'Silent Exodus' From Medicine Threatens Patient Access to Care, Study Says

The nation's physicians are disengaging from the practice of medicine by working fewer hours and seeing fewer patients. This silent exodus from the medical profession, driven by changes in the practice environment, has reduced patient access to physician services.

That's one of the key findings of a study (128-page PDF; About PDFs) conducted by the physician consulting firm Merritt Hawkins on behalf of The Physicians Foundation.

The survey, conducted from late March to early June, is based on e-mail responses to 48 questions from 13,575 physicians throughout the country. It found that physicians are working 5.9 fewer hours per week than they did in 2008, resulting in a loss of 44,250 full-time equivalents (FTEs) from the physician workforce. The survey also found that physicians are seeing 16.6 percent fewer patients per day than they did in 2008, a decline that the authors say could lead to tens of millions of fewer patients seen annually.

Moreover, physicians spend more than 22 percent of their time on nonclinical paperwork, an amount of time equivalent to the loss of some 165,000 FTE physicians, according to the survey. More than 52 percent of physicians, meanwhile, have either limited the access Medicare patients have to their practices or are planning to do so. More than 26 percent of physicians have closed their practices to Medicaid patients.

In the next one to three years, more than 50 percent of physicians "plan to cut back on patients, work part-time, switch to concierge medicine, retire or take other steps that would reduce patient access to services," says the study.

"It is sort of a silent exodus or a silent defection from medicine," says Phil Miller, vice president of communications for Merritt Hawkins and one of the authors of the report. "Physicians are not retiring en masse. We still have more physicians coming into the system than we do exiting right now. The gross supply of physicians is growing, but the net supply of doctors is decreasing. It is not how many doctors are out there, but how they practice."

These trends are occurring as the Patient Protection and Affordable Care Act starts to provide health care coverage to millions more patients, putting even greater pressure on primary care physicians, Miller says, noting that the Affordable Care Act mandates coverage of preventive services in the public and private sectors and that most preventive services are delivered by primary care physicians.

The study, "A Survey of America's Physicians: Practice Patterns and Perspectives," provides a snapshot of the practice environment by gauging physician practice patterns and metrics, the career plans of today's physicians, and the current morale levels of physicians, among other factors. One of the main goals of the survey is to "connect the dots and explain why the person on the street should care," says Miller, adding, "Everybody needs a physician. That is generally the first person you see when you come into this world and the last one you see when you leave."

According to AAFP President Glen Stream, M.D., M.B.I., of Spokane, Wash., the survey findings confirm what the AAFP has been documenting for years. The survey points out, for example, that the practice of medicine is undergoing a fundamental shift away from the classic independent practice model to other practice models that result in fewer hours worked and diminished patient access to physician services.

"Historically, physicians in the United States have operated as independent owners or partners of their practices, typically running them as small businesses," the survey says.

It goes on to add that, in recent years, the independent practice model has been "increasingly supplanted by the employment model, in which physicians are employed by hospitals or multi-physician medical groups … Physicians are embracing employment for a variety of reasons, including the economic security employment offers and the relative absence of administrative and business ownership responsibility it entails."

Employed physicians, in turn, are more likely to work fewer hours and thus to see fewer patients, the survey says.

At the same time, younger physicians -- those 39 and younger -- are working fewer hours than their older counterparts, according to the survey. "We have a new generation of physicians who are embracing a different practice style," Miller says.

The survey also highlights the dramatic growth in the number of female physicians during the past 30 years -- an increase of 430 percent between 1980 and 2009.

"In 1965, 7 percent of medical schools graduates were women," the survey says. "Today, more than 50 percent of new medical students are female, suggesting that females will represent the majority of all physicians within a generation." Further, it points out, "ranks of primary care physicians and obstetrician/gynecologists, in particular, should consist more predominately of female physicians in the near future."

Female physicians work fewer hours on average than male physicians, according to the survey results. For example, more than 27 percent of female physicians work 40 hours a week or less compared with 17.9 percent of male physicians.

In gauging the morale of physicians, the survey found that more than 77 percent are "somewhat pessimistic or very pessimistic about the future of the medical profession," and more than 84 percent agree that the "medical profession is in decline."

Given those numbers, it’s not surprising that more than one-third of physicians say they would not choose medicine if they "had their careers to do over," and more than 60 percent would retire today if they had the means -- up from 45 percent in 2008, according to the survey.

"Doctors as a profession are disillusioned, and they are finding ways to minimize their exposure to the things they don't like in medicine," Miller says. "At the end of the day, that means working fewer hours and seeing fewer patients. And that is going to contribute to what is already a fairly serious physician shortage."

"The fact that physicians are disillusioned with their profession has real-world consequences," he adds. "It impacts whether you will be able to see a physician when you need one."

More than 80 percent of physicians say they have little ability to change the health care system, a finding that concerns Stream.

"I don't think physicians should feel powerless, no matter how complicated the political environment is," says Stream. He urges physicians to engage in the political process and to take part in efforts to improve the health care system.

On a more upbeat note, Stream is pleased that 80 percent of physicians surveyed cite patient relationships as the most satisfying part of their jobs. "We are physicians because we want to help people, and we enjoy interacting with patients," Stream says. "I see that as a positive."