There are too many doctors in the U.S according to Dartmouth’s Goodman and Fisher‘s commentary of the Association of American Medical Colleges’ Center for Workforce Studies report. The AAMC recently made the proud announcement that 85% of medical schools have or are in the process of increasing first year medical school student enrollment by a total of 30% by 2015. In my view, the real issue here isn’t quantity at all.
This country already has just about the world’s highest ratio of doctors per capita. As a group, U.S. physicians deliver more expensive care with no better outcomes than our colleagues in other countries. American patients are not going overseas for elective surgery because they don’t have access to surgeons here – they fly halfway around the world at their insurance companies’ expense to save money. Now, if the strategy behind increasing physician supply is to drive health care costs (read: doctor salaries) down, it might make more sense, but I believe that even if physician reimbursement is ratcheted down even more, prices will have a way of staying up there anyway because of the tremendous overhead in health care.
There are enough studies showing that greater physician supply, particularly at the specialist level, correlates more with increased cost than improved quality. And where do most medical school graduates today end up? They choose specialties with higher incomes and better life styles than Primary Care offers in today’s climate. Right now our little community is trying to recruit one or two new Family Physicians, so I know first hand how few new graduates want my kind of job. At the same time, I read advertisements in the City paper, where Family Doctors are offering laser skin jobs (for cash) instead of accepting new Primary Care patients – and they certainly don’t do house calls. Yes, house calls are good medicine and they can save health care dollars! We have plenty of examples in our community of elderly, homebound people we have kept out of the hospital with the help of weekly or biweekly home visits. One Emergency Room visit via ambulance costs more than a dozen house calls!
One of the hot topics in medicine, Primary Care and Health Care Policy these days is “The (Advanced) Medical Home”, which basically means having a technologically astute old-fashioned Family Doctor, who keeps track of your whole medical situation, actually reads your different specialists’ reports, and makes everything happen. If all of us working in primary care don’t claim the authority that goes with this concept, health care will continue to fragment and become more and more inefficient. In my practice I see patients every week who have been discharged after a very brief hospitalization, with lots of loose ends that I have to pull together in order to keep the patient safe. Only if I have the time and resources to do this well will the hospitalization have been worth the time and money it cost.
What will the first year medical students of 2015 have to look forward to when they graduate from their residencies in 2022 or 2023, especially if nothing is done to strengthen Primary Care? They may have hopped on the band wagon too late to find the destination they expected, particularly in the shortage area of Primary care. By then we may have a lot more clinics within drug stores staffed by Nurse Practitioners and Physician Assistants, pharmacists may be prescribing for common ailments, psychologists will be doling out Prozac®, and RN’s will deliver telemedicine services backed by off-shore corporations with Medical Directors in other time zones.
We must learn from the Europeans and not prioritize specialty care over primary care so heavily. Only then can we provide enough preventive and basic health care to affect the ultimate cost of treating the chronic diseases that now drain so many of our healthcare dollars.
So, don’t give us more specialists! Give us well trained generalists, and pay them enough to make it worth their effort to work in the small towns and Community Health Centers where the underserved patients can get their health care needs met!
A Country Doctor Writes: 
Very well said sir. A good family doctor is more valuable than three specialists any day. I just retired after 40 years in small town medicine as a general surgeon who also did general practice for 15 years. My family docs were far more valuable to me, and the patients we cared for, than any highly paid specialist could ever be.
Most of the ‘new physicians’ in primary care are selling their souls to the highest bidder – usually the hospital they do residency at. Base pays of $210-250,000 are the norm, with ‘bonuses’ if you see over 30 per day (with EMR charting-time that means spending less than 6 minutes in the exam room per visit).
THAT is what our wonderful ‘third party payer’ system has created, and THAT is what we get when we dismiss ‘fee-for-service’ as a greedy-capitalist scam.
The socialized health care advocated by bureaucrats, insurance companies, and the physicians who see FAR higher incomes if they capitulate, is the real problem.
Day after day I mop up the messes, find the missed diagnoses, and treat far more efficiently the problems missed and poorly dealt with by the ‘system’ we have now. My comprehensive preventative care winds up costing about $500 per year for most patients, yet they are told by their insurers that they need to get care elsewhere where it will be ‘in-network’. When they need that bypass surgery, they will only have to pay 10% of it out-of-pocket so they think they are getting a sweet deal.
If they left the ‘system’ they probably would never need the bypass surgery, but that is too complicated for the public to understand when faced with endless propaganda from government and insurers, who have their own bottom-lines to prioritize.