Why We Don’t Need More Doctors

In a society hooked on growth, “enough” just isn’t part of our vocabulary. Thus, the latest issue of The New England Journal of Medicine reports: “Despite the fact that there are now more physicians per capita in the United States than there have been for at least 50 years, the Council on Graduate Medical Education (COGME) recently predicted a 10% shortfall of physicians by 2020…The Association of American Medical Colleges has responded with calls for a 30% expansion of U.S. medical schools and a lifting of the current cap on Medicare funding for graduate medical education so that federal dollars can support the expansion of the workforce.”

Do we really need more doctors?  The boomers are aging and we’ve been told that this will lead to a huge spike in the need for health care. But as I explained just last month, the boomers will age, just as they were born, gradually, over decades.

Exhbit4

And while the boomers are, indeed, a demanding group, the fact is that many boomers have taken quite good care of themselves. It all began twenty-five or thirty years ago when they quite smoking and switched from red meat to fish; from scotch to white wine, from tanning to jogging. In the next decade or two, they just won’t need as much healthcare as their parents did at the same age.

Moreover, as the article’s authors, Dr David C. Goodman and Dr. Elliott S. Fisher, point out: “Physician supply varies dramatically by region of the country. COGME is concerned about a 10% shortfall at a time when the regional supply of physicians varies by more than 50%.” In other words, while more doctors may be needed in some states, in other places we have more than enough, thank you.

And here is the shocker: “the presence of more physicians doesn’t
translate into better care.” According to Fisher, who is the director
of Dartmouth’s highly-respected Center for Health Policy Research, and
Goodman, who is the Center’s associate director, “Medicare
beneficiaries’ satisfaction with their care and perceptions of access
are no better in high-supply regions than in low-supply regions. Nor do
more physicians generally mean better care for hospitalized patients
(See table below, click for larger version).  Meanwhile, physicians in
high-supply regions are more likely to report concerns about inadequate
continuity of care, inadequate communication among physicians, and
greater difficulty providing high-quality care.”  Too many cooks can
create great confusion.

Table1

The kicker: “Patient outcomes are not better in regions with a very large supply of physicians.”

Meanwhile, Fisher and Goodman observe, while an embarrassment of
physicians doesn’t mean higher quality care, “having more physicians
does, however, mean more spending on health care — a strong correlation
that should not be surprising. Physicians’ incomes are an important
component of medical spending, and physicians order most clinical
services.”  That last point is important, and reminds me of this
chestnut: “Can you name the most expensive piece of equipment in a
hospital?” The answer: “a doctor’s pen.”

This is not to say that doctors intentionally over-prescribe
medications, tests or procedures. It is just that when there are more
of them in a community they have more time to see their patients more
often, to consult on other doctors’ patients in the hospital—and to do
more to them. “That’s just what doctors do,” Fisher, one of the authors
of this article once told me: “We keep busy.”

Fisher and Goodman then tick off three reasons why we should not try to expand the physician workforce:

First “unfettered growth is likely to exacerbate regional inequities in
supply and spending.”  Research at the Center reveals that doctors do
not tend to go where the needs is greatest.  On the contrary, between
1979 and 1999, “while the physician supply per capita grew by 45% in
primary care, 118% among medical specialists, and 21% among surgical
specialists, yet four of every five new physicians settled in regions
where the supply was already high.”  They go to Boston, Florida,
Southern California. They do not flock to Nebraska.

Secondly, “unrestricted expansion of graduate medical education…would
probably further undermine primary care and reinforce trends toward a
fragmented, specialist-oriented health care system. Current
reimbursement systems strongly favor procedure-oriented specialties
[like surgery], and training programs would almost certainly respond to
these incentives, which would lead to a relative increase in
subspecialty care that inefficiently disperses patients’ care among
multiple specialists. The flexibility of the workforce will diminish as
more physicians learn narrower skill sets.

“In the absence of reform, expansion of specialist training risks
further marginalizing primary care in medical education and limits our
capacity for building patient-centered delivery systems.”  If we want
patients to have a “medical home” we need more primary care physicians
who might provide the chronic disease management they need—so that they
don’t ever need a surgeon.

Finally, expanding the workforce would eat up health care dollars that
could be spent on “preventive care, disease management, or broader
insurance coverage”—all of which “have known benefits…We estimate that
the additional costs of training the physicians who would expand the
workforce by 30% would be $5 billion to $10 billion per year, depending
on the proportion of subspecialists trained. Once these physicians are
in practice, the costs will be many times greater.” We could use that
money to do the things that we know would improve health.

But if we aren’t suffering from a shortage of physicians, then why do
so many patients have a hard time finding a doctor—especially when it
comes to primary care? About a year ago, a friend in Boston complained
that when he cut his hand, he couldn’t get an appointment with a doctor
to stitch it up. He didn’t want to spend hours in an ER, so he wound up
going to his sister, who put a disinfectant on it sewed it up at her
kitchen table. (It was a small cut.)

The authors agree that there is a “perception” of a shortage of
physicians in places like Massachusetts—which, in fact, “now has the
highest physician-to-population ratio of any state, in primary care as
well as overall.” And in fact, if you don’t already have a doctor, it
can be hard to get an appointment with a primary care physician in a
medical Mecca like Boston.

The authors explain why: “the current fee-for service system makes it
more ‘efficient’”—i.e. more lucrative and less time-consuming—“for
primary care physicians to see patients they already know” and to
provide more services to them (referring them to specialists, and
admitting them to the hospital).  In this way, they earn more, per
hour, than they would if they spent their time taking the histories of
new patients.

None of this means that most physicians let the bottom line determine
how they practice medicine. But many have seen their income flatten
while their costs continue to rise. It’s hardly surprising that this
would have an effect—even if only a subconscious effect—on their
practice.

Ultimately, the problem is not the doctors, Fisher and Goodman say, but
“a largely disorganized and fragmented delivery system characterized by
lack of coordination, incomplete patient information, poor
communication, uneven quality, and rising costs.”  Throwing more
doctors into the mix will not make things better.

Policy-makers need to confront these problems. According to Fisher and
Goodman, they face a clear choice: “respond to pressure to increase
funding for medical education — and risk making things worse — or
accept the evidence that the apparent shortage is but one symptom of
the underlying problems” in the laissez-faire chaos that we call a
healthcare system.

The authors end with some recommendations which include “finding the
best way to reallocate current medical education funding toward
programs (such as primary care residencies and geriatric and palliative
care fellowships) that could lead to improved care coordination and
chronic-disease management.”  This is an excellent suggestion. We do
need more family doctors, gerontologists and palliative care
specialists. But rather than adding to the total number of doctors we
educate, we should redistribute some of the dollars now spent training
doctors in highly-paid specialties where we already have abundant
supply, and use that money to produce the doctors we need.

I would add that programs to forgive medical school loans if
newly-minted primary care doctors, geriatric specialists and palliative
care docs agreed to practice in regions where physicians are needed (at
last for a few years after graduation), this could go a long way toward
redressing regional imbalances. Many would, no doubt, put down roots in
their new communities, and wind up staying.

Finally, Elliot and Goodman point out: “Physicians have a financial
stake in this debate. Pressure to constrain costs is increasing. Growth
of the physician workforce will make it harder to preserve individual
physicians’ incomes.” And, given the income disparities between doctors
who perform procedures on patients (cutting and radiating) and
“cognitive specialists” (who talk, listen and diagnose patients)
allowing further “disproportionate growth in the specialist workforce
will only exacerbate the pressure on incomes.”

29 thoughts on “Why We Don’t Need More Doctors

  1. As a matter of enlightened self-interest, I wish there were a doctor shortage. It would most definitely increase physicians’ political and economic clout to something significantly more than nonexistent. Maggie, once again you’ve rained on my parade.

  2. This was a good piece that served as a nice counterbalance to the “pro” expansion essay in the same issue. You will also notice in that same artice, the large number of new medical schools, both allopathic and ostepathic, that are coming online over the next 3 years. I know the Hoftsra school is embracing a more primary care oriented approach, but we have to wait and see. May not translate to more FP’s, peds, in the end. Either way, more docs on the way, and the size of the bucket to pay all these folks aint getting bigger. Conversely, if cap on trainees not lifted, less IMGs can fill positions, and overall numbers of docs will be stable–however, more competition for desirable residency slots. This means newly minted docs may have to settle with IM, peds, etc (I hear the minions crying already).
    On the Dartmouth Atlas front, I have read parts of the very long report, and as noted in other blogs, fascinating that lower costs DID NOT associate with regions with higher primary care penetration (what changed since last iteration?). Their conclusion: we have to examine systems of care, not just numbers of primary care practiioners in these high utilization regions. That was an unexpected finding, and one I am hoping to see some answers on. Needs more flushing out–very critical piece of the puzzle.
    Brad

  3. I found it interesting that the rate-limiting step really is the cap on residency slots, not the number of medical school graduates. As folks have said, unless that changes, all the new medical schools will cause is a drop in IMGs in residency positions. I suppose if the cap were lifted, but only adding primary care slots, that would drive medical students toward primary care.

  4. This article is absolutely right on. We do not need to train more MDs in the future and I do not anticipate that we will have a shortage of physicians; just the continued maldistribution of doctors congregating in major metropolitan areas. However, the idea of training more doctors at home is not such a bad one if it will stop us from robbing less developed countries of their trained medical resources who flock here for better wages. Foreign medical grads have been filling the holes in the MD pipeline for years. Years ago when specialties like anesthesiology were not as attractive to US grads, they were the ones who took these residencies. Now we find them filling out the untaken slots in primary care programs that have become less attractive to the current crop of US grads. This is an injustice to the countries where these doctors train, which are usually much more in need of doctors than we are.
    The bottom line is that you can open new medical schools, and if these grads supplant the number of foreign trained docs, then this is all well and good. If not, then we will have an excess of docs and persistent overutilization of medical resources. Since foreign medical grads arrive for training at the residency level, unless you increase residency slots, you will have the new bottleneck to creating fully trained docs become the residency training programs.

  5. As I understand the Canadian system, one important difference is that the number and types of residency programs are negotiated, on a national basis, among the specialty boards and the political planners. A basic goal is that half or more of the slots are in primary care; certainly FP, Peds, and EM. I’m not sure about GYN and general internal medicine.

  6. Thanks Maggie. Our high-tech-high cost treatment oriented health care system is bloated in many ways. I agree we DO NOT need more physicians to further medicalize our lives.
    I not only would not build new medical schools or expand existing ones.I would slowly close 1/3rd of existing medical schools or at least radically transform the curriculae to emphasize public health,occupational and environmental medicine,prevention and wellness, chronic disease management, and palliative care.
    Dr. Rick Lippin
    Southampton,Pa

  7. Less IMGs will also help solve the maldistribution since they as a percentage are more likely to work in urban areas. The purpose of the program was to train them so they brought our knowledge to other parts of the world not rob the world of their physicians.

  8. Even in primary care I question the reality of a doctor shortage. Sorry to disagree and I have no data. Just observations.
    Family docs drive demand as do the specialists. Kid got a cold? Oh, might be an EAR INFECTION! Bring ‘em in, I’ll prescribe. (Data do not support such treatment despite it’s prevalence).
    And groups of 2-3 family docs want more partners to ease call demands, despite the true community needs. Suddenly there is a group of 6 docs in a town of 2K.Treating more “disease”.
    And finally, it is a measure of “quality” to be in demand. I saw patients who liked me declare expectantly, “You must be busy!” They looked pained and disappointed when I said,”No, just steady.” For that was my aim. The goal of being “too busy” was never mine and I guarded against it. But I see it as a badge worn proudly by many.
    Honestly, I think an efficient, well-supported family doc could care for 4-5K patients. Of course, some you would see every three years, some weekly. My experience is that family docs just remember the patients they don’t manage well, who are a pain in the rear and call in a demanding or annoying way on Friday afternoon…And the solution is to get a new partner and shift this “difficult patient” to the new guy. Instead of learning to do their job better.
    But, Maggie, don’t we have too many cars, too many DVD players, too many toothbrushes? C’mon, this is America. We want no “solution”, just choices. CHoice=Freedom. If healthcare is a market, let the market solve it. And it will. We may not be any healthier but the supply will meet demand…Which is the goal of the market.

  9. Provider induced demand is at the heart of an unaaacountable system with third party paying the bills. The recent Consumer Directed Healthcare (CDHC) movement is the typical conservative, market oriented solution to this and every other problem. Unless and until we can devise a healthcare system that is so accountable to diagnostic and treatment standards that provider induced demand and widely varied regional treatments become a thing of the past, then CDHC may well be the only ill-conceived and unrealistic social approach to the run-amuck system we see today and in the recent past!

  10. Everyone –
    Thanks for your comments.
    Some replies to specific comments and questions:
    Brad, Keith, Chris, Jenga–
    As you point out, if we have more med school graduates and the cap on residency slots is not lifted that will mean fewer foreign docs in the U.S. Let me make a few points here:
    First, I agree with Keith when he writes that:
    “we find [foreign docs] filling out the untaken slots in primary care programs that have become less attractive to the current crop of US grads. This is an injustice to the countries where these doctors train, which are usually much more in need of doctors than we are.”
    Those countries do need those doctors, and while I think it is fine for us to add to their training by bringing them in as residents, I wish that the vast majority would go back to their home countires.
    But I would point out that, in some cases, conditions in their home countries are so terrible that they don’t feel they can do much good. The infrastructure isn’t there, they don’t have the supplies they would need and violence is pervasive.
    So they stay in the U.S. and, if they are primary care doctors, they take care of our poor. These doctors take the patients that many American-born doctors refuse to see: patients on Medicaid, uninsured patients who come to clinics, etc.
    Many (not all) American-born doctors shun the poor both because Medicaid pays so little and because poor people are often difficult patients. They tend to be –non-compliant (because they forget, are medically illterate and so can’t read the dosage on the bottom,, or are living such chaotic lives). Many suffer from more than one problem; often addiction is a problem, and very hard to treat.
    If we had fewer foreign-born doctors, would American-born doctors treat our poor–or would the poor just get less care? Would disgruntled American-born doctors who had hoped to wind up in a better-paid slot give Medicaid patients good,
    compassionate care?
    I think the real solution here is to recruit more poor African-American, Latino and poor white doctors to go to med school (not adding to
    total numbers but drawing a better mix of students.)
    As I have written on this blog in the past, right now an average of only two students applies for each place in our medical schools, in part because students know that they must have very very high grades and scores to get in, but also becuase med school is so expensive.
    The majority of students who apply come from upper-middle class or upper-class families. If you’re poor,the idea of taking on $250,000 or $300,00 in loans is unimaginable–and you don’t have a family to fall back on as a safety net if you run into major financial trouble.
    My proposal would be new-fashioned “affirmative action” based, not on race but on socioeconomic class–something that my colleague Richard Kahlenberg at the Century Foundation proposes here http://takingnote.tcf.org/2008/04/affirmative-act.html
    where he writes about :
    “giving preferences in college admissions to low-income students of all races.
    “Economic affirmative action can open doors to low-income and working-class students who are currently being shut out of selective colleges. Moreover, if properly structured to reflect economic disadvantage broadly (including such factors as parental income, education, wealth, and neighborhood), the policy can also produce substantial racial diversity. At the University of Los Angeles Law School, for example, African American and Latino students have been far more likely to be admitted through a program of socioeconomic affirmative action than regular programs.”
    If we were going to do this with med schools, I suspect we would need out-reach programs identifying talented poor kids as college freshmen (or even in high school) mentoring them while they go through pre-med courses so that they become highly qualified med school candidates. There is a program like that in the Bronx which I believe reaches out to the kids while still in high school.
    These students would need financial aid for med school, and I would propose (as I have in the past) loan-forgiveness programs for those willing to work in areas where they are most needed for say, 3 or 4 years.. This would also help address the cultural mis-match between patient and doctor in many places. And I expect that many new doctors would wind up staying in the neighborhoods where they are needed.
    On to other issues–
    Brad–
    Yes, I also saw that new puzzle in the Dartmouth findings. I suspect it is because so many primary care docs try to make up for lower fees by doing more volume–seeing more patients, referring them to more specialists who then hospitalize them, sending them for more tests . . .and so they are not practicing medicine the way they do in Minnesota (less agressive, less intensive, more talking and listening).
    But I need to re-read the report and talk to some people up at Dartmouth.
    HCBerkowitz– You’re right, in Canada specialty boards and political planners try to figure out how many of each specialty should be trained based on the actual health needs of the provinces.. .. an unusual way to run a healthcare system, no?
    Dr. Rick, You suggest
    radically transforming the curriculae [in med schools] to emphasize public health,occupational and environmental medicine,prevention and wellness, chronic disease management, and palliative care.”
    I agree. in particular, public health should be part of medical training, not regarded as a poor relative.
    Dxdx-Sounds like you run a very good practice. Wish you were in Manhattan!
    And I agree, the desire for “more” (without ever feeling that we have “plenty”) and to be “too busy” are chronic diseases in our society.
    NG–I couldn’t agree more about consumer-directed healthcare
    Finally
    doc 99– Sorry, but April showers and all that . .

  11. Can I ask your view on where physician attrition (secondary to burn out, etc) fits into the big picture?
    Myself, I worked a few years in primary care and then went back and specialized in hospice/palliative care. Now that I am coming to the end of my fellowship I am seriously thinking of leaving medicine entirely. I have been surprised by the number of docs that are in the same boat.

  12. “And while the boomers are, indeed, a demanding group, the fact is that many boomers have taken quite good care of themselves. It all began twenty-five or thirty years ago when they quite smoking and switched from red meat to fish; from scotch to white wine, from tanning to jogging. In the next decade or two, they just won’t need as much healthcare as their parents did at the same age.”
    I’m not sure where to start on this paragraph. It almost seems literary, an optimistic poem about idealized baby boomer health care.
    I would welcome a look at the average number of prescription medications, imaging studies, doctor visits, procedures, and lab tests for the average 60 year old today vs. that of the last generation. I would predict striking differences, all of which would make it clear how much more medicine the baby boomers are consuming relative to years past. It’s just the way medicine goes these days, more health care available for more diagnoses. And it keeps going.
    viagra for ED, stents for chest pain with any narrowings on angiogram, CT coronary angiograms for any symptoms north of the waistline, new knees/hips to play golf (or jogging, I guess), MRIs for any joint pain, and surgery for any tendons/ligaments that have abnormalities, antidepressants for any “tough times” (don’t get the previous generation started on that one) And don’t forget the more aggressive blood pressure and cholesterol goals compared to years past and more meds available to get people there.
    We certainly can talk about the questionable medical necessity of much of today’s fancy, expensive, pharma-heavy health care. But to claim that trends currently point to less care being given to boomers as they age doesn’t pass the sniff test.
    Maggie, if you have any evidence to the contrary, I’m game. But if you’re going to talk about decreasing boomer demand for services as a reason we don’t need more doctors, you have some more convincing to do.
    (and as an aside, even if you’re right that the scotch to wine, tanning to jogging boomer wisdom will lead to healthier/longer lives, this means a huge jump in financially crippling long term care as these uber-healthy boomers live into their demented 90′s in nursing homes)

  13. Maggie
    When you speak with Dartmouth, I would be interested in knowing if the new Atlas results identified regions that showed no correlation between primary care penetration and utilization, ie, supplier induced demand/subspecialty clustering.
    It seems earlier versions showed inverse association, current showed direct. While in the aggregate, there might be overall trends, if regions do have variations, I would be remiss then to accept the primary care “answer” as dogma. It is more than likely that other factors are at work. What really would be interesting to know are the existence of regions with organized systems (nebulous term), high subspecialty penetration, and average or lower total costs.
    Brad

  14. Hospice Doc and pcb–Thanks for your comments.
    Hospice Doc– I don’t have any good numbers on how many primary care docs are burning out and dropping out, though I can imagine it is happening–more docs retiring in their 50s, would be my guess.
    And if Medicare does decide to begin slashing doctors fees across the board then I think the exodus would be noticeable. . . But for that reason, I just don’t think that Congress will do it. .
    Pcb–You make a good point when you suggest that because some boomers have been over-medicated and over-treated, they may not be as healthy as I suggest.
    But you’re really not describing the boomers when you write:
    “I would welcome a look at the average number of prescription medications, imaging studies, doctor visits, procedures, and lab tests for the average 60 year old today vs. that of the last generation. I would predict striking differences, all of which would make it clear how much more medicine the baby boomers are consuming relative to years past. It’s just the way medicine goes these days, more health care available for more diagnoses. And it keeps going.
    viagra for ED, stents for chest pain with any narrowings on angiogram, CT coronary angiograms for any symptoms north of the waistline, new knees/hips to play golf (or jogging, I guess), MRIs for any joint pain, and surgery for any tendons . . .”
    The very oldest boomers are just hitting 60.
    The vast majority of boomers are in their 50s and 40s. (Born from roughly 1946 to 1966)
    I’m a boomer and I don’t know anyone who has had a knee transplant, a stent operation, or surgery for joint pain. I know a couple of people with sports injuries that started when they were pretty young.
    I haven’t surveyed male friends to ask if they need Viagra, but my impression is that this doesn’t become a problem for most men until they hit their sixties . . .
    At our age, our eyes are going and our hearing is going. . . that’s about it.
    (And of course some of us are doing a lot of cosmetic surgery. But I don’t think most of that is harmful to our health–it just makes us look like hell in an oddly uniform way. (The really good face lift is very rare. Even Botox is beginning to make more and more women in Manhattan look alike in a vacant way. )
    And many of us are just not as enthusiastic about medication and minor surgeries as people currently in their sixties.
    That’s another generation that came of age (turned 21) in the 1950s, and was much more respectful of, and trusting in authority.
    Many boomers are more skeptical. We did drugs in the 1960s and early 1970s and realize that ingesting foreign substances can be hazardous to your health.
    We don’t believe what we see in ads.
    We’re also not as likely to simply do what the doctor tells us to do without asking questions.
    Many of us tend to prefer acupuncture to pain-killers. It would take a lot to persuade us to have back surgery. We believe in organic foods and fresh vegetables rather than drugs advertised on TV.
    Now of course I’m only talking about a segment of boomers who are more likely to be college-educated and relatively affluent. AS I’ve written in the past, if you’re poor, your access to fresh fruits and vegetables, organic food, and places to exercise are very limited. In a ghetto grocery story, if there are fresh vegetables, they are going to be much more expensive than carbs.
    I don’t have any numbers on what percentage of boomers are leading healthier lifestyles than their parents (or even those pre-boomers now in their sixties) but I suspect it’s significant, if not a majority.
    I’m certain that upper-middle income and upper-income boomers are less obsese than our elders were at this age. The social importance of being thin didn’t really kick in until sometime in the early 1960s (think of the model Twiggy . . )
    Before that, if you look at old pictures, you’ll see that Doris Day was what we’d now call decidedly “plump.”

  15. PCB–
    P.S.–I forgot to add that, over the very long-term, I fear that Boomers will turn out to be very expensive because, as you suggest, our bodies will outlive our minds . . .
    This probably won’t begin happening until we’re in our mid to late 80s and 90s–
    26 to 46 years from now (depending on whether we are talking about older boomers or younger boomers.)
    My only hope is that, by then, palliative care will be more pervasive, and we will have found legal ways to allow people to die with dignity before their minds and personalities
    disappear entirely.

  16. PCB–
    P.S.–I forgot to add that, over the very long-term, I fear that Boomers will turn out to be very expensive because, as you suggest, our bodies will outlive our minds . . .
    This probably won’t begin happening until we’re in our mid to late 80s and 90s–
    26 to 46 years from now (depending on whether we are talking about older boomers or younger boomers.)
    My only hope is that, by then, palliative care will be more pervasive, and we will have found legal ways to allow people to die with dignity before their minds and personalities
    disappear entirely.

  17. maggie,
    OK, just wait until the majority of boomers get to their 60s then. :)
    but seriously, it’s nothing personal against the boomers. It’s just what happens with medical progress. If things keep going as they are, the generation after the boomers will be even worse. The new meds/technology/tests (and diagnoses) will inevitably come.
    I really think it would be interesting to look at the volume and intensity of services given to a group of 60 year olds 30 years ago compared to today. Then compared to 30 years from now. At some point, as you’ve pointed out, we have to realize that just because there is a drug or a diagnosis for some condition doesn’t mean it should be treated. (or more importantly, paid for) That means, frankly, we are going to have come to terms with the concept of rationing in a more mature way. (unless we want 50% of our GDP spent on our health care). sure, getting rid of waste and the rest of the low hanging fruit will help, but eventually we’re going to have to tackle the volume and intensity of services, and it’s not all a fee for service issue. it’s a “there’s too much healthcare available” issue.
    I heard a quote somewhere that said, basically: “We can’t afford to give all the healthcare available to everyone for every possible medical issue.” I think that’s true, but I’m not sure the public and policymakers (and patients) believe it, and if they did, I don’t know if they’re ready to discuss the implications.

  18. pcb–
    Basically, as you know, I agree with you.
    Particularly on the hard part –where you quote someone saying:
    “We can’t afford to give all the healthcare available to everyone for every possible medical issue.”
    You add: “I think that’s true, but I’m not sure the public and policymakers (and patients) believe it, and if they did, I don’t know if they’re ready to discuss the implications.”
    Two points here: First, there is So Much low-hanging fruit– treatments and products that have little or no benefit and serious risks that we really could save as much as one out of three health care dollars if we just used a scalpel to (very carefully) cut out the waste.
    It will take quite a bit of comparative effectiveness research to do that–and that will take time
    . Though if we started today, ignored the lobbyists, and just listened to physicians and researchers with no financial interest in the outcome, I think we could reach a consensus in many areas.
    Then, when you move past the low-hanging fruit, you come to the products and services that do have a benefit– but the question is, does the benefit outweigh, not just the risks, but the pain of treatment?
    Is the cancer drug that gives you another 5 months but has some pretty debilitating side effects worth it –to you, the patient??
    Today, patients are rarely given that choice.
    But they should be allowed to take all of the
    pluses and minuses into account.
    I think for many patients, their decision would be based on their age, whether they have young children, tolerance for pain, just how much pain they are already suffering, what quality of life they can hope to have during the extra months, religious beliefs, etc. etc.
    Giving patients a vote would in many, many cases, reduce questionable treatment.
    We already know that when it comes to elective surgery (knee replacement,
    for example) if you
    take patients through the
    whole shared-decision-making process telling(which I’ve written about on this blog–telling them how long recovery will take, what’s entailed in the surgery, risks of infection, etc.)
    a substantial number of patients will decide “you
    know what–it doesn’t hurt that much. I think I’ll wait.”
    Finally I think more and more patients of my generation will want to weigh in on their end-of-life care and what they want to happen if their bodies are outliving their minds.
    This is an area where we need legal protection, all the way round–for the patients, for doctors and hospitals. And we need more palliative care specialists to talk to the families, and explain to them that they shouldn’t be try to make the decisions. If the patient (often their parent) is saying, no, I’m tired. I don’t want that, grown children need to listen–and let go, no matter how painful it is for the grown child.)
    I do believe that patients who don’t want to live on, in great pain with aboslutely no hope, or in a vegetative state–(or worse–the awareness that some mid to late stage Alzheimer’s patients suffer ) should have every right to have their wishes
    respected.
    Clearly, this would have to be done very, very carefully.
    But we really do have quite a long time for medical ethicists and others to work on this problem before the Boomers begin to deteriorate in a truly distressing way.
    And I think many boomers would support legislation that protects them from the kind of agressive, very expensive end-of-life care they many of us won’t want.

  19. “I’m a boomer and I don’t know anyone who has had a knee transplant, a stent operation, or surgery for joint pain. I know a couple of people with sports injuries that started when they were pretty young.”
    My experience is very different. I’m a leading edge boomer (born in late 1945). Since 1999, I’ve had a CABG, needed my gall bladder removed the following year, had a TURP for BPH (2004) and required a stent in 2005. Among friends, neighbors, colleagues and relatives, since 2002, I’m aware of two brain tumors, two cases of multiple myeloma, one breast cancer, two colleagues who needed their appendix out, one who needed her gall bladder removed, one colleague in his late 50′s who recently had a hip replacement and will need the other replaced within a few years, and one who had heavy duty shoulder surgery (related to a long ago sports injury). All of these people are upper middle class except for two who are middle class and one who is mega wealthy. All range in age from the mid-40′s to 62.
    I take five prescription drugs that I will be on forever plus aspirin which my cardiologist tells me is “maximum medical therapy.” I suspect that medical science could have done little or nothing for most of these cases 30 or 40 years ago. I’m alive today because of the miracles of modern medicine including both the skills of surgeons and the availability of effective drugs. That could account for why I have a more positive (or at least balanced) view of the drug industry. While I find some of their practices objectionable, the bottom line is that many of their products extend lives, reduce hospital stays or eliminate them entirely and relieve pain and suffering. On balance, the industry has done a lot of good things and I don’t begrudge them their profits, at least, for the most part.

  20. Some time ago I was told I had to take statins. I took them, resulting in subsequently being prescribed SSRIs, Vioxx, Celebrex, slotted in for gall bladder surgery, persistent knee weakness and damage, rotator cuff injury (neither of the two latter with any trauma), ankle injuries, tendon injuries, worsening of carpal tunnel finally diagnosed as de Quervain’s syndrome, eye bleeds and vision damage from that which has not resolved. All these I found out later are documented adverse effects of statins, which I also subsequently found out I shouldn’t have been prescribed because there’s no evidence for women for statins. There’s no evidence for anyone w/o heart disease. All these ‘illnesses’ arose from using a drug that was supposed to protect me, and caused me to lose my superb fitness and ability to work out (the first line of defense agaiinst cardiovascular disease).
    There is no evidence for CABG, they can’t figure which if either of the stents helps someone but both have high rates of post-insertion harm, and there is no evidence for angioplasty or again, statins affecting mortality.
    If doctors would quit seeing pharma representatives, and quit being drug and device pushers, perhaps there’d be enough time for them to treat actual illnesses.
    In Sweden, Swedish doctors get a 661 page book guiding them in how to prescribe (yep that’s the word used) exercise to prevent illnesses, and to treat them. Arthritis, MS, heart disease, diabetes etc. This is the equivalent to our NA physicians PDR, provided by pharma, written by pharma, and only for drugs which all our physicians get free.
    Lock pharma out of medical education, block pharma reps from doctor’s offices, hospitals and clinics, teach doctors to use their hands. When did doctors forget how to physically examine a sore knee? When someone invented an MRI.
    They aren’t practicing medicine. What they are doing is not motivated by patient care.

  21. Barry & NS
    Thanks for your comments.
    Barry- First, I am very sorry to hear that you have had so many health problems. But as you list the surgeries that friends have had, I can’t help but remember that you live somehwere in the wider NY metropolitian NJ area.
    And, as you know, decades of documented evidence shows that patients in that area receive twice as much care (measured in dollars, number of procedures etc.) as similar patients in other parts of the country–and this is after adjusting for differences in local prices, race, sex and the underlying health of the population.
    And the outcomes are no better.
    No one disputes this anymore.
    So there’s a real possibility that some of those people didn’t need those procedures.
    Some of the supposedly “best” (i.e. most expensive, highly-rated by New York magazine, etc.) doctors are most likely to overtreat.
    NS– You’re right, we now know that many CABGs had no benefit (too much time had elapsed after the heart attack), that we do way too many angioplaties, and the evidence on stents, coated stents, etc. is all pretty murky.
    Most importantly, PHarma should not be controlling the information doctors get about effective treatments. Clearly, they have a conflict of interest .. .

  22. Barry & NS
    Thanks for your comments.
    Barry- First, I am very sorry to hear that you have had so many health problems. But as you list the surgeries that friends have had, I can’t help but remember that you live somehwere in the wider NY metropolitian NJ area.
    And, as you know, decades of documented evidence shows that patients in that area receive twice as much care (measured in dollars, number of procedures etc.) as similar patients in other parts of the country–and this is after adjusting for differences in local prices, race, sex and the underlying health of the population.
    And the outcomes are no better.
    No one disputes this anymore.
    So there’s a real possibility that some of those people didn’t need those procedures.
    Some of the supposedly “best” (i.e. most expensive, highly-rated by New York magazine, etc.) doctors are most likely to overtreat.
    NS– You’re right, we now know that many CABGs had no benefit (too much time had elapsed after the heart attack), that we do way too many angioplaties, and the evidence on stents, coated stents, etc. is all pretty murky.
    Most importantly, PHarma should not be controlling the information doctors get about effective treatments. Clearly, they have a conflict of interest .. .

  23. Ther is no doctor shortage!
    In fact it is just the opposite. There is an overabundance of doctors.
    How can this be?
    Th demand for doctor services has increased tremendously. One factor is due to the leveraged system of healthcare we have today, where patients make minimal payments to get alot, i.e. MRI’s , specialist visits, expensive meds through their rx plan.
    Part of the problem is the third party system, part the demand from the patients for everything because their insurance entitles??? them to it, and part because the doc does too much for the patient, instead of just what was needed.
    Doctors need to get together and agree on one thing, to make patient their first priority, but also to get government regulators, bureaucrats, and third party administrators out of their offices, so they can once again treat patients. That is , BTW, what they were trained to do!!

  24. The number of doctors is not the issue, it is access. We have been burdened with a great deal of tasks that we were not trained for and that takes away from our time with patient’s. The spiral is unbelievably contorted, if I dont spend the appropriate amount of time with patients explaining treatment/diagnostic options, side effects, risks, benefits and expected outcome, they come back next week, the week after etc (thus filling my schedule and reducing access for others), If I do spend the appropriate amount of time, I wont see enough patient’s to stay in business!!!! In the meantime the specialists get paid twice as much to spend twice as much time with patients to discuss and manage a much smaller spectrum of human pathology!!!!!! I QUIT!!!

  25. Hi Maggie, GREAT article! Question for you: Is there a statistic about the percent of illnesses that can be cured without a physician? I’ve been searching and can’t find ANYTHING on that topic; yet, there must be some expert out there who has taken a stab at it! Any help welcome!

  26. As a matter of enlightened self-interest, I wish there were a doctor shortage. It would most definitely increase physicians’ political and economic clout to something significantly more than nonexistent. Maggie, once again you’ve rained on my parade.

  27. I WISH I HAD FOUND THIS ARTICLE EARLIER. THE REASONS FOR PUSHING FOR AN INCREASE IN THE NUMBER OF PHYSICIANS IN THE U.S. ARE PURELY RELATED TO THE FINANCIAL GAIN OF CERTAIN ORGANIZATIONS. TAKE A LOOK WHO IS FIERCELY PUSHING FOR AN INCREASE IN PHYSICIANS WITH INTENSE FLAG WAIVING IN THE NAME OF “BETTER HEALTHCARE” , LIKE THE AAFP, AAP , PRIVATE HOSPITALS, BIG MEDICAL GROUPS, ETC. ALL THESE PEOPLE BENEFIT FINANCIALLY FROM HAVING MORE DOCTORS AROUND (MORE COMPETITION MEANS LESS PAY FOR PHYSICIANS AND BETTER PROFITS FOR CORPORATE BLOOD SUCKING MEDICAL GROUPS). EACH FAMILY PHYSICIAN PAYS A MINIMUM OF AROUND 700 BUCKS PER YEAR TO THE AAFP JUST ON MEMBERSHIP, NOT TO MENTION THEIR COMMERCIAL AND CME ENDEAVORS WHCIH BRING IN AN ADDITIONAL COUPLE OF MILLION BUCKS. I AM NOT SURPRISED BY THEIR FIERCE DRUM SOUNDING ON A TERRIFYNG “SHORTAGE OF FAMILY PHYSICIANS”

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>