• Why can’t we have more doctors?

    Everywhere I turn, I’m faced with concerns about what will happen to the system when we give many more people insurance. People complain that they will have to wait longer to be seen. People complain that doctorswon’t take Medicaid. Some even complain doctors won’t take Medicare.

    Usually, this is coupled to some fear like socialized medicine = increased wait times. But it’s really just a fear that there aren’t enough doctors in the US to go around. There’s some truth to that. This is how we compare  to other countries with respect to the number of physicians we have:

    And, too many are specialists.  Here’s how we compare with respect to general practitioners:

    This matters. For instance, even now, people don’t feel like their doctor knows them:

    Or that their doctor spends enough time with them:

    Too often, we blame the system for issues like these. But, in this case, maybe it’s just the fact that we don’t have enough doctors. Maybe more would accept Medicaid and Medicare if there was more competition. Maybe wait times would be less, visits could be longer, and doctors would know you better.

    So why can’t we have more? I’m sure there are many people who would like to be doctors, but don’t get the chance. It’s a pretty good gig. I understand why doctors themselves might not want the competition, but why not everyone else? What am I missing?

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    • My theory is that doctors are over-trained, especially the GPs. My impression is that registered nurse practitioners and physician assistants do roughly the same job as GPs and do the job about as well, but spend many fewer years in training. But people prefer doctors because they are higher status. Another issue is that training doctors is very expensive and is not as subsidized by the government in the US as in other industrialized countries — perhaps this is part of why doctors are under-supplied?

    • I’m sure there are many people who would like to be doctors, but don’t get the chance.

      I know 2 foreign born and trained Doctors who would love to practice here but cannot get a license

      My nephew who has got A’s in all but one class in which he got a B is panicked that it might keep him out of medical school. This is ridiculous ability to do very well in school is not even that well correlated with ability to be a good doctor.

      We need to make it easier to pass the boards and become a doctor. A 5 year program like of pharmacists should be enough to be a doctor. People learn more on the job anyway.

    • How does the pay of teaching doctors compare to the pay of private practitioners? I wonder if, over the short-term at least, there might be some capacity issues at med schools that leads to the ridiculously low admission rates (I recently watched a friend who graduated from a very good undergrad institution and did well on his MCATs go through an almost endless series of rejections, getting into only one of the maybe 20 schools to which he applied).

      I don’t think this is any excuse for not letting foreign doctors get certified to practice here, but I do know a few teaching doctors myself and wonder if their non-luxurious salaries are affecting the capacity of med schools and residency programs to meet supply.

    • It seems doctors are in charge of how many people and who can do anything that might be considered practicing medicine. Restricting supply has the expected effect of increasing price.

      Accredit more medical schools, allow more non-US doctors to practice hear, allow nurses to do more.

      Doctors also control Medicare reimbursement rates. The relevant panel is controlled by specialists, who over-compensate specialists (under compensate GPs), which is one reason we have too many specialists and not enough GPs.

      We need more medical practitioners. This should not be controversial.

      By the way, I had an email exchange about this with Austin a year or so ago. He said there was data showing that having more doctors raised costs. I believe this would be due the shortage – many people go without, if you increase supply they get some care, which costs. Costs won’t go down until we have a much more competitive. market, IMO.

    • Sorry to add more, but it seems to me that it is excessively hard to get a medical license in the USA. I can understand that you not an untrained person operating on you but you need some balance. It is better to make more doctors since many people have bias against PA’s and nurse practitioners (although research shows that they do no worse in outcomes). Further technology can lower the need for skills.

      This subject need far more attention.

      • We need to make licensing easier, but quality control better. There should be better review and more done to deal with incompetent doctors.

    • an additional factor is that for doctors you are looking at high overhead costs which will eat into your margins, thus, why i think so many specialize.

    • Your post incorporates three questions (at least).

      1) Number of physicians. The AAMC (Association of American Medical Colleges) among others tries to guage physician supply and demand. Those studies, and political decisions that include substantial consideration of the cost of training physicians affect the numbe of physicians that medical schools train. Google ‘Physician Supply and Demand.’

      2) Number of primary care physicians. There’s sizable literature dealing with medical student decisions for specialty vs. primary care. (and practice in rural vs. urban settings.) Indebtedness at the end of training is a part of the decision.

      3) Patient satisfaction after the physician encounter. Partly time, partly attentiveness and empathy. Again, has been extensively studied.

    • ” He said there was data showing that having more doctors raised costs.”

      Doctors have the ability to create more demand. When you look at areas with higher concentrations of physicians, places like major cities, the increased number of docs per patient does not lower costs, as docs just find more things to do.

      “How does the pay of teaching doctors compare to the pay of private practitioners?”

      I am in a private practice group at an academic center. I get paid nothing for teaching. It takes up my time and creates more work for me. In general, relatively few docs get paid to just teach. They usually make less money. Docs who are employed by the academic center get paid based upon having a certain amount of time devoted to teaching. This varies from center to center, so I am sure others do it differently than we do. (We are just starting our medical school but have had many residencies for years.)

      “I know 2 foreign born and trained Doctors who would love to practice here but cannot get a license”

      My group’s experience with foreign trained physicians has been quite uneven. It requires extra effort to discern their ability and level of training.

      Steve

    • The answer is given by Shikha dalmia in her oped : http://reason.com/archives/2009/08/27/the-evil-mongering-of-the-amer.
      AMA has convinced Congress to limit the number of residencies it funds ever year. The residency programs are mostly funded through Medicare and other government programs, and since 1997, the number of federally supported positions — and thus the annual number of freshly credentialed doctors — has been capped by Congress – thus capping the number of new doctors joining the workforce..(http://www.buffalonews.com/editorial-page/viewpoints/article333368.ece)

      • Another source:
        Grassroots Activism and the Pursuit of an Expanded Physician Supply
        John K. Iglehart
        N Engl J Med 2008; 358:1741-1749 April 17, 2008

      • You’re completely wrong. Lobbying for more Graduate Medical Education spots (aka more residency training) is a huge priority for the AMA. In fact it’s one of the top three issues, along with fixing the Sustainable Growth Rate formula permanently and malpractice/liability reform. But they are all over it. Unfortunately it costs money and there isn’t a lot of money to go around. It’s tough enough to play defense on Medicare cuts, much less argue for more money for physician training.

    • Why aren’t there more doctors? Well, there ‘s a finite number students that medical schools can handle, for one. Another issue that we have is that no one who works their tail off to get through medical school wants the lowest paying job out there, and that’s the general practitioner. If you want to pay off your student loans in a reasonable amount of time, you specialize and go to work for a large hospital system where the pay is good, you get time off, and the administrative hassles largely belong to someone else.

      However, I suspect we have a decent number of doctors now, but aren’t making efficient use of them due to the way they are forced to operate by insurance companies. For example, when I saw a Kaiser Permanente GP a few weeks ago and asked for diet recommendations so that I could lose 15 pounds, he referred me to a nutritionist. Pre-HMO era, a GP would have handed me a Xerox copy of recommended foods and caloric intake (like the nutritionist did). Tactics like this allow the insurance company to charge for another visit. A slew of basic medical procedures (removing moles or warts, treating a skin rash, setting a broken finger, etc., etc.) that the GP is trained to do is now only handled by specialists. It’s a form of healthcare rationing in that it costs the consumer more in terms of time and money, but nobody’s calling the insurance companies on it for some reason – we all assume they are experts in healthcare efficiency. What they are efficient at is squeezing the last dime out of every consumer possible.

    • ” He said there was data showing that having more doctors raised costs.”
      I think that it should be:

      ” He said there was data showing that having more doctors raised spending.”

      I have read that before but I believe that at some point that that will turn around and more doctors lowers costs. If more doctor produce more spending we need to learn what is the reason. Are the additional doctors adding any value but below the cost, the 3rd party payers could be the problem. If they are not adding value then the marginal value of medicine is zero or below and Robin Hanson is correct. This would explain why monopsony seems to not cause much harm to health in Japan and Italy where there are even fewer Doctors than in the USA.

      Never the less I would like Governments make it easier to get a doctor’s license and I would like regulations to allow non doctors to do more (maybe anything as long as it is overseen by a Doctor).

    • Thx Brad.

      Steve

    • The choke point for “more doctors” is the number of residency slots, not the number of medical school graduates. As it is, the current system has more residency slots than US grads to fill them, so the balance is filled with “international medical graduates” as they are now called. If there were more US medical school graduates, they would just displace the IMGs from residencies.

      Rashmi is correct that the problem is that the number of residency slots have not been increasing like perhaps they should. I contest his unsupported allegation that the AMA or some other agency is doing that for anti-competitive reasons. My understanding was that it was for budgetary reasons — each residency slot costs HHS $140K per year or so. But I would be interested to better understand the responsible agency for setting the number of residency positions and their method for determining it. Does anyone have that information?

      • “As it is, the current system has more residency slots than US grads to fill them, so the balance is filled with “international medical graduates” as they are now called”

        This is no longer accurate. 2011 was the first year when there were more U.S. Allopathic (M.D.) graduates from U.S. medical schools than there were open positions for residency. If you add in U.S. osteopathic students, this has been the case for some years now. There are still plenty of international medical graduates who are offered U.S. residency programs, but they are overwhelmingly exceptional students or physicians.

        As you said, the bottleneck lies solely in the funding available for residency programs, as well as the intrinsic difficulty of establishing residency programs.

    • Aside from the huge differences in earning power, there is another fundamental reason why medical students avoids the field of primary care like the proverbial plague: much of your time is spent dealing with boring, banal trivia of no great importance in which you play the role of a social worker with a prescription pad (Real social workers probably do a much better job, if for no other reason that their visits are longer than the typical 10 minute PCP visit). Yes, there are some things that are done at this level that are important but without exception it has been repeatedly been shown that they can be done just as well by mid-level practitioners such as nurse practitioners and physician assistants. Management of most patients with chronic diseases is not usually especially complicated and for better or for worse forms the not very interesting basis of primary care. Medical school training is simply not required to provide the basic medical services needed at the level of primary care patient interaction.

      Primary care (aka Family Practice) is not really a bona fide specialty, despite being called one, and medical students are well aware of this. They also question the wisdom of entering a field in which you will compete with NPs and PAs doing exactly the same work. Throw in the lower pay and the very definite lower status of a PCP in the medical hierarchy and the lack of interest in primary care and the palpable unwillingness of medical graduates to enter or stay in the field becomes readily understandable.

    • I think the answer is quite simple. Life and Death is a great commodity. Western medicine is a status symbol. We outsource everything from programming jobs, engineering, manufacturing and what not, because the knowledge is shared globally to create more competition and competitive prices for consumers. The medical field however, is like a giant pyramid scheme or Mafia. Only the elite can afford its education and it is taught in fewer schools. It is NOT in the best interest of Doctors or Pharmacists to have their salaries or prices slashed. I think the medical industry will never allow its education to be subsidized by the government. Wealth breeds wealth, and there is no way in hell they would be willing to share their knowledge and power with Joe the plumber.

    • My doctor in-laws tell me that the coursework in med school is just a repeat of what they learned in undergraduate science classes. Why not take all those underemployed biology/life sciences PhDs, send them through clinicals and then give them MDs? Then use the tuition money they saved by reducing the years of med school to fund their residencies or partly fund them? Doctor shortage solved.