The report’s findings lead the MMS to conclude that “patient demands on these specialties have outstripped supply.” Medical Society officials say the situation is limiting and delaying access to care, causing difficulty in referrals to specialists, and creating long wait times for both primary and specialty care. “Our latest analysis raises serious questions about our ability to efficiently handle the increased demand for health services for both primary and specialty care,” said Bruce Auerbach, M.D., MMS president.

“The success of health care reform in insuring hundreds of thousands more people is a great step forward. But it has put enormous pressure on primary care, and we now know that insurance without access to care will not result in true health care reform, and that universal coverage does not equal universal access,” Dr. Auerbach said. “With more patients, an aging population and rising rates of obesity and chronic disease, demand is overwhelming supply, and our physician workforce is coming under more stress and strain.”

Another major reason cited by Dr. Auerbach for physician shortages is a poor physician practice environment, which the Medical Society believes has consistently hindered recruitment and retention in many specialties. The Society's Physician Practice Environment Index, a statistical indicator of nine factors that shape the environment in which physicians provide patient care, has declined sharply since 1992. After 13 consecutive declines, the 2007 index rose fractionally (up 0.7 percent), likely the result of short-term economic conditions such as falling housing prices and lower office rental rates. However, the Massachusetts Index continues to substantially underperform the U.S. Index. The index takes into account such factors as physicians' cost of doing business, median physician income, and professional liability costs.

Despite the current environment, Dr. Auerbach was quick to point out that several opportunities exist for positive change. “Decreasing administrative burdens, fixing our liability system, and reducing barriers to recruitment and retention such as lowering medical school debt,” he said “are just a few of the immediate steps we can take now to improve the practice environment. Working together to improve chronic disease management and encourage healthy lifestyles will also reduce demand and improve our general health.”

Principal Findings

12 specialties in short supply, three for the first time

The Medical Society’s expanded analysis for 2008 found 12 of 18 specialties studied to be in short supply. Three specialties -- oncology neurology, and dermatology – examined for the first time in this year's study, were declared in shortages for the first time. The other nine seeing shortages are emergency medicine, general surgery, neurosurgery, orthopedics, psychiatry, urology, vascular surgery, internal medicine, and family medicine. Oncology, neurology, and dermatology were included in the study for the first time this year, and urology was added last year.

Of the specialties studied since 2002, eight have been found to be facing critical or severe shortages in at least four of the seven years of the studies.

Primary care: Long waits, more practices closed to new patients, community hospital shortages

The specialties of internal medicine and family medicine are under even more intense pressure with some 440,000 newly insured residents looking for primary care doctors as a result of the health care reform law. The 2008 study marks the third consecutive year that both of these primary care specialties have been found to be in short supply, and the two specialties were the only ones of 18 surveyed deemed to be in “critical shortage” for 2008.

Wait times:  Long wait times for appointments for new patients continue to be a problem, resulting in delayed access and care. For internal medicine, the average wait time is 50 days, just two days shorter than last year’s figure of 52 days. For family medicine, the average wait time is 36 days, two days longer than last year’s figure. Many primary care practices across the state are reporting even longer wait times.

More practices closed to new patients: Two separate polls in the study confirmed that more primary care physicians have closed their practices to new patients. The survey of practicing physicians showed that the percentage of family medicine physicians who are no longer accepting new patients has increased over the past three years from 25% in 2006 to 35% in 2008. The percentage of internal medicine physicians no longer accepting new patients also increased, from 31% in 2006 to 48% in 2008. A separate survey of physician offices showed similar results: 42% of internal medicine and 35% of family medicine physicians were not accepting new patients in 2008.

Community hospital shortages: The Medical Society's study also found that primary care physicians are some of the most critical scarcities facing community hospitals: 56% of community hospitals report shortages in internal medicine, and 44% report shortages in family medicine. Both are increases from the 2007 study.

Specialty care: Continuing Strain, Difficulty with Referrals

The Medical Society says its findings of shortages in 12 specialties should also be a warning sign about diminished and delayed access to specialty care. A large majority of physicians – 70% - reported difficulty in referring patients to a specialist, a recurring problem from previous years. For example: The continuing shortage of psychiatrists – found in “severe” shortage for three consecutive years - may delay access to care as the demand for mental health services continues to rise. The recent congressional approval of a mental health bill requiring private insurers to provide equal benefits for mental illness with physical illness is likely to put further strain on access to psychiatric care.

The shortage of oncologists (cancer physicians) is consistent with a recent report by the American Society for Clinical Oncology that projects a future shortage of these specialists by 2020. The shortage of dermatologists, coupled with the finding that this specialty has by far the longest time to recruit of any specialty, may also affect patient care as the incidence of skin cancer continues to rise dramatically.

Recruitment and retention remain major obstacles, especially with community hospitals

A recurring theme throughout all seven years of the Society's studies is increasing difficulty in recruitment and retention of physicians, and both continue to be major problems in overcoming physician shortages. The situation is especially acute with community hospitals.

Retention: Keeping existing staff has become more difficult for 47% of teaching hospitals, 40% of practicing physicians, and 68% of community hospitals.

Recruitment: Hiring has become more difficult, with 69% of teaching hospitals, 69% of practicing physicians, and 96% of community hospitals experiencing difficulties in filling physician vacancies.

Time to recruit: Difficulty in recruiting is reflected in the time to recruit physicians. The survey of practicing physicians indicated that recruitment times averaged more than one year for 11 of the 18 specialties: dermatology, 26 months; neurology, 24 months, gastroenterology, 23 months; vascular surgery, 22 months; neurosurgery, 22 months; urology, 21 months; general surgery, 19 months; orthopedics, 17 months; cardiology, 17 months; family medicine, 14.5 months; and internal medicine, 13 months.

Professional liability continues to have large negative influence

The 2008 study again found that professional liability (medical malpractice concerns) and the fear of being sued continue to have a substantial negative influence on physicians and the practice of medicine.

• 44% of physicians surveyed said their practice is being altered or limited because of the fear of being sued.
• More than half of physicians in seven specialties said they have altered or limited their practice because of the fear of being sued: neurosurgery (76%), urology (75%), emergency medicine (66%), obstetrics/gynecology (57%), family medicine (53%), general surgery (51%), and orthopedics (51%).
• 25% of physicians reported that professional liability fees were more than 15% of their total operating costs for the last six years. The top five specialties in 2008: obstetrics/gynecology (85%), neurosurgery (60%), emergency medicine (40%), general surgery (40%), orthopedic surgeons (35%).

Neurosurgery: All 7 years in shortage; most affected by liability

The specialty of neurosurgery, critical to emergency and trauma departments, continues to be the specialty under the most stress in the physician labor market. It is the only specialty classified as facing shortages in all seven years of the workforce studies, and a greater percentage of neurosurgeons (76%) have altered or limited their practices because of the fear of being sued than any other specialty. In addition, 60% of neurosurgeons report professional liability (medical malpractice insurance) costs exceeding 15% of total operating costs, and the specialty has one of the longest times to recruit at 22 months.

Regional findings across the state show recruitment remains difficult

The 2008 study repeated its examination of physician workforce issues across five regions in Massachusetts: Boston metropolitan area, New Bedford/Fall River/Barnstable County (Cape Cod), Pittsfield (Berkshire County), Springfield, and Worcester.

A key finding from the regional data is that recruitment of physicians remains difficult. The percentages of practicing physicians reporting difficulty in filling vacancies were 67% in Boston; 74% in Worcester; 75% in Springfield; 76% in Bedford/Fall River/Barnstable County; and 64% in Pittsfield. In all but one region (Pittsfield), the percentages were higher than the average of the previous six years.

Public opinion poll of residents: Difficulty in getting care, high cost, high satisfaction

• More residents (24% in 2008 versus 16% in 2007) reported difficulty in obtaining the care they need, with the most common explanations being cost, long waits, and difficulty finding the right doctor or health plan.
• Nearly one-half (46%) of residents identify the cost of health care or insurance as the single most important health issue facing Massachusetts.
• Only one-third (33%) of residents are aware that the state and insurers are posting quality and cost information of physicians and medical groups on the internet.
• Two percent of residents report having no health insurance, down from 6% in 2007 – evidence of the impact of the state’s health care reform law.
• Eighty-eight percent of residents are satisfied with the health care they received over the last year.

Additional findings

• More than one-half of medical residents pursue the next step of their careers outside of Massachusetts, another reason for physician shortages in all specialties.
• Massachusetts employs a large number of international medical graduates (IMGs) and is highly dependent on IMGs to fill its physician labor market needs. The percentage of IMGs as new hires at teaching hospitals has risen from 19% in 2006 to 23% in 2008. 
• Eighty-three percent of physicians surveyed find their careers rewarding, but 47% say they are dissatisfied with the practice environment in Massachusetts.
• Fifteen of the 18 physician specialties in teaching hospitals had job vacancy rates higher than the 2.9% statewide average for all job industries in 2007. The overall job vacancy rate for the 18 specialties included in the 2008 study is 7.3%; two and one half times the statewide average for all jobs. Ten (10) of the 18 specialties were found to have job vacancy rates of 10% or higher.

About the Physician Workforce Study

The Massachusetts Medical Society’s annual Physician Workforce Study examines the state’s physician workforce through surveys of practicing physicians, medical staff presidents of community hospitals, department chiefs in teaching hospitals, medical groups, residency and fellowship program directors, and public opinion surveys. The 2008 study is the Society’s seventh annual comprehensive look at multiple aspects of the physician workforce.

The study was conducted in collaboration with economist James Howell, Ph.D., of The Howell Group and Andrew Sum, Director of the Center for Labor Market Studies at Northeastern University, who served as consultants. The complete report and an executive summary are available at http:///www.massmed.org/workforce.

About the Massachusetts Medical Society

The Massachusetts Medical Society, with more than 20,000 physicians and student members, is dedicated to educating and advocating for the patients and physicians of Massachusetts. The Society publishes the New England Journal of Medicine, a leading global medical journal and web site, and Journal Watch alerts and newsletters covering 12 specialties. The Society is also a leader in continuing medical education for health care professionals throughout Massachusetts, conducting a variety of medical education programs for physicians and health care professionals. Founded in 1781, MMS is the oldest continuously operating medical society in the country. For more information please visit www.massmed.org, www.nejm.org, www.journalwatch.org.