Increasing rates of physician attrition across the United States

1. In this nationwide longitudinal analysis, attrition rates increased among physicians of all sexes and across all practice settings and specialties.

2. Female physicians and those in rural locations were among the most likely to leave clinical practice entirely.

Evidence Rating Level: 2 (Good)

Study Rundown: There is projected to be a shortage of over thirty-five thousand physicians in ten years, driven in part by physicians leaving clinical practice. A recent nationwide survey showed that more than a quarter of physicians across specialties indicated they would likely or definitely leave their practice over the next two years, but there is limited evidence surrounding actual attrition among practicing physicians. This study aimed to determine trends in clinical practice attrition over recent years as well as factors associated with changes in attrition. A sample of over seven hundred thousand physicians across a wide range of specialties and practice locations showed that the absolute attrition rate grew significantly over the study period. Attrition rates increased among both male and female physicians and in both rural and urban settings; unadjusted attrition rates also increased among all specialties. Attrition rates increased among all age groups except for physicians younger than 35 years. Factors associated with higher risk for attrition included female sex, rural practice, and practicing outside the Northeast. Practicing in psychiatry, primary care, or obstetrics and gynecology was also associated with higher attrition risk compared with hospital-based practice, while practicing in a surgical or medical specialty was associated with lower attrition risk. Medicare beneficiary factors associated with increased attrition risk included higher average risk score, higher average age, and higher percentage of dual-eligible beneficiaries, whereas factors associated with reduced attrition risk were caring for more Medicare beneficiaries or for a higher percentage of Black or Hispanic beneficiaries. The generalizability of this study is limited by its reliance on Medicare fee-for-service claims data. Nevertheless, this study suggests that physician attrition rates are increasing across the board and highlights the need for effective workforce planning.

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Relevant Reading: The 2013 to 2019 Emergency Medicine Workforce: Clinician Entry and Attrition Across the US Geography

In-Depth [retrospective cohort]: This longitudinal study aimed to determine trends in physician attrition between 2013 and 2019, as well as factors associated with those trends. Physician and Medicare beneficiary data were obtained from the Medicare Physician & Other Practitioners and Medicare Data on Provider Practice and Specialty databases. Physicians were included if they had been reimbursed for at least 50 evaluation and management services according to Medicare Part B claims in any year during the study period. Clinical practice attrition was defined as a physician not meeting the billed services threshold for at least 3 consecutive years. A total of 712,395 physicians were included in the sample. A plurality of physicians practiced hospital-based specialties (28.2%), followed by primary care (27.8%), medical specialties (19.9%), surgical specialties (16.5%), obstetrics and gynecology (4.0%), and psychiatry (3.7%). Most physicians (70.8%) were male, and 90.8% practiced in urban settings. A plurality of physicians practiced in the South (34.8%), followed by the Midwest (22.6%), Northeast (22.4%), and West (19.5%), while 0.7% practiced in Puerto Rico and other territories. Unadjusted rates of attrition increased from 3.5% in 2013 to 4.9% in 2019, corresponding to a rate difference (RD) of 1.4 percentage points (95% CI, 1.3 to 1.4 percentage points). Attrition rates increased among both male (3.5% in 2013 to 4.8% in 2019) and female physicians (3.6% in 2013 to 5.1% in 2019) and in both urban (3.4% to 4.7%) and rural settings (4.3% to 6.2%). Unadjusted attrition rates also increased in all specialties: from 3.0% in 2013 to 4.2% in 2019 in hospital-based specialties, from 6.1% to 10.7% in obstetrics and gynecology, and from 7.4% to 10.1% in psychiatry. Attrition rates increased across all geographic locations, for instance from 3.3% in 2013 to 4.8% in 2019 in the Northeast and from 4.1% to 5.5% in the West. Factors associated with increased attrition risk included female versus male sex (HR, 1.44 [95% CI, 1.43 to 1.46]), practicing in a rural versus an urban setting (HR, 1.19 [95% CI, 1.17 to 1.21]), and practicing outside the Northeast (HRs ranging from 1.11 for the Midwest to 2.03 for Puerto Rico and other territories). There was greater risk for attrition in psychiatry (HR, 1.53 [95% CI, 1.50 to 1.57]), primary care (HR, 1.09 [95% CI, 1.07 to 1.10]), and obstetrics and gynecology (HR, 1.62 [CI, 1.58 to 1.65]) as compared with hospital-based specialties. Conversely, there was a lower attrition risk associated with practicing in a surgical (HR, 0.83 [95% CI, 0.81 to 0.84]) or medical specialty (HR, 0.68 [95% CI, 0.67 to 0.69]) versus a hospital-based specialty. Overall, this study suggests that physician attrition is increasing nationwide, with notable differences across a range of geographic, specialty-related, and patient-level factors.

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