The “Messy” Reality of the Doctor Shortage.

(Med School Insiders, 2022)

Wei Yee Chong is currently working at the University of Adelaide, AU; she graduated from University of Malaya, and previously lectured at various institutions of higher education in Malaysia for fifteen years before immigrating to Australia.

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The “Messy” Reality of the Doctor Shortage

1. Introduction: The Global GP Shortage

The doctor shortage is an undeniable universal problem faced by countries around the world. The research paper on the Attitudes of medical students to general practice: a multinational cross-sectional survey published by Family Practice, indicates that, “a shortage of general practitioners (GPs) is common to many European countries,” and “it is essential to understand the factors that encourage or discourage medical students from choosing to become a GP” (Alexander, 2020: p. 265). The study states that there is

an imminent wave of general practitioners (GPs) entering retirement, the increasing number of doctors wanting to work part time and a surplus of specialists, combined with decades of neglect in encouraging young graduates to adopt the profession, as well as lower salaries compared to specialists, have led to a GP recruitment crisis. (Alexander, et al., 2020: p. 266)

This article examines the more detail of the GP shortage worldwide, as this is not an isolated problem to specific country or continent but a pertinent global issue particularly after the onset of Covid-19 pandemic. The shortage of general practitioners has been treated as part of the more general ethical problem of the allocation of scarce medical resources, and there is a standard tool kit of ethical principles for dealing with this, usually by imposing ethical requirements upon individuals, such a medical student, or students seeking a career (Matsumoto & Aikyo, 2023). However, the reality involving the shortage of doctors proves to be somewhat more complex and “messy” (Carel, 2024), more than professional ethics philosophers have contemplated. The paper will set out some of these socio-psychological complexities.

2. The Doctor Shortage in America

Physician shortage has also occurred in the United States. According to the research paper, “Physician Workforce in the United States of America: Forecasting Nationwide Shortages,” “there will be physician workforce shortages throughout the country in 2030” (Zhang et al., 2020: p.1). This study further predicts

that the demand for physician services will significantly outpace the supply of physicians within the United States of America from 2017 to 2030, causing many states to face severe physician workforce shortages. (Zhang et al., 2020: p.4)

An example is the state of Delaware. The paper, “Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA,” examines

the reasons contributing to the physician shortage in the country’s medically underserved areas using the state of Delaware as a focus state. A literature review regarding the shortage of physicians with data compilation from Delaware Department of Public Health (DPH) and Delaware Health and Social services (DHSS) was performed. (Malayala et al., 2021: p.1)

The research further states that, “the trends in the state, about 20% of the country’s population resides in rural areas but only 9% of the physicians practice in rural areas. There has been a decline in US medical graduates that are opting to choose primary care over specialty training” (Malayala et al., 2021: p.6). Lastly, the study concludes that,

[t]he state of Delaware has a significant physician shortage due to multiple factors (rural state, lack of medical school and a national wide decline of enthusiasm towards primary care specialties). The existing programs have their own set of challenges to recruit and retain physicians and not being fully utilized. (Malayala et al., 2021: p.8)

3. The Case of Australia

In Australia, the general practitioners’ shortage problem will remain a critical issue in this coming decade without effective intervention strategies from the Commonwealth government (Laurence et al., 2017). The Australian Medical Association projected that there would be “a staggering shortage of 10,600 GPs by 2031” (Australian Medical Association, 2022). According to AMA President, Professor Robson,

[i]t used to be that a half of all freshly graduated doctors aspired to become a general practitioner. But the way things are looking now, probably about one in seven, which is going to leave us with a tremendous shortfall. And we all understand just how difficult it is to get an appointment to see a GP as it is now. (Australian Medical Association, 2022).

Professor Robson pointed out that the issue of the shortage of general practitioners for Australia is a problem requiring long-term solutions, and an important part of this is to deal with the special difficulties rural and remote areas of Australia face, having been hit the hardest by general practitioner shortage” (Australian Medical Association, 2022).

The Australia University Accord recommended to “significantly increase the number of Commonwealth supported places dedicated and allocated to universities delivering regionally based end-to-end medical schools, to attract and retain medical graduates in regional areas” (Australian Government, 2024: p.37). The Australian University Accord stated that the more general problem of a skills shortage in Australia requires

expanding access to tertiary education to currently under-represented groups—including people from low SES backgrounds, First Nations, people with disability and regional, rural and remote students—can the nation meet its projected skills needs? (Australian Government, 2024: p.11)

Applied to the issue of the shortage of general practitioners, this implies that any fully adequate solution to this problem will require an expansion of such under-represented groups as general practitioners, and strategies to encourage them to service rural and remote regions of Australia (Woodland et al., 2024). Thus, the issues of a general shortage of general practitioners, and the more specific problem of increasing the representation of under-represented people from low SES backgrounds, First Nations, people with disability, are interrelated, and will need be analysed in any future research (Woodland et al., 2024).

4. Socioeconomic Factors in Healthcare and Medical Education

The discussion of the issue of general practitioners’ shortage comes hand in hand with the current scenario of the accessibility of healthcare and medical education that is influenced by socioeconomics and location. According to Shephard et al.,

in many parts of the world, rural communities experience poorer access to health care, compared to people living in urban areas. Limited access to health care has been reported for the 28% of Europeans and 18% of British who live in rural areas (Department for Environment, Food and Rural Affairs, 2021; Dymitrow & Stenseke, 2016). Similarly, in Australia, over 70% of the population live on the continent’s coastal rim and this pattern of urban settlement contributes to difficulties in access to health care for rural communities (Australian Institute of Health & Welfare, 2022; Kwan et al., 2017). Throughout the Global North, there is a shared sense of urban–rural disparity in recruiting and retaining healthcare professionals, heightened by the out-migration of young people from rural areas (Farmer et al., 2003; Nelson et al., 2021; Woods & Heley, 2017). (Shephard et al., 2024: p.2)

Even just a glance at the facts shows that equal opportunity for medical education is indirectly influenced by social inequalities such as capital, social class and location. Not all aspiring students have the same opportunity to pursue medical education, particularly the under-represented. The Australian University Accord highlighted these disadvantage groups as people from low SES backgrounds, First Nations, people with disability, regional, rural, and remote students (Australian Government, 2024). Shepherd et al., in the article, “I’m not ‘Fake Rural’: Rural Student Negotiation of Identity and Place in Medical School,” “addresses the accessibility of medical education for rural students, focusing on the intersection of rurality and socioeconomic privilege” (Shepherd et al., 2024: p.1). According to Shepherd et al.,

medical programmes globally have been criticised for reflecting and reproducing social inequalities (Nicholson & Cleland, 2016; Razack et al., 2015). First Nations peoples, and people of low socioeconomic, regional and/or rural background are disadvantaged in accessing medical education and are persistently underrepresented and underserved (Bassett et al., 2019; Burm et al., 2022; Cleland & Fahey Palma, 2018; Coyle et al., 2021; Garvey et al., 2009; Southgate et al., 2015, 2017). These social inequalities vary across countries and are context-specific, reflecting historical legacies such as colonialism and structural issues such as social class, social immobility or geographical disadvantage. (Shepherd et al., 2024: p.4)

The old colloquial expression “cash is king” speaks volume when comes to attaining seemingly a more commercialised education in this era, particularly medical education. Medical school entrance is not just for the brainy but more for the rich and privileged in this increasingly materialised world. The concept of capital brought by Bourdieu indeed holds some validity. According to Shepard et al.,

Bourdieu’s concepts of capital are often applied to advance understanding of how systems of privilege persist, despite government initiatives aiming to counter them and overt support of meritocratic ideologies … . Economic and intersecting social and cultural capital advantages are foregrounded through Bourdieu’s concepts of capital and habitus, lowlighting privilege based on geographical, colonial and patriarchal systems. (Shepherd et al., 2024: p.5)

5. Morality in Medical Education

Based on this current scenario, does the Hippocratic Oath still resonate with every young medical graduate and aspiring doctor to be, or is the choice of this profession largely based on the monetary gain and prestige that come along? Is the title of “specialist doctor” more glamourous to the intern doctor than the perceived more common title of general practitioner? I believe that apart from thinking of coming out with better incentive for medical graduates to pursue the training for general practitioner, a change of mindset is essential. Medical education needs to cultivate medical freshmen with the mindset “to serve” beginning their first semester. The medical entrance exam needs to have a component for community service.

S.J. Reiser’s essay, “The Concept of Service in Medicine’” indicates that

[r]unning historically parallel to the obligation to serve individuals and health-preserving institutions has been a duty to serve the body of knowledge that bounds health care, called in Hippocratic writings the art. As the Hippocratic treatise Epidemics declares: “The physician is the servant of the art.’’ Such service embodied a commitment to secure the basic soundness of the art, and to prevent inappropriate extensions of its reach. (Reiser, 2012: p.151)

Reiser further points out that

the concept of service has four essential elements: to secure the health of people and the institutions that sustain it; to provide health care equally and nonjudgmentally and to treat people as ends, never as means; to assure the integrity of medical knowledge; and to do this all with benevolent intent. (Reiser, 2012: p.151)

In 2006, the Australian Medical Association

has adopted the World Medical Association’s (WMA) Declaration of Geneva as a contemporary companion to the 2,500-year-old Hippocratic Oath for doctors to declare their commitment to their profession, their patients, and humanity. (Australian Medical Association, 2022)

Fagan et al.’s paper, “Call for amendment of Declaration of Geneva of the World Medical Association,” emphasized that

The Declaration of Geneva should be amended to recognise limitations of physicians to deliver care because of health system constraints and should speak not only of a physician’s duty towards the individual patient but also to broader society. It should provide ethical guidance to those practising in limited resource settings about triaging, protecting elective care, ensuring training of well-rounded physicians, ensuring financial wellness of patients and healthcare systems and ensuring accountability for health and wellness of patients and healthcare systems. (Fagan et al., 2024)

According to Weiner,

nearly all U.S. medical school graduations include a public promise, and some use an updated version of Hippocrates’ words, [but] not a single student utters the original Hippocratic Oath. (Weiner, 2018)

Finally, Singer (2023) states that

today’s medical students should reject being forced to take oaths that have nothing to do with patient care. Instead, a noble profession should require its students and graduates to swear an oath revering patients’ rights and autonomy. (Singer, 2023)

6. Conclusion

It is imperative to conduct an extensive study on the key policy area of using medical education reform to enlarge the number of health practitioners in particularly in targeted areas such as remote places, and from underrepresented groups. Swami and Scott state that the

key policy issue in many countries is the inequitable distribution of primary care physicians in rural and remote areas which has significant implications for access to health services in these underserved areas. Governments, including in Australia, have been implementing a range of policies and incentive schemes to attract and retain physicians in rural areas despite limited robust evidence on their effectiveness. (Swami & Scott, 2021)

Thus, as discussed in this paper, the problem of the shortage of doctors is a multi-dimensional social problem, and “messy” (Carel, 2024), with no simple solutions. It is complicated because to address the issue fully, especially with respect to the shortages of general practitioners in rural and remote areas, will require a fundamental change in values both in medical education and prospective students. And such changes have never happened over night. That seems to be a lesson lost upon moral philosophers who are generally ignorant of sociological complexities.

REFERENCES

(Alexander et al., 2020). Alexander, A., et al. “Attitudes of Medical Students to General Practice: A Multinational Cross-Sectional Survey.” Family Practice 38, 3: 265–271.

(Australian Medical Association, 2024a). Australian Medical Association. “AMA Report Projects ‘Staggering’ GP Shortage.” Available online at URL = <https://www.ama.com.au/ama-rounds/25-november-2022/articles/ama-report-projects-staggering-gp-shortage>.

(Australian Medical Association, 2024b). Australian Medical Association. “Professor Steve Robson on the Projected Shortfall of Over 10,600 GPs.” Available online at URL = <https://www.ama.com.au/media/professor-steve-robson-projected-shortfall-over-10600-gps >.

(Australian Medical Association, 2024c). Australian Medical Association. “AMA Report Confirms Staggering Undersupply of GPs in Next Two Decades.” Available online at URL = <https://www.ama.com.au/media/ama-report-confirms-staggering-undersupply-gps-next-two-decades>.

(Australian Government, 2024). Australian Government, Australian Universities Accord: Final Report. Canberra: Parliament House.

(Carel, 2024). Carel, H. “What a Mess: Can We tidy Up the Concept of Health?” Philosophical Psychology. June 11. Available online at URL = <https://doi.org/10.1080/09515089.2024.2369687>.

(Fagan et al., 2024). Fagan, J.J. et al. “Call for Amendment of Declaration of Geneva of the World Medical Association. eJournal of the Colleges of Medicine of South Africa 2, 1. Available online at URL = <https://journals.co.za/doi/full/10.4102/jcmsa.v2i1.12>.

(Laurence & Karnon, 2017). Laurence, C.O.M. & Karnon, J. “What Will Make a Difference? Assessing the Impact of Policy and Non-Policy Scenarios on Estimations of the Future GP Workforce.” Human Resources for Health 15, 43. Available online at URL = <https://link.springer.com/article/10.1186/s12960-017-0216-1>.

(Malayala et al., 2021). Malayala, S.R. et al. “Primary Care Shortage in Medically Underserved and Health Provider Shortage Areas: Lessons from Delaware, USA.” Journal of Primary Care and Community Health. December-January. Available online at URL = <https://journals.sagepub.com/doi/full/10.1177/2150132721994018>.

(Matsumoto & Aikyo, 2023). Matsumoto, M & Aikyo, T. “Ethical Issues Arising from the Government Allocation of Physicians to Rural Areas: A Case Study from Japan.” Journal of Medical Ethics. 50, 7. Available online at URL = < https://doi.org/10.1136/jme-2023-108971>.

(Med School Insiders, 2022). Jubbal, K. “America’s Doctor Shortage Explained.” Med School Insiders. 16 July. Available online at URL = <https://medschoolinsiders.com/pre-med/americas-doctor-shortage-explained/>.

(Reiser, 2012). Reiser, S. J. “The Concept of Service in Medicine.” Journal of Pain and Symptom Management 44, 1: 150-153.

(Shephard & Gray, 2024). Shephard, N. & Gray, P.W. “I’m Not a ‘Fake Rural’; Rural Student Negotiation of Identity and Place in Medical School.” Sociologia Ruralis. 11 February. Available online at URL = <https://doi.org/10.1111/soru.12473>.

(Singer, 2023). Singer, J.A. “We Need a New Hippocratic Oath That Puts Patient Autonomy First.” Cato Institute. Available online HERE.

(Swami & Scott, 2021). Swami, M. & Scott, A. “Impact of Rural Workforce Incentives on Access to GP Services in Underserved Areas: Evidence from a Natural Experiment.” Social Science & Medicine. 281: 114045. July. Available online at URL = <https://www.sciencedirect.com/science/article/pii/S0277953621003774>.

(Woodland et al., 2024). Woodland, R. et al. “The Experiences of a Regional Aboriginal Community Accessing Primary Health Care During Times of Crisis.” The Australian Journal of Rural Health 32, 1. Available online at URL = <https://onlinelibrary.wiley.com/doi/epdf/10.1111/ajr.13064>.

(Weiner, 2018). Weiner, S. “The Solemn Truth about Medical Oaths.” AAMC News. 10 July. Available online HERE.

(Zhang, et al., 2020). Zhang, X. et al. “Physician Workforce in the United States of America: Forecasting Nationwide Shortages.” Human Resources for Health 18, 8. Available online at URL = <https://link.springer.com/article/10.1186/s12960-020-0448-3>.

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