One of the many, many things that drove me nuts about the health care debate was this framing:
There are not enough primary-care doctors to meet current needs, and providing health insurance to 46 million more people would threaten to overwhelm the system.
Obama administration officials, alarmed at doctor shortages, are looking for ways to increase the supply of physicians to meet the needs of an aging population and millions of uninsured people who would gain coverage under legislation championed by the president.
Health care is always presented in terms of scarcity and fear, where those who we politely term “the uninsured” are going to be mobbing in and grabbing a piece of a fixed “system” that is currently parceled out to “the insured”.
Now that those of you who go without primary care might have a way to pay for it, we’ve hit a brick wall on delivery.
We in the system are afraid you will overwhelm the system. There simply isn’t enough to go around. Sorry.
Is this how a mature grown-up country behaves?
Why not just calmly and deliberately look to providing the service, now that the payment mechanism is or will be in place? People who are terrified generally don’t make good decisions. Maybe we could stop scaring both those “in the system” and those with their noses pressed up against the glass?
Thirty million people who will now have a method to pay for health care isn’t horrible and frightening. It’s a good problem to have. It’s simply the predicate to the next step, which is delivery. An opportunity for someone to step up, fill the huge, gaping hole we decided was “acceptable” for some insane reason, and provide primary care to the people who aren’t getting any. Because if they are going to be flooding waiting rooms when they are insured, they aren’t just “the uninsured”. They’re “the people who don’t get health care”.
Whichever provider group is first in with a proposed solution should get serious consideration, like, 28 states serious, and that’s happening. That’s good. It’s what’s supposed to happen.
It doesn’t have to be a frightening scenario where those of us in “the system” are protecting the allotment we’ve managed to secure, leaving 30 million people to “crowd the waiting room”, fighting for scraps.
Noonan
This is a totally calm, reasoned blog post and therefore has no business being involved in our national health care reform debate.
shirt
When the Texicans opt out of the Medicare system it should free up enough people to take care of “There are not enough primary-care doctors to meet current needs, and providing health insurance to 46 million more people would threaten to overwhelm the system.”
Ah, those noble Texicans, thinking of the nation first before themselves.
WyldPirate
Yeah, we can’t have the system overwhelmed. I mean hell, the AMA and its iron fist is doing such a good job with the free market solution where they control the number of medical schools, the numbers of students enrolled in the schools, the number of residencies and fellowships and the number of foreign docs they allow in to go service the boondock areas of the country.
More of the latex-adorned iron fist of the AMA baby! It feels so good!
dr. bloor
Providing health insurance to brown people is the fastest way to make them vulnerable to getting sick. Can’t have that, silly blogger.
PeakVT
There simply isn’t enough to go around. Sorry.
And we pay twice as much as any other country for less than what we need. Best health care in the world, baby!
Morbo
I believe Dean Baker has an alternative solution to this problem. It’s the same as the solution we use for picking our fruits and vegetables. I don’t think the AMA likes his solution.
LGRooney
If we had a true national health care system, this wouldn’t be an issue. The RNs and doctors who handle patient visits now spend a little less than half their time researching insurance plans and arguing with insurers regarding their patients. Take away the insurance companies and all of a sudden there is quite a bit of slack built into the system.
Additionally, if people have access to health care without worrying about its bankrupting possibilities, they will visit the doctors more often for preventative care and do more follow ups regarding potential problems thus mitigating the time-consuming processes of emergency management and yet more slack becomes available to handle additional individuals in the system.
Kay
@Morbo:
The AMA have actually moved a little. They’re opening up 5,000 additional slots in med schools.
My hope is the nurses crowding their turf have them re-thinking their position :)
I know I’m a foolish optimist, but it isn’t all government. When you get to the delivery side, it’s going to be up to providers, which is as it should be. Let them duke it out.
Bnut
@WyldPirate: My cousin mentioned this to me. He works in rural Kansas and his clinic has a hard time getting Americans doctors to come and stay out in the boondocks where is. He also says that several foreign born doctors have tried to come, but were rejected for reasons unknown. I know where he lives, and there is no chance in hell I would move there if I wasn’t a white male. Kudos to those evil terrorist doctors for trying.
RalfW
Gee, it might even create some jobs during one of the worst recessions in decades. But that’s just a crappy reason, really, isn’t it. And doesn’t scare anyone so it won’t raise campaign cash. (OK, it scares Republicans because if people get jobs in the next two years, they might vote for evil-O again).
MarkJ
In a well functioning market more people with the ability to pay for a service should lead to more service providers – i.e. demand from the previously uninsured should pull more health care providers into the market to supply the demand.
The AMA interferes with this by restricting the supply of medical school spots and graduates, but much primary care can also be handled by physician’s assistants and advanced practice nurses, which the AMA doesn’t control the supply of. I expect these occupations will grow quickly to supply much of the new demand.
Steve LaBonne
Whatever gave you the impression that this is a mature grown-up country? Right now I’m reading Gary Shteyngart’s Super Sad True Love Story and frankly it doesn’t really seem fictional.
RalfW
Seriously, though, I heard some ranking GOPer on Nazi Public Radio y’day still trotting out the “government takeover” meme. The host countered that it would get people into private for profit insurance but of course the GOPer would not be deflected from false talking points.
And the point that it creates activity with private care providers, too, needs to be pushed.
We’ve gotta talk about all the private, non-government healthcare jobs HCR will create – nursing homes, hospitals, doctors offices, private insurers. Except for robo-surgery from Bangalore, most health jobs will remain local, so that helps.
Kay
@Steve LaBonne:
I listened to the nurse’s argument that I linked to on NPR, while I was in the car, which is where I do all my enforced listening.
They’re pretty persuasive.
It was mature and reasonable and not fear-based. The physicians calling in were good, too. It was really heartening.
We could talk like that, nationally. We’re deciding not to.
Jamie
What I want to know is if we have the best health care system in the world why don’t we have enough GPs to cover the US population?
Stefan
Is this how a mature grown-up country behaves?
No, but this is the US we’re talking about.
Linda Featheringill
My health care has come from means-tested sources for many years and I would like to say that I have received very good care from nurse practitioners. These intelligent and trained people can tell when a specialist or other professional is called for. They have treated me with meticulous care. And I am still here. :-)
Not every office visit for every person requires the present of a M.D.
Steve LaBonne
@Kay:
Well, yeah. But I’ve been waiting a hell of a long time for the country as a whole to reverse that decision, and I’m not expecting it to happen in my lifetime or before a general collapse, whichever comes first. (Obviously I hope I’m wrong.)
piratedan
welllll here’s a nifty lil link to a NPR story that is essentially a nice lil bit of Republican projectionism….
http://www.npr.org/2010/11/11/131215308/arizona-budget-cuts-put-organ-transplants-at-risk
kinda cruel to get someone on a list for a transplant for a year and then tell them “sucks to be you, but we’re cutting costs and can’t afford you”. Does make you wish that the Dems had a few more nads to have brought the whole thing up to speed initially instead of incrementally yet it takes Arizona to bring the real cruelty to the forefront.
Crashman
Isn’t this the kind of situation that just cries out for some Galtian free-market entrepreneurial superhero straight out of a Republican wet dream? Why aren’t they embracing this?
Kay
@Steve LaBonne:
I actually thought it would move better once the payment mechanism was in place.
I think health care providers probably do want to provide health care, in the end. I give them that good-faith assumption.
What’s interesting to me is that conservatives have now totally lost any connection to health care, and are screeching about the commerce clause.
They’ve been on a mission to limit the reach of the commerce clause since civil rights, because that’s key to undoing the New Deal, so I’m not surprised, but they’ve stopped mentioning anything about health care.
It’s Mitch McConnell and the Federalist Society and the commerce clause. They’re not even in the same field as everyone else.
Chris
@RalfW:
It’s always impressive to me how they can shrug off things like “so, it’s a government takeover when Wellpoint and Cigna cover Joe Bloggs over there?”
David Fud
Wow, it is like we don’t even want job creation in this country if it means we have to share our health care system with brown people.
Bulworth
Well, no, but I don’t think anyone is confusing us with a grown-up country.
Linda Featheringill
Why am I still in moderation because I said something nice about nurses? It is a totally innocuous comment.
[the world is picking on me]
MCL
The bottle neck isn’t at the medical school level–the problem is residency training. You can’t get a medical license without it, and within the next few years there will be more US medical school graduates than there are residency training spots, leaving the graduates with a ton of debt and no prospect for employment. Even foreign medical graduates who are practicing physicians in their home countries have to complete a US residency training program.
I don’t pretend to understand all of the particulars, the vast majority of funding for residency positions comes from the government (Medicaid money, maybe), and that funding is capped–so there aren’t likely to be more residency positions opening to provide the training for our future care providers. This will likely lead to more reliance on non-MD providers (physician assistants and ARNPs, particularly) for primary care.
Bulworth
@Linda Featheringill: No, the world is only picking on Sarah Palin. She said so herself.
Annelid Gustator
@MarkJ: Part of the reason that the AMA can effectively control things like med school #s is (fairly effective) regulatory capture.
They are trying to quash the NP and PA’s ability to increase the supply of low-end (but trained) service providers by restricting them to work “under a physician’s supervision” and other rent-seeking measures.
Bulworth
Well, it’s kind of like the evangelical Christian doctrine of “limited atonement”: instead of Jesus dying for the whole world, he really only died for the “elect”. So it is with the awesome doctrine of American health care best in the world Feck Yeah!. It’s the bestest because only some people can benefit from it. It depends on excluding people.
Amir_Khalid
@Linda Featheringill: You said “speshalist”. The correct spelling of that word incorporates the name of an erectile dysfunction remedy. So FYWP figured you was a spammer.
PeakVT
@Kay: I like that proposal to formalize and standardize the layers of medical practitioners that don’t have MDs. Ideally we would break down the nurse-doctor divide so there would be a continuum of education and responsibility, but that won’t happen anytime soon.
Kay
@Bulworth:
What’s amazing (and horrible) about the media language of scarcity and fear and insiders versus outsiders is how consistent it is. I could take that opening paragraph from the WaPo story and show you ten thousand nearly identical versions, with a Google.
The print version of the NPR story (the one I liked) actually starts with nearly the same scary paragraph.
I think they just pick up the frame and repeat it. It’s not only a dumb way to present a problem you want to solve, it’s also incredibly boring and repetitive.
sherifffruitfly
You mean this market demand created by “socialism” leads to a business opportunity????
ZOMGNOONECOULDHAVEPREDICTED!!!!!!!
Rommie
It’s just another instance of the veiled threat of our betters Going Galt – in this case, our doctors leaving the country because of health-care reform. They’ll choose to go to some mythical other-place (Randlandia?) rather than work under the boot of the government.
And, surely, none of our young people will want to go into medicine under such tyranny, so it’s a choice of keeping our current doctors, or “forcing” them to walk away, and leave the rest of us to do without.
It’s like foreign-born doctors don’t even exist, or aren’t worthy of practicing in the US. I had Korean doctors in the 1970’s, it’s not a new concept. Sheesh.
elmo
“We want a free-market based medical system! But we don’t want any more demand!”
wait, wut?
Kay
@PeakVT:
I like an alternative approach, so I’ll go first! I volunteer.
I (now) have health insurance, and I have to use the traditional model, because I would have to drive 90 minutes not to, but I once got excellent poor-person pregnancy care from a community health center and it was a good fit for me. It was advanced-degree nurse, dietician, various social worker types to bully me incessantly (they succeeded) about exercise, and finally, occasionally, a check-in by a physician. It was 20 years ago, so you’re spot-on that this must take a while.
I would prefer that “holistic model”, for primary care. It made sense to me. I would seek it out.
de stijl
There are two types of people:
Those who think that life is a zero-sum game, those who don’t, and those who don’t know what a zero-sum game is.
Captain Haddock
Frightened people are easier to control. Our whole system is set up to keep people frightened of something, somewhere.
thm
This all seems to be looking past the rather substantial evidence that, for those with coverage, health outcomes are not really linked to the frequency of physician visits. Jack Wennberg, and others after him, have shown pretty convincingly that physicians, perhaps unconsciously, tend to recommend treatment follow-ups and make other care decisions based largely on their own need to keep busy. A highly trained MD doesn’t want to sit around twiddling his or her thumbs, and so follow-up visits might be every 4 months for a physician with a smaller number of patients, instead of every 6 months that a physician with a larger number of otherwise identical patients recommends. But there really aren’t standards for frequency of care, or enough evidence to set such standards, except a general lack of a measurable improvement in outcomes with more frequent care.
So even if all the uninsured were to flood doctors offices, leaving the insured with fewer trips to the doctor, there is absolutely no evidence that the presently insured would fare any less well.
Of course, this should be all set aside as the moral argument presented in the post is reason enough to reject the “not enough doctors” argument, and the fact that it wasn’t called out, repeatedly, every time it was brought up, can be chalked up as another failure of messaging in health care reform.
Mudge
My daughter is an ICU neuro nurse. She has some extraordinary responsibilities, and deserves more pay, but she very clearly says she teams with the NPs, PAs and doctors in her unit. The physicians fully respect the nursing staff, recognize its enormous value and realize they are in no danger of being replaced by a nurse.
I sense that nurses in the more general medical fields are more of a threat to physicians. Nurses are better trained than ever, partially due to the increasing reliance on lowere paid nursing assistants for less technical tasks. The medical profession will hire less expensive employees to avoid paying a nurse, but rebels when the topic of having lower paid nurses perform sacrosanct physician duties. Hopefully , this expansion of need for fiscally responsible health care due to ACA may allow that barrier to be breached.
Kay
@thm:
It’s a good point. The other issue is that (in my experience) it’s hard for low wage working people to go to the doctor. They have to get permission to get off work in the daytime, they lose wages, and manufacturing facilities here give year-end bonuses for perfect attendance. I don’t know when they’re supposed to go, or how much $ they can sacrifice to get there. The System seems to be set up for some imaginary 1950’s society.
Linda Featheringill
@Amir_Khalid:
I had to laugh. I believe you, but it is soooo silly.
different church-lady
Didn’t being a doctor used to be considered a good job?
Doesn’t the country need more jobs?
Is it me? It’s them, right?
Jeff
Now your sounding like a gol-durn soshulist…
Heaven knows we can’t have more primary care providers,
gotta have more ophthamologists, gastroenterologists, plastic surgeons who specialize in botox ,so that you can clearly see what is making you sick to your stomach , with your tightly stretched skin.
As a primary care provider, I welcome health care reform, and even some of the providers who were screaming the loudest about the glut of patients will be pleasantly surprised when the ERs clear out from the people who were getting their primary care there.
edwin
@Jamie:
Thinking again are we? Off to a re-education camp with you!
scarshapedstar
@MCL:
As a med school applicant, a 1-5% acceptance rate sure as hell feels like a bottleneck to me. I can envision how residency could easily be a bottleneck, though; my home of New Orleans has yet to replace the massive and legendary teaching system that the pre-Katrina Charity Hospital provided.
On the other hand, given that med school applications committees reward Student Body President types whereas residencies reward people who actually do well in medical school, it seems like a better place for a bottleneck.
Jeff
@Jeff: @#$# Blockquote
error
Genine
Reading that makes me think of the scene in Titanic where Molly Brown tries to get the lifeboat to turn back and save more people. The crewman argues against it by saying “They’ll swamp the boat! They’ll swamp the boat! We’ll be pulled under.”
That kind of framing when it comes to health care is truly disturbing.
Of course, the analogy can go further. After all, there weren’t enough lifeboats and the poor were locked down in the lower decks so the wealthy could survive.
This can be applied to more than the healthcare debate.
blondie
Talk about class warfare.
I have health insurance/access to medical care. But there isn’t enough to go around. So they can’t have it.
Being poor is the biggest sin in America.
Medical care is not musical chairs. It is a basic human right. And if you don’t believe a person has a right to medical care, then I really don’t want to know anything more about you.
Nor do I actually believe that we don’t have enough to go around. There are plenty of drs. and medical care providers. If universal health care would create a need for more, then more people will go into those fields.
One problem is, right now, many people who are uninsured treat emergency rooms as their primary care-givers. Thus, by the time they “qualify” for emergency room care, their condition is likely much more expensive to treat. If they had prior access to preventative care or earlier treatment, costs would likely be much smaller.
This is why your health insurers — those of you who have health insurance — often don’t charge a co-pay or deductible for your annual exams. The exams usually involve preventative care and catch problems early. Thus, they are much less expensive than having to pay down the road for things not caught or treated earlier.
Xecky Gilchrist
Health care is always presented in terms of scarcity and fear
To be fair, so is everything else.
Jeff
@Kay: That is changing == at a glacial pace, to be sure,but still— More practices are setting up extended hours for people with odd work schedules.
For instance, at one of the occupational clinics where I work, there is an early shift that starts at 6AM for the 3rd shift workers.
Jeff
@blondie: which is the rationale for increased primary care– if those are treated by a family practice physician or PA or NP, then they wont need the expensive procedure later to treat the out of control problem.
Larkspur
I know some primary care physicians who are so swamped with paperwork and coding and phone calls to insurance gatekeepers, etc., that they are not making enough money per year to sustain an office, equipment, good staff, and still be able to accept patients on MediCare at the current rate of reimbursement. These are docs who planned to become GPs and family physicians – i.e., they knew going in that they would not make the big bucks that specialists can make.
Some of them are retreating to places like Kaiser (and the Kaiser model isn’t bad, but the doctors are allotted fewer and fewer minutes to meet with patients, and the squeeze is on). Some are retreating to boutique practices – no Medicare, probably a narrower range of insurance companies, and patients who can pay up front – even though they may not have meant this to be the type of practice they wanted.
Some are getting out altogether. Given relative salaries, I don’t think it’s exactly shocking for a hard-working family physician to expect to clear at least $100,000 a year, but I have spoken to one such physician in the very wealthy county of my residence, and she has trouble doing that. It’s disheartening when you think that top CEOs are still losing 100K of their bonuses behind the seat cushions of their very fine vehicles every day.
Insurance companies are the impediment*. MediCare is there; it just needs to be brought up to the big leagues: robustly funded, available to many more people, etc. Then it becomes a contender, and the whole scene begins to change.
*Well, I mean, Republicans.
Hawes
An overwhelming number of the uninsured are people between the ages of (now) 25 and 55.
Those of us in that age bracket don’t go to the doctor that often. Part of it – duh – is that we have no health insurance.
The other part of it is that old folks and kids need a ton more health insurance. My kids go to the doctor about three or four times a year. I go about every other year to my GP and a specialist every four or five years.
And I wade through the crowds of Medicare recipients who are in the waiting room to get to the counter.
I’m in my 40s, I have pretty darn good health insurance and I don’t “overwhelm” the system. Neither will the newly insured.
Except, you know when they’re sick. Which is kind of the point.
Dan
Would like to see “town halls” across the country this winter with people asking their representatives why they get govt backed health insurance while their constituents should give up theirs
Omnes Omnibus
@Jeff: One concern with having a PA or NP do treatments is that most people do not know what qualifications these profession possess. People know what a doctor is, med school, internship, residency, etc. PA or NP? Most people don’t know. I admit I do not know. My wife is scheduled to have a small mole removed from her face in December, and she has been scheduled with a derm. PA . She is worried since it is an operation on her face that is being performed by a non-MD. We are with a reputable and highly rated HMO so I presume that the PA is qualified, but …. Real outreach to the public is necessary if changes are going to be made because people want to see a doctor when they have a problem.
kay
@Jeff:
Thanks. I’m glad. I live in a rural area in the rust belt, so everything takes longer to get here.
They’re my clients, and I have to see them when they can get in here, which isn’t fabulous for me, because it means I have to work nights and weekends, but that’s when they’re available. I’ve come to like weird hours, but it takes a while.
I was shocked when I found out they can lose 2 grand if they blow “perfect-perfect” attendance the last week of a perfect attendance year, with an absence. Jesus. That’s brutal. That’s one expensive appointment.
Jay in Oregon
@elmo:
It’s almost enough to make you believe that the people who chant “free market”, “free market” like some kind of Randian zombie don’t actually have a fucking clue how the “free market” is supposed to work.
Maude
@Omnes Omnibus:
I’m with your wife on this. A consult with a PA of how things are going is okay, but I would want an MD to do a proceedure.
Omnes Omnibus
@Maude: Well, that’s the rub, isn’t it? We may be underestimating the capabilities of the PA and insisting on having an MD perform a procedure that she does not need to perform. That kind of resistance to PAs could drive up expenses. On the other hand, it’s my wife’s face and if some one does not convince us that an MD does not need to do it, we are going to be rather insistent.
WyldPirate
@Omnes Omnibus:
I don’t know if this is any coonsolation or not, Omnes Omnibus, but in the past year, I’ve had a good bit of dealings with PAs and was quite satisfied with them.
I had a PA–who I met previously–do the dissection of my radial artery from my arm for use in a coronary bypass. I had a cardiology PA do much of my follow-up care post-surgery. I just switched from a endocrinology fellow to a PA for that.
I’ve been really pleased with all of the PAs I’ve dealt with–particularly the endocrinology PA. He beats the shit out of any of the endocrinology MD fellows I’ve had. Of course, I go to a decent sized university hospital so one has to deal with a bunch of noob MD trainees learning the ropes.
LGRooney
@Omnes Omnibus: In my experience, the PA is not able to write prescriptions or perform such operations except under the direct supervision of an MD. I had a PA who wrote prescriptions, had his own pad and Rx authorization number, but had to clear it with an MD before it would go in my file and he would give me the Rx. As well, I had something removed from my skin a few years ago by a PA but the doctor was watching the whole time which seemed horribly inefficient.
Omnes Omnibus
@WyldPirate: @LGRooney:
Thank you for the info. Ultimately, it is my wife’s face being worked on, so I will back whatever decision she wants to make.
dr. bloor
This is one reason why simply throwing open the doors to med schools (residency issues aside) isn’t likely to solve the problem. An average pediatrician is looking at maybe 130-150K per year for a fifty hour work week. If you figure 40 weeks of work per year, that’s roughly $75 per hour. More family docs would exert a downward pressure on that rate. There’s no reason someone smart enough to become a doctor would choose med school bills and indentured servitude in residency for that kind of return on his/her intellect.
ruemara
@dr. bloor:
$75 bucks an hour isn’t enough? I’d take it. I’m as smart as a doctor. It’s just not my skill. WTF kind of world are people living in that $75 per hour/130-150k per year isn’t an excellent return for your intellect?
dr. bloor
@ruemara:
$75/hour is a miserable return for the time and money invested in a medical education. Become a plumber instead–you’ll make more and won’t rack up six figures worth of student loans in the process.
But if it sounds good to you, go for it. You can start by boning up on your P-chem skills over the holidays.
Capri
@scarshapedstar:
It’s very difficult to conceive how residency could be a bottleneck.
It’s very easy to increase residency slots. It’s also very easy to take US trained residents rather than International. Most hospital with large numbers of international residents have them because they can’t find enough qualified US candidates.
cckids
@blondie:
Many uninsured people do this because so many private MDs and clinics will not see you if you do not have insurance, or a sizable deposit up front for care. So you go to the ER, where they have to see you.
We faced this ourselves this week. My daughter was sparring in taekwondo class, her foot connected with her opponent’s elbow & CRACK! We iced it for 24 hours, but the continued pain & swelling made us fear a break. After hours of calling, trying to get an appointment somewhere, we headed for the ER. She needed an X-ray, the MDs willing to work with me on payment didn’t have a machine, the clinic with the machine demanded an upfront “deposit” that I just do not have this week. Can’t really wait till the first of the month with possible broken bones in her foot.
As it turned out, it is a deep bruise, with only one tiny hairline crack in one bone. But the experience was infuriating. I remember growing up, with my parents having no insurance, then having BC/BS later, it really made no difference, when you needed a doctor, you could go. God knows, with or without insurance, mom & dad did not take us to the doc unless we truly needed it, but still. They never had to sit & wonder “what if”, in these borderline cases. “Do I take my kid in for xrays & wonder how to pay for it, or let him/her suffer & wait it out to see if it is REALLY bad?” They could just schlep us into our regular doc, who had a basic xray machine, get it checked & get out, probably for under $100.
I’m of course THRILLED that she doesn’t have a bad break, but now we have a $1200 bill, that will take us close to a year to pay off. It just doesn’t have to be that expensive, in time, stress & cash. Best health care system in the world, my ass.
kay
@dr. bloor:
I would just suggest that that answer isn’t good enough.
If people aren’t getting primary care, and they aren’t, and we’re spending more than any other country on health care, physicians can’t just respond with “we need people to pay more”.
They can’t pay anymore than they are, and they’re still not getting basic health care. Now what do we do?
I guess physicians can just drop out, but someone or something is going to replace that system, because it has to.
blondie
@cckids: Exactly. And you should not be placed in this position. I favor universal health care — if you fear your child may have a broken bone, you should be able to have it checked out without fear that it will bankrupt you.
scarshapedstar
@Capri:
Bear in mind I was responding to MCL, who said the exact opposite of everything you said.
I have indeed read that “match day” is become more difficult. I do not think “adding residency spots” is as simple as you declare, when international residents do in fact compete for the open spots.
It’s not like every residency is earmarked for a US med school grad, and then after they scrape the bottom of the barrel they reluctantly let in a horde of Indians. I’m not saying the Indians are unqualified, either.
But you don’t give any reasons backing your position, aside from changing “Mexicans pick lettuce because Americans won’t do it” to “Indians do residencies because there aren’t enough American doctors” which doesn’t sound right, even to me, speaking as someone who’s perpetually fretting that I won’t make it in to med school.
Mnemosyne
@dr. bloor:
This is why I keep saying that we need to simultaneously figure out a way to reduce the cost of medical school. At this point, it’s a prestige thing — I got a very expensive education! — but people are graduating with really crippling debt and going into fields because they pay well, not because they’re actually interested in that kind of medicine.
If we could reduce the average loan debt down to, say, $50,000 in debt instead of $200,000, that $75/hr salary looks pretty generous.
dr. bloor
@kay:
Read my posts above the one you replied to–I’m not advocating that physicians be paid more. My initial comment was in response to the idea that allowing more people into med school would be a way to meet demand, and I was just noting that at least for family docs and pediatricians–which is where the biggest shortages are–the economics of the situation will have them looking elsewhere for a career, either in a medical specialty or another field altogether.
Look, I’m not suggesting that 150K is chump change. It’s not. It’s a lot of money and a good living. But unless you dumb down medical education and training, most of the people who are smart and talented enough to become doctors are also smart enough to go into other fields where they can make multiples on that salary point, and not incur as much debt doing so.
Some folks are going to go into general medicine no matter what, and thank FSM for them, they’re doing God’s work. But it’s a labor of love, and love ain’t what motivates a lot of docs.
kay
@dr. bloor:
My point is they either jump in or become irrelevant, because states are practical, and they have to act, and they’re acting.
And by “jump in” I don’t mean lobby to protect a system that nearly everyone is unhappy with, and that is unsustainable.
Physicians are not powerless pawns. They have enormous credibility with the public, they know how to lobby, and they get listened to.
I don’t lay blame on front-line providers. There’s profit at every point in our giant system that consumes 1/6 of every dollar, and that system provides tons of middle class jobs, but if there’s anyone who can start to address the problems, it’s physicians.
dr. bloor
@kay:
Well, the AMA knows how to lobby, but they won’t be of much help in this instance. Left to their own devices, docs are rather like a bunch of cats wandering aimlessly around a room…
I actually think PAs and NPs are the way to go for day-to-day volume. Much more cost effective, and absolutely fine for basic office visits.
MTiffany
Wait a second.. according to the laws of supply and demand, shouldn’t the magic of the free market take care of this all on its magical own?
MCL
@Capri:
It is actually quite difficult to increase a residency quota because a) the accrediting body (ACGME) wants to assure that the increase is education driven rather than service driven (you can’t have more residents just because you have more patients if you don’t have the educational resources available to train them), and b) institutions are capped as to how many residency positions they will receive federal funding to cover. If the ACGME does approve an increase in, say, a Family Practice residency quota for a program, the institution would have to take that number of funded spots away from another specialty or tell the program they can have the spots if they can find their own source of non-governmental funding.
Meanwhile, a dozen new medical schools have opened since 2007 and more are being planned, plus existing schools have increased their enrollment.
kay
@dr. bloor:
Well, every profession is like that, though. And I don’t expect them to spend every free moment agitating for reform.
But they can’t do two things, as far as I’m concerned.
They can’t act as if they are powerless and without prestige and credibility, because that isn’t true, and they can’t bitch about bad solutions being imposed unless they pony up with an alternative.
The nurses made an offer, and you’re happy with it. Anyone who isn’t should counter with a better idea.
James Benson
The ad appeals to Congress to do something urgently. On November 17th – White Coat Wednesday – physicians throughout the USA will be calling on the members of Congress, reminding them that what they do or do not do will have serious and long-reaching consequences for American seniors who depend on Medicare.
MarkJ
@Mnemosyne: I’ve never understood why you get a GA to become a political scientist or economist, which greatly defrays the cost of graduate school, but must take on massive debt to become a health care professional. And I say that as someone who went to graduate school to become an economist.
I don’t mean to denigrate my profession in any way, but even from my (somewhat skewed) perspective the nation clearly needs additional health care providers a lot more than more economists, or political scientists, or history professors, or any of a number of other fields that receive large subsidies to defray the cost of graduate education. Yet if you go into one of these fields you stand a good chance of getting a GA that pays your tuition and provides a wage on top of that to help defray living expenses.
Becoming an MD is definitely a very expensive proposition, but because there are no graduate assistanships in health care fields, it is significantly more expensive to become an advanced practice nurse, physician’s assistant, or physical therapist, than it is to become an economist, sociologist, chemist, or political scientist. And truth be told, if you can find a job as an economist you are likely to make more money than someone in those non-MD health care professions. Granted it’s harder to find a job, but when you do the pay is better, and the student loans are an order of magnitude smaller. Basically we’re subsidizing education for fields we have an adequate supply of and not subsidizing it for fields we have shortages in. But I guess that shouldn’t be surprising.
jl
US has a relatively low MDs per capita. It is a little lower than Australia, a little higher than New Zealand. Canada and UK have lower ratio. Australia and New Zealand definitely get better results in terms of population health.
US has fewer doctor visits than most countries, and a very weird distribution of face time with doc, a bimodal distribution with many very short visits and many very long visits.
So the US does not have a uniquely low number of docs per capita, and other countries with lower rates get better population health. Something is different about how the US allocates its doc time than other countries, probably for the worse, though I am not sure what it is.
New Zealand has been very aggressive, for a long time, in creating a specialized nursing corps that can provide most primary care to pregnant women and children. Australia has developed a corps of doctors trained in managing care for adults with chronic diseases like diabetes, overweight, mild heart disease, since their chronic disease health risk profile is very much like the US’s.
So I guess, American Exceptionalism is the reason we just cannot get it done.
I think these kind of scare stories during the HCR debate showed how depraved and vile the interest groups opposing good reform are. The prance around bragging about how they are so concerned with the health of the country, but issue these kinds of misleading statements designed to keep people ignorant and scared.
If you look around other developed countries, there are plenty of ways to design delivery of care. The US has a crummy one, but one that is producing high profits for soulless corporations. I guess that is American Exceptionalism again.
You can find the data supporting my statements in the OECD Health Statistics CD ROM, and the Commonwealth Fund international healthcare surveys.
Edit: bottom line is that there is absolutely no reason any system has to be over run. The whole issue is bogus, unless the US corporate interests, and AMA, manage to force the US to keep doing things its uniquely inefficient way. Find ways to spread the burden over more health professionals, say nurses, physician assistants, and pharmacists, and there is no problem. Find ways to let docs spend more time seeing people rather than dealing with insurance BS and there is no problem.
JR
Federally subsidized loan repayment.
See, that was easy!
scarshapedstar
@dr. bloor:
As a guy who made the mistake of trying to get an engineering degree from Georgia Tech, instead of breezing through my state school’s biology program with a 4.0 (like several kids I know from the high school class below me who have now gotten into med school before me) and has been atoning for this sin by acing hours and hours of graduate courses (including P. chem) that I’m pretty sure said kids wouldn’t be getting 4.0’s in…
I totally agree.
However, most pre-meds don’t take physical chemistry. They probably should, given that spectroscopy is such a big part of modern O. chem, but they don’t.
Unless you meant to say O chem to begin with.
dr. bloor
@scarshapedstar:
Nope. P-chem was the wash-out requirement where I did undergrad.
annia
Elaine said it best: not a square to share
scarshapedstar
@dr. bloor:
Wow. Where? (if you don’t mind my asking)
Come to think of it, I had to take Inorganic Chem after I changed majors to bio, and that class was sheer terror. Definitely meant as a wash-out.
Gitta
Health is our only real wealth. The one factor noticeably missing is where is the health? A very precious condition, naturally given, why are so many so diseased, so chronically, so overwhemingly, and why are people unable to afford real healthcare, much less medical or disease insurance because, when you’re healthy you don’t need it.