Is there a doctor in the house? Shortage threatens HIV gains

'The current HIV medical workforce is in trouble.'

There have been recurrent warnings that the United States is facing an HIV clinician shortage that could lead to a critical setback in the fight against AIDS. In response, the federal government is proposing a two-year study to assess the risk of attrition in the HIV clinician workforce.

The Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) has proposed conducting a 24-month HIV clinician workforce study to provide state and federal agencies with estimates of the number of primary care clinicians providing medical care to people living with HIV or AIDS in the United States.

The HRSA survey will seek clinician demographics, their hours in direct patient care, the size and characteristics of their HIV patient load, their patient management strategies, and their workload changes and retirement plans.1 The study also will seek projections of the magnitude of the expected shortage through 2015.

HIV physicians in some regions don't need a survey; the provider shortage is a major problem now.

"We have approximately 800 HIV-positive individuals in our practice, and I see most of them myself," says Sharon Lee, MD, executive director of Family Health Care in Kansas City, KS. Lee also is the chief executive officer of the American Conference for the Treatment of HIV (ACT HIV) and is a clinical professor at the University of Kansas Medical Center's department of family medicine, also in Kansas City. Lee has practiced HIV medicine since the 1980s.

"I have a younger doctor who is going to be leaving in a month, and I don't have another one until next year," Lee says.

There is one other provider in Kansas City who sees a large number of HIV patients, and another who sees about 130 patients. Together the three providers see 90% of the people identified with HIV, Lee says.

If something were to happen to Lee and her clinic had to close, then it would be highly unlikely her 800 patients could be absorbed into the current network of Kansas City HIV providers, she says.

"The current HIV medical workforce is in trouble," she says. "I'm 60, and at some point as people of my generation are retiring, there are a lot of folks who are having trouble finding replacements for themselves."

The HIV Medicine Association (HIVMA) of Arlington, VA, has addressed this issue for the last few years. In one survey published last year, the HIVMA asked Ryan White Part C programs to discuss their most serious challenges. The two top barriers they cited were reimbursement and a lack of qualified providers.

"We found the majority of programs reported difficulty recruiting and retaining HIV clinicians," says Andrea Weddle, executive director of HIVMA.

"Our survey was conducted of programs and not individual clinicians, so we've called for a national HIV medical workforce study to assess and get a good handle on the number of HIV clinicians now and how many we'll need," she adds. "HRSA is going to do that, and we're anxious to see the results."

Nationally, it's difficult to find physicians willing to work as HIV clinicians, says Kathleen Squires, MD, professor of medicine, director of the division of infectious diseases, Jefferson Medical College, Thomas Jefferson University of Philadelphia, PA.

Pressure to go into a specialty

There are several reasons behind the trend, including massive student loan debt.

"The average medical school debt is $170,000 for people finishing internal medicine," says Donna E. Sweet, MD, AAHIVS, MACP, a professor of internal medicine at the University of Kansas School of Medicine in Wichita, KS. Sweet is the chair of the American College of Physicians (ACP) Foundation initiative's national HIV workforce expansion steering committee.

"It's like having a mortgage without a house," Sweet adds. "So when they get their first job the impetus is to get into a higher-paying specialty."

These medical students with their huge college debts often believe that going into a specialty area of medicine will help them pay back their obligations, Squires says.

"So there is a dearth of people who are interested in doing primary care medicine," Squires says.

Also, even when medical students decide to go into internal medicine, only a small percentage chooses outpatient medicine, Sweet notes.

"They're hospitalists and go into subspecialties," Sweet says. "It's the money, but also the lifestyle."

Hospitalists work 12-hour days and then get seven days off, while physicians in outpatient medicine have to be available around the clock, she explains.

"Our kids are much more aware of their own needs," Sweet says. "People like me carry a beeper and talk to people at night and make arrangements to have people seen so they don't have to go into the emergency department."

Sweet has experienced this problem first-hand as her own internal medicine practice has had to expand to handle an additional 100-plus HIV patients a year, although Ryan White funding has not kept pace.

"In my clinic, I've made a commitment that we'll find a spot for new patients," she says.

But it's increasingly difficult, and her clinic needs at least one more HIV physician, she says.

"I lost the other HIV physician in my clinic a year ago, and we haven't found one who wants to do HIV care," Sweet says. "This is a time of change and uncertainty."

Another reason for the reduced new HIV physician pipeline is that new physicians who might be attracted to HIV care are more interested in treating international populations, Squires notes.

"I've heard from medical students and residents that their interest in HIV is on an international arena rather than here in the United States," Squires says.

There still are altruistic medical students entering the workforce, but their altruistic tendencies are taking them elsewhere, Lee says.

"I think the issue is that those folks who are tending to be in medicine for altruistic reasons are finding sexier areas to go into," Lee adds. "So if they do HIV care, they're much more likely to do that in Africa; we're exporting some of our doctors and have a brain drain going on."

For new physicians in the 1980s, HIV care was a higher calling. Their patients often were young, very sick, and dying.

"I opened a clinic to care for the poor in Kansas City at the exact moment a lot of people with HIV were losing their jobs and losing their insurance and becoming poor while they were afflicted with this terrible disease that no one had any treatments for," Lee recalls. "There was a difficult period of time when we lost 200 patients a year."

U.S. docs: HIV `not a big problem'

Today's new doctors see HIV care differently. It's the era of antiretrovirals and most Americans with the disease are living long enough to have to worry about heart disease.

Clinicians in training in the 2010s do not get as much exposure to patients with HIV as did young clinicians of the 1980s and 1990s, Squires explains.

"Their perception is that HIV is not a big problem in the United States," Squires says. "Also, it's because residency training for internal medicine is on the inpatient side, and you don't see a lot of HIV on the inpatient side now; it's become an ambulatory care specialty."

The HIV clinician shortage is part of a bigger picture in which the U.S. will experience a shortage of more than 90,000 doctors in the next decade, according to the Washington, DC-based Association of American Medical Colleges (AAMC) in a recent report.

"We're very concerned about the physician crisis and shortage we're facing," says Len Marquez, director of government relations for the AAMC.

"In the next three to five years we're looking at a physician shortage of greater than 60,000 physicians," he adds. "And by 2020, it will be more than 90,000."

The shortage comes at a time when baby boomers are on Medicare, and a third of the physician workforce will be aging and ready to retire, Marquez says.

"You can't just flip a switch and say, 'Let's have more doctors,'" he says. "We need 10 years to educate and train an MD, and we have a concern that if this problem is not addressed now we'll have a real crisis."

While family medicine is facing a bit of a crisis, it's not to the extent of the HIV physician shortage, Lee says.

"The best way to handle the HIV clinician shortage is to take physicians trained as a family doctor and teach them specifics about HIV," Lee suggests. "The problem is our medical schools and residency programs have not geared up quickly enough to respond to this disease as an ambulatory outpatient disease, and this is where we get [in a crunch] right now."

This is why HIVMA is making the provider shortage a priority.

"We're trying to help sort out the workforce issues," says Lee, who is on the HIVMA board.

HIVMA and the American Academy of HIV Medicine jointly made a number of recommendations for addressing the shortage. These included loan forgiveness for some HIV medical providers, increased federal support of clinical training opportunities, and increased Medicaid payment rates for HIV providers.

The current anti-spending climate on Capitol Hill would make federal funding solutions seem improbable, but no less necessary, Marquez notes.

"We have this physician shortage, and it will be a crisis if you just look at the numbers, so we need to do something to address this," he says. "The question becomes, 'How do we pay for this?' And that's the pushback we hear."

Reference

  1. Agency information collection activities: proposed collection: comment request. Fed Reg. May 27, 2011; 76(103):30949-30950.