Dr. Peter Tonui, a trauma surgeon at the Iowa Clinic, said he can tell when one of his colleagues is getting burned out.

“Sometimes they just look really tired,” he said.

And sometimes he notices the frustration with the “inefficiencies that exist in the health care system.” 

“Having to make phone calls to insurance companies or getting denials … and having to appeal … it can wear on you after a while.”

Tonui, who is also chairman of the board of the Iowa Medical Society, said he’s seen physicians move away from Des Moines to seek other jobs. 

“You could just get a sense that if their work environment had been a little slower, a little more efficient, they might have remained,” he said.

Iowa currently sits among the lowest in the nation for per capita physicians per resident, according to the Iowa Medical Society, which has recently developed strategies and recommendations to recruit and retain physicians in Iowa in collaboration with other advocates. As of 2023, Iowa had 233 active physicians per 100,000 people while the top states were the District of Columbia  with 923 and Massachusetts with 486, according to the U.S. Physician Workforce Data Dashboard.

“We are 44th in the nation for the number of physicians per capita,” said Dr. Alison Lynch, president of the Iowa Medical Society, and a psychiatrist and family physician based out of the University of Iowa in Iowa City. “So that’s pretty bad. Pretty low penetration of positions. And when we look at some specialties like obstetrician gynecologists, we’re 51st in the nation, so we have a very big shortage of obstetrician gynecologists, but it’s really impacting many of our specialties.”

The reasons for the physician shortage in Iowa are multifaceted,
advocates say, and range from a lack of training spots for new doctors in the state to a wave of retirements post-COVID and administrative burdens that contribute to burnout.

“I think one of the big reasons is that … most physicians tend to practice where they do their medical training, and we don’t have enough training spots across the state,” Lynch said. “We graduate medical students that have to leave Iowa, because we don’t have enough places for them to train in Iowa, so we are basically an exporter. We’re training physicians for other states.”

“That’s a big issue, and it is not currently getting any better,” she said.

The Iowa Medical Society recently released its final report for the second phase of Operation IOWA (Innovative Opportunities for Workforce Action). The report is designed to advance the  statewide effort started last year to find solutions for Iowa’s physician workforce shortage.

In an interview, Iowa Medical Society leaders said there are several bright spots that indicate progress on the issue.

• In 2023, Iowa passed tort reform, putting a cap on noneconomic damages in cases regarding medical malpractice.
• The Iowa Legislature passed Gov. Kim Reynolds’ physician workforce bill earlier this year, which includes using $150 million in federal funds to create 460 new residency slots over the next four years and increasing funding for the rural health care loan repayment fund supporting physicians practicing in underserved communities from $4.2 million to $8 million.  
• The Iowa Medical Society also authored a bill that passed that shortens the prior authorization process and requires insurers and utilization review organizations to provide a report containing the number of denials and refusals. 

What’s next? Getting federal approval to establish the new residency slots and continued efforts to eliminate bureaucratic and administrative burdens, Lynch said. 

Also, advocates want to recruit more Iowa students into the medical field, building a pipeline as early as elementary school, said Steve Churchill, CEO of the Iowa Medical Society. They also want to improve Medicare reimbursement rates; Iowa’s is low compared to the rest of the nation. The Kaiser Family Foundation Medicaid-to-Medicare Fee Index ranks Iowa as 31st in the nation for physician Medicaid fees relative to Medicare fees. (The Medicare-to-Medicaid fee index is a computed ratio of the Medicaid fee for each service in each state to the Medicare fee for the same services). Finally, advocates want to keep physicians working into the later stages of their careers. 

“Part of the reason we got into this problem was that in the 1980s, the government misdiagnosed how many physicians we needed, and they actually felt that we were producing too many medical students to practice medicine and decreased the number of residency slots, so that we’re kind of gotten a bad position right now,” Churchill said. “They just had a bad prediction in terms of what the needs would be. They didn’t estimate that people would live as long as they’re living, and they didn’t estimate the growth in terms of the population. That miscalculation from 50 years ago is something that we’re paying a price for today.”

Burnout’s ripple effects 

Dr. Bobby Mukkamala, president of the American Medical Association and a practicing ENT in Flint, Mich., said his wife is also a physician, and when they hang out with friends, other doctors, they say they don’t know how much longer they are going to do this.

“We’re in our 50s, and they’re talking about, ‘When I get to 60, I’m going to retire.’ We would call that retirement. But what I call that — when I look at my parents’ generation and those doctors that just worked until they couldn’t physically work anymore — [that] is what I call physician burnout. And that number is pretty darn revealing. It’s almost 50% of doctors in this country are reporting at least one symptom of burnout.”

That’s a little better than the middle of COVID, which was in the 60% range, he said, but it’s still twice the amount of any other white collar profession expressing that burden, he said. 

Nationally, the association predicts the shortage of physicians growing to 86,000 physicians in the next 10 years. 

“It looks like it’s going to get to 100,000 soon after that,” he said. “And it’s not a particular specialty. It’s across the board. So it’s not like, ‘Oh, we need to add more of this or more of that.’ It’s more of everything, from primary care to specialty care. And almost half of [the shortage], like 20,000 to 40,000, are predicted to be primary care physicians. I see that is a major problem.”

Mukkamala has felt the impact of the national trends. He’s a specialist, an otolaryngologist, but he sees many people whose primary care physicians have retired. 

“They said, ‘You know, I’ve had enough. I can’t do this anymore.’ They burn out,” he said. “And because of that shortage, it’s just more weight on the entire system when we can’t prevent disease and screen for it the way a primary care physician is the expert.”

He pointed to AMA statistics that show approximately 80 million people live in areas where they don’t have access to a primary care physician.

“It’s one thing if you live in a big city where it’s still challenging, from what I hear, but it’s a whole other category of problem when you’re in a rural or underserved area like Flint, Michigan,” he said. 

One issue affecting the number of physicians working in rural and underserved areas is the new $100,000 fee required of skilled foreign workers applying for an H-1B visa, Mukkamala said.

“We’re trying to get an exception for international medical graduates, so that we can continue to serve the underserved in those rural areas and other areas,” he said. 

The AMA is also pushing for federal legislation that would add to the number of graduate medical education residency slots.

“For the next seven years, let’s increase the number of residency positions by 2,000 per year. And that’s a huge chunk, and that’s a huge effort to change these numbers … the 14,000 new slots,” he said.

Burnout is a key factor to shortages in other states as well. 

Massachusetts has a lot of specialty care physicians but “we are really in a crisis as far as how little primary care we have,” said Dr. Olivia Liao, president of Massachusetts Medical Society and an ophthalmologist with practices in Lexington and Concord. 

“Massachusetts Medical Society did a survey not too long ago, and it showed that one out of two physicians plan to retire or leave within the next two to three years due to burnout,” she said. “Rates of burnout are incredibly high, maybe 25% of the Editorial/Promopopulation, a lot of it stemming from the burden of keeping electronic health records.”

Liao referred to “pajama time,” meaning physicians often keep working when they get home.

“You’re in your pajamas, and you finish your charts often until midnight. As they estimated in Massachusetts, we’re asking our primary care doctors to work the equivalent of 26.7 hours a day, and you do the math,” she said.

Texas, California invest in physician recruitment, retention

Texas is among the states with the highest retention of physicians from medical school, at 58.8%, according to data from the Association of American Medical Colleges, or AAMC; Iowa’s retention rate is 22.4%, the association reported.

The AAMC data includes medical schools granting both doctor of medicine and doctor of osteopathic medicine degrees. Iowa has two medical schools: University of Iowa Carver College of Medicine (doctor of medicine) and Des Moines University (doctor of osteopathic medicine).

Dr. Robert Emmick, an ER physician who currently lives in Austin, Texas, but practices in Alaska, said the major influence that led to positions coming into the state was back in 2002, when the state set limitations on malpractice.

Also among Texas’ successful efforts to bring physicians into the state is recruiting people who already live there. Emmick, who is active in the Texas Medical Association but spoke independently, pointed to JAMP, or Joint Admission Medical Program. 

JAMP “takes high school students from underserved areas, whether it be rural or urban and it assures them of a place in medical school, going through a route through college and pre-med, and it provides them with tutoring resources and such,” Emmick said. “Then they often go back to where they came from, because that is what they’re familiar with.”

He said the Texas legislature has invested state funds into medical education.

“When I was in med school, back in the late ’80s, early ’90s, there were seven medical schools in Texas,” he said. “There are now a combination of public and private medical schools – 17 total – and the number of people graduating from medical school has significantly increased.”

The legislature also has funded graduate medical education, or GME, programs to try to assure residency slots for every graduate, he said. 

“People don’t have to leave the state,” he said. “We’ve found that in Texas, if a person does their medical school and then their residency in Texas, both of them, and if they’re from Texas, then about 81% will stay in Texas.”

In California, the physician retention rate is 78.5%, compared to the national average of 58.6%, said Lupe Alonzo-Diaz, president and CEO of Physicians for a Healthy California, the philanthropic arm of the California Medical Association.

“[Physicians] are more likely to stay in California in comparison to the national average, and in comparison to other states,” Alonzo-Diaz said. “For us, that’s been a critical component of how we address the physician shortage, how we address the access to care issue, is by ensuring that we are, No.1, prioritizing the graduate medical education program in California; No. 2, ensuring that those GME programs are in underserved areas.” 

Alonzo-Diaz said several ballot initiatives have provided funding to address physician shortages in California. Among those are Proposition 56, which passed in 2016. It is a tax on tobacco that increased California Medi-Cal funding, its state version of Medicaid. The state also passed Proposition 35, which would require the state to spend money from a tax on health care plans on primary and specialty care and other health care services for Californians on Medi-Cal, according to Cal Matters, a nonprofit news organization. 

“Each of those initiatives increases health care funding, and each of those initiatives had specific funding for [Graduate Medical Education] again, because voters recognize … the importance of ensuring that we are training physicians and that those physicians stay and serve in California once they’ve completed their GME programs,” she said.

Editor’s note: The title of Dr. Bobby Mukkamala, president of the American Medical Association, has been updated to reflect he’s a practicing ENT.