A Special Problem

What are Marin medical professionals doing about the short supply of new doctors?

AS THE AMERICAN population ages, our need for specialist care is growing faster than medical schools can turn out graduates. The Association of American Medical Colleges predicts a shortfall of up to 61,800 specialists by 2030.

This news is particularly ominous for Marin County, where 20 percent of residents are 65 or older, compared to a national average of 14.4 percent. By 2030, one in three Marin residents will be over 60, according to a county report. “Individuals, as they age, need more specialists,” Dr. Janis Orlowski, AAMC’s chief health care officer, says

Dr. Joel Sklar, chief medical officer at Marin General Hospital, identifies the specialists most needed by an aging population as oncologists, neurologists, orthopedists and cardiologists. Sklar, a cardiologist, expects his field to be able to keep up with demand here, along with cancer specialists and orthopedists. But neurologists are likely to be in short supply, he warns.

“Neurology is definitely an issue as we have more and more memory and movement problems with Alzheimer’s and Parkinson’s,” he says.

And as patients age, our doctors are aging too.

“It is hard to recruit young people in Marin, in part because of the differential between income and real estate prices. You can go to Omaha or South Carolina and be paid similarly, and the price of real estate is just vastly different,” Sklar says.

Specialists who treat older people aren’t the only ones likely to be scarce in coming years. The following specialties are also under pressure:


Certain areas of the surgical workforce are shrinking each year, even as demand rises, according to an AAMC workforce evaluation. The shortage of new surgeons could come just when they will be needed most, because more than a quarter of U.S. surgeons are older than 65, Orlowski says. One of the shrinking specialties is general surgery — the doctors who perform appendectomies and often operate on trauma victims in the emergency room.

Young doctors are more attracted to other specialties and subspecialties than to the shrinking but still important field of general surgery, both Orlowski and Sklar say.

As Sklar observes, “Robotic urology is cool. General surgery is hard.”

However, nationwide efforts to grow the general surgery pipeline have created a slight uptick, Orlowski says.


This is another specialty in high demand among aging populations, mostly due to Alzheimer’s. Yet psychiatry also has a unique supply problem, Sklar says.

“Per capita, there are a lot of psychiatrists in Marin, but in terms of psychiatrists available to see patients with insurance or Medicare coverage — not somebody who wants counseling or psychotherapy on a cash basis — it’s a limited panel,” he says.


For some communities, the shrinking pool of specialists may have catastrophic consequences.

“We have areas in the country where people go without care, and that has consequences to their life and their health,” Orlowski says.

In Marin, Sklar hopes to use the following measures to contain the problem to the inconvenience level, with patients waiting longer to see some specialists, but not having to look outside the area for care:


Because it takes a year or more to recruit a specialist, Marin General is continually evaluating staffing levels to figure out where future holes will pop up. While the economics of the medical system — and the Bay Area’s challenge of expensive real estate and the lure of lucrative biotech or other medical tech jobs — make recruiting more challenging here, it’s not impossible.

“We’re building a new hospital. Doctors will want to be here,” Sklar says. Marin General has gotten some help in addressing the psychiatrist shortage in particular. The Health Care District board committed in 2015 to spend at least $400,000 over several years beefing up the psychiatry staff, an effort Sklar says “has helped a lot” with the shortage in that specialty by enabling Marin General to hire staff psychiatrists, who accept both private and government insurance.

Giving Doctors More Help

Nationwide and in Marin, more nurse practitioners and physicians’ assistants are coming on board to help doctors maximize their productivity. These professionals, who typically hold a master’s degree or above, are qualified to diagnose illnesses, order tests, prescribe drugs and even perform minor surgical procedures. Because their training is less expensive than an M.D.’s, NPs and PAs typically save hospitals money — and significantly, their ranks are growing much faster than the ranks of doctors.

“It’s probably not necessary to have a board-certified cardiologist standing next to the treadmill” during a stress test, Sklar notes.


Marin General has been venturing into telemedicine both to extend access, as in the case of Western Marin residents who have no specialists nearby, and to save doctors’ time. One example is Marin General’s use of teleconferencing for stroke patients.

“If a neurologist is in San Anselmo in her office, seeing patients, and a potential stroke patient comes into the Marin General ER, that’s a 10- to 15-minute drive both ways,” Sklar says. Instead of the doctor dropping everything and driving in, Marin General can now send all test results to that doctor and set up a quick teleconference so that the doctor can visually determine whether the patient is having a stroke.

“The physician can make the decision from the office, the proper treatment can be done, and then when it’s more convenient, come in to see the patient,” Sklar says.

The looming nationwide shortage of specialists is being driven by economic forces far beyond the control of Marin’s health care authorities. But Orlowski says how local governments and hospitals plan for specialist staffing in the coming years will make all the difference in how local patients feel effects of the shortage.

“Just as you’re planning for jobs, where the roads are and housing, government needs to plan for health care in the community,” Orlowski says.

Categories: Feature Story, Health