America Needs Different Doctors, Not More Doctors

November 10, 2011

The Obama administration is about to unveil a $1 billion plan to beef up the nation’s health care workforce. The goal, in part, is to increase the number of physicians available to serve the nation’s aging population.

If one takes a superficial overview, one can find evidence to back up claims that the U.S. suffers from a physician shortage. According to data from the Organization of Economic Cooperation and Development, cited in a blog post by Matt Yglesias of Think Progress last week, there are only 2.4 practicing physicians per 1,000 population in the U.S., second lowest in the OECD and somewhat below the 3.0 median (the range is from 2.2 physicians per 1,000 population in Japan to 4.0 in Norway). Moreover, the average U.S. medical consumer sees a physician only 3.9 times a year compared to the 6.3 OECD median. Yes, we pay more for physician services (average pay for U.S. physicians is higher than six other well-off OECD countries, whether it’s highly paid orthopedic surgeons or relatively poorly paid primary care docs). But we pay more for everything in health care. The bottom line is that America needs more docs, the administration and Yglesias have concluded.

This is a classic case where picking out a few trees as signposts in a dense forest of data leads one down the wrong path. His own charts show that the relatively small population of Japanese physicians enables that country’s general population to see a physician a stunning 13.2 times a year, twice the OECD average. One gets an image of a team of six doctors greeting every patient who walks in the door. Actually, that isn’t far from wrong. During my most recent trip to Japan in August, I visited a community clinic in Kumamoto Prefecture that provides annual wellness exams to local citizens, which is a reimbursable service under their national health care system. Indeed, every person is given a day off work to get this exam. At the clinic, the patients moved from room to room. At each stop over the course of a day, they were examined by different physicians and technicians who specialized in various aspects of  personal health. A small number of doctors. A high level of primary preventive care with many hands-on encounters. Few visits to high-priced surgeons. Low overall health care costs.

The real issue lies in the physician pay, which Yglesias touches on but draws the wrong conclusion. He forgot to pull the crucial statistic: the distribution of doctors among specialties in U.S. and their relative pay. Here’s data from the Bureau of Labor Statistics annual occupational employment survey:

Occupation Employment Annual mean wage
Dentists, General                    87,700 $158,770
Oral and Maxillofacial Surgeons                      5,330 $214,120
Orthodontists                      5,580 $200,290
Prosthodontists                          670 $139,620
Dentists All Other Specialists                      5,010 $162,190
Optometrists                    26,480 $106,750
Anesthesiologists                    34,820 $220,100
Family and General Practitioners                    97,820 $173,860
Internists General                    50,070 $189,480
Obstetricians and Gynecologists                    19,940 $210,340
Pediatricians General                    30,100 $165,720
Psychiatrists                    22,690 $167,610
Surgeons                    43,230 $225,390
Physicians and Surgeons All Other                 293,740 $180,870
TOTAL                 723,180
Source: Bureau of Labor Statistics

If you look over that data carefully, you’ll see that there are nearly as many anesthesiologists and surgeons (78,050) as there are family and general practitioners (97,820). The median salary for the former group (which most people only see once in any given year, unless they’re unlucky or very, very sick) is about $50,000 higher than the latter group. As has been reported many, many times by the Dartmouth Atlas of Health folks, we have a severe over-utilization problem in the U.S., driven in large part by the U.S.’s very high rates of coronary interventions, urological surgeries, and orthopedic surgeries (artificial knees, hips and backs).

Imagine getting rid of, say, 30 percent of those unnecessary surgeries (this again is the Dartmouth derived number for their estimate of over-utilization in the U.S.). This could, of course, lead to about one-third fewer surgeons without generating long queues for their services. But rather than laying them all off (ha!), imagine they were magically transformed (perhaps a local medical school could set up a retraining program) into general practitioners who would see and manage patients in Accountable Care Organizations (and who would properly oversee patients with chronic conditions so they could avoid needless surgery). You would then have the same number of doctors, more patient visits, and save billions annually in reduced physician salaries (they’d be earning at the median about $50,000 a year less).

Or, you could take the $50,000 per year saved from the one-third of surgeons who lost their jobs and end the “doc fix” problem on Capitol Hill. Or, you could provide new slots for just-out-of-med school general practitioners. In other words, you’d have more docs or higher paid (general practitioner) docs, or a mix of those two approaches without increasing overall health care costs.

Do we need more docs? Of a certain kind, yes. But overall? In my view, absolutely not.

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4 Responses to America Needs Different Doctors, Not More Doctors

  1. Dr Robert Schertzer on November 14, 2011 at 6:56 am

    They tried this in Quebec when I was finishing my ophthalmology residency in 1994 – restrict where any specialists can get licensed to practice within the province and only allow general physicians everywhere. I fled the province for good as did most grads. The result was complete decimation of the healthcare system because as economical as it sounds to have a healthcare system of mostly GPs, specialist are still very much needed. This is similar to the principical that most healthcare systems seem to adhere to these days – they can save so much more money if they didn’t have to actually care for any patients. Sorry, but yes it does cost the system money to have patients get healthcare and getting rid of specialist does not fix things anymore than stopping to provide any healthcare to patients does.

  2. David Welch, RN on November 14, 2011 at 10:57 am

    Oh so very true! And has a simple, but relatively long-term solution – cut the cost of medical education. Docs today come out of school with massive student loan debt. Many of them would love to do primary care, but they look at the economics and conclude that they’ll be living in poverty until the student loans are paid off. So they go into a more lucrative specialty. And when you have more specialists it’s guaranteed that you will get more of what specialists do: expensive tests, surgeries and procedures. Along with this, we need to rebalance payments to better reward office time relative to procedures. This would even improve many of the specialties that provide actual patient care – especially the internal medicine subspecialties like oncology, cardiology, nephrology. But the place to have the biggest impact is in the cost of education. In France, the foreign system I know best, medical education is hard to get into, demanding to do, but basically free – and that’s how you get the right number of primary care docs.

  3. Ann Fonfa on November 14, 2011 at 11:11 am

    What do we know about the oncologists/hematologists? Salary? Distribution? Love to know that.


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