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Too Many Doctors, But Too Few Primary Care Ones

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As a result of the recent passage of the health care bill an increased number of Americans will be insured and require medical care. More primary care doctors will be needed to direct much of that care. Along with the expanding patient pool, there has evolved a changed American mindset concerning the role of primary care. This transformation is based on the realization that a primary care based medical system both controls medical costs and improves quality of care far better than a specialist based system. These changes -- more insured patients and a greater importance placed on primary care medicine -- will worsen an already long-standing shortage of primary care doctors present in America. There are now about 355,000 primary care doctors in the U.S. but the Association of American Medical Colleges predict that at least 45,000 more will be needed by 2020.

From the 1960s to 2002, about 25,000 new physicians went into practice yearly with the physician population in the U.S. increasing at a rate of 3% while the general population increased at only 1% yearly. As a result each year the concentration of physicians in the population increased. However, the vast majority of young doctors have sought careers in specialty areas, which has caused the primary care shortage to worsen. To address this shortage, a national policy has been initiated to increase the total number of medical school graduates. Since 2002 new medical schools have been opened and existing medical school classes have been expanded. This past year, the freshman medical school class was increased from levels a decade age by over 3,000 students with the goal of eventually increasing class size by 5,000 in 2116. The hope is, that by increasing the number of medical school graduates sufficiently, enough new doctors will be available to fill all the specialty residency positions and still leave over a large population of physicians who will go into primary care. How this increase in American medical graduates will affect the 9,000 foreign medical graduates who come to the U.S. to practice is unclear, but the likelihood is that the overall physician population will increase overall 5-10% faster than the general population.

Although we clearly need more primary care doctors in the U.S. if we want to provide the best care possible and also control costs, the plan outlined will only make the situation worse. For, although we have a primary care doctor shortage, we do not have a total physician shortage. The present concentration of physicians in the U.S., 29 doctors per 10,000 people, compares favorably with most countries and is considerably higher than many countries, like Japan, Canada, New Zealand, and the United Kingdom, that are generally regarded as having better health care systems than the U.S. Other countries with worse health care systems, like Bulgaria, Azerbajin, and Kazakistan, have even higher physician concentrations than the U.S. So the concentration of physicians in the overall population bears only a weak correlation with the quality of medical care. Attempting to increase our physician concentration avoids addressing the real problem: an overspecialized physician population.

An ideal health care system consists of 70% primary care doctors -- internists, family physicians and pediatricians -- and 30% specialists. Unfortunately, America has it backward-70% specialists and 30% primary care. This overspecialization results in needless tests and procedures and compromises quality. Our maldistribution of physicians is a major cause of our overpriced, yet underperforming, health care system. Throwing more doctors into the mix will inevitably result in higher costs since American medicine does not obey the usual laws of supply and demand. Doctors create their own demand by recommending more appointments, tests, procedures and surgeries to their patients. More doctors, more medical care -- even if that care is not really indicated.

A rational approach to correcting the problem, and one more effective than just graduating more doctors, involves looking at the root causes for our top-heavy physician population. Certainly life style plays a role, with specialists enjoying greater income, generally easier hours, and higher social prestige than primary care doctors. These inequities are being discussed at a national level and attempts to narrow the financial gap are being proposed. But the overabundance of training programs is also vitally important and needs to be addressed. It is in the interests of medical centers to have highly specialized training programs and they produce far too many specialists to serve our best national medical interests. Specialty residency programs, all of which are supported by the government, must be limited so that only the optimal number of specialists are trained to meet America's needs. With fewer specialists, more doctors would be available to go into primary care. In that way, both the specialists glut and the primary care shortages could be corrected. Cost would be better controlled and quality improved. The transition to having a ratio of physicians that provided the best care possible would necessarily take years to achieve; but it is achievable and must start soon before we go too far down the wrong path.