Posts Tagged 'Medical Education'

New Doctors: Too Few, Too Many or Too Late?

There are too many doctors in the U.S according to Dartmouth’s Goodman and Fishers 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!

Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.


CONDITIONS, Chapter 1: An Old, New Diagnosis

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