Supply of physicians will be adequate through 2020
Threat of too few doctors not real, study suggests
Bleak reports threatening that there will be too few doctors to manage the growing elderly population are wrong, according to researchers at Dartmouth Medical School’s Center for the Evaluative Clinical Sciences (CECS). In a recently published study, they argue that if employed efficiently, the current supply of physicians and medical students will be adequate through 2020.
The Association of American Medical Colleges (AAMC) and others, warning that population and economic trends will necessitate a greater and greater supply of physicians, have called for expanded enrollments at medical schools. But David Goodman, MD, professor of community and family medicine and of pediatrics at Dartmouth Medical School, and his CECS colleagues assert that shifting the current work force to more efficient practice styles would avert the need to train additional physicians.
"Spending millions of dollars annually to expand our capacity to train physicians will not only create an oversupply, but will also divert health care dollars from care that has been shown to improve the health and well-being of patients," writes Goodman.
Instead of expanding the number of physicians being trained, Goodman and his team write, efforts should be aimed at increasing the efficiency of medical practice and directing resources to care that has proved to be effective. They cite as an example the large interdisciplinary (or multispecialty) group practice, a structure that has been in place in many parts of the United States since early in the 20th century, as a model of both clinical excellence and efficiency.
One such practice, the Mayo Clinic in Rochester, MN, is widely viewed as one of the most outstanding providers of medical care in the United States, despite using fewer doctors and fewer resources in managing patients with chronic illnesses compared to other academic medical centers, they point out.
Using the Medicare claims database to examine the experience of chronically ill people who received most of their medical care at academic medical centers, the researchers calculated the physician work force inputs per patient during their last six months of life. Their analysis found that the full-time equivalent physician input per 1,000 chronically ill patients varied by a factor of five, from about six per 1,000 to almost 30 per 1,000.
For example, patients treated at the Mayo Clinic used fewer than nine physicians on average, among the lowest in the country, while patients treated at New York University Medical Center, another medical school-affiliated facility, used 28.3 physicians per 1,000 in the six months before death.
Goodman says the results seem to support the idea that "less is more, and that quality of care, rather than quantity, is the critical factor."
The research focuses on the management of severe chronic illness because it is the area where health care resources are most heavily used—about half of Medicare’s budget goes to the care of chronically ill Americans. Additionally, the need for such management is expected to increase as the population ages and baby boomers acquire a growing number of ailments.
Prior studies by CECS have demonstrated that in some parts of the country, people with severe chronic illnesses receive more physician care in visits, hospitalizations, and procedures than people who live in areas with fewer physicians per capita. But contrary to popular belief, patients who have more doctor visits and treatments do not realize a benefit. Instead, Goodman points out, evidence shows they may actually be harmed by unnecessary medical care. If all medical practices adopted the practice style and resource use of efficient providers, he continues, patient care would cost less and patients would be less subject to interventions that could do more harm than good.
The argument for expanding the physician work force is based on a faulty assumption, according to the authors. Proponents reason that the practices of the highest-intensity medical centers where many more doctors and resources are used in providing medical services at the end of life, should be the standard for the country as a whole.
"Instead of financing further growth in our medical education system, resources might be better directed to reorganizing delivery systems that have already demonstrated that they can deliver good care at relatively low cost," the authors write. The study appears in the March/April 2006 issue of Health Affairs.
AAMC: Problem is not unequal distribution
The AAMC, in a fact sheet distributed with its 2005 position advocating more medical school admissions, notes that while there are serious problems with the geographic distribution of physicians, their forecasts indicate a much bigger problem.
The AAMC asserts that what it foresees as an increasing shortage will only make the distribution inequities worse, especially in areas already underserved.
"We don't disagree that there are variations that we need to understand and that there are inefficiencies in the system," says Edward Salsberg, AAMC associate vice president and director of the AAMC's Center for Workforce Studies. "But that doesn't change our position that we'll face a shortage in physicians, and that even if we can improve efficiency, there's strong evidence that we need to increase U.S. medical schools' production."
- David Goodman, MD, professor, community and family medicine and pediatrics, Dartmouth Medical School, Hanover, NH. E-mail: email@example.com.