Less is more: Dartmouth argues against more doctors

This group has been championing the “less healthcare” for awhile. Here is what they say in the NY Times:

The association of medical colleges has argued that increasing the doctor supply overall can remedy regional shortages. But in the past 20 years, as the number of doctors per capita grew by more than 50 percent, according to our measurements, most of the new ones settled in areas where the supply was already above average “” places like Florida or New York “” rather than in regions that lack doctors, like the rural South. Medical training is an expensive business, and it makes little sense to waste additional public dollars to perpetuate doctors’ preference to live in affluent places.

By training more doctors than we need, we will continue to fill more hospital beds, order more diagnostic tests “” in short, spend more money.

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  • Anonymous

    The article does not specify the common denominator of the patients interviewed. Did they interview only the local patient population or any patient present in the hospital or clinics? I am sure that places like New York and Florida are also large referral centers from outlying rural areas.

  • Anonymous

    oh–but I thought everyone was leaving medicine because all the doctors are afraid of the big bad tort lawyers.
    Hmm. . . seems like they’re just afraid that their malpractice premia may be too high to afford a lexis

  • Anonymous

    The referenced editorial is about what I expected from a self-serving member of the existing community who is afeared of competition. The current system is based on restricting the domestic production of providers in order to enhance their compensation and social status. Coupled with legislative control over vast swaths of healthcare, no allopathic provider has to ever worry about being put out of business by the competition (there isn’t any). A review of the Flexner Report and a reading the Social Transformation of American Medicine (Starr) are in order if one does not remember one’s history.

    The issue of quality of care, in the context of the production of additional allopathic providers, is a red herring. If one wishes to discuss quality of care then the proper topics of discussion are the broken kangaroo court medical disciplinary systems, the AMA’s obstruction on the mandatory reporting of medical errors and the continued allowance of practice of those in the field that are responsible for the majority of the medical malprctice cases.

    The proper issue of discussion is one of access to care or more generally the quantity of care available. In the current system, rural and urban areas are left without access to care because there are not enough providers being produced such that there is sufficient competition to ensure that providers, needing to have a patient base, serve these communities or else are fiscally unable to practice. Instead of providers choosing to serve these areas, they choose to work in suburban settings. Even worse are the ones that waste the valuable and limited slots at the medical schools in order to become saline bag stuffers for the vainglorious.

    The truth of the matter is that the plebeian population needs to pull their heads out of their rectal cavities and start looking out for their own interests. The current system of training of providers exists to serve the needs of the provides first (not the plebeians). For the inevitable “I went to school for X years and thus am entitled to three Ferraris per year” response that this post is sure to engender… can it and take a course in economics. There is no legal basis that says that X years of school automatically equates to Y dollars of after-expense compensation. The reason why current providers receive the king’s ransom in after-expense compensation is because the providers of the 1920s actively worked to ensure that the majority of healthcare services could only be provided by allopaths and once this was done they made sure to severely restrict the number of allopathic providers (monopoly conditions, fixed or increasing demand for services, supply side restriction –> limited access to care and $$$ for those controlling the supply). For a country that imports 25% of its provider base, the words of our esteemed Dartmouth sage are about as worthy of consideration as those of the owners of Standard Oil and the railroads of yore.

  • Anonymous

    I don’t disagree that we need to “reallocate” doctors but how to do it? How do you give Doctor’s incentive to move to rural Mississippi or Arizona? Inspite of what the “knowledgable” anons above state, typical family docs, peds docs, or general internists aren’t in it for their lexus or three ferrari’s per year (I can’t believe you are so utterly clueless to think state that). I myself drive an 8 year old chevy. Not whining, just the fact. So how do you get these guys and subspecialists into rural areas? This is America after all. You can’t round them up and put them in a cattle car. I’m all ears but let me tell you now any reasonable reason will involve incentives which cost $$. For those living on another planet medicare is actively cutting wherever possible. Please to give me an answer. One other comment about the good Dartmouth professor’s opinion note he once again uses the statement:
    “More than 100,000 deaths a year are estimated to be caused by medical mishaps”
    Once again I will say if you go back to the orginal papers (as our good professor should) you will realize this is all based on extrapolated data from the early to mid 1980′s. Remember that car you drove back in the early 80′s. Cars are a little different today. I am saying we need a RECENT study before parroting 20 year old data like that for present needs…..capiche professor.

  • Anonymous

    …typical family docs, peds docs, or general internists aren’t in it for their lexus or three ferrari’s per year (I can’t believe you are so utterly clueless to think state that).

    Sure they are not. Need I remind you of the recent “work stoppage” by the New Jersey Medical Association (providers from all specialties) in which the President of the organization explicitly stated that by using their captive audience (patients) that they could blackmail the legislature into providing special legal protection to the providers. You want to tell me that was not about money?!?

    I consider myself a bit of a free-marketeer. The solution to the problem is to increase, increase and increase the supply of providers. One could get the AMA and their arm, the CME, out of the training business, decouple medical schools from large research facilities, allow for proft medical schools, pay Mexico to open dozens of new schools (pass the boards and do your residency and even with a degree from the acadmeic powerhouse Tijuana Tech you too can practice in the US) or follow the California legal model and open schools that produce providers who are only accredited in-state (non-ABA California graduates can sit for the California State bar but don’t enjoy comity with other state bars). By flooding the market with providers, once the suburban and plastic surgery markets take their fill, the remaining providers will have no other choice but the practice in traditionally underserved areas if they wish to have a sufficiently large patient base to ensure a viable practice. By this method there is no need to bribe providers to “do no harm.” As far as an 8-year old Chevy goes.. what are you doing? Every single provider that I know (and I know a very large number of them) would not drive anything less than a Jag.

  • Anonymous

    I said this in a different thread but I’ll say it again: It’s not just a question of the numbers, it’s how those numbers are geographically distributed. By every measure, most rural areas are underserved.

    How do you fix this? I don’t know. Some of the facts of rural practice cannot be changed. It is isolating, it involves being on call and working a lot of evenings and weekends, and it usually requires you to give up easy access to nice restaurants, pro sports events, the theater, private schools for your kids and the rest of the stuff that gets classified as “quality of life.”

    The people who tend to be the most successful in rural practice are those who have either grown up in a rural area or who have spent part of their training in a rural area.

    I challenged Kevin in the earlier thread to post something positive about rural practice. I’m still waiting.

  • Anonymous

    said this in a different thread but I’ll say it again: It’s not just a question of the numbers, it’s how those numbers are geographically distributed. By every measure, most rural areas are underserved.

    In the current system it is not a question of numbers. Look at it this way. Given a finite population for any large metropolitan area, there is only a finite number of providers that can be supported. If the provider supply is sufficiently high, then in the limit, any additional provider put into the system will have to make the choice of either (a) moving to the areas where there are patients (rural and urban areas) whose healthcare needs are not being met or (b) not practice because there is an insufficient patient base in the suburban areas secondary to a high provider density and massive competition for patients.

    If we made healthcare providers as ubiquitous and numerous as auto mechanics, then, just like the auto mechanics, some portion would be forced to serve the rural areas in order to stay in the business.

  • Dr. Steve

    “Three Ferari’s a year” – Wow. That’s like $400,000. Even the Department of Labor states that the average physician salary is around $150k. If I buy $400,000 in cars that leaves, hmmmm NEGATIVE $250,000. Unless you’re George Bush, that does not add up.

    Also, a monopolist traditionally enriches himself by having total control over the cost for a good or serivce. Funny how a primary care doc can double their fees and get less than 5% return (prices with insurance companies are agreed to beforehand, and only the uninsured see the higher prices).

    You’re going to need a new pet rant. That one is full of holes.

    Bottom line is that thinly populated areas are thinly populated for a reason. And those reasons are the same whether you have an MD after your name or not. Forger about private schools for the kids – how about DECENT schools for the kids.

  • Anonymous

    Pulling in the “paltry” average salary are we? You must have chosen the wrong specialty. The BLS does not include other sources of income such as capitol returns from investments. The large majority of providers that I know are not making due with a measly $150K per year. It might have something to do with their medical-legal work… but we won’t touch that one… now will we?

    The legal definition of a monopoly is the abuse of free commerce by which one or more individuals have procured the advantage of selling alone all of a particular kind or merchandise or service, to the detriment of the public. Are you sure you want to get into a discussion of how the practice of the art of medicine has been monopolized since the 1920s by organized allopathic medicine? Whether or not you can wring financial concessions from the insurance companies is irrelevent to the course and scope of practice and the supply side restrictions placed thereupon.

    If we are going to start judging providers on the same metric as the plebeians… then that goes for the perks as well as the expectations from the providers.

  • Dr. Steve

    While it is true that gastroenterologist, cardiologists, and some types of surgeons make a good deal more than $150k, it is also true that the vast numbers of primary care docs (internal med, peds, family practice) and some of the lower paying specialties (rheumatology, endocrine) make less – and there are lots more of them.

    I’m sure you know dozens of doctors who let you sift through their tax returns at will so that your statistics are demonstrably more valid than the DOL. Yes?

    Medico-legal work? Why would I not “touch” that? I have known only one doctor that did that with any regularity.

    It’s pretty obvious that you have no idea what you are talking about. Your overly wrought language is a dead giveaway, as is this statement “One could get the AMA and their arm, the CME.” There is no organization called “the CME”.

  • Anonymous

    Making a lot less than 150K? While median wage data would be a better estimte, the mean wage data does not support your contention.

    Let us look at National wage estimates:

    http://www.bls.gov/oes/current/naics4_621100.htm#b29-0000

    Family and GP: 150,280
    General Internists: 164,350
    General Pediatrics: 143,970

    Is there any particular reason you turned to the BLS data instead of providing your own after-expense compensation rate? One can only surmise that if your own data point fit your contention that you would have produced it. Most of the providers that I know and interact with are orthopods and neurosurgeons. For some reason, they have very little restraint when it comes to describing both the gross incomes of their practices and their personal incomes. As far as the medico-legal issues go, I look forward to hearing your underlying basis for patient reliability as a function of provider status as profiteer vs. defendant as well as the justification for why the provider profession alone should be provided special liability status.

    CME = Council on Medical Education.

  • Dr. Steve

    “Is there any particular reason you turned to the BLS data instead of providing your own after-expense compensation rate? “

    Um, yes. You see, I am one person. Therefore my wages and expenses are anecdotal and influenced by myriad factors unique to my situation. Whereas the BLS, using wage data from more than just one provider (I would hope) has a much more reliable statistic.

    Don’t you think your view is slanted by interacting with only the very highest-paying specialties?

  • Anonymous

    Granted. My views are a bit slanted by dealing with the providers that I interact with. Also, seeing what I have seen in the legal system both first hand and through such wonderful advances to the field of science such as the Twinkie Defense, Prozac Defense, and patient parroting on causation… my view of the medical profession mirrors my view of the legal profession.

  • Anonymous

    Well, you must admit, Twinkies are tasty and just begging to be dipped in batter and deep fried.

  • Anonymous

    You know anon your story is so full of holes you make the New Orleans levee system great by comparison.

    1: “The BLS does not include other sources of income such as capitol returns from investments. The large majority of providers that I know are not making due with a measly $150K per year. It might have something to do with their medical-legal work… but we won’t touch that one… now will we?”

    You go from 150 K to 400 K for PCP’s based on their investments? 250K yearly in investments. Jeez at 10% of investments as income that comes to 2.5 million. I doubt very many primary care docs have close to that kind of money until late in their career. As far as medico-legal work. I also have only met 1-2 docs who do that kind of work on a regular basis.

    2: “Family and GP: 150,280
    General Internists: 164,350
    General Pediatrics: 143,970″

    Still doesn’t come close to 400K. Also lookey lookey many many of these docs in these fields make well under this number.

    3: You give the CME way way to much power. Their main purpose is to make sure we stay uptodate in our field through classes and such. Though admitedly it could be done much better and without pharm company involvement. You also give the AMA way way to much power. Do you realize only 1/3 of all docs are members? Quite the powerful organization if they can’t even attract their own now.

    4:” Most of the providers that I know and interact with are orthopods and neurosurgeon”

    Oh jeez you are judging us all based on those two specialities? Well of course you think we all drive jags. Neurosurgeons probably make the most of all the surgical specialties. GI docs are tops in pay (or second to interventinal cards docs) in the medicine subspecialties. You really are deluded if you get your evidence from those two groups of docs. Please do tell me where I can get at least one of my three ferrari’s per year as my 8 year old chevy needs a rest :)

    PS: I do agree you must come from the George Bush school of mathamatics.

  • Anonymous

    George Bush School of Mathematics? New Orleans Levies? I am unsure as to what your fixation with El Presidente is… Perhaps it is guilt associated with the special liability protections being afforded to the clinicians that are not affored to anyone else? The three Ferraris per year was purposeful hyperbole on my part – It is interesting to see if the clinicians are willing to debate the issues or jump on the hyperbole. The BLS data was in response to Dr. Steve. If the mean is that for a normally distributed curve without deviation then we know that some make more and some make less. Without information regarding the dispersion from the mean, how muc more or less is speculative.

    I think I give the CME the appropriate level of respct that it deserves given its history for stifling competition by limiting the supply of providers (and please spare me the we need to have very small numbers of providers at schools that are only at large research institutions to ensure provider quality – allowing providers trained at the proverbial Tijuana Techs of the world to practive domestically obviates this arguement). There is no other field of work in which the practitioners enjoy the perpetual employment and job security of allopathic medicine. You didn’t think that this happened simply because the sheeple bought into the “do not harm” slogan? The current state of allopathic medicine is secondary to the deliberate use and exercise of political power and the exercise of basic economics knowledge.

    As far as the providers that engage in the medicolegal world – you should take a gander at what they are saying. If you are a person of science, it would be very disenchanting. Post hoc ergo propter hoc is perhaps the best way to describe it. As far as relying on my interactions with the Orthopods and Neurosurgeons – are you suggesting that they don’t exemplify the allopathic ethos and thus are unreliable when it comes to conclusions regarding the practice of clinical medicine?

  • Anonymous

    For those that think that the CME is without power:

    http://jama.ama-assn.org/cgi/content/full/291/17/2139

  • Anonymous

    the long rants by anonymous are spoken by someone who is totally ignorant of the medical profession

    1) AMA does not control medical schools. Florida just recently opened up 3 new med schools and the AMA was neither consulted, nor did they “approve” any of them. The florida state legislature has sole purview to open up however many med schools they want, and the AMA has zero control over it.

    2) There are currently 30 new MD and DO schools either built in the last 5 years or planned in the next 15 years. What were you saying about the AMA keeping an iron fist on med schools?

    3) MDs, DOs, NPs, PAs, DDS/DMD, NDs, can all script medications. Thats at least 7 different training pathways, and the AMA is involved in only ONE of them. Again, where is this “monopoly” you speak of?

    4) USA takes more foreign doctors than all other nations COMBINED. Again, where is this iron fist AMA approach you speak of?

    5) USA per capita doctor ratio has risen by 50% in less than 20 years. Again, where is this lockbox you speak of that The AMA keeps on doctors?

    6) Orthopods and neurosurgeons collectively make up less than 5% of all doctors. Thats not too smart to judge and entire profession by a 5% sampling. Neurosurgeons alone average 3 standard deviations above the median aggregate doctor income. Your comparison is similiar to me stating that business owners are overpaid because Bill GAtes makes X billions per year.

    7) In terms of doctors per capita, USA ranks #5 in the world among 35 industrialized nations. If the US AMA has a lockbox on doctors, then the european nations have an even tighter monopoly than the USA does.

    8) The study in teh original article proves that more doctors does NOT lead to lower costs. Thats because doctors dont compete against each other, because healthcare is NOT a free market. Medicare control ensures that healthcare will NEVER be a free market. The only way to create a free market in which doctors would compete against each other would be to remove government control. Medicare controls 60% of all healthcare dollars in the USA, making it a virtual monopolistic owner.

    9) 20 years of increaseing doctors per capita in the USA has done NOTHING to change rural doctor shortages. More doctors just means more docs living in New York or Miami.

    10) Boston and New York have more per capita docs than anywhere on the planet. According to your logic, that means Boston and NY docs should make the least amount of money, since they compete against each other. WRONG. Boston and NY docs make MORE money on average than their counterparts in less crowded markets.

    11) Boston and NY have the highest per capita # of docs, therefore healthcare costs should be lower according to your logic. WRONG. NY and Boston routinely have the HIGHEST PER CAPITA HEALTHCARE EXPENDITURES IN THE UNITED STATES.

    Case closed. Healthcare is NOT a free market, therefore your analysis is BULLSHIT.

  • Anonymous

    1. At least in regards to FSU (if this is one of the thee) you are wrong.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16249293&dopt=Abstract

    In February 2005, the FSU College of Medicine received full accreditation from the Liaison Committee on Medical Education.

    The good old CME again. On the other two schools… if you have information that the CME has kept their mits off… please let me know.

    2. Thirty new schools built in the last 5 or planned in the next 15?

    “In 2000, the Florida State University (FSU) College of Medicine was founded, becoming the first new allopathic medical school in the United States in over 20 years.”

    Outside of FSU, the two other schools in Florida that you have mentioned and the one in Arizona… where are the others?

    3. Outside of MD and DOs, the prescription writing capabilities of the other professions is heavily limited. You aren’t suggesting that the prescription writing capabilities are the same for all of these professions.

    4. Why do we take foreign doctors in… Hmmmm… Perhaps because we don’t produce enough of our own?

    5, 7, 9, 10, 11 – Let us try this again… it is not a difficult concept to understand. We have a 90 year history of undersupply. This has to be made up for prior to seeing any effects of sufficient or oversupply. The current supply of providers, regardless of regional concentration, is still not sufficient.

    8. There are still providers that take Medicare? I had heard a rumor that they Meicare patients were being dropped like hot potatoes because it did more harm to the provider to have to accept lower reimbursements? The healthcare market is not a free market system… however it is not a fixed price market as you are suggesting.

    6. Point conceded. I should not judge the whole profession by those that gouge the most.

    “Case closed. Healthcare is NOT a free market, therefore your analysis is BULLSHIT.”

    How erudite and scholarly (particularly the all caps tantrum). Besides the medical errors and “bad outcomes” it is this type of attitude that causes people to sue those in your profession.

  • Stupid as stupid does

    Lets see, people compain about bad doctors and those with accents that they can’t understand so lets lower the standards so more incompetents are practicing???? That doesn’t make sense.

    When I went to medical school in the 80′s my buddies and I (who were all AOA) used to talk about our classmates a lot. We felt that 10% were just frankly stupid but somehow were able squeak by. Another 20% have severe personality disorders that are often advantageous as a coping mechanism for malignant hard core residencies. Regardless of all of anon 7:43′s rants I don’t see any advantage in lowering standards and letting more stupid people, or those with malignant personality disorders out to practice on the unsuspecting public.

  • Anonymous

    Yeah you AOA types usually had your head so far up the professor’s asses you could do colonoscopy’s on them. Most of us older med school types had a real laugh at you guys. Fighting over every pathetic little point the first two years. Breaking out the kneepads the third year. You boneheads were hilarious to watch for those of us who had previous careers. AOA has nothing to with being a good doc yet everything to do with being a pompous ass.

  • Anonymous

    “Ranting?”

    Remind to file that in the same place as I would an intellectually vacant response on race issues starting with “racist.” The good ol’ cirucular file.

  • Anonymous

    “1. At least in regards to FSU (if this is one of the thee) you are wrong.

    http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16249293&dopt=Abstract

    In February 2005, the FSU College of Medicine received full accreditation from the Liaison Committee on Medical Education.

    The good old CME again. On the other two schools… if you have information that the CME has kept their mits off… please let me know”

    Yes, the LCME sets accreditation standards. So what. Most of the 30 new planned med schools have already met provisional accreditation standards. Are you trying to claim that the LCME standards are too high? Where is your evidence of that?

    “In 2000, the Florida State University (FSU) College of Medicine was founded, becoming the first new allopathic medical school in the United States in over 20 years.”

    The key word here is “allopathic.” Osteopathic medical schools have nothing at all to do with the LCME, which totally bashes your claim that the AMA holds monopolistic control over the doctor supply. Osteopathic schools have been increasing like wildfire over the past 20 years. In addition allopathics have been greatly increasing their enrollment sizes over that same time period. Since FSU Med was created, a literal flood of new allopathic med schools have been in development.

    Here’s a list of them:

    NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT HAVE OFFICIALLY OPENED

    MD – University of Hawaii-Kakaako – 2006
    DO – Touro/Las Vegas – 2005
    DO – PCOM/Atlanta – 2005
    MD – University of Miami/FAU joint program – 2004
    MD – Cleveland Clinic/Lerner – 2004
    DO – LECOM/Bradenton – 2004
    MD – Florida State University – 2002
    DO – VCOM – 2002

    NEW MEDICAL SCHOOLS THAT WILL OPEN SOON

    MD – Florida International Univ – 2008
    MD – Univ Central Florida – 2008
    MD – Touro/NJ – 2008
    DO – Touro/Harlem – 2008
    DO – Pacific Northwest/Yakima – 2007
    MD – Michigan State University/Grand Rapids – 2008
    MD – University of Arizona/Phoenix – 2007

    NEW MEDICAL SCHOOLS/BRANCH CAMPUSES THAT ARE IN PLANNING

    MD – University of Cal Merced
    MD – University of Cal Riverside
    MD – University of Texas El Paso
    DO – Vista/Colorado (for-profit)
    MD – OHSU/Eugene
    DO – MSUCOM/Detroit
    DO – Barry University/Miami FL

    3. Outside of MD and DOs, the prescription writing capabilities of the other professions is heavily limited. You aren’t suggesting that the prescription writing capabilities are the same for all of these professions.”

    Heavily limited my ass. PAs and NPs can script for anything an MD can. Psychologists can also script drugs. Of course you wouldnt want a psychologist scripting a beta blocker. DCs can script drugs, pharmacists can script drugs

    “5, 7, 9, 10, 11 – Let us try this again… it is not a difficult concept to understand. We have a 90 year history of undersupply. This has to be made up for prior to seeing any effects of sufficient or oversupply. The current supply of providers, regardless of regional concentration, is still not sufficient.”

    Again, USA ranks #5 out of 35 in the industrialized world for number of docs per capita. We have plenty of docs.

    “The healthcare market is not a free market system… however it is not a fixed price market as you are suggesting.”

    Of course its a fixed price market. All insurance carriers base their reimbursements to what Medicare pays. When Medicare changes its billing, insurance companies immediately revise their reimbursement schedule accordingly. Thats ABSOLUTELY a fixed price market.

  • Anonymous

    Actually, I don’t think there is any state where a DC can script a med :)

    But your point is still well taken (and you forgot DPM’s!) Dentists, podiatrists, nurse practitioners and physician assistants have no restrictions on the scope of their prescribing privileges. In very few places (I know Georgia is one) a mid-level can’t script for narcotics but that’s about it.

    The statement to the contrary is clue number four thousand seventy six that a certain anon around here has very little practical knowledge about the delivery of health care…

  • ismd

    “Need I remind you of the recent “work stoppage” by the New Jersey Medical Association (providers from all specialties) in which the President of the organization explicitly stated that by using their captive audience (patients) that they could blackmail the legislature into providing special legal protection to the providers. You want to tell me that was not about money?!?”

    Let’s get some facts straight here, as I woefully live in NJ. Aside from the misnaming of the state medical society in NJ (it’s actually the Medical Society of NJ), the president of MSNJ never at any time made any such statement that you claim he made. The work slowdown, NOT stoppage (there was coverage by ER docs, some offices were open for emergent care, and some docs actually blew off the slowdown) was a grassroots effort not organized or even sanctioned by MSNJ. It was intended to alert the legislature to the deterioration in access to care, and the need for caps (yep, I brought it up).

  • larry

    Typical greedy comments from typical greedy doctors. The doctors hold down the numbers of medical schools through the LCME to keep their own digusting incomes at the stratospheric level.
    The AMA is quite simply america’s most powerful union. Its time for ordinary taxpayers and consumers, sick of being gouged by these people to rise up, and say enough is enough. Allow more of the excellent candidates who want to become doctors through and stop this monopolistic nonsense. Lets stand up to this special interest once and for all!!!