PHYSICIANS/POLICY: Physician Shortage Looms–hold onto your wallet

Quoting a bunch of head hunters and a rural doc who can’t find anyone willing to move to Ukiah, the Los Angeles Times says this:

A looming doctor shortage threatens to create a national healthcare crisis by further limiting access to physicians, jeopardizing quality and accelerating cost increases.

And so apparently we must build more medical schools and train more doctors, even though the doubling of the number trained in the 1970s hasn’t fully worked its way through the system and won’t for another ten years.

Momentum for change is building. This month, the executive council of the Assn. of American Medical Colleges will consider calling for a 30% boost in enrollment, double the increase it called for last year.

Meanwhile the Dartmouth guys (who maintain their starring role in THCB) say something oh so slightly different:

AMC inputs were highly correlated with the number of physician FTEs per Medicare beneficiary in AMC regions. Given the apparent inefficiency of current physician practices, the supply pipeline is sufficient to meet future needs through 2020, with adoption of the workforce deployment patterns now seen among AMCs and regions dominated by large group practices.

The powers that be in health care are advocating more money to come directly from the taxpayer into the system to train more doctors, who will then cost the nation much more when they go into practice. Of course that’s a much easier answer for them than rational reorganization of the health care system by somehow or other making it all look more like Mayo.

So how do they start using language to persuade those of us suckers who are going to have to pony up for this that they’re right and the Dartmouth crew are wrong?

The AMA changed its position on the physician workforce a year ago, acknowledging that a shortage was indeed emerging. The consensus has shifted so quickly that experts who view the physician workforce as adequate — though poorly distributed, inefficient or wasteful — now are seen as contrarians.

So that’s it. Wennberg (and Goodman and Fischer and the rest of them) are now officially “contrarians”. Hmm…aren’t they the ones who make all the money on Wall Street?

CODA: The same edition of the LA Times has an article about the international outsourcing of radiology reading, which gives a clue as to how some of that “rational reorganization” might happen.

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  1. I need help completing my medical training due financial constraints my med school offers no financial assistance I am a 3rd year med students from a carribean med school Windsor Unv.School of medicine I HAVE EXCELLENT CREDIT SCORES my school unwilling to give school code/info.to get loan please if anyone can help contact me at aljrmccrea@yahoo.com or 3015291204 desperately need assistance will explain in detail my situation I am in dire straits sincerely Albert McCrea

  2. The marvelous thing about the economics American health care is that it is a system of infinitely expanding demand. More doctors won’t mean lower incomes; it will mean more health care gets delivered! Hoorah for the market!
    I’m kidding, of course.
    When you dig deep into the Dartmouth Atlas data and especially into Elliott Fisher’s 2003 paper published in the Annals of Internal Medicine, it’s clear that one of the central problems we face is not a doctor shortage, but a patchy oversupply of specialists. The quality of care goes down, and mortality rates go up (!) in systems with more specialist FTEs and fewer PCPs.
    See “The Implications of Regional Variations in Medicare SPending. Parts 1 and 2.” Annals of Internal Medicine 2003 vol 138 no 4 http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=32&morg_id=0&gsec_id=1706&item_id=1706&category_id=41
    We probably don’t need more physicians in total, but we do need to shift the balance toward the lowly, underpaid, and underappreciated PCP.
    I think there are two groups capable of bringing about this change. Medicare needs to rebalance reibursement rates. Proceduralists are paid too much, and PCPs are paid too little. Medicare/Congress could tell the AMA that Medicare will continue paying out the same total in physician reimbursement (about 30 percent of total expenditures, if I’m remembering correctly) but it will reconfigure who gets paid what. Private insurers follow Medicare’s lead, and this would trigger a shift in how many medical students are willing to go into primary care, where the hours are long and the current reimbursement is simply not attractice enough for somebody who spends years in training.
    (I”ve never quite understood why the managed care revolution led to dramatically lower reimbursement rates for PCPs, the very physicians who should have been rewarded for taking a lead in actually managing care — and who can’t possibly do so when they are forced to see 30 patients in the morning, and 30 in the afternoon in order to maintain their incomes. What on earth were insurers thinking?)
    Of course, any change in reimbursment that leads to lower incomes for specialists will trigger armed revolt. Well, maybe not armed, but specialists have successfully lobbied against real payment reforms in the past. When Medicare went to the RBRVU system — which is too complicated to go into right now — it initially offered PCPs a better deal, and specialists less compensation. That didn’t last long. When the dust settled, PCPs got a little more, but it wans’t enough to shift the balance of power away from specialists.
    Throwing more money at PCPs probably won’t be enough to increase their numbers substantially. Medical schools will have to also beef up their family practice departments, and create more internships for PCPs. (Some of the most respected medical schools in the country don’t even have a family practice department.)
    Probably the hardest part in all of this is going to be finding ways to shift patient expectations. America worships the specialist and all his gizmos and technology. We’ve got to get over this infatuation with technology and realize that high tech medicine isn’t where we are going to get the greatest returns in health.

  3. While it’s quite possible that I’ve said virtually anything about the AMA over time in this blog, I’ve never really subscribed to the “AMA restricts licensing to increase doctor incomes” school. Most data suggests that unless you control how doctors get paid, more doctors equals more care delivery equals higher health care costs and even higher “same store sales” doctor incomes. It’s manipulating how doctors get paid that has been teh AMA’s great success.
    The rationalization required would certainly change the ways doctors get paid…which is why I think the AMA is now saying, OK we’d rather you just made more doctors.
    Otherwise Jack Daniels is basically correct.

  4. FWIW, in terms of per capita doctor/patient ratio, the USA is in the top 3 in the world among OECD nations. Most industrialized nations have less doctors per capita than the US.
    Doctor shortage, my ass

  5. This is a strange conversation, because I swore Holt argued awhile back that the AMA was involved in a massive conspiracy to keep an artificial shortage of doctors to jack up wages.
    Lo and behold, he changes his theory and now he believes that the AMA is involved in a money grubbing conspiracy to divert money from public tax funds.
    FWIW, I dont see any evidence of an overall doc shortage. Some specialties perhaps but not docs as a whole. All the “physician shortage” studies fail to account for 5 things which render their findings null and void:
    1) They ignore the impact of DOs, osteopathic doctors. Quite frankly, most studies pretend that DOs dont exist.
    2) DO schools have increased greatly over the last 20 years. MD programs are hot on the trail. My current list shows about 25 new medical schools either built the last 5 years, scheduled to open soon, or in the planning stages.
    3) They ignore the impact of NPs and PAs. These studies make the wrongful assumption that ONLY doctors provide healthcare in the USA.
    4) They ignore the impact of FMGs (foreign medical grads). FMGs make up about 30% of all doctors entering postgrad residency training programs. Most studies look at the number of US med school slots in a vaccuum and ignore the influx of FMGs every year. The USA takes in more FMGs than all other nations, COMBINED.
    5) They ignore the impact of market restructuring. For example, the nighthawk radiology systems mean you dont need as many rads docs in the USA as previously.

  6. Maybe our medical training system is too long, but there’s absolutely no evidence to indicate that it is subpar. If you are going to claim that its subpar, you’d better have some damn good evidence from other nations showing their doctors to be superior to ours. I see no evidence of this. I think US docs are roughly equivalent to european and asian counterparts.
    In most other nations, you go to med school straight out of high school. HOWEVER, med school in these nations is usually 6-7 years long, compared with 4 in the USA, meaning that you dont same that much time by switching to their scheme.
    Furthermore, residency training after med school is usually LONGER in other OECD nations comapred to the United States.
    So if we switched to a euro system, we wouldnt save that much time in training, its just loaded onto the back end.

  7. I agree that the first 2 years of the BS degree is exactly BS when compared to other countries.
    I took the O levels (7 As and 2 Bs for Matthew who has some idea as to how tough they are) when living in England in the mid 80s. Upon my return to the US, I could have skipped 11th and 12th grade in highschool and gone straight to college but opted to do 12th grade. Entering college at 15 years of age was a little too much for my parents. Even after skipping 11th grade I felt like I was repeating what I already knew from England all the way up to and through my sophmore year in college.
    Medical school can probably be compressed into 3 years with continuous study through the summers, but who wants to do that? Maybe some may, thus this option should be available.
    Postgraduate residency training is a different story. This is where we learn the art of medicine. In respect to surgical training, I don’t think it can be watered down anymore without putting out subpar surgeons. The 80 hour work week has already had a significant negative impact on residency training. From my observations resident skill levels have been siginificantly impacted. Even after a 6 year Urology residency I have partners in my practice that are 1-2 years out of trainng that still need handholding through some of the more difficult cases.
    In summary, for the surgical training world, the years needed are proper and any shortening would lead to further erosion of the skill set needed to practice surgery/medicine safely.

  8. I would be interested to hear what the experts think about how much time could be removed from the process of educating and training a doctor (post high school) if you had complete freedom to redesign the curriculum and the internship / residency / fellowship process, and what are the key changes and substitutions in the program that you would recommend?

  9. Agree with Theora. US medical education is outmoded. The requirement of a 4 year liberal arts degree before entering med school(for most students) is an absolute waste of time. Most other countries teach in high school what is taught in the first four semesters of a BS degeree in the USA. In essence, the first two years of the US college ed is remedial education. The consistent answer from the brightest students / high school high school seniors to “what do you want to study in the next 6 years?” is “I don’t know, I have not decided” . Students enter med school when they are in their mid 20s. They are very distracted, confused , spent out and deeply in debt to concentrate on studies. They do part time bartending and other odd jobs to make up cash for their expensive,unaffordable lifestyle. When they come out of med school they are close to 30 years in age and have family issues /severe financial problems.
    In other countries they pick the best and brightest students at 12th grade to enter medical schools, screening them with tough entrance exams somewhat similar to MCAT, their eduction ( even food) is subsidized and they are put through the grind in their teenage years. This model may not be applicable to the USA. In the USA , knowing what questions to ask and where to find answers are important. Memorizing long lists of medical terminology will not impart useful knowledge. It would be nice if potential bright students are identified in their 3rd/4th year of medical school and channeled into demanding specialties or to basic science research with rich funding. Society should invest in the future doctors and force them to work for the communities that sponsered them for 10 years. In the next 5-6 years, the bulk of work being done by Primary care physicians ( and even some specialists) will be done by physician extenders and more complex problems outsourced to specialist doctors elsewhere. A centralized reimbursement with centralized utilization and outcomes review ( eg: Sweden) will help to weed out useless protocols and procedures. Just abolishing routine “Wellness” visits can save a bundle and free up docs time to practice real medicine….The doctor of tomorrow has to attain a breadth of knowledge to practice sensible medicine, acquire technical skills to “fix” problems, develop analytical skills to recognize problems accurately and find correct answers, understand statistical analysis to apply published knowledge to real-life situations. It is hard to teach all these things that make a good doctor in med schools. Med schools can just lay the foundation to learning. What we need is a few good, highly motivated doctors, not more of the same.

  10. Theora–you;re far too sensible to be involved in this discussion. Go sit in the corner with the other contrarians and be ignored!

  11. It’s also bizarre that anyone would suggest we send another person through our archaic medical training system.
    It’s a system that’s been largely unchanged since 1920, and so much of it is a waste–from 4 years of undergraduate school followed by 4 years of medical school followed by a ridiculously long itnernship, a ridiculous amount of which is spent in a state of total physical exhaustion, doing “scut work.” Not to mention the ridiculous amount of energy that’s spent in a mid-twentieth century curriculum, teaching students to memorize well and rely on the knowledge in their head–um, there’s these things called computers and a thing called an internet that’s made every other human pursuit more efficient and effective?
    We’re trying to make up for our inefficient and poor medical system by throwing more doctors at it–who are themselves the product of an inefficient and poor training system. At some point, you’d hope outside observers would step back and say, “wait a minute, I think we really need to rethink how we deliver care in this nation…”

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