Three patients were waiting in a queue for their telemedicine visit. Four others were in exam rooms, waiting for their appointments. Another patient was on the phone, requesting a prescription renewal.
On a sunny Wednesday afternoon in February, David Ahdoot, MD, FACOG, an ob.gyn. in Burbank, Calif., about 10 miles north of downtown Los Angeles, knows he’ll be working late.
“Normally, we would be closed on Wednesday afternoon,” he said. That time would ordinarily be used to schedule surgeries, make dictation, and perform other tasks. But those were the old days, before the COVID-19 pandemic, before the ob.gyn. shortage got even worse, and before many of the other obstacles that make his practice more burdensome worsened.
Those Wednesday afternoon tasks must be done another time. “There are too many patients to see in the office,” said Dr. Ahdoot, who’s also an assistant clinical professor at UCLA. Because of the shortage of primary care physicians, he has taken on new patients, although he said he would like to focus on his existing ones.
Many of those existing patients have been coming to Dr. Ahdoot for years. “I love my job,” he said, and it shows.
His patient reviews online include the usual grumblings about waiting time and being rushed, but many, especially those from new parents, praise him as caring, compassionate, exceptional – the kind of doctor women trust to deliver their first baby and their next ones, then guide them through menopause and other issues.
The shortage of ob.gyns. in California, as elsewhere, is real, as Dr. Ahdoot’s day-to-day attests. The implications are in evidence well beyond his higher patient loads. Lately, Dr. Ahdoot said, the calls from headhunters seeking to fill positions for locum tenens have increased from twice a month to three times a day. Despite his love for his practice, he admits he thinks about stepping away. He is 56, 8 years short of the average retirement age for ob.gyns. nationally, according to a 2018 report.
Projected shortages
The shortage of primary care doctors, including ob.gyns., is nationwide. Dr. Ahdoot is one of many faces behind the statistics. According to a 2021 update from the U.S. Department of Health & Human Services, the number of ob.gyns. nationwide is expected to decrease 7% between 2018 and 2030, from 50,850 to 47,490. Meanwhile, demand is headed in the other direction – it is projected to rise 4%, from 50,850 to 52,660 ob.gyns. needed. The need for nurse-midwives, nurse-practitioners, and physician assistants who provide women’s health care is also expected to exceed the supply in coming years.
Some areas are harder hit. The Northeast is expected to have enough maternal health care providers to meet the current average level of care nationally but the West, Midwest, and South will not, according to HHS.
California will likely need an additional 4,700 primary care clinicians by 2025, according to projections by the HealthForce Center at the University of California, San Francisco.
Solutions in sight?
Efforts are increasing to make it easier or more appealing for ob.gyns. to practice, or remain in practice, in California. Some existing programs have received funding, while new initiatives to improve the situation are launching.
Some of these efforts and programs will be viewed as a model by some other states, said Janet Coffman, PhD, associate professor at UC San Francisco and a health policy expert who is familiar with new programs and established ones.
“I would say that California offers an example of a multifaceted approach to addressing the shortage of reproductive health providers in general and abortion providers in particular.”
The state has not sat idly in the face of dire predictions of shortfalls in the number of ob.gyns. Over the past decade, Dr. Coffman said, the legislature has “substantially” boosted funding for grants to support ob.gyn. residency programs through CalMedForce and the Song-Brown Healthcare Workforce Training Program. The result: an 18% increase in the number of residents entering the field over the past decade.
“These programs have also substantially increased funding for family medicine residency programs, which are important because family physicians are trained to provide preventive reproductive health services and manage low-risk deliveries,” she added. “Funding for midwifery, nurse midwifery, and nurse practitioner education has been more modest, which I find disappointing because they are qualified to provide many reproductive health services and are more likely to care for underserved populations.”
Other new programs and legislation are focused on expanding the scope of practice for nonphysician health care providers who care for women. Many of these measures are meant to ensure continued access to abortion services not just for California residents, who are guaranteed that right in the state constitution, but for the influx of women expected from states that limited or prohibited abortion after the overturn of Roe v. Wade.
Gavin Newsom, the state’s Democratic governor, has promoted California as a safe haven for women seeking abortions. In September, Gov. Newsom’s reelection campaign rented billboards in six states that have restrictive abortion laws with messages directing women to a website informing them “abortion is legal and protected in California.” The website includes a search function for women looking for providers – representing a further potential strain on the already stressed pool of clinicians. Each year, an estimated 8,000 to 16,100 more people are expected to travel to California for abortions, according to projections made in 2022 by the UCLA Center on Reproductive Health, Law, and Policy.
The questions are, will the efforts be enough to stall or reverse the shortage, and will the efforts to expand other health care providers’ scope of practice be met with cooperation or resistance by MDs?
Just launched: California reproductive health service corps
Brand new, as of January 2023, is the California Reproductive Health Service Corps, created by a bill Gov. Newsom signed into law last September. The program operates within the Department of Health Care Access and Information. Rajeena Victoria Bisla, a spokesperson for assemblywoman Cottie Petrie-Norris (D-Irvine), who authored the bill, said: “The Corps will be responsible for recruiting, training, and retaining a diverse workforce of health care professionals who will be part of reproductive health care teams assigned to work in underserved areas.”
The teams will include MDs as well as licensed midwives, nurses, physician’s assistants, doulas, and medical assistants. They will provide abortion care, contraception, perinatal care, gynecology services, and gender-affirming care, among other needs, Ms. Bisla said.
The California Medical Association’s philanthropic arm, Physicians for a Healthy California (PHC), has two programs that aim to grow and diversify the physician workforce and invest in the state’s underserved areas, according to Lupe Alonzo-Diaz, CEO and president of PHC.
CalMedForce gives annual grants to fund new residency positions at graduate medical education (GME) programs throughout the state. The goal, Ms. Alonzo-Diaz said, is to expand the physician training pool. Funds were generated by Proposition 56, which was passed in 2016. The legislation generates tax on tobacco products. To date, GME programs have received more than $112 million to retain and expand primary care GME programs.
A second program, CalHealthCares, also funded by Proposition 56, offers a loan repayment program of up to $300,000 for physicians who meet certain criteria. “We are incentivizing young physicians and dentists to practice in Medi-Cal communities,” Ms. Alonzo-Diaz said, referring to the state’s Medicaid program. Clinicians must have graduated within the past 5 years (since Jan. 1, 2018) or will be graduating from a residency or fellowship program no later than June 30, 2023. Dentists applying for the practice support grant must have graduated from dental school or residency program within the past 15 years (since Jan. 1, 2008).
In exchange for the loan repayment, the health care providers are asked to commit to 5 years of service in the underserved community. So far, about 800 providers are part of the program, she said. According to Ms. Alonzo-Diaz, the average educational debt for health care providers in California is $315,000 to $350,000. That is as much as $100,000 above the national average.
What else is needed? Shannan Velayas, a spokesperson for the California Medical Association, said the state should invest in the Medi-Cal system to improve “meaningful access” to health care services and to expand loan repayment and residency programs like CalHealthCares and CalMedForce.
“Workforce shortages are not a reason to sacrifice quality of care or compromise patient safety but do warrant additional investment to increase access to medical providers working within their scope of practice,” Ms. Velayas said.