Thursday, November 15, 2007

Too many doctors?

I read an interesting piece in the Atlantic Monthly last week questioning the almost dogmatic assumption that the United States is facing a physician shortage is the coming years. The link only gives you the first couple of paragraphs unless you're a subscriber, so either subscribe or buy the hard copy off the rack. We're always reading that we need to train more doctors, that with the aging population there won't be enough physicians to satisfy demand. But then I was waiting for the elevator the other day, reading the names of all the doctors on the peg board who practice at one of my hospitals. The board is 4x4 feet and just crammed with names, names, names. It's unbelievable how many doctors there are. There's two large GI groups. There's three general surgery groups. There's three separate pulmonary groups. The ID group has 7 doctors. (Don't get me started on ID again). And on and on. What we have isn't a physician shortage, but rather a physician overabundance. And I don't think it's too different at most suburban hospitals across the country. The scenario isn't one of overworked doctors struggling to keep up with the demands of patients waiting in line for care. Rather, it's a hyper-competitive world of doctors in the same specialty fighting over a limited supply of patients. Hence, all the ass-kissing and overwrought phony letters specialists have to send to primary care docs for "the privilege of assisting in the care of this highly interesting and fascinating patient." If I were to suddenly disappear from the face pf the earth like that Chris McCandless dude in "Into the Wild", the other surgeons here would be more than willing to swoop in and score my referral base. Patients would not be affected (other than in quality, of course). I mean, maybe if you live somewhere in the middle of nowhere in Nebraska or Wyoming, you worry about physician availability, but not in major metropolitan areas at private hospitals if you have insurance.

So here's a moral dilemma. As a physician in training, what obligations do you have to society in undertaking a career than is essentially one of service? Everyone wants to be a specialist. It pays more. It's more interesting. You get to do procedures. Maybe the lifestyle is better. These are important issues. You're just a human being with selfish desires like everyone else. Why should you go into primary care and work long hours at low pay, based in some practice in Coscocton, Ohio because there's a demographic need? Increasing medical school enrollments isn't going to solve the problem. You'll just end up with proportionally more cardiologists, more gastroenterologists, more cardiac surgeons to flood an already supesaturated metropolitan market. Until we compensate primary care/family practice in such a way wo make it financially appealing to medical students, there's still going to be physician shortages in South Dakota and Southern Ohio and Rural Kansas.

At Cook County hospital in Chicago where I trained, people wait 6-8 months to get their hernias repaired or gallbladders removed. Old guys show up lugging around these fifty pound scrotal hernias. At Northwestern or Rush, you wait a few days or weeks. If you're a VIP, you wait a few hours. Now, I'm not naive enough to be morally offended by this. That's the way the world works. Money talks. Nothing different than the way things have been for a thousand years of human interaction. But there are physician shortages. Right here in front of us. Right in the middle of cosmopolitan, wealthy, sophisticated Chicago. People go without access to health care. What is a physician's responsibility to help remedy this? We all go into six figures of debt to pay for med school. We defer gratification for material things until well into our thirties. And now we have to accept low paying jobs taking care of ungrateful patients in lousy isolated rural towns or inner city free clinics? I don't know. Maybe we should. It's something all docs need to explore, I think. I know I've been thinking about it. Doctors without borders, and other volunteer opportunites are an option. Maybe I'll have to show up one day in South Africa and see what I can do to help old Bongi.

13 comments:

Lizzie said...

May I suggest a bit of both worlds? Some docs enjoy their well paying practices most of the time and volunteer a few days a month at the local free clinic. It's a way to serve both areas and meet your own, well deserved rewards.

Anonymous said...

why not just limit the fellowship slots for cardiologists and gastroenterologists?
or at some point, with too many gi docs, they will either make less money or move to less served areas, addressing the problem. if we continue to oversupply them, then they will start doing some primary care or take further paycuts.

Bongi said...

just come visit.

Jason said...

I would have to disagree with the Atlantic. I recuit for my hospital (the VA) and we have an easy time recuiting docs for primary care here in las vegas. It is almost impossible to hire a GI doc or Cardiologist. It took me a year to get an orthopedist to work for 300k yr with a VA type schedule.

I do agree that there are health inequities in this country that need to be fixed, but this entire country has become a giant inequity between the have's and the have-nots.

I do agree that primary care docs do need to get paid more. Perhaps that will eventually happen, it has supposedly been coming down the pipe since 1995. Must be a long pipe.

janemarieMD said...

Jason, the VA is probably paying very competitive salaries for primary care, especially with benefits and some job security, whereas there's no way in hell the VA pays its cardiologists and gastroenterologists comparable to what those specialists can make in a group practice. It's all about the money. When primary care docs are paid enough that new MDs will feel it is a worthwhile career choice, more of them will choose it. For now they are going to specialties and hospital medicine in droves, and I wonder who is going to take care of us all when we need a doctor for general medical problems and old age.

Sid Schwab said...

It's an important rumination. As the world gets less and less altruistic, it seems unreasonable to expect that docs will or should get more and more. Maybe there will come a time when all docs are expected to be deployed where needed for the first two years (or so) out of training. If it were universal, it might both solve the distribution problem and be considered acceptable. But I'd like to think that other professions would be similarly mandated.

Anonymous said...

Maybe instead of ramping up primary care pay, pare back specialist pay. Of course, there's no way that's going to happen.

"why not just limit the fellowship slots for cardiologists and gastroenterologists?"- Bad idea, creates cartels with more leverage than they have already.

"Some docs enjoy their well paying practices most of the time and volunteer a few days a month at the local free clinic."- unfair expectation.

The way to address the "doctor shortage" is for the customer to pay the full fee with no government assistance. If medical bills stayed at their current levels legislating this would turn a "doctor shortage" into a "doctor surplus" with the stroke of a pen. Necessarily fees would plummet.

shadowfax said...

Well said. I couldn't agree more. And if you wonder why primary care pay lags behind that of specialists, look no further than the AMA and the RUC which sets the compensation levels for physician services.

I rant a bit about that over here at Movin' Meat

Cheers,

SF

Shawn said...

Maybe the gov't will flood the field with high-IQ doc's from India and China, to lower wages? (Snark)

By the way, I need to be paid more, and I am not a doctor, Government, government, where are you????

Anonymous said...

THERE IS NO SHORTAGE. I CANNOT STRESS THIS ENOUGH. I HATE TO SOUND LIKE A CONSPIRACY NUT, BUT WHO BENEFITS FROM A POSSIBLE DOCTOR SURPLUS? YOU KNOW, A TIME WHEN DOCS ARE STRUGGLING TO GET A JOB AND BARELY GETTING PAID, MAKING THE REGULAR DOC TO ACCEPT LESS AND LESS SALARY...THAT´S RIGHT, HOSPITALS, PHARMACEUTICAL COMPANIES, BIG MEDICAL GROUPS ETC. THE SURPLUS IN THE U.S. IS SOO HUGE YOU CAN ACTUALLY SEE IT FROM SPACE. OBVIOUSLY ITS ALL ABOUT THE MONEY: ONLY THE VERY FEW SEE THE INDIGENT AND UNINSURED. WE NEED TO CLOSE RESIDENCY PROGRAMS, LIMIT THE MEDICAL SCHOOL SLOTS AND MAKE IT A REQUIREMENT THAT ALL DOCS ACCEPT INDIGENT PATIENTS TO KEEP A STATE LICENSE: PROBLEM SOLVED

Anonymous said...

I want to get you started on ID again . . .

Anonymous said...

I want to get you started on ID again . . .

Anonymous said...

Stop the flow of all doctors from foreign medical schools...they are coming here in droves!!

You can't tell me the admission process is the same for them as it is here in the US...let alone the classes and the requirements.

I say only doctors that attend an American medical school can be eligle to practice medicine in America!,