Where have all the doctors gone?

By Joseph B. Martin

imageTHE QUESTION OF whether there are enough doctors to care for patients, particularly if the nation moves toward a new scheme for universal health coverage, is the elephant in the room of the presidential campaign debate on health reform.

Fifteen to 20 years ago there were worries about too many doctors, particularly in some specialties. Now, the Association of American Medical Colleges is requesting medical schools to increase enrollments by 30 percent over the next seven to 15 years.

Serious shortages are expected in fields like general surgery, particularly in smaller urban centers and rural districts, and in neuro-ophthalmology, where doctors, unlike ophthalmologists, have a tough time making enough to pay off school debts.

And with an aging population there will be an increasing demand for geriatric medicine as well.

But the gravest concern is about the lack of primary care doctors to work in settings where the patient load is high and the pay is less.

Indeed, Massachusetts is finding that there are not enough primary care venues to deliver care to all the enrollees in the new universal healthcare plan.

Let’s step back and put this medical supply-and-demand equation in context. Every year US medical schools graduate about 15,000 students. They welcome another 6,500 foreign medical graduates into first year post-graduate residency slots; most of these international graduates will remain in the United States, unfortunately depriving their home countries of the work force required to deliver adequate medical care there.

Where do all the new doctors go? The current view is that they are hitting the ROAD: Radiology, Ophthalmology, Anesthesiology, and Dermatology. In all these specialties the pay is better and lifestyle issues permit regular work hours, a point often of great importance to women graduates, who now make up a full 50 percent of the graduating doctors.

I’ve done some checking on doctors’ career plans based on their residency match. They show some distinct trends. At both Harvard and the University of Rochester medical schools, for example, 16-27 percent of the graduates chose internal medicine, 10-15 percent pediatrics, 4-11 percent obstetrics and gynecology and 7-11 percent general surgery. Sadly, at the low end of the spectrum, less than 5 percent went into primary care and family medicine.

This march into more lucrative medical specialties is severely crimping the ranks of needed primary care doctors at the very moment the demand for primary care is on the rise.

So what can be done to deliver the quality of care expected by patients? How will healthcare increasingly focus on the importance of prevention and public health measures – encouraging parents to vaccinate their children, supporting major initiatives to stop smoking, developing regimens for weight control that actually work, and turning the focus from treatment to preventing and managing chronic diseases?

The solution entails more than simply producing more doctors; it requires educating doctors and care givers in new collaborative ways. Those who are trained need the right training and the right jobs with the right pay commensurate with the contributions made.

But most important, new models of healthcare delivery must be developed – with a new focus on team work, where, for example, doctors, nurses, pharmacists, and social workers form efficient groupings to consider patient-centered care. Teamwork and new ways of delegating treatment will take the load off of the hard-pressed primary care physician.

Also needed to be addressed is the disparity in reimbursement where doing procedures pays well but thinking deeply about a patient’s problems has financial limitations. Reimbursements should be based on quality of care, not quantity.

Bottom line: the new requirements in medical care require new thinking in how to deliver that care.

And new thinking is what is needed in an election year featuring a major debate on healthcare. This debate needs to move beyond the issue of access and coverage to how the delivery system can be restructured to provide the best healthcare possible at an affordable cost.

So let the real debate over health reform begin.

Dr. Joseph B. Martin, professor of neurobiology and former dean of Harvard Medical School, is chairman of the New England Healthcare Institute.

© Copyright 2008 Globe Newspaper Company.

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