How measuring physician shortages reveals hidden gaps

Physician shortage forecasts influence everything from residency expansion to rural workforce policy. But many of those forecasts begin with a deceptively simple question: How many physicians are practicing?

A physician with a full clinical schedule and a physician approaching retirement who sees patients only a few days each month may both appear as one physician in a workforce database. Yet their contributions to patient care differ dramatically. When workforce planning relies primarily on headcounts, declining clinical capacity can remain hidden until access problems become impossible to ignore.

Retirement isn’t always well defined. For many physicians, clinical work tapers before it stops. A population-based study in British Columbia found that many physicians reduced their clinical activity substantially in the years before retirement. Women and rural physicians tended to reduce activity earlier than conventional headcounts and surveys suggested. When a physician who is winding down counts the same as one maintaining a full clinical workload, that decline can remain largely invisible in workforce estimates.

This problem also appears across the United States. A JAMA study compared physician supply estimates from the American Medical Association (AMA) Masterfile with Census survey data and found that the Masterfile counted many more active physicians each year. This gap mostly came from older doctors who kept their licenses but no longer worked at full capacity. Over time, the two methods differed by tens of thousands of physicians.

A better approach measures physician supply using full-time equivalents that reflect actual clinical work, rather than relying on raw headcounts. Another study developed a method that adjusts physician numbers based on workforce data, resulting in a more accurate picture of clinically active doctors and highlighting where graduate medical education should expand. While this approach yields a lower number, it provides a truer sense of clinical capacity.

England offers a striking example. A recent study showed that while the total number of general practitioners (GPs) increased over the past decade, the number of fully qualified, full-time-equivalent GPs actually fell. Counting individuals suggests general practice is expanding, but measuring clinical work reveals a decline. Ultimately, patient access depends on the latter.

There is also evidence of an overall decline in physician work hours. One study found that over the past twenty years, average work hours for U.S. physicians dropped by about 8 percent, with both men and women starting to work less in their mid-fifties. Since the population grew faster than total physician hours, physician hours per person stayed about the same. Nurse practitioners and physician assistants filled much of this gap, as their hours per person increased substantially. As a result, physicians today contribute fewer clinical hours per physician than before. Skeptics will note that these rising NP and PA hours per capita are why overall clinician supply per person held roughly steady even as physician hours fell, but that offset assumes non-physician growth keeps pace with an accelerating wave of retirements and is distributed unevenly across rural areas and specialties, so treating physician and non-physician hours as interchangeable softens the shortfall rather than eliminating it and hides the very capacity gap that better measurement is meant to expose.

Gradual retirement is not always harmless. A study on physician part-time clinical work and patient outcomes found that patients treated by doctors who worked fewer clinical days had slightly higher 30-day mortality rates than those treated by doctors with more clinical activity. The finding raises the possibility that very low clinical volume may affect clinical proficiency, although it does not explain why the outcome difference occurred. The main point is not to force doctors to work forever, but to treat slowing down as a transition that needs thoughtful support instead of being left unmanaged.

Counting clinical work instead of licenses leads to three main consequences:

• First: Shortage projections would look worse, especially in specialties and rural areas that are already stretched thin, because many of the doctors counted are winding down. The British Columbia study showed that clinical activity can decline before formal retirement, and another study showed ways to adjust raw counts to reflect clinically active doctors better. Specialties and states can use these measures to plan for expanding graduate medical education. If planning is based on inflated numbers, shortages will arrive sooner than expected.
• Second: Systems should plan for gradual retirement by creating structured phased-retirement pathways. These could include predictable reductions in call and overnight shifts, as well as valuable roles like precepting, mentoring, quality review, and complex-case conferences. This approach helps capture experienced doctors’ clinical judgment before they leave. Without these pathways, each retirement becomes an unexpected vacancy and a loss of valuable expertise.
• Third: It is important to consider how doctors who work less can stay current in their field. The study on physician part-time clinical work and patient outcomes suggests that lower clinical activity may affect patient outcomes. If working less puts doctors at risk of falling behind, retirement pathways should include focused continuing education, simulation, and a deliberately narrowed scope of practice, instead of letting skills fade across the board.

Some of the best data on slowing down comes from Canada and is several years old. Also, labels like “retirement,” “active,” and “full-time” mean different things in different systems, specialties, and datasets. Still, research from British Columbia, the United States, and England shows a clear trend, even if the exact numbers are uncertain.

True physician shortages often begin well before formal retirement, as clinical activity declines gradually. Effective workforce planning must move beyond headcounts and capture real clinical capacity. Only by measuring the actual work being done can systems accurately anticipate shortages and ensure patients have the access they need.

Timothy Lesaca is a psychiatrist in private practice at New Directions Mental Health in Pittsburgh, Pennsylvania, with more than forty years of experience treating children, adolescents, and adults across outpatient, inpatient, and community mental health settings. He has published in peer-reviewed and professional venues including the Patient Experience Journal, Psychiatric Times, the Allegheny County Medical Society Bulletin, and other clinical journals, with work addressing topics such as open-access scheduling, Landau-Kleffner syndrome, physician suicide, and the dynamics of contemporary medical practice. His recent writing examines issues of identity, ethical complexity, and patient–clinician relationships in modern health care. Additional information about his clinical practice and professional work is available on his website, timothylesacamd.com. His professional profile also appears on his ResearchGate profile, where further publications and details may be found.