Second Opinion

News and perspectives from AAMC's Chief Public Policy Officer, Atul Grover, M.D., Ph.D.

June 6, 2014

VA Wait Time Delays: Case Study in Physician Shortage

When I look back on my residency training, I remember a man with a little discomfort who, after much convincing from his wife, drove several hours to the San Francisco VA. He came in and we quickly diagnosed a massive heart attack-one where the typical patient would have been dying in front of us, or at least screaming in pain.

That day, that veteran got the care he needed. And over the years, the VA has worked hard to improve the care they provide. For example, the VA was among the first to implement electronic health records, now a best practice throughout medicine, as well as the patient-centered medical home. The VA also plays an important role in medical innovation. The first successful liver transplants were performed at VA facilities, and advances such as the pacemaker and CAT scans were pioneered by VA research. These and many other innovations have improved the lives of veterans and patients around the country and around the world.

VA hospitals also are major sites of health care training. About 70 percent of the nation's practicing physicians are educated in a VA facility. According to the VA's Office of Academic Affiliations, in 2013, more than 20,000 medical students and 40,000 medical residents received some of their education in VA hospitals.

But, as the recent news about tragic delays in care at VA facilities shows, there is clearly more that needs to be done to improve health care for our nation's veterans. And a large part of making sure our veterans get the care they need depends on having timely access to a physician.

Veterans of the Iraq and Afghanistan wars, along with Baby Boomer veterans, are placing challenging demands on the VA for health care services. As National Public Radio correspondent Quil Lawrence recently said, "Especially in the last three years, you've seen a 50 percent... jump in (VA) primary care visits, but only a nine percent increase in the number of physicians. That's because of Iraq and Afghanistan veterans. It's also because Vietnam veterans are hitting the age where they need a lot more medical care."

In recent media coverage, some have begun to question whether the problems at the VA reflect, in part, a larger, national problem: a looming physician shortage that threatens access to care for all Americans. With the AAMC projecting a shortage of more than 91,000 doctors in 2020-almost evenly divided between primary care physicians and specialists-the most vulnerable among us, including our veterans, will feel the impact first. Certainly as the VA faces growing challenges in meeting that demand, the situation will only be exacerbated by a nationwide shortage of all physicians.

For many years, veterans' advocates and health care professionals have expressed strong concern about the shortage of physicians serving veterans, the lengthening wait times they experience, and the health risks such delays pose. In 2007, the AAMC testified to Congress that "(c)oncerns about physician staffing at the VA come at a time when the nation faces a pending shortage of physicians." The Independent Budget, supported by more than 50 veterans' service organizations, has said veterans' access to care is a major concern.

Whatever the specific obstacles to veterans' access to care may be, a physician shortage is surely one of them, as several witnesses observed at last month's Senate hearing.

The VA already has made a concerted effort to grow the numbers and improve the training and distribution of physicians serving veterans. Between 2001 and 2012, its efforts increased the number of residency training positions at VA facilities by nearly 1,500. The VA reports it "is the only U.S. Federal payer that is increasing funding for physician residents (GME Enhancement Initiative)."

But the VA faces ongoing budget pressures at a time when it also faces an increasingly competitive market in which the shortage of physicians drives both demand and compensation for physicians. That's especially true for specialists trained to treat the highly complex physical and psychological challenges often found among injured veterans. And the growing national shortage makes the competition even more demanding.

The need for more physicians, as well as new systems of care in the VA, illustrate not only the impact of physician shortages overall, but also that the shortages are not evenly distributed over time, geography, and need. Vulnerable populations-defined by geographic location, income status, or complexity of needs-are often the first and hardest hit by physician workforce shortages.

Clearly, the time has come for a multi-pronged strategy to address the national shortage of physicians-one that includes team-based care and innovative delivery models, as well as more physicians to provide care. Congress must do its part by lifting the federal cap on the number of residency training positions supported through Medicare, the nation's single largest funder of physician training. Without these residency positions, all new M.D.s graduating from the nation's medical schools may soon not be able to complete their training and begin practicing independently.

Passage of legislation to lift the cap (S.577, H.R. 1180, or H.R. 1201) would be a critical step toward solving the national shortage of physicians.

The news about tragic delays in care at the VA is disturbing on many levels. But it also should serve as a warning about the urgent need to increase federal support for residency training so that our veterans-and our growing, aging population-can receive the care they need when they need it.

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