OP-ED

The Answer To the Doctor Shortage Isn’t More Doctors

flying cadeuciiThe answer to the doctor shortage isn’t more doctors

Yesterday, the New York Time’s Editorial Board published a piece on the shortage of physicians in the United States and what’s needed for healthcare workforce redesign.

It’s a good, concise piece about the common thinking around the gap between the needs of our growing patient population and the number of doctors available to deliver the care they need. As as an example, the article refers to a recent statement by the Association of American Medical Colleges whose models predict a shortage of 90,000 doctors in the U.S. by 2020. In Canada, the story is sometimes different where physician unemployment is growing due to inadequate infrastructure and poor workforce planning.

While I do agree that ensuring access to care is important, to think that the solution is simply more doctors comes from framing the question incorrectly.

The question shouldn’t be “how many doctors do we need for a growing population?”. Rather, the question should be “how do we care for a growing population in a cost-effective way?”

When you reframe the problem in this manner, it’s  easy to see that simply churning out more doctors isn’t the answer. In fact, with the direction healthcare is heading, those numbers are likely overestimates.

The major problem with workforce planning models is that they assume healthcare delivery of the future looks very much like healthcare delivery of the present. That the future will continue to be, in many ways, very doctor-centric.

It won’t.

First, we tend to underestimate the impact technology will have on healthcare delivery in the future. Over the past few years, we are already seeing that some processes of care can be shifted from in-person doctor-patient encounters to virtual care (telemedicine, doctor-patient messaging, etc.). We are seeing increased consumerization of healthcare (e.g. activity trackers, self-management apps, etc.) and as we enter the age of technology-powered convenience, patients are expecting healthcare to come to them.

We have barely scratched the surface when it comes to digital health, and I suspect the virtualization of healthcare will increase exponentially over the next 10 years. This will allow many more patients to be cared for by fewer physicians.

Second, there has been an ongoing shift of roles from physicians to other healthcare providers. For instance, much of care in the community can been shifted from primary care physicians to nurse practitioners and other providers with excellent outcomes. Unfortunately, fear of losing “job territory” is an impediment to progress, both in terms of adopting new technology and shifting processes of care to more cost-effective models. The medical culture on these issues must change.

As the culture in healthcare makes the shift from provider-centered care to true patient-centered care, the need for more physicians will fall with it.

Once we stop equating “more care” with “more doctors”, we are one step closer to building a more sustainable healthcare system.

 Liu is the CEO of SeamlessMD, working to transform surgical care with mobile technology. He was named a Forbes 30 Under 30 in Healthcare in 2014.

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DikeDrummondMDWayne CaswellSteve O'Victorialew Recent comment authors
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DikeDrummondMD
Member

A face-to-face physician visit is the most expensive and inconvenient way to deal with a non-life threatening symptom … for all involved – patient, patient’s family, physician and provider organization. The future of healthcare – if you choose to use your insurance – will be team based with layers of non-physician coaches and outreach caregivers interacting with you via different electronic channels. Phone, text, email, webcam, booth in a retail setting. That is not a bad thing and is certainly a way to expand access without needing more doctors. The questions remain, is this really what patients want and will… Read more »

Steve O'
Guest
Steve O'

The HMS Titanic sailed on her maiden voyage and set a steamship speed record approximating 45 kt (about 50 mph). Unfortunately, her speed record was set in the vertical direction – that is the peak speed as she pierced the briny under, and slammed into the bottom of the ocean. We go in cycles of impressing the hell out of ourselves with our technological prowess, and then smacking into Reality at an impressive speed. From the Tower of Babel until the Technomiracle of 21st Century Medicine, human culture often collides with Reality. Rarely does Reality suffer from the impact.

lew
Guest
lew

Steve O…. Here’s just another in a long list of articles from British newspapers telling the story of their own medical system. http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-crisis-extra-cash-is-not-reaching-critical-areas-effectively-9963719.html I’m not sure I want to try their system either. Nothing’s free in life no matter whether I’m told that by a Brit or American socialist or not. While there’s obviously a problem with drug companies pushing drugs and doctor’s pushing them, it isn’t exclusive to drug pushers or any other pusher. Litigation is a huge problem which is directly connected to the above issue. A doc will prescribe any and all because if sister suzzy dies,… Read more »

Steve O'
Guest
Steve O'

Here is what IS coming. It is not the same as what ought to be coming. In America we have pretty much written off any responsibility for the future, and let THEM tell us how it’s going. “Oto, the cellphone attachment that snaps an image of the inner ear sparing frazzled parents one more trip to the doctor’s office for yet another infection….” Model: 1) Visits to actual-MD physicians will be rare, and subject to gatekeeping, unless you are a cash-payer. 2) Mid-level inflation will rise to the point where EMT’s prescribe for some things. PA’s can practice independently, why… Read more »

lew
Guest
lew

I remember when technology was going to eradicate the need for paper. That was how long ago? Even ‘IF’ it eliminates paper, will it be more efficient if the computers at the store go down, which happens quite often. How many times have you made a call and heard this: I’m sorry, our system is reaaaaly slow today or.. I’m sorry, but our system is down today Our computers have been down for 3 days now. We can’t take your order. Will technology that is hacked today in ALL sectors including military (non-public) be what you want directing medicine? Why… Read more »

Edward Mohebi
Guest

We think one key is the ability to increase Doctor : Patient Ratios without affecting the quality of care. We have the tools to accomplish this now!

Steve O'
Guest
Steve O'

Oh, rubbish. “Lose weight now, ask me how.” The first wave in every revolution is the Vanguard of the Nitwits. Fire them up, give them a sledgehammer, let them do some “creative wrecking!” Lenin and Hitler were cunning students of revolution – they both let the eggheads and goo-goo boys wear themselves out, and wreck the infrastructure so that nothing worked and everybody was terrified. Then, the Second Wave. When the second wave comes, none of this nonsense about “Twitter EKG’s” and “Digital Ear Monitors” will be heard any more. The people of the Second Wave are not sympathetic, and… Read more »

Wayne Caswell, Modern Health Talk
Guest

Thanks, Bill, for your response and conversation. While my perspective is from 40+ years in technology and marketing with 30 at IBM, I appreciate yours in medicine and acknowledge my shortcomings there. One thing I’ve noticed in my career is that predictions of future technology applications are often too conservative, not too aggressive. (See False Predictions at http://cazitech.com/press_quotes.htm ) And I’ve seen some amazing progress when engineers are given a challenge and an incentive, including landing a man on the moon. Success or failure, however, can sometimes depend more on a set of non-technical market drivers and inhibitors, including politics… Read more »

William Hersh, MD
Guest

Wayne, as the Chair of a medical school department devoted to biomedical informatics, I am bullish on technology too. But I am also evidence-based. There have been plenty of instances over the years when technology has not lived up to what we hoped, and sometimes even made life worse. (Just read the other replies!) We need to apply technology in ways that benefit patients and clinicians, and approach it in a positive but skeptical manner.

Steve O'
Guest
Steve O'

“…one would think it should be easy to cut in half our $3 trillion/year spending while simultaneously improving care, but there are forces in the medical industrial complex that don’t want to lose money, and their total spending on lobbyist is more than twice that of the military industrial complex…”
C’mon. That’s either utterly wrong, or we are doomed. What makes the MIC a standard anyhow?

Wayne Caswell
Guest

I’m not wrong about the political spending of healthcare companies, so we may be close to being doomed, given the Supreme Court’s Citizens United decision and the fact that the Koch brothers plans to spend nearly $900 BILLION in the 2016 election.

But I try not to hide my head in the sand as a pessimist. Instead, I’m bullish on the future of healthcare, because I believe in those innovative entrepreneurs who have the “potential” of upsetting the whole “sick care” system. I invite you to follow my posts on http://www.mHealthTalk.com.

J. Kirschman MD
Guest
J. Kirschman MD

1. It’s 900 million that the Koch brothers have budgeted for the 2016 election. They can spend it how they see fit.
2. Money and politics have been dating for a long, long time. Citizen’s United just updated their relationship.
3. Yeah, it’s still a lot of money.

Steve O'
Guest
Steve O'

“A Lot Of People In This Industry Are Just Evil.” Swell. That’s just the kind of reformers that are running around in Iraq and Syria getting rid of all the evil people. Everyone with a Kalashnikov is an idealist.

“I believe in those innovative entrepreneurs who have the “potential” of upsetting the whole “sick care” system.” It’s just a new version of the Red Guards of the 60’s, but with snappier suits.

A jolly good purge of the counter-revolutionaries always shines a fresh beam of sunshine into every problem, yah.

William Hersh, MD
Guest

Wayne, The site won’t let me reply to your message directly, so I am starting a new reply here. Your “proof” of scientific efficacy of Watson all comes from news articles, and mostly consist of quoting a Dr. Samuel Nussbaum of Wellpoint. I am not able to find any articles in the peer-reviewed scientific literature by Dr. Nussbaum relating to Watson. Are you aware of any? The only peer-revewied study of Watson in medicine I have seen was discussed in my blog post [Ferrucci, D, Levas, A, et al. (2012). Watson: beyond Jeopardy! Artificial Intelligence. 199-200: 93-105.] and showed a… Read more »

Granpappy Yokum
Guest
Granpappy Yokum

“minimal care with maximum documentation”

Great post. Thank you.

Autry
Guest
Autry

I continue to hear that technology is going to revolutionize medicine. As an ER nurse, I can tell you, it’s changing the focus away from the patient to the EMR, the medication reconciliation program and ways to extrapolate more data in a ‘more efficient way’. It takes the physician longer to document the care provided than it does to provide it. They have gone from scribbling on their T-sheets or other documents, to scribbling on a blank page instead so they (or their scribe) can enter that same data once they’ve left the bedside. Or, they are having good discussions… Read more »

allan
Guest
allan

Excellent post. Physicians put a lot of time into treating the EMR and when they press enter it is recorded. So far I haven’t heard of any EMR deaths, but patient death and morbidity is another problem.

What happens when the physician spends more time treating the
EMR than the patient?

Joshua Liu
Guest

All good points here regarding limitations of the EMR experience. I certainly agree that the clinician and patient experience for any new technologies must be significantly better than their predecessors. I would encourage clinicians and patients to demand that better experience.

Granpappy Yokum
Guest
Granpappy Yokum

“I would encourage clinicians and patients to demand that better experience.”

How do we do that?

Joshua Liu
Guest

Companies that clinicians and healthcare organizations would work should be constantly improving the user experience. A lot of the incumbents don’t or do so too slowly, and that’s not okay. When possible, stop working with technology companies that don’t take user experience and feedback seriously, and start working with those who do. I know it’s not this simple of course, unfortunately.

lawyerdoctor
Guest

Excellent post, Nurse Autrey!! AS someone who also has spent years in the ER, I would agree with you 1000%. I also do not think that we will “need fewer doctors” in the future. Unless NPs are being trained to do cardiac caths and PTCA’s, and robots are going to do colonscopies and cataract surgeries, I think there will be a pretty decent need for doctors. I have discovered that I actually have a pretty rare skill = I know how to take care of actual sick people and occasionally save their lives. This skill was NOT acquired easily, it… Read more »

Perry
Guest
Perry

We should all become lawyer/doctors at this stage.

Perry
Guest
Perry

One other consideration is like many others in professions. How much of the doctor’s time is wasted doing non-patient essential functions? Yes we all need to complete charts, paperwork and the like, but how much of this nonsense is Meaningless Use? How much more could be gained from doctors spending quality time with explanations and teaching rather that just handing the patient info and turning back to a computer?

J. Kirschman MD
Guest
J. Kirschman MD

If we are going to redesign the healthcare workforce, we will need to first understand what we want to accomplish with “healthcare” and how we will address “sickcare” where the majority of the money is dedicated in the system. Currently, much of the payment system, including Medicare and Medicaid, is structured around the fact that the patient has to be seen by a doctor to receive payment–so to redesign the workforce, you will have to redesign the payment system to support it, then licensing and scope of practice, and then maybe you will see change. If “healthcare” means working to… Read more »

allan
Guest
allan

We make so many predictions that are wrong because the future has unexpected turns that change the dynamics. Technology could make the necessity of more physicians greater or lesser.

The real determiner of how many physicians we need will be who has predominant control over the healthcare sector. Government or patients? If the former, like its own bureaucracy, we will likely need many more practitioners no matter how they are named. If the latter then perhaps we will need less than predicted even without the highly trained ancillary personal.

Joshua Liu
Guest

Hi Allan,

That’s a wonderful point. Government regulation will have a significant impact on the potential for technology-enabled care delivery, as it is for other major fields currently undergoing technology/regulation challenges (e.g. transportation). With the FDA’s recent efforts on mobile medical app guidelines, including revisions post-Apple’s announcement of HealthKit, I’m momentarily optimistic.

allan
Guest
allan

Joshua, I’m not so optimistic where government is concerned. Look at the ACA and since you brought up transportation look up Amtrack. Then again look at Hemolung. Not yet approved by the FDA, but approved in Europe and Canada. The first use of that machine in the US just occurred without approval. Less expensive, less invasive for its specific use, proven success, simplicity yet no approval. I would think the FDA would want a tentative approval on such technology, but no for they haven’t had their field tests to prove its safety when it is the only alternative for specific… Read more »

Joshua Liu
Guest

Allan,

Certainly those are unfortunate cases where regulation hasn’t gone well. It’s been better in the U.S. than Canada when it comes to digital health, but again cautiously optimistic. Things can change quickly. Here’s to hoping it improves, because without it, technological progress and care delivery will be hampered.

allan
Guest
allan

Joshua, I hate to be so negative when a person is so pleasantly optimistic, but we have almost 50 years of Medicare and Medicare fixes by government to take the smile out of anyone’s face. None of the fixes worked and the technology at hand was misused and abused by our bureaucrats. In fact the bureaucracy prevented technology from developing organically and now they are trying to control some of that technology they previously prevented. I don’t enjoy saying these things because I wish I had confidence that government was the answer. My many decades tell me otherwise. Enjoy and… Read more »

Wayne Caswell, Modern Health Talk
Guest

The exponentially accelerating pace of tech innovation is having a profound effect on health care. (See http://www.mhealthtalk.com/2013/07/moores-law-and-the-future-of-healthcare/.) As a result of cheaper, smaller, and easier to use devices, many medical functions will move down-market for MD to PA, NP, RN, LVN, aide or tech, and to consumers themselves. Telehealth video consultations can then occur between the patient and remote experts across town, across state lines, and across international borders. Canada’s doctor surplus could be put to work providing remote support for U.S. Patients, for example. And if care is cheaper and better in the Philippines, then patients could choose that… Read more »

LeoHolmMD
Guest
LeoHolmMD

I think you are way overestimating the effects of technology. Health and tech are not strangers. Routinely, costs rise with both when partnering. Remember how Home Health was going to save money, reduce office visits and prevent hospitalizations? Now you must have a face to face encounter because the fraud got so out of control. Still waiting on all those promised outcomes. In your example, Siri is going to tell you to take her to the nearest Emergency Room where you will pay for that in addition to the SiriDoc app or whatever.

Wayne Caswell, Modern Health Talk
Guest

No. Siri will connect your with IBM’s Watson, which has a better diagnosis track record than any physician, even though it does not yet replace the MD but is used by her as a tool. That, I think, will change, but one of the keys to effective application of any technology is getting the incentives right, and right now the medical industrial complex has a lot to lose from health reform — at least half of the $3 trillion/year that we currently spend. That’s why they spend twice as much on lobbying as the military industrial complex. As an amateur… Read more »

William Hersh, MD
Guest

No, IBM Watson does not have a better diagnostic record than physicians. Please cite a source that shows otherwise. I have written about what Watson does and does not do: http://informaticsprofessor.blogspot.com/2013/06/what-is-thinking-informatician-to-think.html

Wayne Caswell, Modern Health Talk
Guest

My claim that Watson has a better diagnosis track record than “any physician” was a bit premature since it’s only used as a tool for docs today and is not yet intended to replace them. I too have written a lot on Watson (http://www.mhealthtalk.com/?s=watson&search=Search), but not to belittle the point, I’m citing some external references that back up my viewpoint. http://www.businessinsider.com/ibms-watson-may-soon-be-the-best-doctor-in-the-world-2014-4 “According to Samuel Nessbaum of Wellpoint, Watson’s diagnostic accuracy rate for lung cancer is 90%. In comparison, the average diagnostic accuracy rate for lung cancer for human physicians is only 50%.” (http://www.qmed.com/news/ibms-watson-could-diagnose-cancer-better-doctors ) “Its ability to absorb and analyse… Read more »

Al Lewis
Guest
Al Lewis

One elegant if partial fix would be to stop allowing companies to pay people to go to the doctor when they aren’t sick, or fine them if they don’t. Ultimately, the co-pay for preventive visits should be reinstated.

When a product is in shortage, the last thing you want to be doing is subsidzing it. This is particularly true when, like checkups, the particular product has no value.

Jeff Goldsmith
Guest
Jeff Goldsmith

We should be paying for visits at all, but for relationships. . .

Victoria
Guest

Are you saying we shouldn’t have preventive care?