Too Many Doctors?
everal national and regional surveys have indicated an overabundance of physicians, and the gap between supply and demand may widen as managed care continues to grow. So why should medical schools like the University of Miami and teaching hospitals like Jackson Memorial Hospital continue to train physicians? And how will society and the medical center respond to an oversupplied marketplace?
Christopher Dudley, assistant vice president for medical communications, discussed these issues with Gerard Kaiser, M.D., professor of cardiothoracic surgery, senior vice president for medical affairs at Jackson Memorial Hospital, and deputy dean for clinical affairs for the University of Miami School of Medicine. Active on the 1996-97 panel to examine the status of the physician workforce of the State of Florida, Dr. Kaiser oversees Jackson's graduate training programs, among other areas.
CD The American Medical Association, the Pew Health Professions Commission, and several other independent studies have concluded that the United States has too many doctors, especially as practice moves toward a managed care model. Why keep training physicians?
GK This is a most complex question-especially for the state of Florida, which is still a net importer of physicians due to the needs of our increasing population. If there is an issue concerning the number of physicians, it relates to the number of specialists currently practicing, the need for generalists, and a geographic maldistribution.
CD Is economics driving some of that?
GK Until recently, medicine has not responded the way most businesses would in the marketplace. In a business model, if you have four gas stations at an intersection, each would charge less until the competition is driven out of business. In medicine, if you have four specialists in a town, they would each see fewer patients but continue to practice.
CD Which is at least one reason why health care costs have risen.
GK Possibly; however, this happens less today because of the constraints of managed care, reductions in reimbursements from government programs [Medicare] and from managed care case and disease management, and the development of practice profiles in the hospital.
CD Pundits say we need a 50:50 ratio of primary care physicians to specialists. How will we get there?
GK That ratio reflects the staffing model in a full managed care environment. The change in absolute numbers will take many years because physicians currently in specialty training are completing those programs. I believe it will be the marketplace that will ultimately determine career choices within medicine.
CD Can some of that be effected by the way graduate training is funded?
GK There are several ideas on the national level. First, we've got to determine how to fund the costs of graduate medical education, which is currently funded by Medicare and by disproportionate share funds. There are several proposals before Congress that seem to be coalescing around an all-payer system, which would tax all health insurance premiums by probably one-half to 1 percent; that would raise the necessary dollars.
CD Another proposal is to limit the number of graduates from foreign medical schools getting their training in these programs?
GK Each year, there are approximately 17,000 graduates from U.S. medical schools for 25,000 graduate training positions in hospitals like Jackson. The balance is made up by international medical graduates (IMGs). Remember, there are many U.S. citizens who receive their medical education at foreign medical schools, and they want to come back to this country to practice. Proposals range from limiting the number of graduate training slots to the number of U.S. graduates or capping them at 110 percent [approximately 18,700]. Of course that would do nothing to direct graduates toward primary care careers.
CD How would that happen?
GK There have not been any mandates from Congress or draconian measures that, for example, would call for forgiveness of student loans if the new physician chooses a career in primary care. Many of our students are more than $100,000 in debt when they graduate. In the last three years, more than half of the University's graduates went into primary care-at least starting out in family or internal medicine, general pediatrics, or obstetrics and gynecology.
CD Is that driven by the marketplace?
GK Absolutely. Since there's no mandate, the marketplace is driving it for several reasons: starting salaries for primary care doctors have gone up over the past two to three years, and some of the starting salaries for some of the traditionally high-paying specialties have gone down, as well as the expectation for later salary increases. Ophthalmology, orthopaedics, and other specialties have been under tremendous income pressure.
CD With not as many people choosing some of those highly specialized areas, are the IMGs making up the difference?
GK Yes, and that's okay because they need that expertise in their countries. We should keep training IMGs because graduate medical training in this country is better than anywhere else in the world. For three decades, the Harrington program has attracted the best and the brightest graduates from medical schools in Central and South America. Over 240 residents [more than 1,600 includ-ing medical students and residents spending rotations] have come, and about two-thirds of them have returned home.
CD Assuming at least some of these restrictions will become reality, will this affect the quality of people attracted to medicine?
GK The quality of applicants
to medical schools has continued to remain high, and the number
of applicants remains high. So despite the bad press about medicine
as a profession, I think that it will still attract individuals
who enjoy caring for people and will give personal satisfaction
as well as attractive compensation-not necessarily the large
incomes of years past, but a comfortable lifestyle nevertheless.
CD Patients are becoming highly educated consumers. How will physicians adjust to that change?
GK We need to educate physicians to spend time with patients and return to some of the values in medicine's earlier days. We've gone from high-touch, low-tech medicine at the beginning of this century to a high-tech, no-touch approach. We need to go to high-tech, high-touch medicine that allows us to diagnose quickly and to devise a treatment plan that will reduce costs and avoid duplication.
CD How will that happen?
GK A very important role for our medical center is to define quality care and do outcomes research, where we find the best strategies for treating patients. We've got to define "value," because in some cases it may be better to spend additional dollars up front to have the best long-term outcome for the patient and society in the most cost-effective manner.