Doctor shortage cripples timely health care access, and patients limp along
May 24—To New Hampshire residents with pressing medical needs, a statewide doctor shortage feels like a fever that won't abate.
Janice Braley'd had two strokes before she went to the hospital by ambulance in October for a transient ischemic attack or TIA, a brief blockage of blood flow that causes stroke-like symptoms.
Before the Greater Manchester resident was released from the emergency department, the doctor told her to see a neurologist. She took the first available opening.
"Why are you here? You needed to be here three months ago," the neurologist told her when she went in.
With a history of strokes, Braley said, "You would have thought they'd try to get me in right away."
Across New Hampshire, a dearth of trained, practicing physicians is straining health care. The side effects are chronic, expanding and universal, including delayed diagnostic exams and time-sensitive treatments, procedures and surgeries.
Medical practices are full, not taking new patients or putting everyone on a waitlist. Health care systems and outpatient practices are using more nurse practitioners and physician assistants than ever to diagnose and treat a wider variety of conditions, reserving the few doctors on staff for the most complex or serious ailments.
The crunch is occurring across specialties, including family medicine. First-time appointments with neurologists, rheumatologists, endocrinologists and psychiatrists — if you can find one that accepts insurance and is taking new patients — are booked months out. For some, the wait can be close to nine months.
Patients are using urgent or walk-in care when they have no primary doctor — and can't find one because practices are full. Health care systems are juggling staff and resources amid a stagnant or shrinking doctor pool and rising consumer demand.
"It is, in my opinion, a systemic problem and shortage," said Dr. Matthew Gibb, medical director of Concord Hospital, which has satellites in Laconia and Franklin and 55 outpatient practices in central New Hampshire. "Access is quality. Quality is the care you get. If we can't get you in, we can't give you any quality."
"There's a national crunch in terms of primary providers," said Dr. Berry Gendron, chief medical officer at Huggins Hospital in Wolfeboro, which covers Carroll County from Lake Winnipesaukee to Maine. Most of its physician openings are in internal and family medicine — the backbone of personal health. Rural hospitals are particularly strapped, Gendron said.
"We are looking at substantial shortages of doctors that will not meet our future health care needs," once health care access improves for all populations, said David Skorton, M.D., president of the Association of American Medical Colleges (AAMC), in a March report on the U.S. doctor workforce.
Medical school enrollment has increased nationwide, Skorton said, but there aren't enough residency programs to provide a steady and sufficient stream, especially outside urban areas.
New Hampshire will need 300 more primary care doctors by 2030 to meet demand by all ages of patients, according to a 2013 estimate by the Robert Graham Center, which tracks the primary care workforce.
A range of Band-Aids
To meet Carroll County's demand for specialty health care, Huggins uses visiting doctors for urology; cardiology; audiology; and ear, nose and throat, and sends patients to larger hospitals for neurology, endocrinology and rheumatology appointments.
Through its Telestroke program, Huggins treats stroke remotely, with a nurse and the patient at the hospital connected through a monitor to a physician elsewhere. Hospital patients who need psychiatric care receive it through a telemedicine provider in a Southern state that has tele-psychiatrists on call. It may prove to be a long-term strategy for Huggins Hospital: Carroll County has no practicing psychiatrists.
"Increasingly, we're leveraging telemedicine to provide patient care," Gendron said. "We have strategies to determine which patients can be seen by telemedicine and which cannot. It can be a real patient satisfier" because many people prefer not to leave home or work, and spend time and money driving."
Huggins is fully staffed with orthopedists and general surgeons, he said, but the primary care doctor shortage is a chronic condition. The hospital's 25 primary care providers are spread across seven different practices from Alton to Ossipee.
To attract and keep current and new physicians, Huggins is offering them a 32-hour workweek for patient appointments and a flexible eight hours to do paperwork, return patient phone calls or tend to personal and family demands. He said the hospital's "generous paid-time-off policy" has attracted applicants who seek a work-life balance with less burnout.
Shortage hits home
According to the Association of American Medical Colleges' most recent projections, 42% of the nation's clinical physician workforce will reach retirement age in the next 10 years. By 2036, the number of people 65 and older will grow by 34%, and the number of those 75 and up will more than double.
Without considering in-migration, death rates, rising health conditions or evolving diseases, the U.S. can expect a shortage of up to 86,000 doctors in the next 12 years, according to AAMC.
In New Hampshire, it's difficult to estimate the number needed now or in the future, especially as more nurse practitioners and physician assistants are filling front-line roles.
In rural areas such as the Lakes Region, where many doctors are at or near retirement age, the shortage is aggravated by a striking mismatch between the number of new doctors licensed and practicing locally and the number of local physicians retiring.
"I am acutely aware of the strain and toll" of the state's physician shortage, particularly in primary care, said Maria Boylan, D.O., a family medicine doctor and president of the New Hampshire Medical Society. She is site leader for Elliot Family Medicine in Bedford, where she cares for close to 2,000 patients.
The doctor shortage means more primary care providers manage complex conditions until appointments with specialists become available. Wait times for referrals to specialists continue to grow, Boylan said, which delays diagnosis and treatment for time-sensitive conditions that will be more advanced when those patients finally get seen.
"Specialists do their best in getting patients in quickly depending on acuity, but there's only so much we all can do in a day," she said.
At Speare Memorial Hospital in Plymouth, the solution has been to use more physician assistants and nurse practitioners, especially in pediatrics and primary care, while the hospital looks out a year to recruit doctors who will become available in 2025, CEO Michelle McEwen said. Vacancies are filled with "locum tenens" — traveling doctors who cost more to hire but who fill gaps temporarily.
Grow your own
Cheshire Medical Center, Concord Hospital and Portsmouth Hospital are hoping that on-site residency programs in family medicine will result in more primary care physicians staying to practice in New Hampshire.
Like other regional hospital and health care networks, Cheshire Medical Center's doctor crunch accelerated during COVID, putting pressure on an already tight supply of family doctors.
"It's a combination of increased aging and health needs and the aging physician workforce retiring. Cheshire is the second-oldest county in the second-oldest state," said Dr. Karl Dietrich, head of family medicine at the Monadnock Region's hospital in Keene. "We have older, sicker patients that need more care, and fewer folks to deliver it."
Cheshire Medical Center, which is part of Dartmouth Health, decided the solution was to prepare its own family medicine workforce. Research shows that a large percentage of residents remain where they train.
Dietrich said Cheshire's new family medicine residency will graduate six new family care doctors in 2026.
Cheshire's program adds to two other family medicine residencies (at Concord Hospital and Portsmouth Regional Hospital), which together produce up to 16 new family doctors each year.
At Cheshire, a caseload of 2,300 patients has been the norm for a family doctor and nurse practitioner team, or two nurse practitioners working together.
Whither the family doc?
Fewer U.S. medical school graduates are choosing family medicine now, for reasons that include lower compensation, the job's demanding nature and less prestige than other medical specialties.
But it remains a critical niche.
"As a family doctor, you really value the continuity that comes with having long-standing relationships and taking on the role of personal physician," Dietrich said.
Concord Regional Health Care employs roughly 525 providers. Two years ago it had 69 openings. Now there are about 40, mostly in primary care.
The central New Hampshire hospital system is developing a rheumatology practice that will open this summer with three or four rheumatologists, said Gibb, the medical director. Concord plans to add two to a team of seven practitioners in neurology. Access and appointment-making has been streamlined through online booking up to a year in advance, which allows patients to move up as openings arise.
Gibb believes the solution for heart patients is to hire more cardiologists and cardiology technicians statewide.
Dartmouth Health has the state's only cardiovascular training program. Most are in major metropolitan areas in other states.
Catholic Medical Center in Manchester "is experiencing staffing challenges among physicians," according to a statement emailed this past week. To boost recruitment in specialty and primary care, CMC has increased sign-on and retention bonuses and added nurse practitioners and physician assistants to support doctors and reduce their administrative duties.
