I heard a rumor that the Association of American Medical Colleges (AAMC) was pushing the concept that U.S. medical schools should be expanding the enrollment of students for the M.D. degree, based on predictions of a physician shortage. Upon a few milliseconds of reflection, I can’t think of a worse idea than increasing the numbers of physicians who are trained each year.
OK, before you clog my inbox with screaming e-mail messages, such as, Dr. Brody, now you’ve completely lost your sanity, I confess to perhaps never having been completely sane in the first place, so I may not have lost anything with this pronouncement. However, I do have some method to my madness, so take a few minutes to hear me out.
First, while there has long been a physician shortage in the United States, it traditionally has not been in total numbers but in maldistribution: too many specialist physicians and too few in primary care, too many in urban areas and too few in rural locations. Despite identifying these issues, our country has not figured out a way to reduce the maldistribution. Limited incentives have provided only transitory relief. In my view, increasing the pool of M.D. graduates will only exacerbate the maldistribution, not reduce it.
Predictions of the required levels of health care professionals have proved notoriously inaccurate. In the 1960s, the federal government supported the rapid expansion of medical school enrollment, predicting dire shortages that never materialized. Similar studies more than a decade later indicated that with widespread fluoridation, dentists would become obsolete. Quite a number of U.S. dental schools closed their doors, leaving us today with a true shortage of dentists. While the prediction of fewer cavities in the reports was true, the rapid growth of the over-65 population who pre-fluoride might have been edentulous, now created an oversupply of teeth in situ whose owners required crowns, root canals and implants.
Second, there’s the argument that physicians drive up the cost of health care. Physician salaries account for only about 20 percent or less of total health care expenditures, but they drive more than 80 percent of health care costs. And because professional fee reimbursement is mostly capped, physicians can only reach a targeted income amount by driving up utilization. This phenomenon is known as “Roemer’s Law,” after an economist who documented that the more hospital beds or physicians there are in a given locale, the higher the utilization of doctors and facilities. Therefore, producing more physicians who settle in urban areas and gravitate toward specialties—especially procedure-based specialties—is likely to drive up health care utilization and costs.
Third, it isn’t in physicians’ best interest to expand the pool of doctors. If the federal government believes there is a doctor shortage, it should fund medical schools to produce more physicians, as it did in the 1960s, and to provide scholarship support for medical students, especially if they gravitate to primary care and rural locations. Right now, physicians are held hostage by the payment system, and unless there is a bona fide shortage, reimbursement for physician services is not likely to increase any time soon.
In fact, now that I think about it, maybe we should train fewer, not more physicians.
