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, California, 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 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 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 Ahdoot's day-to-day attests. The implications are in evidence well beyond his higher patient loads. Lately, 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.
The shortage of primary care doctors, including ob/gyns, is nationwide. Ahdoot is one of many faces behind the statistics. According to a 2021 update from the US Department of Health and Human Services (HHS), 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 healthcare is also expected to exceed the supply in coming years.
Some areas are harder hit. The Northeast is expected to have enough maternal healthcare providers to meet the current average level of care nationally; the West, Midwest, and South will not, according to HHS.
California will likely need an additional 4700 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, 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 healthcare 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, 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 8000 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 healthcare 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 healthcare professionals who will be part of reproductive healthcare 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, 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, 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," Alonzo-Diaz said, referring to the state's Medicaid program. Clinicians must have graduated within the past 5 years (since January 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 January 1, 2008).
In exchange for the loan repayment, the healthcare 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 Alonzo-Diaz, the average educational debt for healthcare 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 healthcare 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," Velayas said.
Efforts are also underway to expand the scope of practice for nurse-practitioners, certified nurse-midwives, and physician assistants. Triggering these efforts has been the fallout and expected consequences of the overturning last June of Roe v Wade , removing the federal right to abortion care.
Effective January 2023, trained and qualified nurse-practitioners and certified nurse-midwives in California can perform first-trimester abortions without a doctor's supervision. Toni Atkins (D-San Diego), now president pro tempore of the California State Senate, authored the bill, SB1375. The measure builds on a 2013 law she spearheaded that allowed certain advanced-practice providers to perform first-trimester abortions with physician supervision.
On February 13, Atkins introduced SB385, which gives physician assistants the same ability to become qualified in abortion care.
In a statement to Medscape, Atkins expressed confidence that teamwork would prevail in the efforts to have enough providers in the state. "One of the biggest lessons I learned working at a women's health clinic [prior to her assuming her legislative positions] is that providers put their patients above all else, whether they are doctors, registered nurses, nurse practitioners, certified nurse-midwives, or physician assistants," she said. "Everyone is on the same team when it comes to breaking down barriers and ensuring all Californians get the care they need without delay."
Will other states follow suit?
"This is pure speculation, but I believe states in which the political leadership supports abortion rights may see the California Reproductive Service Corps and the changes to scope-of-practice laws that allow specially trained CNMs, NPs, and PAs to provide abortions as a model for preserving access to abortion in their states," UCSF's Coffman said.
However, she said, "other states are less likely to view CalMedForce and CalHealthCares as models, because other states have had similar programs for many years, and some have historically invested larger shares of state budget resources into these programs, especially some rural states."
Reports From the Trenches
Laurie Love, DNP, RN, is a family nurse practitioner in Valencia and a clinical instructor and lecturer at the UCLA School of Nursing. When a patient becomes pregnant, she refers her to one of four local ob/gyns.
The working relationships she has with them, she said, "are extremely collaborative. There is no animosity or lack of respect because I don't have an MD behind my name."
One of those doctors is Ahdoot, who said he welcomes the expansion of scope of practice for non-MD healthcare providers. Some of his colleagues, he said, have tried to fight it, but many have come to the point of welcoming the help. "The consensus is, you can't practice without a nurse practitioner anymore," Ahdoot told Medscape.
Expanding the scope of practice for other clinicians helps everyone, including patients, he said. He thinks about how the shortage affects them. "For patients, there is frustration," he said. He said he often hears women saying they can't schedule a Pap smear for 3 months, or they can't get a return call from their doctor.
Nalo Hamilton, PhD, an ob/gyn nurse practitioner and associate professor at UCLA, said the physicians she interacts with support the expanded scope of practice. "Many are confused about details, about what it means and how it will impact them," she said. "Those who understand it, yes, they agree with it. Doctors will simply have more healthcare providers who are able to do independent practice." And she makes another point clear: "We won't replace ob/gyns."
None of the persons quoted in this story have disclosed any relevant financial relationships.
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Lead image: XXX
Image 1: Dr David Ahdoot
Image 2: UCSF
Image 3: California Medical Association
Image 4: Laurie Love
Image 5: @jmadkinphoto
Medscape Medical News © 2023
Cite this: Can California Solve Its Ob/Gyn Shortage? - Medscape - Feb 27, 2023.