The Grand Illusion
The other day my wife discovered that she couldn’t get her yearly eye check-up until September, because her ophthalmologist was booked up that far in advance. Dental appointments need to be scheduled a month in advance, except for emergencies. So do yearly health check-ups. The time-lag for all of these health-related matters has been creeping up year by year.
The reason is simple. While few are talking about it, the population of the United States is growing faster than the number of physicians. Some of this has been disguised/alleviated by nurse practitioners and physician assistants providing some services, but there are more and more areas of the country without physicians, with more than 80 million people in the US living in areas in which access to a primary care physician is scarce or non-existent.
In many fields, higher pay creates more incentives for people to get the training and experience, but in medicine in the U.S., the number of doctors is limited by the number of medical schools and the number of openings for residency positions available. Currently, almost 1,000 medical school graduates every year cannot obtain a residency position, and those numbers are growing. Without successful completion of residency, those medical school graduates cannot be certified to practice medicine.
Residency programs are expensive to operate, and most hospitals rely on federal support, but the number of federally supported positions has been fixed at the current level for several years, which isn’t adequate to provide training for all the M.D./D.O. graduates, particularly since 35% of all current physicians will reach retirement age over the next five years. At the same time, because of the increased work-load, including more and more paperwork, doctor “burn-out” is increasing, and more doctors are retiring earlier and/or cutting back on working hours.
The most obvious result of the high cost of medical school and the shortage of residency positions is that inner city and rural areas are the most impacted. That impact is reflected in the fact that while the U.S. spends more than twice as much on health care per capita as do other high-tech societies, that spending is disproportionately targeted to advanced medical systems and technologies. For all that technology, the U.S. has the highest number of hospitalizations from preventable causes, the highest rate of avoidable deaths, and the lowest life expectancy among the 11 OECD nations… and one of the highest rates of maternal and infant mortality of all developed nations.
Studies from all over the world show that the availability of doctors makes more of a difference in the health of most people than a plethora of high-tech medical technology that primarily benefits the well-off or fortunate, and, not surprisingly, the U.S. also has fewer physician visits per capita than in most other developed countries.
And unless matters change, the situation is going to get worse.
Medical school and CME assure doctors have the available data to be “medical care givers”. Only the combination of knowledge and empathy can potentially cure a physician’s or (even) a surgeon’s patient.
70 or more years ago doctors handed the embarrassment of asking for payment to insurance companies (the government became one of those insurance companies later). Now these companies are between the doctor and the patient. The medical profession is a business paid as if for piece work and as such there is little time/opportunity for empathy. Doctors have a high suicide rate. Perhaps it is just a sign of the times?
https://www.straitstimes.com/singapore/what-is-the-point-singapore-has-more-quiet-quitters-than-global-average-survey-shows
Social problems and psychological problems of poor inter-personal engagement may be the cause of our observations? Wine Guy and others may know for sure.
Ironically the doctor shortage isn’t a US specific issue, it’s pretty common all around the world.
Mostly because the majority of medical professionals aren’t in the sexy daytime soaps of surgery, they’re in the endless drudgery of General Practice. And GP work doesn’t pay nearly so well, despite being a lot harder – it’s more challenging to be up to date as a generalist than a specialist.
People don’t want to live in the country and work long hours, so rural practices are struggling. Ageing populations mean people are breaking in more complex ways than they did half a century ago.
Modern medical practices are more complex, drug and medical interactions more challenging, and the paperwork is triple what it was in order to try and keep everyone accountable. That’s a recipe to drive the younger doctors out of general practice, which is already seen as lower status.
Add to that four years of high intensity burnout and there’s some big holes across the board internationally in most medical systems. You see it in Australia, in the UK, in Japan, even India and China who train thousands of doctors.
The US just cops it worse because of the complexity of how insurance works and the legal costs of potentially being sued or harasses by both practice and patients, especially should some group get outraged by the sorts of medicine performed. And you can’t fix that easily because there are hundreds of thousands of jobs interlinked to the medical and insurance industries – any change is a guaranteed vote loss.
as someone living in Australia, I tend to agree with your overall view. Locally, we have a couple of other factors although I don’t know how well this translates elsewhere. First is the limitation placed by our AMA on any attempts to improve the number of positions. Given that the government funds hospitals, there should be fewer barriers but this particular union exerts an outsized influence on the availability of the doctor “resource”. The second seems to be an increasing corporatising of GP practices where the GPs become employees and don’t have as much skin in the game as they used to. Having moved relatively recently to a remote-ish area, I can attest to LEM’s observations about the availability of GPs in rural environments
Another issue that hasn’t been covered is the cost of starting up a practice. I have watched my physician go from a resident, to a practicing physician in someone elses practice, and then to owning a practice. The barrier to entry is huge. The rewards are large but it is going to be difficult to make the transition in a rural community where it will be more difficult to get a loan. This is why the doc-in-a-box places are on the rise. But they don’t build a long term patient-physician relationship.
Speaking as one of the dwindling number of MD/DOs in the US…. There are new med schools being founded and current med schools are expanding, but not enough and not widely spread enough. Plus, there aren’t enough residencies for post grad training and those are NOT expanding because they are even more expensive than med schools. The residencies are what separate new docs into the various specialties, Fam Med, Internal medicine, surgery, etc.
What it will take is a prolonged political will and far reaching vision. These are not hallmarks of the US political system at this time.