politics
The Health Care Crisis
Part Three: Potential Remedies
Introduction
Having established that we do, and will continue to, face a shortage of physicians in coming decades, are we currently doing anything about this? Do we have a plan to address this problem in the future?
Class Size and Number of Medical Schools
The number of available positions in medical schools has changed little in the past twenty years, in contrast to a steadily increasing population of people who require medical care. The surge of potential patients resulting from the maturation of “Baby Boomers” can only complicate matters further.
It has been proposed that we may simply increase the number of available positions in medical schools, or perhaps build additional medical schools, to meet that projected need.
Some medical schools have indicated that they intend to do just this, but how many new positions are proposed?
Information from 58% of medical school deans and 86% of state medical society executives provided information regarding their perceptions of shortages or surpluses of physicians by specialty and any plans to increase medical school class size.1
85% of both deans and medical society respondents perceived shortages of physicians, usually in multiple specialties, while only 10% perceived surpluses. There were reports of planned increases in class size, but also some reports of plans to decrease class size. If reported changes in class sizes were generalized, we could expect a 7.6% increase in matriculants annually.
This represents an increase in capacity that is woefully inadequate to alleviate anticipated shortages simply by expanding class sizes.
Most of today’s medical schools expanded in the 1960s and 1970s, making further expansion unlikely. New schools built during this period were smaller and could potentially expand more, but there are fewer of them.2
Public medical schools are dependent upon public funding to increase class sizes.
Suppose that by an act of God medical school positions increased by 50% each year until there were more positions available than anyone could have ever hoped for. Would this do anything to change the trend of the most qualified college graduates opting for alternate careers, or would we be left with a glut of poorly qualified students to fill those additional positions and a subsequent abundance of poorly qualified physicians?
Even if substantial increases in medical school class sizes were possible and practical, it would do nothing to address the issues related to the quality of applicants and the decline in retention.
Affirmative Action and Foreign Physicians
Exaggerating the current disparity between requirements for minorities and non-minorities and relaxing the standards for physicians trained outside of the US would undoubtedly create more warm bodies, but again, we are left with the question of trading quantity for quality.
Quality Not Quantity
If Dr. Goodman3 is correct in his assertion that we need only focus on the efficiency and quality of healthcare delivery, rather than the number of physicians we produce, additional medical school positions may not be necessary.
However, we are then left with the task of accomplishing this feat. While he offers the Mayo Clinic as an example of “just how to do it”, it is difficult to imagine that we can transform any, not to mention the majority of programs around the country, to approximate the Mayo model. There are numerous aspects of the Mayo Clinic model that make it unique and distinguish it from any other organization of this type.
Curbing Decaying Retention
Given the reasons that physicians cite for leaving medical practice, an effective intervention at this level would be politically complex and unattractive. It would likely involve substantial increases in reimbursement by both the government and insurance companies, neither of which seem prepared to consider this option.
It would also be necessary to at least consider a reduction in the hours worked, especially with respect to “on-call” responsibilities, an equally distasteful proposition for government and insurance carriers.
A reduction in government oversight and regulation would be the easiest change to implement, but who can imagine this possibility.
Aggressive malpractice reform would undoubtedly invigorate every physician currently in practice, but who could predict how beneficial this might be in terms of swaying physicians who are currently taking a hard look at retirement or a career change.
Summary
All things considered, the bottom line seems to be embarrassingly simple and painfully clear. We must make every effort to fully restore the practice of medicine to what it was when “the best of the best” were clamoring outside the doors of every institution across the country that provided medical education.
This would be no simple undertaking and initially would involve radical changes in a number of areas. Is anyone prepared to make those changes?
It will not be enough to simply pay physicians what they are worth (earnings something short of what professional athletes or entertainers currently command). In the beginning, they will demand shorter hours, better benefits, less litigation, autonomy, respect and influence, but all of this will not be enough.
It will be necessary to reassure practicing physicians and apprehensive prospects that the government’s refrain from excessive interference and any diminished exploitation by insurance companies is not merely a subversive and temporary hiatus.
Sadly, even if the ministrations offered are genuine and sincere, many physicians will simply be unable to muster the trust necessary to again risk everything in the hope that there will be lasting change.
Certainly there will be those who can, but even all of these concessions will not be enough to avert some degree of cataclysm. There will be a considerable lag before the investment and sacrifice necessary to complete twelve or more years of rigorous training after high school again yields the high esteem that once characterized medicine and continues to distinguish other professions.
Until then, we will be forced to swallowed a bitter pill.
1Cooper, RA, Stoflet, SJ, Wartman, SA Perceptions of Medical School Deans and State Medical Society Executives About Physician Supply JAMA 2003;290:2992-2995
2Cooper, RA. Medical schools and their applicants--an analysis: if more physicians are required, can medical schools fill the gap? Health Affairs. 2003;22(4):71-84.
3The Healthcare Crisis Part One: Are We Facing a Shortage of Qualified Physicians?
(Sources: The author’s knowledge base, unless otherwise noted.)
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