• Surgeons 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 sur-
gery is hard.”
However, nationwide efforts to grow the general surgery
pipeline have created a slight uptick, Orlowski says.
• Psychiatrists 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.
WHAT MARIN IS DOING ABOUT IT
For some communities, the shrinking pool of specialists may
have catastrophic consequences.
“We have areas in the country where people go with-
out 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 hav-
ing to look outside the area for care:
• Recruiting 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 psychia-
trists, 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.
• Telemedicine 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. m