How to tackle the physician shortage [PODCAST]

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“The national physician shortage is an urgent issue that requires immediate attention. Otherwise, the next time you seek medical care, you might be treated by a non-physician for a condition that requires physician attention. This could be expensive and detrimental unless we solve the issue of training and retaining physicians.

Physicians are uniquely positioned to advocate for solutions in three roles: trusted messenger, physician-administrator, and political officeholders.

Surveys consistently show that health care is in the top three motivators for voters, yet patients are likely unaware that the physician shortage is a grave threat to their health and wellness. As trusted messengers, physicians can educate and inform the public about this particular peril in our broadly broken health care system. Voters can only effectively advocate for themselves and their communities and compel their elected officials to legislate change if they understand the roots of these issues.”

Sujan Gogu is a family physician.

He shares his story and discusses the KevinMD article, “How to tackle the physician shortage.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at kevinmd.com/rate. Subscribe at kevinmd.com/follow. Today on the show, we have Sujan Gogu. He is a family and sports medicine physician. He co-wrote the KevinMD article “How to tackle the physician shortage.” Sujan, welcome to the show.

Sujan Gogu: Thank you for having me.

Kevin Pho: We’ll get to the article in a little bit. First off, briefly share your story and journey to where you are today.

Sujan Gogu: I come from a household where my father was a non-traditional medical student. What I mean by that is he was 37, 38 when he went to medical school, and I was in the first grade when he started med school. I got to see his journey going through medical school, going through residency, working in a rural community, and then starting his own private practice in a major metropolitan area such as San Antonio. I’d seen that journey, and it was a journey that really appealed to me at the time. At the time, I really enjoyed science as well, and so I thought medicine was a good fit.

So I went to undergraduate school at the University of Texas at San Antonio, and I went to medical school at the Virginia College of Osteopathic Medicine. Being a DO, we have more of a holistic approach to patient care. We really put an emphasis on musculoskeletal medicine, so right then and there, I knew I had an interest in sports medicine, and a route to take for that is family medicine. I wanted to come back home, so I went to UT Health Science Center in San Antonio, which was a great training program. Then I went on and did a sports medicine fellowship at Texas A&M. Then I wanted to learn how to do more interventional spine procedures, because so many people have back pain, neck pain, and so forth, and I did a pain fellowship at the Texas Pain Institute.

Then I came down to a rural community such as the Rio Grande Valley. I didn’t know what to expect down here. My wife is doing a residency down here, so that’s what brought me down to the Rio Grande Valley. The Rio Grande Valley is one of the most underserved communities in all of America. There are just not enough people to provide care for patients. And then you combine that with the problems that we have with the social determinants of health that some of these patients have, whether it’s economic viability, whether it’s their community viability, whether it’s just not having access to clean water or roads, or not having insurance. It’s really hard to take care of patients here.

That was probably a little bit of my inspiration for writing this article, because here in the Rio Grande Valley, I literally practice a lot of disciplines. I do family medicine, I work in an ER, I do sports medicine, and I do interventional spine procedures, just because there’s such a need down here for physicians to really provide good, comprehensive, evidence-based care to patients.

Kevin Pho: So before getting into the article, and you mentioned this, I want this to be context before we talk about your article. Tell us a story that really paints a picture of how there is a lack of clinicians serving the Rio Grande Valley. Any stories that you could tell that really illustrate that point?

Sujan Gogu: Yeah, absolutely. There was a moment where I was doing a shift in an emergency room, and this was obviously during the height of the COVID pandemic, probably the third or fourth wave, so it wasn’t as bad, but we still had that wave. The patient had come in to me really fatigued and dehydrated, and he went and saw his primary care physician that week three times, and he still ended up in the ER. For this patient, the only thing that had been done was a COVID test. It was done three times. It was a rapid antigen done three times, and every single time it came back negative. But there were no other lab tests that were done. There was no other inquiry into: Does this patient really have COVID? Is there some other upper respiratory virus that’s going on here? Is there some type of metabolic abnormality that’s going on here? There was no further inquiry. There was just a COVID test, and “Let’s discharge them. It’s not COVID. It’s nothing else.”

And obviously, when I saw the patient, I looked at this patient and I was like, “Oh.” I asked basic questions like, “What’s your medical history? Do you have a family history of diabetes?” You know, that’s one thing in the Rio Grande Valley: You have to ask, because one in three people here have diabetes, and a lot of people here are not on medication. One, medication is so expensive, and people can’t afford it. And two, the health literacy here is just not what it is in other populations. And so a lot of times, I really ask, “What are your parents going through? What medical conditions do your parents have? How are they living right now? Did they die? What did they die from?” I have to ask those tough questions. And so he said, “My mom, my dad, they all have diabetes. I don’t have diabetes myself,” is what he said, which kind of shocked me. And so, basic testing: You do a glucose level on him, and the glucometer couldn’t even read it. So right then and there, I knew this patient was in diabetic ketoacidosis, and I had to treat him for that in the emergency room.

But I think what frustrated me about that case is a nurse practitioner saw this patient three times. There was no lack of supervision by an attending or a physician, and this is something that would not have been missed if there was a physician who was looking at it, because it was clear-cut, very easy to pick up on. Every basic primary care clinic can do a glucose level test very quickly. And that, to me, was really frustrating, because the patient, at the end of the day, he’s like, “Well, I was treated well. I have nothing, no problems. There’s nothing wrong.”

But I think when you look at the health system as a whole, you forget that this patient went to the primary care clinic three times. So there are three visits. There are insurance companies paying for three visits that didn’t really diagnose anything. You also take into account that the patient is wasting his time, because he had to waste three of his days and was not feeling well for one week. So there’s an economic strain on that family, but not only that, it puts an economic strain on his job, because they don’t have an employee. And then now he comes into an ER, and now he’s being treated for DKA, and that bill, at the end of the day, is going to be astronomical, and now that patient is going to be stuck with that bill. So I think that is what frustrates me with this health care system, especially with unsupervised midlevels. I think there is a lot that’s being missed, and I think we’re starting to have studies that really show some of this that’s coming out.

Kevin Pho: All right, so let’s talk about some of the approaches going forward. You wrote about that in the KevinMD article that you co-wrote, “How to tackle the physician shortage.” For those who didn’t get a chance to read your article, just walk my audience through it.

Sujan Gogu: The one big thing that we really have to understand is we are creating far more medical schools. Combine that with the fact that we have a lot of foreign medical schools as well, and we have people applying to a limited number of residency slots. I think the one big thing that we’re starting to notice in American medical schools is we’re seeing a lot more medical graduates go unmatched. That number’s increasing every year. In 2021, that was about 10, so that’s about 9,000 graduates. And so in 2021, Congress tried to rectify this issue by expanding the residency programs, but they only did 200 more slots for five years. So it’s a step in the right direction, but it’s nowhere near the 9,000 that we probably need. And to be quite frank with you, we could even go above and beyond 9,000, because we have so many foreign medical graduates who really seek a license or a training program here in the United States. And so I think that’s the one big step we really need to take: Start to expand these residency programs and get more programs so we can get people here.

I think the other thing that I mentioned in my article is that we really have to capitalize on the non-practicing workforce. If you look at America, you read these stories in The New York Times, or you read these stories in the Chicago Tribune, where you often see an international medical graduate who’s driving a taxi or working at a gas station, and he was a doctor in another country. And you can’t say that we can’t tap into that talent, because that talent would be very useful in rural America right now. It would have been very useful during the height of the pandemic if we could find a way to get them into this workforce to help their communities, or another community that they want to be part of.

And one thing that we really do have, that was hugely successful a long time ago, is waiver programs for foreign medical graduates to go practice in rural and underserved communities. There’s something called a Conrad 30 waiver, and right now there are only 30 such waivers in every state. In my community, I know the health system I work for, we utilize that waiver for one or two specialties that are very difficult to get here in the Rio Grande Valley. I’ll give you an example: Here in the Rio Grande Valley, it’s very tough to see a rheumatologist. We’ve been trying to recruit one for many years, and we’ve just not been successful. So one thing that’s really helpful is that we tap into using one of our waivers that we do have to get a physician to come to this community, and then my system will sponsor their visa so they can ultimately practice here. I think it’s hugely beneficial to communities such as mine, because that would give us access to a rheumatologist. But not only that, we’re just one community. There are so many other communities here in America that are like that.

I think the other thing, obviously, is licensure. Everyone has written about this. Everyone has talked about this. In Texas, for example, I’m only licensed in Texas, so I can’t really provide care in other states unless I get that license, and it’s so burdensome and expensive to try to get licensures and maintain them in so many other states. That makes it a challenge if you’re trying to do telemedicine. That makes it a challenge when there are other hospital systems that really need physicians, or other types of non-physicians, to really provide care. And so if we can ease that, I think that would be very beneficial.

One thing that I think we really also need to keep in mind, and I think you’ve probably noticed this as well, is that during the height of the pandemic, a lot of physician practices shut down, about 8 to 10 percent. The other thing that’s very noticeable that happened during this pandemic was that a lot of physicians who were thinking about retirement retired early. They’re like, “I don’t want to keep up with this. I’m getting burnt out.” And one of the things that’s really causing burnout is electronic medical records. EMR is very painful, and it’s just highly inefficient.

And I look at myself: When I go see a patient, I’m oftentimes more stressed out about documentation, about prior authorizations, about other forms that I have to fill out, rather than just spending time with my patient, getting to know them, talking to them, and so forth. And I think sometimes I feel like I’m a secretary more than a physician, just because of how much documentation I have to do. In my job doing sports medicine, oftentimes I have to get an X-ray, I have to look at the X-ray, I have to make an assessment on that, tell the patient, figure out what’s going on with the patient, and then decide: Do I need to cast them? Do I need to do an intervention? And so forth. And then I do that, and I have three or four other patients waiting, but in the meantime I have to document that. It’s an impossible task for physicians to really do without getting burnt out. EHRs have got to be optimized to prevent burnout in some shape or form. And so those are some of the things that I think are very important.

At the end of my article, I really try to go into the solution: What do we do about this? Physicians are really uniquely positioned, as we’ve seen in this pandemic. We’re a trusted messenger. We are physicians. We play a good role in hospital systems and in being administrators. But I think the way we really need to move forward to really get policy change, because we’re really not seeing it with their medical organizations, is we really need to get physicians in political office. You know, the only way change is possible in the health care system, and we’re seeing this with the overturning of Roe, whether it’s physician legislatures really enabling non-physician providers to provide care, whether it’s really Medicaid expansion, all of these problems that we do have in health care, they’re actually political problems. They’re not something that I feel like the AFP, the AMA, and other big medical organizations can really solve on their own. And one thing that I’m part of: I’m part of Doctors in Politics, which is a political action committee that’s really trying to support doctors to run for office so we can solve these problems, because they’re political at the end of the day.

Kevin Pho: So you mentioned a variety of issues that are preventing enough clinicians from practicing. What’s some of the lowest-hanging fruit that’s out there? Because with some of the solutions that you mentioned, getting doctors elected to political office, the effects of that aren’t going to be felt for years to come. Any low-hanging fruit that can address some of the problems that you mentioned, that could provide a more immediate response?

Sujan Gogu: Yeah, I think there are two things. I think they’re low-hanging fruit, but obviously, in this political environment, it’s difficult to pass anything. Obviously, I think expanding residency programs is one, because that would get more doctors in the community. But I also think another thing, which I think would really get good bipartisan support, is to really expand the Conrad 30 waiver program. There are 30 waivers available for each state. Let’s bump that up. Let’s get it to 50. Let’s get it to 75 or whatnot, because there are just some communities down here in Texas, especially in my community, where we cannot get certain specialists that we really need to provide care. And I think that would help patients a lot, because if you need highly specialized care, patients in the Valley where I live have to go to San Antonio. They have to go to Houston. Well, that’s like a four- or six-hour drive. And I think that is a very low-hanging fruit that could get bipartisan support.

Kevin Pho: Now, what are some of the obstacles that are preventing an initiative like that from moving forward?

Sujan Gogu: I think we need more people in political office who are knowledgeable in health care, who really understand these problems. I think that would be very beneficial. I don’t think we have nearly as many. I think in the last political cycle, we had 17 physicians when you combined the Congress and Senate. I don’t think that’s nearly enough. I think getting more people knowledgeable about health care would be beneficial. And a lot of these are just the gridlock that we have, unfortunately, in state legislatures and in the Congress and Senate. It’s hard to get anything passed in health care, and some of these do require spending money or moving around money in certain ways. But at the end of the day, the cost savings that you get are astronomical, and we should be looking at cost savings, and some of these are highly beneficial for that.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Sujan Gogu: We as physicians, one, I think we serve as leaders in our community, and I think being a leader means really being involved in the political cycle: getting involved in local races, educating people, being part of supervisory boards and advisory boards of your hospital system. I think leadership is where advocacy can be done, and so I think that’s very important. Two, I think, as physicians, if you have the avenue, run for school board, run for a state legislature seat. You can still keep your job as a state legislator in a lot of states and be practicing medicine. There are many physicians who are actually out there doing that.

Kevin Pho: Sujan, thank you so much for sharing your time and insight, and thanks again for being on the show.

Sujan Gogu: Yeah, thank you so much, Kevin. Really appreciate it.

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