based cross-sectional study based on US Census data and data from the American Urological Association annual census and the Data Resource Book of the Accreditation Council for Graduate Medical Education, Nam et al² calculate the expected per capita availability of urologists. Provided are 2 scenarios: a stagnant one that assumes no growth in urology training positions and a continued growth scenario in which a recent 13.8% increase in training positions is sustained each year. They concentrate their analysis on patients older than 65 years, who make up the preponderance of persons needing urology services, and include consideration of female urologists per capita with regard to the population of older women. Their findings draw attention to an impending serious shortage of urologists as both the nation and its urologist workforce age.

Using a 2020 per capita figure of 23.8 urologists per 100 000 persons aged 65 years and older, they calculate an expected decline by 2035 to 15.8 urologists per 100 000 under the growth scenario and 13.1 urologists per 100 000 by 2060 under the stagnant scenario. Much of the decline derives from retirement during this period, given the current median age range of US urologists of 55 to 59 years. Without any growth, the decline continues to 2060, and only with growth is there a return to 2020 levels by 2060. Reflecting the increase in women entering the field, the current per capita figure of 0.8 female urologists per capita for older female patients increases by 2035 to 2.5 urologists per 100 000 under the growth scenario and 1.5 urologists per 100 000 under the stagnant scenario.

Although the study by Nam et al² is methodologically sound, it excludes consideration of possible and likely changes to the practice of urology over the next several decades and the impact these changes might have. Some of these changes are already starting to be implemented, most notably increasing use of robotic techniques,³ as well as greater incorporation of advanced practice nurses and physician assistants into the urology care team, more use of telehealth technology, and reductions in administrative burdens. Urology is noteworthy for its growing inclusion of women into its ranks and the positive effects that diversity, equity, and inclusion efforts can have on the workforce equation, as seen in this study.² More efforts at recruitment to ensure the urology workforce better matches the populations for which it cares would help.

These measures make no assumptions about the nature and duration of training, but these deserve consideration for workforce projections and pertain to all fields of clinical care. Movement from time-based training and certification to competency-based training and certification has the potential to shorten the duration and cost of both undergraduate and graduate medical education.⁴ General surgery and its subspecialties have long promoted competency-based certification and could lead in this effort. Similarly, enhanced training in multidisciplinary team care is a natural direction for surgical specialties to pursue, particularly with regard to the care of elderly patients.⁵ The importance of factors leading to physician burnout has been underscored by experience during the COVID-19 pandemic.⁶ Attention to the details of daily work life and helping to ensure work-life balance become essential to ensuring long, productive careers and a resilient workforce.

Many of the aforementioned measures can be addressed within the medical community, but public policy initiatives will be critical to support them. This begins with increasing the number of federally funded residency training slots in fields with impending critical shortages. Urology has had some small successes, but as the data show, not enough to deal with the needs of the next 15 years. Second, correcting glaringly irrational disparities in pay are essential to rationalizing career choices and ending decades-long distortions in career choice among US medical school graduates.⁷

Although the workforce projections for urology and many other fields of medicine look grim from a demographic, steady-state perspective, they may be brightened considerably by a concerted, multidimensional effort at reforming training, practice, and payment. The time to start is now because of the long lead time necessary to produce highly qualified, highly skilled medical professionals.

Published: November 16, 2021. doi:10.1001/jamanetworkopen.2021.34464

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Goroll AH. JAMA Network Open.

Corresponding Author: Allan H. Goroll, MD, Division of General Internal Medicine, Massachusetts General Hospital, Harvard Medical School, 15 Parkman St, Ste 645, Boston, MA 02114 (ahgoroll@partners.org).

Conflict of Interest Disclosures: None reported.