If You Want More Doctors, Maybe Depending on the Feds is a Bad Idea

olgaolgaThe fiasco at the Veterans Health Administration is only the tip of the iceberg; the United States is running out of doctors, and soon we'll all be begging for scraps of medical care, warns Marina Koren of the National Journal.

The part about the physician shortage is probably true (though it assumes that the shape of the health care industry, and who provides care, is unchangeable). But that shortage is likely inevitable in a country that has come to depend on Uncle Sugar to foot the bill for graduate medical education (GME)—residencies—which has become a bottleneck now that the federal government is broke and in a lousy position to increase spending on anything.

Writes Koren:

America is running out of doctors. The country will be 91,500 physicians short of what it needs to treat patients by 2020, according to the Association of American Medical Colleges. By 2025, it will be short 130,600.

Like at the Veterans Affairs Department, demand will be highest for primary-care physicians, the kinds of doctors many people go to first before they are referred to specialists.

While students are applying to and enrolling in medical schools in record numbers, high interest does not necessarily mean more doctors. The number of residences—crucial stages of medical training—has not risen with the number of applicants, thanks to a government-imposed cap. The Association of American Medical Colleges has pushed Congress to change the law, predicting that there won't be enough residencies for young doctors by next year.

Sure enough, the American Medical Association is waging a campaign to "SaveGME," which just means that it's lobbying for more federal bucks to subsidize residencies. As it is, the federal government places a cap on residency slots that it is willing to subsidize through Medicare and Medicaid. That's because the current process is expensive with "the public investment per physician in training comes to half a million dollars or more, according to HealthAffairs. Health insurance companies also subsidize residency slots with higher payments to teaching hospitals, but the feds are the biggest source of funding for GME.

Note that in terms of physician training, this is the chokepoint. Medical schools are opening all over the place. But medical students pay for their education, while residents are paid, so everybody wants Uncle Sugar to pick up the tab.

But what if the feds did find some loose change in the already well-probed seat cushions to expand residencies? Would that necessarily alleviate the doctor shortage?

Not so much. The shortage is in primary care. Researchers find that "despite evidence tying access to primary care physicians to improved community health outcomes and decreased costs, medical student interest in primary care and, thus, medical school output of primary care physicians, has been declining."

The researchers propose all sorts of schemes for coordinating care and cherrypicking potential students who would want to go into primary care, without asking why students might not choose to enter a field where they would seem to have guaranteed employment.

But medical students aren't idiots. The realities of primary care, according to Dr. John Schuman, are "fifteen-minute visits with patients on multiple medications, oodles of paperwork that cause office docs to run a gauntlet just to get through their day, and more documentation and regulatory burdens than ever before."

So new doctors make logical choices—many become subspecialists working for hospitals where somebody else fields the paperwork and the paychecks are regular.

We have a shortage of primary care physicians largely caused by a bankrupt government that we've become dependent on to subsidize the education of primary care physicians. There just may be a common thread here.

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  • Fist of Etiquette||

    The choice for the government is obvious. A primary care physician mandate must be passed.

  • The Original Jason||

    If you're studying to become an engineer, a lawyer, or a teacher and not a physician, you are part of the problem. Your student loans will be denied unless you switch to studying to become a primary care physician.

  • Jordan||

    Yeah, that Selective Service system is just collecting dust. Why not put it to use?

  • anon||

    Congratulations! You've been selected to shovel shit all day every day for the rest of your life. The line for Beets is right around the corner from you too! Also, surrender all of your bread immediately.

  • Brandon||

    The thought of putting my health in the hands of Education majors is horrifying.

  • Rasilio||

    Actually if they are going to subsidize student loans it would make a hell of a lot of sense to give then out on the basis of which fields of study will give you the best chance of finding a job in that field.

    So taking money from womens studies majors and giving it to Med Students would not be the worst idea in the world.

  • Sevo||

    I'm sure we could check with Venezuela to see how the government is managing, oh, drinking water. They'll know how to handle this.

  • LiveFreeOrDiet||

    How do you screw that up? Water literally falls from the sky. 3/4 of the surface of the Earth is covered with drinking water ore. This planet is lousy with the stuff!

  • Sevo||

    Socialism is truly a magical system! But not in the Kruggy thinks.
    Or, Murphy had nothing on Marx.

  • ||

    Water literally falls from the sky.

    Lies!

    /Californian

  • gimmeasammich||

    You make your own water!

    /Kevin Costner in Waterworld

  • LiveFreeOrDiet||

    With OC/ACA there can be no shortages! Phlogiston for everybody!

  • The Late P Brooks||

    But la Propaganda Nacional Radio just told me the doctor shortage is a myth.

    Whom should I believe?

  • Brandon||

    Anything that goes against the narrative is a myth!

  • nova3930||

    "But medical students pay for their education, while residents are paid, so everybody wants Uncle Sugar to pick up the tab."

    Yeah, residents get paid, barely. Per hour it's entirely possible to make more working at McDs or Wal-Mart though. My wife spent her 3 years of 80 hour work weeks making right at $35k, which works out to a little over $8.50 an hour.

    If you're looking for the culprit in GME costs, resident pay damn sure isn't it...

  • anon||

    My wife spent her 3 years of 80 hour work weeks making right at $35k, which works out to a little over $8.50 an hour.

    I love how everyone that says this considers the value of the workplace education to be zero.

  • nova3930||

    The value isn't zero and I didn't imply it was. The discussion is about the costs of graduate medical education and the educational value recieved by the resident doesn't add to that, only their salary does.

  • C. Anacreon||

    She should feel lucky because she worked after residency hours caps were created (they're now 60 hrs/week, by the way, if she wants to feel bad.) When I was a first-year resident in San Francisco in 1986, we had 120-hour work weeks (36 hours on, 12 off, then 12 on, 12 off, then 36 hours again)and I was paid $21,000 for the year. That's about $4 an hour. But we did get a free bag lunch on overnight shifts!

  • Jordan||

    They routinely violate those caps.

  • Jordan||

    Or so I've heard, anyway.

  • nova3930||

    That is truth. It's one of those "Don't you dare go over X hours when your record your time but do what you've got to do to get the work done **wink wink nudge nudge***

  • nova3930||

    All this I know. The stupid hours both previously and in present time are what convinced me the GME system is not intended to educate doctors but to get as much work out of them for as little cost as possible. It's almost institutionalized hazing in reality.

  • nova3930||

    And the issue with paperwork is a big one. My wife spends 1.5-2 hours a night doing paperwork after she gets home from the clinic, with a singificant portion of it tied to new Obamacare reporting requirements. That in addition to working 7:30-5:30 every day for less $ than specialists. Doing everything we can to get it where she can just work when and as much as she wants describes us to a T....

  • Jordan||

    But medical students aren't idiots. The realities of primary care, according to Dr. John Schuman, are "fifteen-minute visits with patients on multiple medications, oodles of paperwork that cause office docs to run a gauntlet just to get through their day, and more documentation and regulatory burdens than ever before."

    And Medicare and Medicaid have such low reimbursement rates that doctors have to squeeze as many patients in as possible to even have a chance of making a profit. Fifteen minutes will probably seem generous in the not too distant future.

  • sarcasmic||

    Add to that the fact that O'Bummer Care insurance doesn't cover shit, leaving patients on the hook for the costs. Many of whom will not pay.

  • gimmeasammich||

    That's the part that people always seem to forget.

    The doctor has to go through as many patients as possible in a given day. To give *quality* healthcare you have to sacrifice the *quantity* of healthcare. They aren't mutually exclusive.

  • Almanian!||

    If You Want More Doctors, MaybeDepending on the Feds is a Bad Idea

    fixed that, JD. Welcome!

  • anon||

    Not sure I agree with the premise here. Just because Medicare/caid won't dole out residencies doesn't mean hospitals won't pay for them out of their own profits.

    In other words, I don't think this is a problem that needs to be solved; furthermore, Congress sure as fuck can't solve it if it is a problem.

  • Jordan||

    Congress sure as fuck can't solve it if it is a problem.

    That was the premise, I think.

  • anon||

    We have a shortage of primary care physicians largely caused by a bankrupt government that we've become dependent on to subsidize the education of primary care physicians. There just may be a common thread here.

    Hmm, maybe. It's kinda vague whether it's implied that the cause is a broke government or whether the cause is depending on government.

  • Brandon||

    If You Want More Doctors, Maybe Depending on the Feds is a Bad Idea

    Not that vague.

  • Adam330||

    Hospitals are pretty unlikely to do that under the current system. Why pay to train a resident when the resident can just turn around and work somewhere else?They'd have to be able to get some agreement from the doctor that they would stick around to make that money back, but that's verbotten now.

  • NoVAHockey||

    Sen. Sanders (I-VT) held a HELP subcommittee hearing on this a few weeks ago. It was about what you'd expect.

  • Rich||

    Obviously the solution is to require everyone to fill out a detailed health status report every year for automatic processing. You would do this on line, probably at healthcare.gov, and be referred eventually by a sophisticated algorithm to a specialist(s) based on the answers, which of course would be completely confidential.

  • GILMORE||

    Alt-Text should be "Fuck you = Pay Me"

  • GILMORE||

    "We have a shortage of primary care physicians largely caused by a bankrupt government that we've become dependent on to subsidize the education of primary care physicians. There just may be a common thread here."

    This vaguely reminds me of yesterday's comment where I said, 'Government doesn't just create more problems through its involvement, but does so on a scale so grand as to seem nearly impossible to fix without *blowing up the world*'

    (paraphrased)

    Meanwhile, we've got lefties shrieking that the ACA 'has slowed healthcare cost-growth' when there hasnt even been a single year of data to refer to.

    not mentioning that the admin is actively postponing/deflecting/rejigging things to attempt to ensure that next year's health premiums don't skyrocket. Yes, bully for you, progs. You've bet on a real winner.

  • Steve G||

    Call me crazy, but I'm sincerely considering taking the MCAT and applying to med school within the next year. I'm getting ready to either get promoted or retire from the mil, and if the former doesn't happen, I want a career change 180 out from my current field (logistics/maintenance) since it bores me to tears and I can't imagine trying to tolerate another 20 yrs in a civil service/DoD contracting gig of the same mind-numbing work.
    I'm reminded of the investing phrase, 'buy on bad news' since going to med school under the current circumstances seems like an insane idea, but that might be why it JUST MIGHT WORK!
    I look forward to your criticism.

  • GILMORE||

    Go for it

    be forewarned that what seems attractive from ones current position often turns out to be mind-numbing work of a different kind. The trick is to get paid enough that you don't care.

  • Steve G||

    Copy on the grass/greener bit. Has crossed my mind, esp when thinking I could wind up the sad primary care dude talking to the computer instead of the patient in the ridiculous 15 min appts they have now, but at least there's (for now) $ incentives and a range of actual specialties that career #2 could take. Also, I'd have an actual practical skill set, vs the mad powerpoint/outlook skillz I have now.

  • Steve G||

    I got the idea from a colleague who left the office last year, but instead of med school he went law school. After 25 yrs in this biz, he took the LCATs and all of a sudden he was getting spammed by law schools all itching to all but admit him. Granted, it wasn't harvard law, but who cares, he's on the beach in FL going to law school.

  • C. Anacreon||

    To be honest (and speaking as someone who's been a physician for 28 years) you'd be better off going for a mid-level certification such as Physician Assistant or Nurse Practitioner. In less than two years you will have most of the same opportunities that will be available to physicians, which would take a minimum of seven years of med school and residency the traditional way. And the way things are going, the mid-level practitioners will likely soon be paid very similarly, if not exactly the same, as primary care docs. Only the primary care docs will have, on average, over $200,000 in student loans to repay and the mid-level won't.

    It makes a lot of docs very angry but that's not going to stop the progression. The days of an MD being a hotshot profession are dwindling fast and it really won't be worth the time and money for the minor additional prestige of the title.

    I've told a number of other people this, it's not just ranting on a posting board. And if the physician social media sites are any indication, the majority of current docs agree. A recent poll showed something like 80% of current physicians wouldn't enter medical school today if just starting out.

  • Steve G||

    yikes, thx for the perspective. Of note, I plan on using the post-9/11 GI bill to foot (most of) the med school bill...if that sways your advice any.

  • Dweebston||

    Where's PBP been? Did he tire of ministering to the unwashed masses here? Or is news finally so gloomy even he can't read from his bulleted list of talking points without grimacing?

  • muskegonlibertarian||

    We should remember here that thanks to prescription laws, doctors effectively have a government enforced legal monopoly over access to medical drugs. Remove that legal monopoly and the picture changes. The comment made about nurse practitioners and physician assistants is also valid as both of these occupations allow you to write prescriptions. So at a lower fee level, these occupations are likely to eventually replace primary care MD's. The MD's will likely be all specialists instead, as they offer a level of service well above the primary level.

  • Jayburd||

    Eventually the Gov will have to control costs at the expense of physicians by limiting reimbursements or the actual number of doctors that can get reimbursements. Then you will see the medical profession become very unpopular as a career choice. Invest in private clinics overseas.

  • GamerFromJump||

    I hear Singapore is nice...

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