Last week I wrote about the nursing shortage, and I took the mainstream view that it really was a big problem, while suggesting that technology may help solve that problem; (in an update to that post, the Industry Veteran somewhat dissented!). Last year following the COGME recommendations my THCB article on physician supply suggested that we may not have the future shortage of doctors that current mainstream thinking suggests is coming around 2020.
Following an article by David Blumenthal in the NEJM, Mike Magee, the Pfizer-backed doc who does the weekly Health Politics web-column, had a pretty interesting recent summary of the whole topic of physician supply. Magee’s article included a very valuable discussion of the different contributions of different medical schools (MD, DO and Foreign) to the supply of residents, and the changes over time for funding of resident positions.
The three major sources of physician numbers in the U.S. remain deeply segregated from and in partial denial of one another. They include 126 MD-granting allopathic medical schools, 20 DO-granting osteopathic medical schools, and a wide array of non-U.S. medical schools. Together they create our supply of men and women graduates who fill hospital residency positions. The residents, in turn, provide our ongoing supply of licensed physicians. In 2001-2002, there were approximately 100,958 persons in approved residency training programs. Approximately 65 percent of our supply of licensed, practicing resident physicians in training were MD-educated, nine percent were DO-educated, and 26 percent were non-U.S. educated.
Magee basically rewrites the question underlying the debate into this format: Is more health care and more physicians better for the nations health or worse for its economy? In other words is health care spending a drain on limited resources or an acceptable use of resources in an era of discretionary spending on "luxury" services? While you could argue over which, there’s no real argument that the more physicians we have, the more we’ll spend on health care. Vic Fuchs proved that with his research on supplier induced demand for physician services more than 25 years ago. That’s why every other country limits the amount of physicians going into residency positions. But being as economic analysis never got anything done in this country we’re instead hearing rumblings about the "demand" that we’ll be facing from aging baby boomers, without thinking much about whether more physicians per se is the answer to that "demand" and ignoring the fact that we know from Fuch’s work that more physicians will indeed "create" more "demand". Magee starts to pose some of the right questions in his last paragraph:
What are the 21st century environmental factors that should shape this debate? First, physicians remain highly respected worldwide, and consumers expect physicians to be partners and team leaders. Second, globalization, the Internet, aging populations, population mobility, and disease migration demand that we see physician-supply planning in global terms rather than national terms. Third, new technologies allow the development of virtual medical education and virtual medical schools, which could affect the speed and efficiency of medical training worldwide. The U.S. should be actively involved in this environment. Fourth, the Internet and overnight delivery are making geographic borders obsolete. What are the new boundaries for licensing and credentialing? And finally, with borders evaporating, regulatory bodies that provide oversight for medicine and patient care need to better harmonize their approaches.
What he doesn’t say but what needs saying is, does this new world of technology make the use of physicians for much care obsolete and replaceable by clinicians with lesser training, and where does that show up in the projected numbers? Of course that eventually leads to nasty questions about whether the physician role needs to be so venerated, and of course, so highly rewarded. But we wouldn’t want to start that conversation when the AMA and its fellow travellers have been so prominent in spreading universal cost-effective health care throughout the US over the last 90 years.