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June 06, 2006

The Coming Doctor Shortage

Q: How many doctors does it take to screw in a lightbulb?

A: More than we have. At least that's the implication of this LA Times article, which reports on the looming physician shortage. The number of medical school graduates has remained steady for about the last 25 years, capped because the industry feared creating too many graduates in an age of HMO's and declining salaries. Unfortunately, demand is exploding, both because of the baby boomers and the ever-increasing number of treatments demanded by patients. And the situation will only get worse: a full third of the nation's 750,000 doctors are readying to collect their own Social Security, and will be retired before the boomer wave crests. Meanwhile, younger doctors have no interest in letting their jobs be as all-consuming as the last generation did, and are thus expected to prove 10 percent less productive. So we'll have fewer doctors, and the one's left won't treat as many patients.

So what's going to happen? Well, wait times, for one. Folks already wait months diagnostic procedures, and that's only going to get worse. At the moment, a dermatological appointment in requires an average 24 day wait, gynecologists take 23 days, cardiologists 19, orthopedists 17. When my friend recently needed a complicated knee surgery, the wait was months. Tell me again about the horrors of Canada. Additionally, prices will go up, and time with physicians will drop. Caseloads for good doctors will fill up and close, and rural and underserved areas will lack alternative options. And because physician training takes so long, and requires so many resources, quick adjustments can't be made. Some of the slack could be filled by nurse practitioners , but there's little effort to do so. And, in case you were wondering, America averages 2.3 physicians per 1,000 residents, well below the OECD average of 2.9. Just another benefit that comes from spending double what anyone else does for less than everyone else gets.

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Comments

While this is a real problem, I don't see how single payer health care would address this.

Posted by: Dave Justus | Jun 6, 2006 11:06:52 AM

Who said it would?

Posted by: Ezra | Jun 6, 2006 11:11:19 AM

I think it could. The annual number of new MDs (native US plus immigration) should be controlled by some entity other than the medical schools. A logical place to start would be some committee of civilians (MDs and others) appointed by DHHS. Financing of medical education for students should also be substantially changed so that more US students could afford the arduous and expensive undergraduate and graduate tuition, plus costs of internship and residency.

A rational system would plan for both supply and demand. Right now, who makes sure the supply is adequate? The 'market' is clearly not playing a major role now.

Posted by: JimPortlandOR | Jun 6, 2006 11:33:00 AM

Medical students pay a substantial price for their training, but far less than the complete cost. State legislatures need to cough up the dough to increase class size or add additional medical schools, but currently it's more popular to import newly graduated MDs from other states and third world countries.

The internal medicine match did not fill this last year as there were not enough graduating students interested in primary care or even sub-specialty careers for the number of IM residency positions. The deficit has to be made up most years by foreign graduates. I guess that there are certain jobs that Americans just don't want to do.

I would be quite happy to earn a French doc pay, if only I could work a French doc's hours....

Posted by: J Bean | Jun 6, 2006 11:52:05 AM

What are you worried about, Ezra? Tort reform will fix of this. President Bush says so himself!

Posted by: Charles Kuffner | Jun 6, 2006 12:25:22 PM

The Doctor's Guild is limiting entry into the profession. Gee, that sure is startling.

Posted by: ostap | Jun 6, 2006 12:44:14 PM

And when they aren't actively limiting it, they're requiring future doctors to go through a residency process that amounts to a months-long hazing.

Posted by: Kylroy | Jun 6, 2006 1:34:13 PM

Some of the slack could be filled by nurse practitioners

I talked with an LPN last weekend who is studying to be an RN. The waiting lists to even get into training are years long. She waited 18 months to get into an LPN course. The RN time was less but only because she knew to sign up early - - before finishing LPN training.

...

Posted by: Emma Zahn | Jun 6, 2006 1:34:45 PM

"Demanded by patients?" I see what you're getting at, but as one who spends a fair amount of time in medical waiting rooms, the people (mostly old and tired) that I see actually look like there there because of what they "need."

Posted by: Gene O'Grady | Jun 6, 2006 2:08:17 PM

The AMA as we know it must be broken and scattered to the winds before meaningful health care reform will occur in the US. People die every day because the AMA wants to keep the price of doctoring high more than it wants to save lives.

Posted by: NBarnes | Jun 6, 2006 3:27:44 PM

AMA does NOT control medical schools, how many times do I have to tell you guys this?

The only barrier to med schools is money. As long as you have money, you can build as many med schools as you want. The AMA does NOT control this, its governed by the LCME. The LCME sets the accreditation standards. As long as you meet those standards, you can open a new MD program.

If the AMA was so powerful, how do you explain the fact that there are 20 new or planned med schools? YOu want to guess how many of those schools had AMA approval? ZERO. Florida is in the process of opening 3 new med schools within a span of 5 years. What role did the AMA have in that? ABSOLUTELY NONE. In fact, the AMA was not even aware of the new med schools until after it was published in the newspapers.

Oh and lets not forget DO schools. The AMA has ZERO control over these schools too. Hell the LCME doesnt even control DO programs, they have their own accreditation committee.

Posted by: joe blow | Jun 6, 2006 4:17:02 PM

Here’s a current list of new or planned med schools:

NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT HAVE OFFICIALLY OPENED

MD - University of Hawaii-Kakaako - 2006
DO - Touro/Las Vegas - 2005
DO - PCOM/Atlanta - 2005
MD - University of Miami/FAU joint program - 2004
MD - Cleveland Clinic/Lerner - 2004
DO - LECOM/Bradenton - 2004
MD - Florida State University - 2002
DO - VCOM - 2002

NEW MEDICAL SCHOOLS THAT WILL OPEN SOON

MD - Florida International Univ - 2008
MD - Univ Central Florida - 2008
MD - Touro/NJ - 2008
DO - Touro/Harlem - 2008
DO - Pacific Northwest/Yakima - 2007
MD - Michigan State University/Grand Rapids - 2008
MD - University of Arizona/Phoenix - 2007

NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT ARE IN PLANNING

MD - University of Cal Merced
MD - University of Cal Riverside
MD - University of Texas El Paso
DO - Vista/Colorado
MD - OHSU/Eugene
DO - MSUCOM/Detroit
DO - Barry University/Miami FL


If anybody can provide a single link showing that the AMA lobbied against any of these programs, or fought to prevent them from opening, I'll give you $50.

Please get informed before you hold up the AMA as a vast medical conspiracy. To most doctors, they are irrelevant. Hell less than 30% of all docs in the USA are members.

Note also that Vista/Colorado is the first private, FOR-PROFIT medical school in the USA since the days of Abraham Flexner. Please read the Flexner report if you want to wax nostalgic about the days of for-profit med schools. I dont think we want to go there.

Posted by: joe blow | Jun 6, 2006 4:20:57 PM

BTW, all the studies showing a so-called doctor shortage are faulty because:

1) They dont include osteopathic doctors.

2) They dont include the impact of NPs and PAs. These studies assume wrongly that the only source of healthcare in the USA is doctors.

3) They dont include the impact of FMGs. FMGs are foreign medical grads who make up about 30% of all postgraduate residency positions. USA takes more FMGs than all other nations COMBINED. The UK recently banned FMGs from entering the country.

4) They dont include marketplace innovations, such as Nighthawk radiology setups, where x-rays are sent overseas for reading instead of being read by american radiologists.

Posted by: joe blow | Jun 6, 2006 4:25:58 PM

"And when they aren't actively limiting it"

See my post above, the notion that the AMA controls the number of medical schools is ridiculous. AMA has ZERO SAY whether a new medical school opens or not. If you gave me a few million dollars, I could open a med school within a matter of months.


"they're requiring future doctors to go through a residency process that amounts to a months-long hazing."


Every OECD nation in the world requires residency training. Hell in most countries, residency training is LONGER than the USA. Are you suggesting we abandon the residency training model? We'll be the first and only nation to do so.

USA docs take about the same number of years to train as all other OECD nations. There are some minor differences, but when you add up the overall training pathway its virtually identical.

Posted by: joe blow | Jun 6, 2006 4:29:31 PM

Mr. Blow,

You say that “AMA has ZERO SAY whether a new medical school opens or not,” that “its [sic] governed by the LCME.”

According to the LCME’s website:

1. “The LCME is sponsored by the Association of American Medical Colleges and the American Medical Association.”

2. Of the 17 members of the LCME, 7 are appointed by the Association of American Medical Colleges, 7 by the Council on Medical Education of the AMA, and 2 by the LCME, and 1 “is appointed” (passive in original, by whom is not revealed) to represent the Canadians.

If you think this equates to the AMA having ZERO SAY, you’re, uh, oh, never mind.

Posted by: ostap | Jun 6, 2006 4:56:27 PM

People who pin blame for various real or supposed medical failings on the AMA don't really have a clue what they are talking about. The AMA is a lobbying organization and professional society for physicians. There are other similar, albeit smaller groups that physicians belong to on a voluntary basis. The AMA has absolutely no power to control medical schools, malpractice insurance, MD licensing, prescription practices or any of the other functions regularly assigned to it by the ignorant. I don't belong to the AMA. I never have and I never will and that has zero effect on my status as a physician.

Residency is not "hazing". It's hard work, but entirely do-able by healthy young people. Physicians have to learn and absorb enormous amounts of material and there is just no way to do that without putting in a lot of hours of study. Sick people need to be cared for nights, weekends, and holidays. Medicine becomes more complex every year and there is talk about increasing the length of residencies, not decreasing them. I enjoyed residency although there were a few days when I was tired, for the most part it was exciting and challenging.

Posted by: J Bean | Jun 6, 2006 5:07:31 PM

So ostap what you are saying is that the 15 or so medical schools that opened or will open this decade are just sneaking past the AMA? The medical school that I attended in the mid-90s increased its class size, again on the sly so that the AMA wouldn't find out?

Joe: UCR and UC Merced are squabbling over which school gets to have the new medical school. I don't believe that there are plans to open two.

Posted by: J Bean | Jun 6, 2006 5:44:53 PM

ostap,

the AMA influence on the LCME notwithstanding, you dont understand how creating a new med school works.

As joe blow stated, building a new med school comes down to one thing: money. The LCME criteria is a well defined listing of bulleted items that the prospective school has to meet. As long as the school meets that criteria, the AMA has no say over whether it opens or not.

If you could prove that the AMA keeps changing the accred criteria, then you might have a good argument, but thats not whats happening. As long you have money, then you have med schools.

BTW, you do know that the AMA has explicitly called for the addition of new med schools and expansion of existing programs, right?

Posted by: sam j | Jun 6, 2006 7:01:57 PM

Actually, the real reason this is all suspect is because whether there's a doctor shortage or not all completely depends on who you're talking to, and what metropolitan area they live in. If we assume that the country uses resources like they do in LA, we're in for a severe shortage. But if we look at how they use them in say, Kansas City, the data says we're fine. These are the conclusions of a famous Dartmouth health policy professor whose name I can't recall right now.

Posted by: Graham | Jun 6, 2006 7:41:01 PM

Graham, you're right.

Goodman is the lead author, Wennberg is the more famous:

http://content.healthaffairs.org/cgi/content/abstract/25/2/521?ck=nck

The work was also summarized in Forbes:

http://www.forbes.com/lifestyle/health/feeds/hscout/2006/03/07/hscout531419.html

There's alot of supplier-induced demand in medicine.

Posted by: quietstorm | Jun 6, 2006 8:52:05 PM

1. Doctors control entry to the profession.
2. Demand for the profession has skyrocketed for 25 years.
3. Supply of the profession has not grown for 25 years.
4. It is well known that guilds run by practitioners place obstacles in the way of entry, not in the name of protecting incomes, but rather in the name of protecting quality.
5. In the medical profession, there are obstacles in the way of entry, not in the name of protecting incomes, but rather in the name of protecting quality.
6. Draw your own conclusions.

Posted by: ostap | Jun 7, 2006 8:44:33 AM

"1. Doctors control entry to the profession."

so what. every profession works that way. Lawyers control access to the legal profession. Accountants control access to CPA licensing.

"2. Demand for the profession has skyrocketed for 25 years."


There is no evidence that demand has outstripped supply. If that were true, then doctors salaries would have skyrocketed the last few years, but in fact doctor incomes are down.

"3. Supply of the profession has not grown for 25 years."

Wrong. America has the same number of doctors per capita as it has since the early 1900s.

"4. It is well known that guilds run by practitioners place obstacles in the way of entry, not in the name of protecting incomes, but rather in the name of protecting quality."


You got it all wrong. It was the state politicians and hte GENERAL PUBLIC that was outraged at the "profession" of medicine in the early 1900s. The public outcry led to the Abraham Flexner report, which revolutionized medical education. Flexner had no ties to the AMA or to doctors in general. He was commissioned by concerned state representatives to study the issue.

It was outside pressure from the public, NOT the doctors, who instituted new barriers to practicing medicine.

"5. In the medical profession, there are obstacles in the way of entry, not in the name of protecting incomes, but rather in the name of protecting quality."


Again, so what. All professions operate this way. I cant become a certified CPA by just taking the test, I'm required to get training in accounting first. Likewise, I cant file a lawsuit until I have earned a JD degree. All profesions have barriers. If there were no barriers, then BY DEFINITION, its NOT a profession.


Posted by: jason pitos | Jun 7, 2006 8:05:32 PM

Question for docs on this thread. Does medical school run year round or do med students get the summers off?

I ask because if the summers are off, you could switch to a trimester or a quarter system and speed up med school by a third or 25% and get more students in the pipeline without adding any schools.

Alternately, you make med school admissions from high school graduates-- if the norm is the combined BS/MD program that some universities now offer, you could cut one or two years off the total amount of time needed to educated a doc (though with longer residencies and fellowships, it would just be tacked on to the back end).

Posted by: beowulf | Jun 8, 2006 2:53:54 AM

Med students get the summer after the first year off, but the other summers are filled with clinical clerkships.

So if you cut out that free summer, you could shorten med school to 3.5 years instead of 4.

We could switch to the European model, in which you go to med school straight out of high school. But med school in europe is 6 years long instead of 4, and the residency process is longer in europe compared to the states.

Posted by: Hopkins Medical Student | Jun 8, 2006 6:11:05 PM

In response to a post that says "The UK recently banned FMGs from entering the country" This information is totally wrong. Here in the US there is a big discrimination between US Medical Graduates and Foreign Medical Graduates. But in the UK they recently made it hard for doctors who are FOREGIN CITIZEN to work in the UK. I am a born US citizen. I did my medical school in Europe but I am still considered a Foreign Medical Graduate. And this is totally stupid.
The money for residency training comes from the government but as a US citizen because of the school that I went to I am disadvantaged and my application for residency is rejected only based on the medical school that I went to. And I must say that many of the "FMGs" are much more knowledgeable and qualified as doctors than US graduates. This is one of the things that should certainly change in this country. If there is any discrimination it should be based on the citizenship which is totally lawful. I am a US citizen so I should have a priority for the jobs that are government sponsored. I see foreign nationals who went to US medical schools and they get the residency position only because they are graduated from US medical schools.
As everyone knows medical schools are businesses. So no wonder they try to send their own graduates to the system and enforce this.
US citizenship should be a priority for getting a residency not the school that a person is graduated from. So I rephrase the above quotation:” The UK recently banned FOREGIN CITIZEN Doctors from entering the country” Or “Legally the priority should be given to US citizens when applying for the same residency spot”
Ironically many illegal simple workers now a days are gaining access to jobs in the US but a US citizen medical doctor after so many years of study and hardship have a hard time finding a residency in the US.

Posted by: B.J | Jun 13, 2006 7:18:36 PM

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