Primary Care - North Greece Internal Medicine & Pediatrics

The Infectious Disease Doctor Shortage Will Hit Marginalized People The Hardest

The Covid-19 pandemic underscored the importance of infectious disease doctors — but the field is still facing a shortage, with consequences for the health of communities across the U.S. Specialists spoke out about the impact of the shortage and potential solutions at a recent press briefing organized by the Infectious Diseases Society of America.

"Nearly 80% of counties in the U.S. Don't have an ID physician," said Kinna Thakarar, an infectious disease physician at MaineHealth Maine Medical Center.

In 2023, only half of infectious disease residency training programs were filled — a continuation of a long-running trend. Applications in the programs temporarily went up in the aftermath of the pandemic, a phenomenon known as the "Fauci effect," but soon fell again.

Input from infectious disease health care teams is necessary across all kinds of areas, from oncology to maternal health. Patients who are more vulnerable because they're undergoing surgeries or on immunosuppressive medication need access to infectious disease care. More broadly, "as a population we are all getting older, and the proportion of immunocompromised people is going up," said Paul Pottinger, an ID physician and director of the ID Fellowship Training Program at the University of Washington.

Climate change also means that as animals, including mosquitoes, ticks, and fleas, move to new areas, the risk of new and reemerging infectious diseases is increasing.

As with many other other public health issues, the shortage is particularly impactful for people who live far from urban centers and for those struggling with problems like addiction. "In rural areas, patients may be driving hours to access care or may not have access at all," said Thakarar. When it comes to infectious diseases, early intervention is crucial to prevent adverse outcomes. Thakarar, who provides infectious disease care to unhoused people in Maine, noted that infections related to substance use are also on the rise.

A major hurdle to growing the number of infectious disease physicians is that the field is one of the lowest-compensated medical specialties. "People are graduating from medical school with debt," said Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America.

In hopes of addressing the issue, the infectious disease community is now asking Congress to fund the already-authorized Bio-Preparedness Workforce Pilot Program, which, according to Jezek,  would "provide a loan repayment incentive in exchange for up to three years of service as ID professionals in areas of health professional shortage [such as in] medically underserved communities or in federally funded clinics."

Previous programs aimed at increasing the workforce using financial incentives to recruit more physicians to underserved specialties, such as primary care and rural care, have been a point of contention. While medical students typically graduate with high amounts of debt, structural considerations beyond financial incentives, such as levels of physician burnout and long hours, can also impact students' residency choices.

Physician shortages span across all specialties: A recent Association of American Medical Colleges report projected that by 2036, the U.S. Will have a deficit of 86,000 physicians. The speakers at the press briefing noted that the infectious disease care shortage itself goes beyond insufficient numbers of physicians — there's also a dearth of infectious disease specialized nurses, clinical microbiologists, pharmacists, and lab technicians.

"There just aren't enough of us to do the work and for that reason our patients and communities are suffering," said Pottinger.

The First Step To Addressing The Physician Shortage

By Nicole C. McCann and Rochelle Walensky

Jan. 15, 2025

McCann is a Ph.D. Candidate in health services and policy research at Boston University School of Public Health. Walensky is an executive fellow at the Harvard Kennedy School of Government and at the Harvard Business School, and the former director of the Centers for Disease Control and Prevention.

If you've ever faced long waits for a doctor's appointment, or traveled hours for care, it might surprise you that as recently as the turn of the century, policymakers sounded the alarm regarding a glut of U.S. Physicians. In 1980, the Department of Health, Education, and Welfare (now the Department of Health and Human Services) issued a pivotal report, "Graduate Medical Education National Advisory Committee Report," that documented the surplus concerns that persisted for about 20 years.  

Today, to the contrary, the U.S. Faces a dramatic physician shortage. Across the country, 76 million people live in primary care deserts, most frequently in rural areas. The supply of health care workers is lagging woefully behind the demand, in part caused by pressing health care needs of the aging U.S. Population. By 2037, the estimated physician deficit is expected to reach 187,000 doctors, including a shortfall of 87,000 primary care providers. Rural areas are projected to face a 56% shortage compared with 6% in urban areas, exacerbating ongoing geographic and demographic health disparities, such as higher rates of stroke and lower life expectancy in low-income, rural areas.

Addressing this physician shortage will require a multi-pronged approach, including increasing the number of medical students, incentivizing geographic and specialty diversity, and adjusting physician compensation. However, for such strategies to be successful, one key bottleneck must be addressed: limited physician training opportunities, especially in high-need specialities and settings.

After graduating medical (or osteopathic) school, physicians complete residencies in graduate medical education (GME) that last between three (e.G., internist) and seven (e.G., surgeon) years. The role of a resident is unique, bridging the gap between student and independent physician. In this apprentice-like phase, residents transition from paying for education to earning a modest salary, a fraction of what attending physicians receive. To secure a residency, final-year medical students are competitively paired with training programs through a national "matching" algorithm based on their mutual preferences and rankings. GME residency slots within each training program are largely funded through Medicare with some additional support from other federal and state governmental agencies.

In 1997, as "Medicare's open-ended subsidies" were seen as a major culprit of the physician surplus, the Balanced Budget Act capped the number of residents GME programs could train. Despite a profoundly different outlook on physician supply today, GME structures have largely remained unchanged, leaving the U.S. Ill-equipped to build a robust physician workforce. Each year, thousands of medical school graduates don't match to residency, with lower match rates in rural settings and in financially less-lucrative specialties such as family medicine and primary care. The need for more primary care doctors in underserved rural regions is widely recognized, and physicians often practice where they train. Even so, of the $16.2 billion Medicare budget for GME in 2020, only 2% of Medicare-funded resident training slots were located in rural areas — areas where 18% of the U.S. Population resides.  

The infectious disease doctor shortage will hit marginalized people the hardest

Academic Medical Centers (AMCs) receive Medicare training funding through direct and indirect payments. Direct payments, totaling $4.5 billion in 2020, help cover residency program costs based on hospital costs from 1984 (adjusted for inflation), the number of residents from 1996 (which informed the 1997 caps), and the hospital's Medicare patient volume. GME indirect payments, amounting to $11.7 billion in 2020, are meant to offset additional costs of training residents — such as increased diagnostic testing — and are tied to the ratio of residents (subject to the 1997 caps) relative to hospital beds. The outdated GME funding formulas poorly reflect current population health trends and advancements in medical practices, and also reward hospitals based on care volume, rather than care quality. As a result of these GME funding structures, medical residencies and GME slots are condensed in the Northeast where hospitals boast sub-specialty and super-specialty programs, disadvantaging both rural and primary care programs.

Conventional wisdom holds that residents are a financial burden on hospitals, thus requiring Medicare reimbursement to offset resident training-related costs. However, this theory lacks economic evidence. Despite flat GME funding and the 1997 federal residency caps, hospitals themselves have financed 15,000 new slots over 20 years. In academic medical centers with already well-established training programs and infrastructure across numerous sub-specialties, residents, in fact, help offset training costs with below-market salaries and modest bargaining power.  

Efforts to modernize GME include the Consolidated Appropriations Act of 2021, which added 1,000 new Medicare-funded GME slots in priority areas. While these slots were appropriately dedicated to primary care specialties in high-need areas, one study found that most were allocated to urban regions. Another proposed bill aims to add 2,000 GME positions annually to settings including rural shortage areas and historically Black colleges and universities; it has been stalled in the House of Representatives since early 2023.  

Swift and substantial GME reform is urgently needed. In 2014 — now over a decade ago — an Institute of Medicine (IOM, now the National Academy of Medicine) report titled "Graduate Medical Education That Meets the Nation's Health Needs" called for phasing out of current GME fee-for-service payment structures in favor of value-based payment; building a strategic plan to work towards geographic and specialty-aligned goals; and transforming GME funding toward positions in priority areas. Importantly, the IOM report also proposed a new transformational fund to support pilot studies on innovative policies to improve GME structure.

But progress toward the IOM report recommendations has been thwarted, in part by interest group politics and subsets of physicians or hospital systems who disproportionately benefit from the current or alternative approaches. Societies like the American Hospital Association and the Council of Teaching Hospitals have lobbied Congress to continue using the outdated GME structure to fund their member teaching hospitals. The Alliance for Academic Internal Medicine and the American College of Physicians published a joint paper opposing the IOM recommendations and instead recommended modest changes, like lifting of GME caps, spreading the cost of GME across all payers (e.G., private insurance), combining direct and indirect payments, and increasing GME funding transparency. Ultimately, GME reform must be transformative, seting aside special interest priorities and serving the greater good of the entire system.

Free med school tuition won't solve the shortage of primary care physicians

Reforming GME is necessary but insufficient to address the physician shortage. In our recent review in the New England Journal of Medicine, we discuss the need for change at all steps of the complex physician production process: medical school entry and costs, training, compensation, and retention. In that review, we highlight an "evidence emergency": There is little consensus on the most efficient way to address the physician shortage as a step on the pathway to improved U.S. Health care outcomes. We call for investment in the independent evaluation of initiatives to strengthen the physician workforce, including strategies for GME reform.

In the 2024 Commonwealth Fund report "Mirror Mirror 2024", the U.S. Ranked 10th (among 10 similar high-income countries) on health systems performance, 10th on access to care, and 10th on health outcomes. While recent federal action on drug pricing has worked to address some access issues, there is pressing, essential work ahead to tackle the escalating physician shortage. Small, incremental improvements in the number of rural and primary care GME slots will not keep up with the intensifying shortage in the least healthy areas of the country. The large-scale critical changes needed — such as GME reform — demand urgent congressional action. The current neglect is leading to dire consequences: The health of our nation is deteriorating, and without bold action, we will continue to grow sicker.

Nicole C. McCann is a Ph.D. Candidate in health services and policy research at Boston University School of Public Health. Rochelle Walensky, M.D., M.P.H., is an executive fellow at the Harvard Kennedy School of Government and at the Harvard Business School, and the former director of the Centers for Disease Control and Prevention.

Why Redding Has A Doctor Shortage And What Medical Centers Are Doing About It

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