• JAMA Forum: Too Few Generalist Physicians Doesn’t Necessarily Mean Too Many Specialits

    A recently released article in Washington Monthly, “First Teach No Harm,” takes a hard look at the educational system producing our physician workforce. It notes we train too few generalists, and and also suggests we have too many specialists.

    But do we? I address this in my latest post at the JAMA forum. Go read!


    • You are absolutely correct. Government interference in the market place has led to a maldistribution of physician choice of specialty. The solution is less government interference.

    • When was the last new medical school opened in the US? Here in Kentucky, they opened one new Pharmacy school, and suddenly we have a glut of pharmacists. All types of pharmacy positions are being filled, and pharmacist salaries are trending downward slightly.

      I just saw where KY is short 4000 or so doctors. So how about a new medical school in Kentucky? Maybe at WKU? Or, how about 2 or 3 new medical schools in Kentucky? Why do I keep reading about doctor shortages but no plans for more medical schools?

      Oh, sorry, I forgot. AMA doesn’t want more med schools. They don’t want any, any possible physician salary downward trends.

      In my lifetime, I’ve known so many people who loved medicine and wanted to help people, but couldn’t get into a med school. What is wrong with this picture?

      Come on AMA! Fix it! Stop keeping new med schools from being open! We’ll give you malpractice/tort reform in return, I promise!

      • Unlike physicians pharmacists don’t have a work product that they control. Thus, though like physicians they have an unending bucket of funds that come from third parties, there are factors that limit their need.

        Will an increase in physicians reduce physician fees and thus produce savings (minimal savings at that)? Studies in the past say NO and that a glut of physicians might reduce their fees, but at the same time increase total costs.

        Are there shortages of physicians? Common knowledge says yes, but is that really true? I don’t think so or perhaps we could use a few more physicians, but that is not the problem. We are not using our physicians wisely and that is largely because of our third party payer system.

        ” people who loved medicine and wanted to help people, but couldn’t get into a med school.”

        You bring up an interesting point, inadvertently perhaps, do we need the best and the brightest going to medical school? This method would provide less academically minded individuals to the medical schools while at the same time release the better students to engineering and other scientific endeavors that create wealth for our nation. It is an interesting trade-off.

        Unfortunately the healthcare debate doesn’t focus on concepts rather it focus’s on ideologies so the hope for improvement of our system is dim at best.

      • A 30 second Google search shows 17 new medical schools opened in the US since 2005, a 15% increase. Residency spots are now the rate limiting step

        In my lifetime, I’ve known so many people who loved X, but couldn’t get into Y. What is wrong with this picture?
        X,Y = flying, Air Force Academy
        Music, Juilliard
        Football, NFL
        Money, Goldman Sachs

        There are many valid critiques of medical education to be made, but the AMA restricting supply is not one of them, IMO

    • The dichotomy between specialist and non-specialist, or primary care, is outdated. For many people their specialist is their primary care physician. Cardiologists, gynecologists, gastroenterologists, pulmonologists, and even some oncologists often act as their patients’ primary care physician. Some group practices in these specialties hire primary care physicians (internal medicine, etc.), but they often end up leaving because they feel as though they are treated as being less qualified than their specialist partners. In some of my cardiology group practices, they will hire a non-interventional cardiologist who essentially serves the role of primary care physician. Whether this practice is good or bad may be debatable, but it’s common.

    • There was a natural experiment in Quebec which was the last province to provide universal coverage under the Canada Health Act. Many previously uncovered patients were suddenly covered and the physicians had to cope. The number of visits went up some but less than expected. The visits by the poor (and previously uncovered) in particular were higher and the visits by the well to do previously covered) decreased or stayed flat. I suspect that many of the visits scheduled by PCP’s were marginal are could be less often (say every 4 months rather than every three) or that the delay in visits due to crowded schedules resulted in many minor complaints self resolving as they often do. I am not sure there is as much of a true severe shortage as is feared. I suspect that there is more flexibility in the system than previously estimated to cover the uninsured. The market answer to the PCP shortage is to pay for what you want. I suspect that if the hours and pay of primary care were more comparable to specialists (not necessarily higher, the pay of specialists could be lower) that the distribution would even out.

    • This is a request. About 5% of men are color blind. We cannot read color-coded graphs unaccompanied by numbers or by labels distinguishing one line from another. Several of the lines appear to be of similar coloration; the line on the top and the line on the bottom look very similar. I am told that there are different colors known as “green” and “gray” which correspond to different nations on the graph, but am unable to see which is which. So this is a plea to creators of graphs: please remember that about one man in twenty will not be able to decipher color coded displays of data.

    • Also worth considering: we have a much lower population density than Germany, Italy, France and the UK (but we have a higher population density than Canada). Because of our level of suburbanization, I think it’s likely that our metropolitan areas are more sparsely populated than those four countries.


      This increases travel times to physicians for many. This means we might want more general practitioners per capita than those countries. Instead, we have much fewer.

      • Some areas that might be medically underserved offer benefits to encourage more physicians in the area. Additionally when the need becomes great enough we see clinics opening up and physicians opening up satellite clinics that are shared with only limited hours and days of the week. This type of activity is inhibited by Medicare because of their restrictive rules.