• The road less traveled

    There’s a very nice Perspectives piece at NEJM today. I fear that it will be behind a paywall, which is tragic, because the people who need to read it most likely don’t subscribe to NEJM:

    I worry that the primary care physician is a dying breed. Though it was once considered the noblest profession, U.S. medical students today believe the work is too hard, the hours too long, the pay too low. So they’re choosing to hit the “ROAD” — the high-paying specialties of radiology, ophthalmology, anesthesia, and dermatology.

    But if you think being a primary care doctor is hard, meet Mary. Not many people have it harder than Mary. She always leaps to mind when I consider how our health care system fails our patients — and why I chose primary care. I’m Mary’s doctor, and though I care deeply about her, seeing her name on my schedule evokes mixed feelings: irritation that I’ll be an hour behind schedule the rest of the day; trepidation over the 50-50 chance she’ll need to be admitted, disrupting my busy day; and fear about intractable social problems.

    The problems that Dr. Feingold faces with Mary are specific and rare, but the difficulties docs can face in providing patient care are broad and common. And, on a personal note, imagine how much harder things if you were trying to care for Mary’s child. This isn’t meant as a complaint, nor is it said with any bitterness; as Dr. Feingold notes, we chose these paths, and we continue to walk them gladly.


    (h/t Austin, from an undisclosed location)

    • Despite the claims of medical professionals, there is simply no kind of true market in which would there be a shortage of underpaid, overworked generalists, and an excess of overpaid, underworked specialists? In the parlance of economists, the markets for these two categories of physicians are not clearing.

      A cursory look at data from the AAMC provides some clues. It shows that the supply of university seats for medical school is as little as half what would exist in a competitive market… roughly 17,000 new matriculates against about 30,000 qualified NEW applicatants and an additional 10,000 -12,000 reapplications each year:


      Additionally, around 96% of those who matriculate, eventually get their degree… compared with 60% of all other advanced graduate programs.

      Worse, these numbers (30,000 new applicants, 17,000 annual matriculates, 96% graduation rate) have been the same for about 30 years!

      This is amazing. And yet one explanation is clear… the number of medical seats is controlled by the LCME, which is itself sponsored by the AMA and the AAMC.

      The AMA is explicitly designed to represent physicians’ interests… I quote from the AMA home page: “The American Medical Association advocates aggressively for physicians’ interests and delivers valuable member benefits that help physicians practice medicine every day.” (http://www.ama-assn.org/ama/pub/membership/membership-benefits.page?)

      The insider control of the supply of physicians is becoming intolerable. Shortages of generalists is a great problem, and will only worsen with the aging population. More importantly, we need the entire supply of physicians to grow.

      However, supply is being tightly controlled by the same group who represent physician interests and seek to increase physican wages. The supply has been held constant for decades, and yet there is simply no discussion about changing this.

      To Drs. Carroll and Frakt: I wonder what are your thoughts about the situation and if you know of any efforts to resolve these problems.

    • While there may be influence over the total number of students ( I am lees sure of this after what we went through starting our new medical school), it is more difficult to find direct influence on selection of specialty. That seems to be pretty much an economic driven choice by students. That is driven more by insurers. Should you increase the number of med students graduating, you will then need more residency slots.

      Fixing this, like most things in medicine, is not easy. I have no idea how we persuade private insurers to pay more for primary care. On the Medicare side I would prefer a freeze on specialty pay for a while with increases for PCPs.


    • Hello,
      Really appreciate you posting this comment. Is there any way you can pdf this article or be so kind as to email it to me? The abstract makes it sound like a very intriguing piece.

      I am a family medicine resident about to graduate. Still searching for some answers and the best road forward, as are many of my fellow classmates.

      If there is any chance you could fwd this article my way, I would be so appreciative!

      In appreciation,
      Stephanie Van Dyke