Does the U.S. Have Too Many Doctors?

On the Buckeye Surgeon blog, a general surgeon from Cleveland, Ohio, questions what he calls “the almost dogmatic assumption that the United States is facing a physician shortage is the coming years…We're always reading that we need to train more doctors, that with the aging population there won't be enough physicians to satisfy demand. But then I was waiting for the elevator the other day, reading the names of all the doctors on the peg board who practice at one of my hospitals. The board is 4x4 feet and just crammed with names, names, names. It's unbelievable how many doctors there are.”

“There's two large GI groups,” Buckeye Surgeon continues. “There's three general surgery groups. There's three separate pulmonary groups. The ID group has 7 doctors. (Don't get me started on ID again). And on and on. What we have isn't a physician shortage, but rather a physician overabundance. And I don't think it's too different at most suburban hospitals across the country. The scenario isn't one of overworked doctors struggling to keep up with the demands of patients waiting in line for care. Rather, it's a hyper-competitive world of doctors in the same specialty fighting over a limited supply of patients.”  (Thanks to Kevin, M.D. for calling my attention to Buck Eye’s post.)

Buck Eye Surgeon is offering an anecdotal view of physician supply, but rational research backs up his claim. When the Council on Graduate Medical Education (COGME) warns that we need to train more physicians to meet the demands of aging baby boomers, the Council assumes that the current national physician-to-population ratio is optimal.  Those who call for more physicians “never examine the relationship between physician supply and the health of patients and population” notes Dartmouth’s Dr. David Goodman in a 2005 Health Affairs article, “The Physician Workforce Crisis: Where Is the Evidence?” (For more about Dr. Goodman, his background and his evidence, see "David Goodman, M.D.: Counting All Doctors" in Dartmouth Medicine )

Take a look at the evidence, and it’s clear that the conventional wisdom is wrong. As I’ve discussed in the past, in areas of the country that boast more specialists, patient outcomes are worse—even after adjusting for differences in age, race and the overall health of the population. (I have written about this for both Health Beat and Dartmouth) A greater supply of primary care physicians, on the other hand, leads to better outcomes. So, Goodman quite sensibly concludes: “If improving the health and well-being of the population remains our goal we need more generalists and fewer specialists, today and in the future.”

Meanwhile, Buck Eye Surgeon reports, today’s surplus of specialists means that too many specialists are chasing too few patients: “Hence, all the a**-kissing and overwrought phony letters specialists have to send to primary care docs for ‘the privilege of assisting in the care of this highly interesting and fascinating patient.’ If I were to suddenly disappear from the face of the earth like that Chris McCandless dude in ‘Into the Wild’, the other surgeons here would be more than willing to swoop in and score my referral base. Patients would not be affected (other than in quality, of course). I mean, maybe if you live somewhere in the middle of nowhere in Nebraska or Wyoming, you worry about physician availability, but not in major metropolitan areas at private hospitals if you have insurance.” [my emphasis]

Of course, if you’re poor, you’re in a different category, he observes: “At Cook County hospital in Chicago where I trained, people wait 6-8 months to get their hernias repaired or gallbladders removed. Old guys show up lugging around these fifty pound scrotal hernia. At [hospitals that draw a more upscale population such as] Northwestern or Rush, you wait a few days or weeks. If you're a VIP, you wait a few hours.

“Now, I'm not naive enough to be morally offended by this,” he continues. “That's the way the world works. Money talks. Nothing different than the way things have been for a thousand years of human interaction. But there are physician shortages. Right here in front of us. Right in the middle of cosmopolitan, wealthy, sophisticated Chicago. People go without access to health care. What is a physician's responsibility to help remedy this? We all go into six figures of debt to pay for med school. We defer gratification for material things until well into our thirties. And now we have to accept low paying jobs taking care of ungrateful patients in lousy isolated rural towns or inner city free clinics? I don't know. Maybe we should.”

Buck Eye is candid about the moral dilemma. And he is also realistic enough to understand that increasing medical school enrollments is not the answer: “You'll just end up with proportionally more cardiologists, more gastroenterologists, more cardiac surgeons to flood an already supersaturated metropolitan market. Until we compensate primary care/family practice in such a way as to make it financially appealing to medical students, there's still going to be physician shortages in South Dakota and Southern Ohio and Rural Kansas.”

Unfortunately, the nation’s medical schools are not quite so clear-sighted. A few weeks ago the American Medical Association’s amednews.com reported that “the largest medical school expansion since the 1970s is taking place,  fueled by growing alarm that not enough new physicians are graduating each year to keep up with the needs of a surging U.S. population.

"Nearly all of the nation's 149 medical schools have increased enrollment or are considering it. One health policy watcher estimates that the public will spend $3 billion to $5 billion annually to cover the expansion. That's on top of private donations in the hundreds of millions.”

“So far, medical schools seem to be expanding in areas experiencing some of the largest population booms,” Edward Salsberg, director of the Assn. of American Medical Colleges' Center for Workforce Studies, told amednews. “This would be the southern belt of the United States, including California, Florida and Texas.”

Doctors tend to settle close to where they trained. Unfortunately, southern California, Florida and the more affluent sections of Texas already enjoy an embarrassment of specialists—which is why treatment is so costly, and over-treatment so common in these areas. (One of the perverse features of the healthcare market is that when you have more competitors boosting  supply—i.e. more hospitals and more specialists vying for patients—prices go up, not down.)

Jonathan P. Weiner, a professor of health policy and management at the Johns Hopkins University, laments the waste: “Today taxpayers wind up spending $500,000 to $1 million to train each new doctor through programs such as Medicare and subsidies to state medical schools,” Weiner told The Chronicle of Higher Education earlier this year. "We're talking about spending many billions of dollars more per year without considering whether the population really needs as many doctors as it thinks it does.” Weiner would like to see the government target the spending “by making a greater investment in tuition forgiveness programs tied to public service for physicians.

“The distribution of resident training funds also should be reworked,” Dr. Weiner told amednews. “The government spends more to produce a surgeon than it does to train a family physician, because surgeons take longer to train and the government subsidizes each year of their salaries.” Weiner suggests that the government give programs a certain amount for each resident regardless of “whether they train for three years or seven,” noting that “this would create more equity between primary care and subspecialty residency programs.

“If you think we need more primary care physicians, and I do, then we need to fix this market imbalance,” Weiner concluded.

Comments

[Medical Schools Sacramento]

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[IFiOnLyHADaBRAIN]

I am Curious, what would the dementions be if you were to post the names of patients on a "peg board", on any given day? oh wait, add a second board to house the names of 47 million more patients whom soon will be forced to have health care, then mulitply that by the rediculous number that the population in this country alone has grown over the last 50 years, then multiply that by the percentage of the 47 million newly insured who would choose to have 1 or more children now that they have health insurance, then divide by the number of licensed medical doctors. Enough doctors?? Enough said!!!!!

[lancet]

Then why general practiioners have thousand of patients in their lists?

[Dr. Dan]

Well, now we know what many doctors are thinking about behind their smocks and smirks. I dont see any unemployed physicians or any driving taxis. Yes, there are complaints about the cost of school. Yet again that argument is deflated by admission that gov't. hospitals and six-figure incomes quickly dissipate that expense. We import doctors every year, doctors have six-figure incomes and graduates easily get many offers. DUH! Obviously, there is a doctor shortage!!! If there were a surplus of doctors you would see us actually exporting American doctors. This is actually a case of protectionism for a favored class at the expense of the general population. You are acting like you want to be the only coffee shop in your town. Well, I got news for ya, buddy. Not everybody likes Starbucks. People want choice because most physicians are egotistical and take their customers --YES, CUSTOMERS!-- for granted. I didnt enter medical school until I was 40. I wasnt selfish enough to get in earlier. I had to do so on my own after putting my wife through medical school and getting a divorce.
Doctor Shortage?!?! That would be like Buckeye Surgeon saying "Recession? What recession?! I'VE GOT PLENTY TO EAT. Who cares about anybody else. Let them eat cake!" I am tired of going to dinner parties where all the physicians do is complain about their reimbursements as they dine on $60 steaks, talk about their custom house build and then wait for their valet to pick out their new Lexus out of a parking lot full of luxury cars. Maybe it is time we weeded out those physicians who cannot balance quality with compassion.

[jaysi]

so, how many primary care physicians are there in the usa?
thanks.

[Maggie Mahar]

I just rediscovered this
thread when Ambulance
Doctor replied.

As I've written recently, I envision raising fees for family doctors while
lowering fees for some of the most expensive, agressive services --particularly in grey areas where we don't have medical evidence they are effective, and in areas where high fees may be creating perverse incentives to do "too many."

I like Tim's ideas regarding loan-forgiveness, agree with Rick that in some areas our system is, indeed, "bloated" and finally, Ambulance Doctor,
yes, it would be nice to lose the doctors who think of themselves as "businessmen" rather than as professionals.

[Ambulance Doctor]

May be the USA has too many doctors, but we still suffer from the lack of professionals.
http://air-lifeline.com/services.html

[Dr. Rick Lippin]

I am a doctor toward the end of my career but I believe we need a massive downsizing of our bloated paternalistic-medicalize everything- disease care system.

This will be very painful because it means fewer medical schools, fewer doctors fewer hospitals etc.

We have taken a miracle enterprise to extreme excess.

We don't need more Docs.We need more safe and healthy jobs,a safe and healthy environment, a safe and healthy food supply and basic, proven to be efficacious,health care for all American citizens

Dr. Rick Lippin
http://medicalcrises.blogspot.com

[Gregory D. Pawelski]

I would guess everyone knows (which I doubt it) that primary care docs are pinched for time and money these days. There is a proposal to steer patients to the best primary care doctors and to pay them to spend more time with their patients, this NYT reports.

The idea is to shore up primary care as a means to boost health care quality. The plan calls for rewarding doctors to communicate with patients outside the office and to spend more time dealing with patients' chronic health conditions, and decreasing visits to emergency rooms and hospitals. Who can argue with that?

My PCP tells me it's a good idea, however, the final comment says it all....how can one expect payment to go up, time spend with patients to go up, quality of care to go up, and by the way keep it budget neutral? He thinks those doctors who do a better job will continue to do so at the same low pay and will ultimately retire. They will be replaced by doctors and corporations that watch their bottomline more than their patients health. In the end, everyone will get exactly what they pay for.

By the way, he says, don't forget to to have everyone get their flu shot at their local gas station (afterall why do we need to go to a doctor to get healthcare when we can get it at Wawa).

A Model for Health Care That Pays for Quality

http://www.nytimes.com/2007/11/07/business/07care.html?8br

[Tim]

I'm not completely sold on the idea of providing a large amount of grants and stipends for med students in the *general* case, but if we are going to do it, we should be smart about it and target the incentives to the medical specialties (or becoming a PCP which is a "non-specialty") and areas where more doctors are needed.

For example, if a student needs help getting through med school financially, I see no reason why the "strings" attached to the assistance would require a certain number of years in an under-served location, and perhaps as a PCP or other specialty which is in short supply in that region. Perhaps this could take the form of a loan which is at least partially forgivable over time -- complete the time and field requirements, and at least part of the loan is wiped clean.

If a physician fails to meet the requirement after they begin practicing, at least some of the assistance they received would become due.

I can see good reasons for helping those lower- to middle-class prospective med students who have the aptitude and desire to become doctors, and perhaps if the more wealthy students don't want to be "forced" to be a small-town PCP for a few years, they can pay their own way and leave the assistance for the more needy...and appreciative.