Facts about doctors

by on March 4, 2013 at 3:22 pm in Data Source, Medicine | Permalink

…new M.D.s per senior fell by about a third over the last three decades.

Much as I sometimes mistrust doctors, that is not good news.  And I find it sad how infrequently this number is discussed.  There is more from Bryan Caplan here.  And get this:

New male M.D.s per person are down by over 45%.

That is a sign of rising female prominence when it comes to educational success, but there is no good reason why the flow of male doctors should be falling so rapidly; it’s not as if men suddenly have lost the ability to doctor.

Givco March 4, 2013 at 3:32 pm

If only trained medical professionals resided in other countries who the U.S. could welcome here to do work that our best & brightest no longer consider remunerative enough. If only.

Rahul March 5, 2013 at 12:07 am

it’s not as if men suddenly have lost the ability to doctor.

70% of shoes get made my third-world employees now. That is puzzling. It is not as if western nation shoemakers have suddenly lost the ability to stitch shoes.

Frederic Mari March 5, 2013 at 2:43 am

Rahul, that would only be a valid point if Givco is incorrect and the US is importing masses of foreign doctors.

I think it’s easier to believe that quotas are in action, formally and less formally limiting the amount of doctors. After that, it might be that in a competitive race for too-few spots, female students outsmart male candidates.

It’s not that male students have lost the ability to become doctors, it’s just that they now have female competition + the fact that they might select other careers, for a host of reasons.

NB: I am not saying that this is what’s going on but it might fit the facts…

dan1111 March 5, 2013 at 3:39 am

I think you missed Rahul’s analogy.

The point is, any time a new pool of workers enters the labor force, the numbers from the existing pool are going to go down (all else being equal).

Women now attend medical school at nearly the same rate as men. In 1976 they were only 20% of medical school students. Thus (roughly) the same number of doctors is being drawn from a much larger pool. It is no surprise that the share of men has gone down.

http://en.wikipedia.org/wiki/Women_in_medicine

TheAJ March 4, 2013 at 3:34 pm

Government barriers to entry?

What about the AMA’s barriers to entry?

Pub Editor March 4, 2013 at 5:06 pm

Governments and professional guilds work hand in hand. They are mutually reinforcing, mutually enabling components of the same system.

foosion March 4, 2013 at 6:16 pm

Barriers to entry distort markets? Who would have thought?

Reduced competition raises prices?

Free trade in medical services would help. Given how much higher doctor pay is in the US than the rest of the world, free trade would no doubt reduce prices and increase doctors per capita, increasing coverage, reducing wait times, etc.

V March 4, 2013 at 7:57 pm

Massively increasing doctor supply is a sure-fire way to massively increase total health care costs. South Florida has shown just how dangerous it is to have a high concentration of physicians in one’s area (not to be anti-doctor)

Rationing doctor supply has been one of the only effective cost-control techniques the US health system has had (given that physician reimbursement is fixed, prices have not risen significantly for the professional fees doctors are paid over the last 10 years) and removing it (while it could theoretically decrease individual doctor pay) will almost certainly increase massively utilization which is why insurance companies for example never campaign to loosen this “monopoly”

Cliff March 4, 2013 at 8:46 pm

What’s the mechanism? We all want to go to the doctor but we can’t because the waiting lists are so long? That doesn’t sound right.

V March 5, 2013 at 12:26 am

Fewer doctors reduces number of tests, amount of unnecessary (or non-critical care), decreases the cycle of specialist referrals, etc. Also, as medical care is inevitably triaged, fewer doctors does not mean the important cases don’t receive attention but only that fewer people with conditions that resolve themselves waste resources on placebo care.

Ape Man March 4, 2013 at 9:02 pm

Errr…..

I don’t think South Florida proves anything about increasing the supply of doctors. The supply is always a relative to thing to demand. And south Florida also has an above average concentration of relatively well off seniors (if they were poor they would not have moved there). Both factors (wealth and age) increase the demand for health care/Doctors. Move that same concentration of Doctors to Texas and see what happens to doctors wages.

Benny Lava March 4, 2013 at 11:56 pm

This. The idea that rationing reduces prices is crazy.

V March 5, 2013 at 12:28 am

Doctors’ wages are not the relevant factor here (they are roughly similar in Texas and Florida) but instead cost of care to the system which is wildly higher in S. Florida than in parts of Texas where the concentration of physicians is less. See the Dartmouth Atlas or CMS data to show just how significant an effect this is (even after demographic and socioeconomic controls).

There is a reason why almost every health care system that has controlled costs restricts severely doctors’ numbers.

Rahul March 5, 2013 at 1:00 am

South Florida has shown just how dangerous it is to have a high concentration of physicians in one’s area

Hurricane Katrina has shown how dangerous it is to have a large number of FEMA employees in one’s area. Hurricanes always seem to strike when there’s a large number of FEMA employees in the area.

prior_approval March 5, 2013 at 1:21 am

Then I guess DC gets a special dispensation.

Andrew' March 5, 2013 at 7:51 am

“Government barriers to entry? What about the AMA’s barriers to entry?”

As has been said above, the AMA’s ARE the government’s barriers to entry. It’s called political economy. There shouldn’t have had to be a Public Choice revolution, but such is the economics version of bedding the state.

PPP March 4, 2013 at 3:35 pm

Men went to finance and tech.

albert magnus March 4, 2013 at 3:50 pm

I know a lot of male pre-meds who didn’t get into medical school because they needed the amazing GPA. I also know some women, who were perfectly capable of being doctors, who didn’t have the grades. I have a hard time believing that medical schools aren’t too selective.

mavery March 4, 2013 at 4:13 pm

Med schools are taking as many students as they can handle. It’s not like there’s a problem with too many vacancies. The limiting factor is the number/size of med schools. There need to be more of them. One problem is, relative to something like a Statistics department, it’s relatively difficult to scale a medical department. You have to have access to a hospital and sufficient patients to give the students adequate access. You need to have residency programs for them to enroll in. When demand for statisticians increases, you hire some more professors and allocate a few more rooms to that department. It’s not nearly on the same scale.

Plus, there are far fewer places certified to teach MDs than to give out BAs or MAs in Statistics. This ensures that the graduates are generally very good, but it limits the total output much more strictly. And while a lot of what most people need statisticians can be done by folks with professional MAs in stats, there are laws in many states that prevent the medical analog (NPs) from doing the same.

Gomavery March 4, 2013 at 6:07 pm

Great comment. I am glad there is someone that knows what they are talking about and does not just talk out of their ass.

I should also add, there are some states in the US that do not even have medical schools and a majority of residency programs are congregated in the Northeast.

Cynthia March 4, 2013 at 6:19 pm

“Too Many Medical School Grads, Not Enough Residencies” (see link below)

The way I see it, medical-school grads, who fail to get into a residency program, can always spend just an extra year or two in grad school getting an MBA degree. That way they’ll have the necessary credentials under their belt to land a highly lucrative job in a large hospital chain or network as a top-tier administrator or a so-called “physician executive” (a term that literally makes my skin crawl.) And they can do that without experiencing any of the stress or strains of diagnosing, treating, or operating on patients. Talking about having the good life, getting something for nothing!

For reasons that totally escape me, there’s a recent push in hospitals to add additional layers of management to manage physicians! This has happened to nursing, it is now starting to happen to medicine as well. Tell me, though, how is this gonna do anything but cause healthcare costs to go up even further?

We all know that administrative costs are the primary and overarching reason why health costs are spiraling out of control, and physician executives, as do nurse executives, clearly fall under the category of administrative costs — whether they are on the provider side or the insurer side of things.

http://www.physiciansnews.com/2013/02/14/this-chart-is-scaring-medical-students/

Cliff March 4, 2013 at 8:47 pm

We all know that??

Bender Bending Rodriguez March 4, 2013 at 6:27 pm

As I understand it, Medicare, the VA, and the DoD fund the lion’s share of residency programs. The AMA (I know, I know) has been screaming about there not being enough funding for residency programs for 10+ years.

Cynthia March 4, 2013 at 7:56 pm

No, it’s more the case that the AMA, as well as the AHA (American Hospital Association), doesn’t want to use their own money to pay for the training of newbie doctors, including giving them $50,000 to $60,000 a year just to learn.

Doctors and hospitals have mastered the game of privatizing profits and socializing losses. They’ve figured out how to get extraordinarily rich by feeding at the trough of the corporate welfare state.

Cliff March 4, 2013 at 8:48 pm

Medicine: the only field in the world where no new practitioners can ever be trained without the government paying for it.

Steve J March 4, 2013 at 10:09 pm

I had thought my opinion of the healthcare industry could get no lower until I read Cynthia’s comment. You can say it is not the doctors’ fault but they sure as hell do not appear to be trying to make things better. The fact that doctors still show up as one of the most trusted professions just astounds me.

Rahul March 5, 2013 at 1:05 am

@mavery

Given the number of sick / hospitalized Americans it is really hard to imagine that sufficient patients / hospitals / cadavers is a limiting factor…..

mavery March 5, 2013 at 9:55 am

I’m not sure if this was supposed to be witty (do we have more sick/hospitalized folks than other countries? I was not aware.), so I’ll treat it as serious. Hospitals have limited capacities. It’s often hard to expand this capacity because you need physically larger structures which requires new construction as a baseline and demolition of adjacent buildings plus zoning changes when you’re in denser environments like inner cities. Only a few hospitals are attached to med schools. It’s nontrivial to turn a for-profit institution into a teaching hospital with a residency program.For on thing, I bet it’s less lucrative. So given that the number of teaching hospitals is slow to increase and the capacity of these hospitals is also hard to increase, residency programs don’t scale. It’s not the total number of sick people/hospitals cadavers. It’s that those that the supply that is actually available to be used for teaching is very hard to change.

Rahul March 5, 2013 at 11:51 am

@mavery:

What you describe are mostly logistical / affiliation challenges which, although not trivial, are not insurmountable either. And I am not talking about building new edifices but adding pedagogic potential to the large number of existing non-teaching hospitals.

To me the larger question seems: Do current doctors have an incentive to train more doctors? The will seems weak.

Dan in Philly March 4, 2013 at 3:46 pm

Declining return on investment? Work as hard as a doctor in business and you’ll make far more money with much less student debt.

A Berman March 5, 2013 at 6:12 pm

Doctor friends of mine tell me that the field is subject to continued increased regulation and decreased salary, down to below $100K for some gps. Perhaps the question is not why men are not becoming doctors, but why women continue to do so.

Adam March 4, 2013 at 3:51 pm

The men went into finance.

Rahul March 5, 2013 at 12:16 am

My feeling is medical curriculum has failed to match / reward the brainpower of the smartest students. I’m not saying Med School isn’t challenging. It is; but it draws more upon attributes like extreme stamina, stress resistance, time management, memory etc.

Sectors like Finance, IT, AI etc. reward pure analytic / creative brainpower much better. I don’t know whether this difference is a bug or a feature of medical education.

Joe Smith March 4, 2013 at 3:58 pm

I believe that the stats are that a female doctor over a typical career will have half as many patient visits as a male doctor so the problem is bigger than the number of doctors alone suggests. If we apply that ratio to the changed composition of the medical profession we find that the number of doctor visits per senior has fallen by roughly half rather than a third.

Roy March 4, 2013 at 5:18 pm

+1

My mother is a doctor and it is astonishing how many of her female colleagues worked only half time by their forties, this is not nearly as common among male physicians. Also this is a phenomena I have noticed since the early nineties.

Scott Lange March 4, 2013 at 4:00 pm

Maybe technology has allowed each doctor to do more doctoring.

Maybe increased capabilities of nurses and PAs has allowed more patients to receive care without seeing a doctor.

Maybe men have “suddenly lost the ability to doctor” if by “suddenly,” you mean “over thirty years,” and by “lost the ability to doctor,” you mean “faced increasing competition as medical schools open their doors to female applicants.”

Slocum March 4, 2013 at 4:38 pm

and by “lost the ability to doctor,” you mean “faced increasing competition as medical schools open their doors to female applicants.”

Well, yes, exactly. The point is that in the past (in the absence of strong female competition) there were many more men who were admitted to medical schools and then graduated and became physicians. Those MD-capable men are no longer being admitted due to A) competition and B) the fact that we have a fixed lump of MDs (gated by medical school and residency slots). Which is stupid. And, what makes this fixed capacity significantly worse now, is that (as Joe Smith points out), female MDs see far fewer patients on average over the course of their careers.

It seems to me that one of the major inefficiencies in the system is many years of arduous generalized training that is required before specialization. Do radiologists and anesthesiologists, for example, *really* need general physician training? Or do the incumbents insist on maintaining this arrangement as yet another way of limiting entry to the field, restricting competition, and keeping salaries high?

So Much for Subtlety March 4, 2013 at 5:28 pm

Competition, sure. But also discrimination. Most Western countries have been moving away from exams to other forms of assessment in an explicit effort to benefit girls. At the same time, more female teachers work in schools and they have repeatedly been shown to discriminate when marking boys on the whole. Naturally girls have been doing better at getting into University because the system is set up to help them succeed in getting in. Doesn’t mean that there is real competition. After all, if you take the Smartest 1%, as Larry Summers observed, they will be largely male. Thus Medical Schools are not taking the smartest students.

Interviews to determine “empathy” is just another way of keeping boys out.

Steve J March 4, 2013 at 10:19 pm

“Interviews to determine “empathy” is just another way of keeping boys out.”

I have always prided myself on being a very good test taker but sorry I am not sure how that relates to being a good doctor. I think they changed how they do assessment not to benefit girls but to find better doctors.

Roy March 4, 2013 at 10:10 pm

Considering all the things that can go wrong with anesthesia, I think anesthesiologists do need all that training. As to radiologists, they need the training in order to know what they are looking at, and how to look at it.

You are confusing the technician aspect of both fields which is met by nurse anesthetists and radiology techs with the actual practice of anesthesiology and radiology.

Adam II March 4, 2013 at 4:01 pm

This could be good news if the decline in doctors per patient were due to technological innovation, but that probably doesn’t explain much of the drop, although I thought it was the case that more and more medical procedures/visits are being handled by nurses and PA’s, which I think is a good thing.

Dan in Philly March 4, 2013 at 4:05 pm

Any way to parse the numbers of male/female docs? More and more pediatric docs I know are women, in part because its the kind of practice where you can have a child. Do men dominate the less family friendly practices?

save_the_rustbelt March 4, 2013 at 4:29 pm

Men dominate the surgical specialties, especially orthopedics (basically tool time with bones) and trauma. Long hours, bad hours, hard physical work.

Pub Editor March 4, 2013 at 5:10 pm

See page 12 in this report (pdf): https://www.aamc.org/download/47352/data/specialtydata.pdf

Data from 2008, but I suspect the figures have not changed too much since then.

dave smith March 4, 2013 at 4:06 pm

When my brother in law started Medical school, I went to his white coat ceremony, I expected the students to come from the most prestigious undergraduate institutions in the country. It turned out that almost all of them got their BA degrees from regional schools in the state where the medical school was. And almost every one of the was coated by a mother, father or uncle…

So our doctors might be getting scarcer and dumber.

Roy March 4, 2013 at 5:23 pm

Why does this make them dumber? If you want to get into Med School what matters is a perfect GPA and a high MCAT, a top school not so much… I know the dean of admissions for one of the best medical schools in the South and as long as you go to a decent state school it doesn’t make a difference. I suspect this proves these students are smarter than you believe.

Dan Weber March 4, 2013 at 5:35 pm

Yeah, for at least a while the best way to get into medical school was to go to a regional school, get all As, and then go to medical school. In many ways they are smarter than the ones who go to a hard school and struggle to get B’s.

dave smith March 4, 2013 at 5:50 pm

Poorly chosen words by me. But it certainly was not what I expected.

paul March 4, 2013 at 5:58 pm

The prestigious school grads went into finance? Or law?

Roy March 4, 2013 at 10:22 pm

I understand where you are coming from, if med schools were training researchers this would matter, but what makes a good clinician and what makes a good researcher have very little in common. These days I think that except in very exceptional cases the qualities needed are in direct conflict.

You don’t want a project Engineer to be a research physicist or chemist either.

Roy March 4, 2013 at 10:18 pm

You still need to pass the MCAT, and for many of those courses, basic science for science majors, there is not a huge amount of difference in how much you learn between the mediocre schools and the good nes. Of course the very top technical and engineering schools, MIT, Caltech, etc… are a lot better but the differences aren’t all that apparent between State U and Flagship U. I am in natural sciences and the engineers quality of science and engineering grad students in basic sciences is completely indistinguishable between State U and U of or Ivy.

ad*m March 4, 2013 at 4:07 pm

Two observations:
1) I am a physician, my wife is a physician, and we have three sons. I am pushing them as hard as I can not to do medical school. If I had had daughters I would have recommended medical school. I hear my male colleagues doing the same
2) I was the first physician in my family, but I see many fourth generation physicians that have the same specialty as their great-grandfathers. Further, see 1).

Urso March 4, 2013 at 4:12 pm

Can you explain 1) a little?

mavery March 4, 2013 at 4:30 pm

Or at all? It’s probably the most interesting part of your post but you omitted any explanation.

Richard March 5, 2013 at 5:07 am

Yeah, it’s easy. Do the calculations. Consider someone coming out of HS to work, someone graduating with a 2 yr degree and going into nursing/rad tech/path tech/etc, a 4 yr degree grad in CS, a 6 yr MBA grad in finance, and MD grad after 11 yrs. Tabulate debt, expected income, accrue interest as appropriate, grow salaries at constant rate to simulate inflation, and have each profession save a constant percentage each year after taxes. I’ve done the calculations and the MD doesn’t break even with the janitor or CS guy until 20 years after his graduation. The difference is due to lost time in education when savings could have been compounding, higher income spread over less time (meaning more taxes paid), and high debt compounding. The finance guy is light years ahead of everyone else even if he stays at associate level pay.

Combine this with public disdain (read the comments here), increasing loss of autonomy, brutal work schedule, work itself becoming more bureaucratic, mid levels pushing from the bottom, medicare cuts coming from above, and you’ll see why it’s obvious that those in the know want to get the hell out, and convince their kids not to go down the hellhole.

Americans should just give up on medicine and go into finance. Let the Indians who have subsidized education and who start their medical schooling earlier come in and take all the jobs. They’ll be satisfied with a markedly reduced $40k/year pay which is still tons better than what they can make in their country.

maguro March 5, 2013 at 8:35 am

I think what people are wondering is why he would have recommended med school if he had daughters, but not for his sons. If it’s such a terrible deal all the way around, you shouldn’t want it for your duaghters either, right?

Finch March 5, 2013 at 9:14 am

If female doctors work fewer total hours (and see fewer patients) over the course of a career, it’s a worse deal for them, too. They get a lot less out of the medical school and residency slots allocated to them.

Urso March 5, 2013 at 11:26 am

“I’ve done the calculations and the MD doesn’t break even with the janitor”

Sorry but I’m calling hyperbole. Survey a half dozen 40 year old MDs and a half dozen 40 year old janitors and see who has the higher standard of living.

What you’ve done in this analysis is an old accounting trick. You’ve frontloaded all debts (so all student loans are treated as accrued by age 25, even though the payments are stretched over decades) but haven’t given the same treatment to the expected income. It’s true, in one sense, to say that the 25 year old owes $300,000 in student loans. But from a pragmatic standpoint it’s more true to say he owes $1,300, on a monthly basis. So the real question is whether being a doctor allows him to make at least $1,300 more than being a janitor would have. The answer is obviously yes.

You may be right as to the CS guy, depending on your assumptions. But a lot of CS guys end up doing low level IT work for $35 grand as well.

John Skookum March 5, 2013 at 8:43 pm

It’s a stretch to compare a doctor’s income to a janitor, unless they are a big-city school janitor with a mighty union.

However, it’s not a stretch to compare it unfavorably to a teacher, or any number of GS-12s sending memos to each other all day. Or a UPS driver, believe it or not.

Take a look at this detailed analysis of how someone who drives a UPS van right out of high school ends up better off over a lifetime than an MD. And that doesn’t even take into account the fact that the MD daily risks being stripped of everything he owns by the pirates of the plaintiff’s bar.

http://benbrownmd.wordpress.com/

JH March 5, 2013 at 3:08 pm

Richard. Bingo! I’m a doctor. I didn’t have to convince my sons not to go into medicine. They did the calculations for themselves. The eldest does IT, business degree. Second is MBA. Third is economist. Not a fool in the bunch. Makes their mother proud.

Bill March 4, 2013 at 4:24 pm

My daughter is a pathologist; her husband is in internal medicine. Both make a lot of money. They are encouraging their kids to go into medicine…but, what limits them is the number of spaces in medical school and residency positions.

Keep encouraging your kids not to go into medicine.

My daughter also interviews students for medical school as a contribution to her alma mater. There are a number of geeky kids with high GPAs that look at the floor whom you would not want attending to your car, but you would trust them with your computer.

I am heartened, however, by one development: one of my law partner’s daughter went to Yale, became an Econ major and didn’t like the profession, and decided to do medicinebut, since she didn’t have much of a chem or bio background, so she took a special make program at Northwestern for concentrated pre-med for those who have graduated from college. Today, she is an ob-gyn resident, quite happy, and looking forward to a family of her own.

In some ways, lawyers are smarter than doctors.

Urso March 4, 2013 at 4:47 pm

It certainly is heartwarming to know that anyone can become a doctor and all it takes is four years of Yale, another year or so of Northwestern, and several years of medical school. What’s the total bill there, like half a mill? EASILY within the reach of anyone with the simple good sense to be born to the partner in a law firm.

zbicyclist March 4, 2013 at 10:05 pm

+1. I feel good for Bill’s friend’s daughter, but this is not efficient enough to be a good model.

Andrew' March 5, 2013 at 4:47 am

Bill provides facts, y’all. Get over it.

Bill March 5, 2013 at 7:11 am

Zbyclist, I actually agree with you regarding this not being a good model, but I was using the example to illustrate that the pasture looks greener on the other side, and that an econ major can switch to a doc and be happier. I certainly do not like the fact that richer parents can help their kids make different choices later, but they do in reality help their kids. I would like every kid to have opportunities and the barriers to career change or entry low, and not influenced by parental endowment.

Careless March 5, 2013 at 12:10 pm

For the record, that pre-med stuff can be taken on the cheap at NW without any real admissions requirement. Probably $1,300 a class now

Joe Smith March 4, 2013 at 5:04 pm

“There are a number of geeky kids with high GPAs that look at the floor”

I am a lawyer as well. A few years ago I needed some surgery (reconstructing an eye socket after a blow to the face) and I wanted someone really smart with steady hands. I could not have cared less about his social graces or his empathy.

Bill March 4, 2013 at 5:20 pm

Your choice. But if the only choice you are given (because of Med School Selection policies) is the geeky kid who stares at the floor, can’t communicate, or empathise, etc. Steady hands and some human emotion are not mutually exclusive, are they?

Bill#2 March 4, 2013 at 7:22 pm

For surgery empathy doesn’t matter. For other specialties it does. Half of the art of healing is a mind game. I think the large number of papers out there that show that a little therapy is more effective than even the most expensive tests is proof enough of that.

Take chronic pain as an example. Chronic pain is a huge deal and is extremely expensive to treat, not only in direct medical costs but also in lost productivity. My dad works with chronic pain patients, and in his experience, there are often psychological factors behind pain. A good doctor needs to be able to separate the physical from the psychological components by conducting objective tests as well as playing the psychiatrist. This takes “soft skills”. The ability to communicate with them, to establish trust, and to get them to do what they need to do to heal themselves is critical.

I think a rational, highly education person who lives a reasonably secure and comfortable lifestyle (such as perhaps the typical reader of this blog) may find this difficult to understand. But many, many people are profoundly unhappy, and they must establish relationships with empathetic and caring physicians before they are willing to heal.

middle aged vet March 4, 2013 at 9:57 pm

Some great comments on this thread, but yours strikes me as being at the top if the measurement is
correspondence to the most important parts of reality. Sadly (for me), I know lots (20 or so, to be precise) of these profoundly unhappy people and the thought
never
occurred to me before that any of them had a very good chance of meeting a sufficiently talented empathetic doctor (plus, there is also the reality that past a certain age lots of chronic pain in one part of the body masks pain in another part and even an empathetic doctor at the level of a Horowitz or a Glenn Gould-equivalent couldn’t harmonize the ensuing difficulties, the only thing outside of full-on palliative care that I’ve seen work is divine intervention, which the constant distractions of big med, big entertainment and big media tend to block)

Careless March 5, 2013 at 12:12 pm

You sure you didn’t want someone who could look you in the eye for that one?

anon March 4, 2013 at 9:00 pm

In some ways, lawyers are smarter than doctors.

Bumper sticker seen at my law school in the mid-1980s:

“Support a lawyer; become a doctor.”

My physician is talking about retiring in the next year or two (10 years early) because he is much more of a bureaucrat (paperwork) than doctor.

mavery March 5, 2013 at 10:05 am

My buddy down at the local precinct said the same thing.

Same with the prof. in my grad program.

ThomasH March 4, 2013 at 4:28 pm

Looks like a failure to invest in suffient number of medical schools and being too restrictive on the number of foreign trained medical personel. I have no prior on the optimal ratio of male to female doctors is, but have no reason to think it should be 50:50.

JasonL March 4, 2013 at 4:31 pm

How do we square the story that doctoring is no longer a desireable career with the story that we spend a bojillion times more on healthcare than every other country? Who is getting all that spend?

V March 4, 2013 at 8:01 pm

Doctor compensation is only 7-8% of spend (net) which is why the disproportionate attention to their comp is destructive. Why is McKesson for instance a 100 billion dollar company when it provides little discernible value to the health system (and in many ways damages it)?

quigley March 4, 2013 at 10:24 pm

So true.

Andrew' March 5, 2013 at 8:53 am

I don’t think you know for certain that a bottleneck on doctors doesn’t increase the other costs. Part of the job of a doctor is to reduce utilization.

Andrew' March 5, 2013 at 9:58 am

And to add, if the government screwed up the role of the doctor by mandating fee-for-service, then fix THAT.

DocMerlin March 5, 2013 at 12:51 pm

“Who is getting all that spend?”
Administrators.

Mathieu Gauthier March 4, 2013 at 4:36 pm

I think the school system is sick. I never understood why a student needed exceptional grades to get in med school. To me it is only a barrier to the entry. As an economic fact I’ve never understood why universities have not produced much more physicians since the demand is so hight.

Roy March 4, 2013 at 5:29 pm

So given a choice med schools should accept the students with lower grades and lower MCATS? Why?

As an aside the MCAT and admissions criteria were changed in the 80s to get allow more female students, with the science components reduced, personally I would be delighted if the more science and math heavy requirements were reinstated, it is not like medicine has not become more quantitative in the past 30 years.

quigley March 4, 2013 at 10:25 pm

You are right. Medical education is sick at the med school, residency, and professional level. There are many thoughtful people working on the problem.

MPS March 4, 2013 at 5:02 pm

My guess the problem comes from poor market incentives stemming ultimately from capital protections and privileged status of capital gains, which has finance industry and other business sectors attracting more talent than medicine, due to higher pay.

Juan A-D March 4, 2013 at 5:19 pm

I don’t know whether the European experience has any relation to the one in the US, but in many European countries the very high demand for student places in medicine has led schools to place higher and higher admission standards. The stellar grades required both in the university admission exams and in the last few years of secondary school are almost universally only obtained by girls, who study harder from an earlier age. I would say 8 out of 10 medical students in Spain are female.

Cdn Expat March 4, 2013 at 5:25 pm

It certainly isn’t clear to me that society is better off with more doctors. Remember that doctors, to a fairly large extent, control the demand for their own services. They can tell their patients that they absolutely must come back for another visit in a month, even if that appointment isn’t the slightest bit necessary. And in a fee-for-service environment where few people pay their own bills, those are the seeds of financial disaster for the medical system.

Pshrnk March 4, 2013 at 5:35 pm

Dumber doctors use a shotgun approach of ordering more tests and procedures rather than thinking carefully. Dumber doctors are much more expensive because of the unnecessary and often even harmful things they order.

anon March 4, 2013 at 9:03 pm

Dumber doctors use a shotgun approach of ordering more tests and procedures rather than thinking carefully.

Not sure about dumber, but doctors have a big incentive to cover their malpractice asses and can do so in part by ordering “more tests and procedures”.

Ted Craig March 4, 2013 at 5:30 pm

The key letters: M.D.
” In 1980, there were 17,620 practicing D.O.s and 1,059 D.O. graduates. In 2010, there are 63,000 practicing D.O.s and 3,845 D.O. graduates. The number of colleges of osteopathic medicine has increased from 15 to 26 colleges and 5 branch campuses.”
Source: http://www.kevinmd.com/blog/2011/03/osteopathic-medicine-growth-graduates-physicians.html

Pub Editor March 5, 2013 at 5:19 pm

+1 this.

Dangerman March 4, 2013 at 5:42 pm

“it’s not as if men suddenly have lost the ability to doctor.”

Or maybe many of them never had the ability, and sexism kept them over-represented?

Seriously, as my wife has gone though the process of becoming a doctor… it has been readily apparent to me: don’t trust old, white doctors. They are MUCH more likely to be subpar.

elcapitan March 4, 2013 at 7:33 pm

I’m surprised Tyler didn’t excerpt this part of the post:

“In any normal labor market, massive female entry would have led to a large increase in total workers. But the market for new doctors is anything but normal. The rise in new female doctors has been almost perfectly offset by a matching fall in new male doctors.”

If the number of slots for new doctors remains static, but a new pool of qualified applicants (women) is given equal opportunity to compete those slots, gender representation after thirty years is naturally going to move closer to 50/50, resulting in a drop in new male doctors.

Unless the issue is that a greater percentage of doctors should be men as they’re clearly better at medicine than women, which is a sexist thing that I’m sure no commenter on this site would ever say, I don’t see why anyone is surprised.

Brian Donohue March 4, 2013 at 8:27 pm

Nope. This site only endorses sentiments along the lines of “don’t trust old, [male], white doctors.” Just imagine the reaction of writing that sentence with different adjectives.

anon March 4, 2013 at 9:04 pm

+1

quigley March 4, 2013 at 10:28 pm

“Just imagine the reaction of writing that sentence with different adjectives.”
Too simple. Dig deeper.
Just imagine a society where people described by those different adjectives had a three hundred year head start.

ladderff March 4, 2013 at 11:57 pm

You know many three-hundred-year-olds?

Slocum March 5, 2013 at 8:01 am

“Unless the issue is that a greater percentage of doctors should be men as they’re clearly better at medicine than women, which is a sexist thing that I’m sure no commenter on this site would ever say, I don’t see why anyone is surprised.”

The point is that males or females are better MDs. The point is that it would have been far better if the field had *expanded* with the entry of qualified female candidates rather than remaining fixed in size and thereby having qualified males displaced (after all, there are virtually no physicians facing involuntary unemployment). As everywhere, barriers to entry are keeping the supply low, prices high, and causing shortages (e.g. Medicaid and Medicare patients having a hard time finding anyone to treat them).

And, of course, there is one very real sense in which male MDs *are* better — for society at large though not necessarily for any individual patient. And that is, male MDs are more productive. They work more hours and more years, see more patients, and therefore provide more care. If the number of MDs was not limited by a fixed number medical school and residency slots, that wouldn’t matter. But since the pipeline does have a fixed capacity, the substitution of female for male physicians is exacerbating the problem.

Andrew' March 5, 2013 at 9:02 am

Come on folks.

The point is that the standard is not an objective one if you double the applicants but the seats remain constant. Thus the de facto bottleneck is the seats. So, we could have roughly double the number of doctors at the same quality as previously allowed.

David Bley March 4, 2013 at 6:06 pm

There are a lot more players in the healthcare system than the medical profession. Insurance companies, drug companies, equipment manufacturers, hospitals and lawyers all extract profit from the system and I am not sure that the system has made us healthier. Most conditions that affect the developed world are managed rather than cured and are blamed on the patient. There are fewer doctors in part because they have so many hoops to jump through to provide care.

Ray March 4, 2013 at 6:22 pm

I don’t know what the gatekeeping effects are, but the number of slots in medical school each year has had a ridiculously low rate of growth, being essentially static throughout my lifetime – about 17000 per year in 1983, to about 19000 per year in 2012. (https://www.aamc.org/download/153708/data/charts1982to2012.pdf)

The number of doctors coming through this pipeline hasn’t even kept pace with population growth, to say absolutely nothing about the explosion in the elderly population, in available treatment technologies, and increased dropout rates (MDs who do not practice medicine)

quigley March 4, 2013 at 10:30 pm

Do these figures account for the expansion in “offshore” med schools, D.O. schools, and intermediate providers (N.A., P.A., N.P.)?

joe March 4, 2013 at 6:34 pm

The way our medical education system works, if more women become doctors, then fewer men will. The supply of medical education is peculiarly static. Whether this is an innate characteristic of medicine (e.g., medical school teachers have to be really, really smart and are therefore scarce) or an artificial barrier (e.g., current doctors protect their incomes by making it harder for other people to become doctors), I don’t know.

byomtov March 4, 2013 at 7:03 pm

That is a sign of rising female prominence when it comes to educational success, but there is no good reason why the flow of male doctors should be falling so rapidly; it’s not as if men suddenly have lost the ability to doctor.

I don’t understand this concern. If some time ago we had 100 M.D.’s, all male, and now we have 120 M.D.’s, sixty male, sixty female, the number of male M.D.’s has fallen by 40%. So what? That doesn’t mean men have “lost the ability to doctor,” it means lots of women are becoming physicians.

Cliff March 4, 2013 at 8:54 pm

So what? Now we should have at least 160 M.D.s

byomtov March 4, 2013 at 9:08 pm

So what? Now we should have at least 160 M.D.s

Care to explain?

V March 5, 2013 at 12:34 am

Why dont we also just fork over 70% of our pay checks to pay for Medicare then? I am sure all these doctors wont be ordering tests and creating the demand to justify their new salaries.

Oh yeah and I bet because it says in an intro Econ 101 textbook, prices should fall, that is what exactly will happen contrary to every other study of a sector able to create its own bad and where third party payors exist.

Andrew' March 5, 2013 at 9:05 am

So, under your theory we should just nix half the doctors?

V March 5, 2013 at 2:06 pm

Under my theory, we should restrict doctors to the numbers needed to make sure outcomes do not get worse. Given that the last few expansions of doctor numbers (e.g., the building of D.O. schools) have not improved outcomes while still massively raising costs, one would think we are nowhere near the point of needing more of them.

CPV March 4, 2013 at 7:12 pm
Bill March 4, 2013 at 7:55 pm

Interesting, but let’s let the facts get in the way, as they say on MR.

You might also add that physicians/population statistic does not include adjustments for growth of physicians assistants displacing docs, or telemedicine interfaces that may let docs, or nurses, see more patients, or electronic medical records which might limit the number of test retakes. In other words, how many physicians you need may depend on technology and physician complements, such as nurses or physician assistants

Also, on a technical note, physicians/population measure doesn’t control for the growth of specialists…a neurologist is not a substitute for a rhuematologist, for example. So, if you see more growth of physicians/pop, it could be that there may be more specialists.

On the issue of physician efficiency, it’s surprising how little information there is. I recently listened to a lecture on a paper measuring physician efficiency…not a good draft paper, by the way…but the upshot was that there is no current measure of physician efficiency, and that current payment mechanisms do not adjust for physician substituting nurses, for example, for part of their job before they see the patient.

Ted Craig March 4, 2013 at 8:14 pm

Or, as I said above, DOs.

Bill March 5, 2013 at 7:13 am

Ted, Your empirical observations were spot on.

Andrew' March 5, 2013 at 8:23 am

Why do you think your metric is better, that it contradicts the post, or that this fucked out premise that we don’t deal in facts here isn’t fucked out?

Don’t you suppose the growth in osteopaths is a workaround? If not, then what could possibly be the explanation? Little Jimmy dreamed of being an osteopath since he was 3?

mulp March 5, 2013 at 1:43 am

The OECD uses the metric “practicing physician” which:
1) eliminates the retired, the managers, the members of Congress fighting Obamacare, the members of Congress settling for Obamacare as the closest to single payer, the researchers, CEOs,…
2) eliminates the distinction between type of degree and factions calling the other types of doctors quacks

From 1993, the OECD number increased from 2.1/1000 population to 2.4 in 2009. Compared to wikipedia’s ~3/1000 pop.

But then we have the data from http://www.ahrq.gov/research/findings/factsheets/pcwork1.html

“Of the 624,434 physicians in the United States who spend the majority of their time in direct patient care, slightly less than one-third are specialists in primary care. Primary care physicians consist of family physicians and general practitioners, general internists, general pediatricians, and geriatricians. Of the nearly 956 million visits that Americans made to office-based physicians in 2008, 51.3% were to primary care physicians.1″

“According to the 2010 American Medical Association Physician Masterfile, there are slightly more than 246,000 primary care physicians in the United States. This number, however, overestimates the number of practicing physicians and needs to be adjusted because the AMA Physician Masterfile includes some retired physicians and others who have left the workforce and a substantial number of primary care trained physicians now practice in non-primary care settings, including as hospitalists and in emergency departments. After adjusting for these two factors, the number of practicing primary care physicians in the U.S. is estimated to be approximately 209,000.”

That comes to 2/1000 total, but on 0.67 /1000 primary care.

That same source also states “In 2010, approximately 56,000 nurse practitioners and 30,000 physician assistants were practicing primary care in the U.S.”

Aaron Young, Ph.D., Humayun J. Chaudhry, D.O., Janelle Rhyne, M.D. and Michael Dugan, M.B.A. report in their paper on the State licensed physicians in the US, Their count is

Total 850,085 100.0%
Degree Type
Doctor of Medicine (M.D.) 789,788 92.9%
Doctor of Osteopathic Medicine (D.O.) 58,329 6.9%
Unknown 1,968 0.2%
http://www.nationalahec.org/pdfs/FSMBPhysicianCensus.pdf

Kaiser reports 2.5/1000 pop
http://www.statehealthfacts.org/comparemaptable.jsp?ind=935&cat=8&sub=100&yr=63&typ=1&rgnhl=1

What is notable in their data is that Idaho and Mississippi have ~17/10,000 while VT, CT have 30, RI, NY 33, MD 35, Mass with Romneycare has nearly 40, and DC has 65 presumable involved with Federal public policy.

Presumably the “red states” which dominate the States with less than the average number of physicians/1000 pop have fewer doctors because conservatives in places like Mississippi chose to be healthy and thus generate less demand.

Andrew' March 5, 2013 at 8:26 am

http://www.nationmaster.com/graph/hea_phy_per_1000_peo-physicians-per-1-000-people

Note that the US is 52nd on the list, so the null hypothesis would probably be any growth in total physicians per 1000 people is just catching up and isn’t even the right metric anyway when considering demographics changes.

If your plan is that doctors are so bad that we need less of them because of how much damage they do to health, then I’m all ears on your model.

Bill Gardner March 4, 2013 at 7:45 pm

Some evidence, please, that the health care system would benefit from more doctors.

Cliff March 4, 2013 at 8:56 pm

Since we don’t have any evidence, let’s just set really restrictive regulations limiting the number of new doctors to some unnatural and very low number. That’s probably optimal.

V March 5, 2013 at 12:36 am

Cliff–the evidence that higher numbers of physicians raise total health care costs is pretty definitive (google it). A potential marginal decline in their salaries (has never been actually shown to occur btw) is not going to compensate for the massive increase in health care utilization

Andrew' March 5, 2013 at 4:52 am

Why not start with the null hypothesis that more people who know about health will increase the general knowledge of health?

How the government in cahoots with private interests has fucked up the financing and specialization of healthcare is a separate issue.

Andrew' March 5, 2013 at 9:08 am

“Some evidence, please, that the health care system would benefit from more doctors.”

The evidence is the de facto observation that the medical education system used to approve X out of Y applicants to be doctors. Y doubled, and yet they did not double X. So, were they wrong before, or are they wrong now?

Granted, the female nurses of yore did a lot of the doctoring. But either way, they have some explaining to do.

CPV March 4, 2013 at 7:54 pm

Yes, the problem is an oversupply of healthcare. Prices per procedure are not that out of hand. The number of procedures is too high. This is a strange argument.

CPV March 4, 2013 at 7:58 pm

Doctors create their own demand since they can order any procedures they like. This point seems lost on the GMU bloggers. the rise in total health care expenditures is mostly due to increase in number fo procedures, not procedure cost. That’s the real enchilada here.

SRM March 5, 2013 at 12:28 am

But why are they ordering more procedures? Part of it is to “game” the system, for either pure greed or more commonly because insurance does not reimburse many procedures/tests, often even if they are necessary. More striking is the “cover your ass” or CYA attitude we have in medicine. Since doctors are so afraid of being sued, they must order more tests to back up, double check, or strengthen their diagnoses or non-diagnoses. This costs the system money. Without “pain and suffering” caps and other tort reform, these practices will continue.

Richard March 5, 2013 at 4:56 am

How about doctors are ordering more tests because new evidence is coming out showing that it’s a worthwhile or better test than something we had rejected in the past. The same thing applies to new procedures that yield [marginally] better results. If you leave the decision up to the individual patient, covered by insurance, of choosing between older+cheaper vs newer+better+more expensive, which one do you think they will choose given a constant copay?

Most doctors I’ve worked with are not “evil” in ordering more tests to drum up business. It’s not how we’re screened or trained. However, I do hear on the wards all the time nurses strictly refusing to work 10 minutes beyond their shift due to high patient volume. Instead, the charge nurse has to beg/bribe them with 1.5x pay+extra vacation. Talking about compensation is taboo among doctors (they learn quickly about how sensitive a topic this is) but nurses in the break room talk all the time about moving up to CRNA and getting MD level pay for not very much work.

Pshrnk March 5, 2013 at 9:36 am

How about too many doctors do not understand Bayesian analysis, or base rates and test sensitivity and specificity? Many docs still insist, for examples, on too frequent PSAs and mammograms. As a result morbidity, mortality, and cost increase!

Andrew' March 5, 2013 at 8:30 am

You are confusing hospitals for doctors. And you are confusing doctors and their incentives. And none of this is lost on the people you think it is.

V March 4, 2013 at 8:05 pm

Adjusted repost from above:

This focus on increasing doctor supply when health care is a market with supply-induced demand and third payer payment is a disaster for budgets.Massively increasing doctor supply is a sure-fire way to massively increase total health care costs. South Florida has shown just how dangerous it is to have a high concentration of physicians in one’s area (not to be anti-doctor)

Rationing doctor supply has been one of the only effective cost-control techniques the US health system has had (given that physician reimbursement is fixed, prices have not risen significantly for the professional fees doctors are paid over the last 10 years) and removing it (while it could theoretically decrease individual doctor pay) will almost certainly increase massively utilization which is why insurance companies for example never campaign to loosen this “monopoly”

The evidence that restricting doctor supply meaningfully worsens outcomes is unsurprisingly nonexistent

Steve J March 4, 2013 at 10:34 pm

My head is just about spinning reading through these posts. After getting angry about artificial limitations on the number of doctors you remind us that increasing the supply of doctors will not reduce costs anyway. And I feel like I have read about the exact problem you are referring to on MR before. Healthcare is one messed up subject.

Andrew' March 5, 2013 at 8:37 am

And yet the solution is so simple. Allow nurses to make calls and allow patients with medical savings accounts to accept responsibility for the decisions. We are already doing that, btw. We just don’t get the savings yet. We saw an NP about three months ago. I was a bit miffed because of course we are still paying the doctor rate. She correctly diagnosed a pharyngitis. Then about a month ago we saw 3 doctors to get one correct diagnosis of pharyngitis. So, when they get to capture the delta, they are all for it. They will continue to pretend that the doctor’s imprimatur is paramount.

Steve J March 5, 2013 at 9:46 am

“Allow nurses to make calls and allow patients with medical savings accounts to accept responsibility for the decisions.”

100% agree. The study I want to see is what is the value add of the doctor over the nurse. The extra training has to provide value (at least I would think so) but we need to quantify in some fashion what we are paying for. I would also guess a nurse with 20 years experience is more valuable than a doctor fresh out of residency. After reading that Time article on healthcare costs (http://healthland.time.com/2013/02/20/bitter-pill-why-medical-bills-are-killing-us/print/) I am pretty unhappy with that industry in general.

V March 5, 2013 at 2:12 pm

Steve–the right study probably is the value of the nurse over doing nothing. Nurses are not really trained to do much more than the basics (e.g., taking blood pressure, administering injections, recognizing that a patient is crashing and a doctor needs to be called) and so the nurse-doctor comparison is futile. A doctor fresh out of residency is much more knowledgeable and trained than any nurse could ever be (mainly because no nurse has been trained with that material not necessarily because of intrinsics) and for instance, can (if a surgeon) do surgery, or read CT scans or do procedures like paracentesis, etc. unlike any nurse.

Medicine is not just about giving you cold medicine when you have a cold and its dangerous that folks think like that. If we want to cut doctor pay, then we should do so as we have a mechanism in place to do it (the RVU scale). Pretending that we can replace physicians with people who also hang out in hospitals is just foolhardy and why no single-payer system (or any type of system) does that.

Steve J March 5, 2013 at 3:39 pm

V – I think we may be talking about two different things. I am imagining nurses being used more in non-critical situations. And I think they are already being used that way but we should pursue that even further. When you need an MD should be based on statistics and an acknowledgement that the quality of care will go down in exchange for reduced costs. An easy example from the layman’s perspective is how often do we really need an OB-GYN involved in the pregnancy/birthing process?

maguro March 5, 2013 at 8:42 am

I suppose you also think that having a large number of construction workers in an area causes a lot of houses to be built.

Andrew' March 5, 2013 at 9:37 am

It depends, of course. If there are supposed to be more houses built then they will be. Total spending on houses will in fact increase. This is why most tests for induced demand are lacking. They often show that more doctors equals more doctoring. Well, duh. They don’t tease out unnecessary treatment from pent-up demand. Even then, the problem is the control doctors have. While others do, I have no trouble telling my doctor to take a hike with any unnecessary treatments. I have a lot of trouble getting him to approve a treatment that he thinks is unnecessary. This probably results in higher bills down the road. Regardless, the problem is not the numbers but the incentives. This paper shows that Medicare reimbursement changes affect induced demand. That is nothing I haven’t been saying forever. It is not necessarily generalizable to all doctors.
http://www.jstor.org/discover/10.2307/3764772?

Lonely Libertarian March 4, 2013 at 8:24 pm

Let me expand on what CPV suggests…

There is virtually no data to support a positive correlation between the care consumed and better health – in fact there are studies that seem to support the inverse – that if you see a doctor MORE often you will die younger [but correlation does not equal causation I will concede].

Expensive hardware must be paid for – If I buy the latest whippy skippy imaging device I will work very hard to make sure it is busy – and that I bill out a lot of procedures – without regard to whether they are needed or warranted. If I am an investor in a lab or test facility – I have a bias to see that that facility is profitable. I may not make a lot from my practice – but if I can order a lot of tests for my lab – well then things will be ok…

If I were a doctor I would be a compassionate provider – I would care about my patients. So if my ordering a marginal/incremental test made things more difficult for them then I would never do it – but heck the test is paid for by Medicare/Insurance Provider – so why not play it safe and order the test.

Andrew' March 5, 2013 at 4:58 am

I have this doctor. And he is too conservative. A relative went to this doctor with arthritis and swelling and got the diagnosis of arthritis and swelling. So, we use an average of 3 doctors. Last time it took all three to diagnose a pharyngitis with the first two being misdiagnoses. It was fun listening to them badmouth eachother. Because I am the final arbiter of care, this works because I routinely refuse advanced treatments.

Perhaps a new class of nurse/doctor with shorter time to train would be useful – the undiagnostic doctor. Like a nurse who does more than take your weight and temperature and rules out diagnoses. Since the government is in charge of certifications and who can do what this is their problem.

Marc March 4, 2013 at 8:24 pm

My wife works in a man’s field: She is a rabbi.

There is a common notion in such fields that women entering a field degrades the value and prestige of the field for men. In Conservative and Reform Judaism, the ordination of women seems to have reduced the supply of male rabbinical students beyond what people would perceive as crowding out or competition. (No, there is no data…this is a perception that may or may not be true.)

Add to that the notion that pastoral care duties are not viewed as a typical strong suit for men, means 21st century Jews might be better served (on average) by women rabbis.

It seems likely that medicine could share a very similar result: Bringing women into medical schools, (beyond the novelty cases of old,) drove qualified (implicitly or explicitly sexist) men into other fields.

Mm March 4, 2013 at 8:59 pm

Cynthia & Slocum- before commenting it is standard practice to have a clue about what you say. Paid $59K+ just for just learning? Get a few facts Cynthia-residents work 80+hrs(in the bad old days it was a lot more) providing patient care most of the time, if they were eliminated their replacements would cost more than $50K+. Slocum- yes specialists do need their general training. Anesthesiologist provide, in essence, critical resuscitation and medical care intraoperatively and therefore need many “general” skills. Radiologists and pathologists need to understand the concerns of generalists when test are ordered to better perform & report the results. Another point is that MDs do not create much of their own demand-age, bad lifestyles, trauma do that BUT the best way to ration care in the future will be to restrict acess by a provider shortage- ie delay entry to the system by queuing to see the MD

anon March 4, 2013 at 9:10 pm

residents work 80+hrs

Is this still true? A friend whose son is a “fellow” at a teaching hospital in Baltimore told me recently that new rules / regs restrict how much residents can work so the hospitals now hire post-residency “fellows” and work them long and hard instead.

quigley March 4, 2013 at 10:41 pm

I trained in the “bad old days” and worked ~ 110 hr/wk for 12 weeks at a stretch. This wasn’t a record. It was common.
The 80 hr work week restrictions are being followed. Furthermore, there is a lot more down time for residents now that hospitals have better support staff. I’ve repeatedly stated that I think residency is now easier than medical school. Also, trainees are not as well trained because they see substantially fewer cases. Canada has extended some residency programs to compensate for similar changes in experience.

V March 5, 2013 at 12:40 am

I trained in the new days and there was no real down time nor were the 80 hour regulations followed. Frankly, that was a disaster for the physicians who were too tired to learn much, if anything, and for patients who were put at risk because of people who don’t understand the basic physiology of sleep.

You need to read some basic articles by Czeisler et al. to realize just how much danger you are placing innocent folks in because you have some romanticized view of training in the past (when all you or most of your colleagues could do was hold the patient’s hands and give them an aspirin unlike with modern medicine).

quigley March 5, 2013 at 12:58 am

“you have some romanticized view of training in the past”
I didn’t say it was better for anyone. I said training now is inadequate.

“basic articles by Czeisler et al…give them an aspirin”
You’re ignorance of what came before you should not be viewed as knowledge. If you understood the limitations of current medical practice, your arrogance may be tempered.

Andrew' March 5, 2013 at 5:00 am

So, then. Why are doctors so stupid? Or, why is the profession so oriented towards washing people out? I think we know why. But do they KNOW why?

Steve J March 4, 2013 at 10:44 pm

“delay entry to the system by queuing to see the MD”

I would like to understand what percentage of people need to see an MD compared to a PA or RN. How many people can we screen out so that the MDs are only seeing the harder to diagnose cases? The MD’s response is always a PA or RN cannot do my job. I agree with that but what percentage of the time can the PA or RN do good enough? It seems like this is just a math problem that should drive how we use our limited supply of MDs. Note I know that care will be worse but it will also be cheaper. It is similar to how we have decided to increase our speed limits so that we can get places faster knowing that more people will die.

V March 5, 2013 at 12:46 am

Steve–its tough to answer that question because the value of the physician is in separating the routine from the dangerous and one can’t know which category a patient falls in before examining them (at which point, the subsequent value of deputizing their care to a PA or RN falls precipitously).

Also, unfortunately, the Affordable Care Act made reimbursements for NPs, et al. identical to Family practice docs for the same diseases so the cost savings argument is moot and potentially could even run the other way. On the other hand, for providers, the profit margin on employing these pseudo-docs just got a lot higher.

Richard March 5, 2013 at 4:59 am

Yeah, it’s moot, because mid-levels want equal levels of reimbursement. It’s not in their interest to be a cheaper provider (though that tagline worked wonders when convincing states to expand their practice privileges) in underserved areas. Their ultimate objective (read their forums) is to take all the routine/easy cases and stick the poor doctor with sicker, more complicated ones that take more time/effort, and get paid the same!

Bill March 5, 2013 at 7:25 am

V, I disagree with your comments re ACA: by making NP reimbursement equal does not mean that the docs (or the clinic) will PAY the NP what it receives in reimbursement. In fact, making payments equal for same work causes docs in private practice to use NPs so they make more money, or clinics to use NPs so they make more money. See my comments above regarding efficiency measurements of docs and how employing NPs gets cranked into the efficiency measure and profitability of a docs practice

quigley March 5, 2013 at 11:23 am

I think V is talking about savings to society.
I think Bill is talking about savings to net to the practice.

Steve J March 5, 2013 at 10:44 am

“Also, unfortunately, the Affordable Care Act made reimbursements for NPs, et al. identical to Family practice docs for the same diseases so the cost savings argument is moot and potentially could even run the other way.”

You have got to be kidding me… I would love to hear the reasoning behind that.

Mm March 5, 2013 at 1:04 pm

The problem with deciding wether an “extender” (NP/PA etc) can do the job is, firstly: the patient doesn’t present with a diagnosis so they can be easily triaged(routine to extender, complex to MD), secondly, to be used properly the extender needs to be supervised by an MD – in many small clinics you can’t gain the claimed efficiency since you can get to the proper supervision ratio. Furthermore, you need night coverage, so in small clinics the supervisors night coverage becomes unbearable if he hires extenders rather than MDs

quigley March 4, 2013 at 10:51 pm

You bring up several good points, but you don’t look deep into the problems.

1. Trainees are much better paid now than in the past when salary data was not easily obtained and their were no standards. That said, I value and appreciate the contribution of medical housestaff and am glad they are paid better.

2. Other developed countries do not have specialists obtain broad training. I trained and teach in the US so this is the system I know best, but I have plenty of smart European colleagues that had a different experience.

3. Your point about demand needs punctuation and data.

4. You have a poor understanding of the true costs of having a training program and overestimate the benefits and efficiency it brings to patient care. A skilled, trained MD can cover what currently requires three teams of internal medicine housestaff ( > 10 trainees). Do the math.

Andrew' March 5, 2013 at 5:07 am

Considering I frequently only see a nurse, and the patient is the final arbiter of treatment, the patient could decide and take responsibility. In fact, almost no meetings with the doctor don’t end with “well, you need to decide.” I’m never sure what I’m giving these guys my thousands of dollars for.

In fact, I’d rather not have the awkward conversation with dentist after the hygienist does everything too- as long as we get to split it halfsies.

Richard March 5, 2013 at 5:24 am

Hey, no one’s satisfied in the end. Some patients prefer the very way you describe. Others prefer something different, and no one puts this in writing how they expect to be treated.

Do I give you all the information and let you decide in the end, do I suggest the standard approach, or do I tell you what I would do if I were in your shoes?

Medical training is moving more towards patient autonomy in decision making, as opposed to the paternalistic dictates from up high, because studies have found that’s what most patients want.

Mm March 5, 2013 at 1:18 pm

You are looking at internal medicine a nonprocedural field. In other fields house staff can add a great deal more value.

Pshrnk March 4, 2013 at 9:05 pm

So, when women are becoming a greater percentage of doctors. some expect there to be government pressure to pay doctors less. Hmm!

Mike in Qingdao March 4, 2013 at 11:43 pm

What’s so difficult to understand? In developed countries, Men’s internal discount rates have skyrocketed over the last 30 years due to a variety of factors including outsize returns to finance and women’s preferences for 6-pack abs over a stable future.

Husker Don't March 5, 2013 at 10:48 am

Bahahaha!!! Yes!!

Andreas Moser March 5, 2013 at 2:00 am

Maybe more seniors are doctors themselves now?

Andrew' March 5, 2013 at 5:03 am

Don’t trust doctors? I don’t trust them any less than any other people bestowed with massive power by the state and granted incredible arrogance and insulation by their station. Who else routinely makes you wait an hour plus but will charge you if you are late?

Andrew' March 5, 2013 at 5:13 am

And with the number of medical errors and iatrogenic morbidity and mortality, who wants to step up and engage on whether patients can decide? Anyone? Please.

Andrew' March 5, 2013 at 5:16 am

I had a relative die from falling off an MRI table. I’ll bet you all of their tax writeoff payout that they still don’t have a railing. Anyone?

Richard March 5, 2013 at 5:17 am

Guess what, errors happen everywhere, and in every profession. It just so happens that medicine is a field where you’re expected to be 100% perfect (which adds insane amounts of stress to work every day). Mistakes in engineering (Boeing 787) and finance (last decade+) happen all the time, but hey, the public seems to absolve them of responsibility all the time. But no, the doc has to be perfect!

Richard March 5, 2013 at 5:14 am

Do you know why that happens? It’s because the prior patient doesn’t stick to a pre-defined 15 or 30 minute appointment window. He arrives late, still expects to be seen, asks tons of questions, and brings up multiple other issues that you now have to address. What can you do? Shoo him out?

The US is the only country I’ve been in where the patient has such visceral hatred directed at doctors. Try getting care in India where you can queue up to 2-3 hours waiting for your turn in line. Oh, it also happens that the attitude of doctors there is less empathetic and more a paternalistic “do what I say”.

Andrew' March 5, 2013 at 5:16 am

“Who else routinely makes you wait an hour plus but will charge you if you are late?”

You MUST be a doctor. Reading comprehension.

Andrew' March 5, 2013 at 5:17 am

This is why I take just a little satisfaction in Obama decimating the medical profession.

Richard March 5, 2013 at 5:26 am

So much vitriol. Tell me your profession so I can bash it on groundless personal anecdotes/preference.

Andrew' March 5, 2013 at 6:27 am

So, I nailed you right?

I’ve cleared my schedule for the day. I’d rather argue with statists, but I don’t mind doctors.

And for the peanut gallery: http://lewrockwell.com/wenzel/wenzel217.html

Richard March 5, 2013 at 5:21 am

I fail to see how I missed something in reading comprehension. Nice ad-hominem attack, btw.

Is the doctor making you wait and hour plus? No, he obviously wants to get through the day as efficiently as possible. Remember that he also has to work late if things get behind. As I mentioned from what I’ve seen it’s due to fixed time allotment and poisson-distribution actual time spent. Oh, and of course you can’t start early on the next patient if you finish with the previous one early, because he’s not here yet. As for charging if late, most of the time now that’s a clinic/hospital system policy that’s controlled by *administrators*. And besides, what’s wrong with having that as an incentive to prevent tardiness, which I’ve mentioned is a prominent cause of delays for other patients?

Spend some hands on time in the medical field and you may walk away with a changed perspective. I’ve known spouses do that when they see just how rough their partner’s life really is.

Andrew' March 5, 2013 at 6:50 am

No. It is “Who else does that?” on a routine basis? And cry me a river on how hard their life is to make $150k. They control their monopoly.

Rahul March 5, 2013 at 6:52 am

It’s because the prior patient doesn’t stick to a pre-defined 15 or 30 minute appointment window.

That isn’t a novel problem. Solution typically involves buffer slots or other options. I don’t hate doctors. But that traditionally doctors had atrociously long wait times is also fact.

Things are improving though. My HMO has a placard asking patients to talk to a receptionist if they’ve been waiting longer than 20 minutes post-appointment time. Not sure what the receptionist then does though.

Andrew' March 5, 2013 at 7:53 am

My profession is engineering. Have at it. We aren’t a bunch of prima donnas.

Andrew' March 5, 2013 at 8:00 am

Or if you have critiques about academia, I’d love to add them to my catalog.

Ray Lopez March 5, 2013 at 6:49 am

It’s true that queuing occurs outside the USA. Here in Greece a two hour wait to see the doctor is not unheard of, but the care given is about the same as in the USA (from what I can tell) and the fees for an office visit are either $0 (if you go during the day to a state doctor, and have your “medicare” book with you), or $13 US/ $10 euro for an office visit in the afternoon with a moonlighting doctor. I think both countries distrust doctors as much, but at least you don’t get stuck with a big bill outside the USA. As for paternalistic attitudes, I’ve not seen much difference in Greece vs the USA vs some SE asian countries I’ve visited and received medical care in, but I think it’s because they know I’m a professional and don’t treat me like a local.

Jack Two March 5, 2013 at 1:35 pm

Two ways to lower cost of producing doctors:

1. Make the academic part of a medical education an undergraduate major that costs the same as any other undergraduate major. Also, allow anyone to take a series of rigorous and comprehensive exams to exempt them from having to get the degree in order to do a residency.

2. Make the residency part of a medical education free to the student (and to the hospital) and allow students to borrow up to $20K per year for living expenses.

Husker Don't March 5, 2013 at 3:21 pm

Umm, residency is free to the student. They get paid a salary to go to it (~50k per year). I think it’s also mostly free for the hospital as resident salary’s are paid (at least partially – not as sure on this point) from the medicare trust.

Mm March 6, 2013 at 9:23 am

Lower? More like shift the cost- maybe a good idea but you need to be honest about it. Historically, shifting the cost to the government doesn’t lower the cost. Furthermore, postHS, pre residency is EIGHT years, pretty long for an undergrad degree. You could cut 2 years out(& get geekier MDs) but it still isn’t undergrad level work. 4years of med school is like 8 years of undergrad in the work load- that isn’t n exagerration,

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