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 4×4 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.

16 thoughts on “Does the U.S. Have Too Many Doctors?

  1. 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.

  2. 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

  3. 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

  4. 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.

  5. 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.

  6. 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!!!!!

  7. I really am not seeing the so-called “physician surplus” purported here. There might be, as the article hints at, a surplus of specialists, but if there were a surplus of physicians, then you would not have patients sitting in a hospital all day simply “waiting on the word” until the physician wanders in 2000 or 2100 hours, as is the case in some of the mediuwm sized city (approx 50,000 in population) hospitals where I live in Indiana. When the physician gets there, especially if he is a specialist to whom the patient has been referred, he might not even know the patient from Moses and is reliant upon the chart and from the on-duty nurses to get an idea of the patient’s status and baseline. It’s generally the nurses who really know what is really going on with the patient, and sometimes I wonder if there is a GP physician somewhere who is putting the pieces of the puzzle together; the cardiologist can tell you that he has a supraventricular dysrhythmia and give him some antidysrhythmics, and the pulmonologist can see the infiltrates in his lung lobes and prescribe some diuretics, and the GI doc can treat his GERD, but unless someone is out there synthesizing all of these expert diagnoses into a concrete picture and a plan of care, you’re not liable to improve the patient’s overall condition without any other problems…this is what general practice physicians need to do, and is probably why we need more of them, to avoid fragmentation of care.

  8. J–
    J–
    We don’t have enough primary care physicians, but we have more than enough specialists in most parts of the country– more than enough dermatologists, cardiologists, radiologists, orthopedic surgeons.
    And too often they are doing procedures, tests and surgeries that patients don’t really need–exposing patients to unnecessary risks.
    The patient that you dexcribe sitting in a hospital, waiting for a doctor to come round, may well be not need to be in the hospital in the first place. Iver the past 10 years, more and more patients are undergoing surgery, yet the overall health of the population is not improving. All of these surgeries are also not reducing the number of deaths from most diseases.
    Under reform, Medicare is raising fees for primary care docs, and lowering reimbursements for specialists offering certain very lucraative services that we know tend to be overdone.
    Over time, under reform, we will be moving away from “fee for service”medicne (which eoncourages dotors to do more)abd moving toward payign docs more for treatments that provides greater benefits to patients, with better outocmes. (Often this is primary care.) We’ll be paying doctors more to listent to and talk to patients.
    In this way, we can lift quality and reduce spending.

  9. 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.

  10. being myself a doc I have seen on numerous occasions how fragmented US health care is. PCPs are poorly paid generalists while specialists are well paid technicians. Pts are often not viewed as one human being but as a system.

  11. I’m a single dad of 2 age 2 and 5. I recently came across this article and have been reading along. This is a greate site and contains fantastic contents. Your site contains a lot of valuable information as well.

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