Reducing the number of high pay residency slots has merit

I believe that Nilesh Kalyanaraman’s idea of reducing the number of high-pay residency slots has merit.

Of course, this would have to be based on an accurate, bonafide need for the particular specialty service, and would require, at the very least, a biannually updated data base for medical schools to plan with. I believe that some states already make available disease prevalence data —broken down by regions or, in some instances, even by counties. Certainly, if motivated for doing so, such disease prevalence data banks could be generated.

The point is that, currently, many of the high-pay, procedure-oriented specialties are becoming over-crowded—when measured against bonafide, valid statistical needs for their services—where need is defined as the number of cases definitely requiring their particular area of expertise or technique, for achieving a significantly better outcome than could have been achieved by primary care alone.

Yet the evidence suggests today that the ratio of primary care specialty physicians to non—primary care specialty physicians is heavily weighted toward non—primary care specialists. This is an irrational and expensive direction, given the quality and economic issues the system is currently struggling with. Currently it would appear that supply of many of the high-profile, high-pay specialties is now exceeding bonafide needs for their services. If so, this creates the ideal conditions for producing an increase in unnecessary procedures and surgeries, and, for the same reasons, creates a temptation for sub specialist physicians—trained for very focused areas of medical practice—to begin dabbling in areas of medicine unfamiliar to them, in order to remain sufficiently busy.

Until our medical schools meet their responsibility for valid demographic, need-studies, based on disease prevalence statistics—and adjust their specialty residency programs sizes accordingly—tremendous sums of healthcare dollars will be spent needlessly in this manner. Remember the interview with the candid young medical student of the nineties and his admission of planning to enter a specialty with a procedure associated with it, “because that’s where the money is.”

Alan Cato is the author of The Medical Profession Is Dead and the Doctor Is “Critically Ill!”

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  • MassachusettsPCP

    I have long thought of this when patients, the government, and health policy wonks lament the few students that want to go into primary care. Reduce funding the residencies of specialists and fellowships — don’t listen to that argument about the Baby Boomers needing more care — and the government can “force” more students go into primary care specialties because these would be the bulk of residency slots available. It would require a lot of planning to make sure certain students can’t choose their specialty based on their desires, abilties, expected lifestyle, and hours. But wouldn’t it be just? The government already funds much of a medical student’s training so the government should have I say in which fields these graduating students will practice. This way, more PCPs are produced de-facto, pressure on PCP salaries will go down, and hopefully by then we’ll capitate the specialists too. I wouldn’t count my cookies on that last speculation.

    • pcp

      Forcing medical students against their wishes into primary care is a recipe for disaster.

      • http://twitter.com/Cascadia Sherry Reynolds

        It’s not like there is a dearth of qualified students who apply to medical school last time I checked?

        How about simply recruiting students into medical school for primary care?. I know people who become ND’s at an average income of less then 45 k and their medical school is just as expensive as medical school. They have 10 times the number of applicants as open slots and they are ALL primary care.

  • DrDutch

    I don’t follow the OPs logic- reduce the total “n” of fellowships so as to encourage primary care? Is that the argument?

    Good luck. Our current med students are emerging with a debt of around $300k. Thats not including undergrad loans. Some are interested in primary care. I have no idea how they will afford that career given that expected annual income in primary care being lower. When I finished my peds residency, my colleagues who chose primary care were receiving offers of ~ $90-100K per year. And most of us had debt around $150K. Hard to pay-off those loans, buy a home, and start (or expand) a family when the bills can’t get paid.

    A better question is “why” people choose one field versus another. Its not *all* about the Benjamins. Yes, I know a handful of specialists who did it because it paid well. But the vast majority I’ve met (and yes, I freely admit using personal anecdotes) have chosen their field because it is what interested them. I found primary care to be very boring, and critical care work intellectually stimulating. But that was for me. I wouldve been in misery in primary care. And so would the majority of friends and aquaintances who decided to further their education.

    • Doc

      >>Our current med students are emerging with a debt of around $300k.>>

      Perhaps at your medical school, but overall, not true. According to the AMA, the average medical school debt in 2010 was around $139K, not including undergraduate debt.

      • http://twitter.com/Cascadia Sherry Reynolds

        Plus the majority of the residency and internship is paid for by the US government to the tune of 11 billion a year. (about 100k per for 4 to 11 years). What we see happening is that young docs have a good line of credit based on future income and start to rack up debt in graduate school.

  • http://www.mdwrites.com MD

    Why not just make primary care more lucrative? This would solve the problem.

    • http://medschoolodyssey.wordpress.com Med School Odyssey

      As if it were that simple.

  • Angela Caffaratti, MD

    I’m sure even more docs would flee medicine if primary care was the only option for them, and this solution does nothing to address the fact that primary care is insolvent, requiring heavy overhead to meet the demand of increased administrative costs. I’ve heard said that if they are smart enough to get into medical school they are smart enough not to do primary care. Nothing will change until you increase primary care pay and decrease their paperwork.

  • Justin

    Reducing “lucrative specialty” residency positions will lead to lower supply and allow the specialties to continue to charge more money. RVU size for primary care, peds and psych need to increase if you want more people to go to the needed specialties.

  • Brian

    This solution deals with the symptoms, not the underlying disease that affects our healthcare system and causes medical students to pursue specialties other than primary care. The responsible approach is to address the perverse incentives that de-value primary care. Delivery models that remove the third payer from the examination room, reduce the administrative burden, and improve income, and allow the primary care physician to practice the kind of medicine he or she learned in medical school would achieve this.

  • Brian L

    This solution deals with the symptoms, not the underlying disease that affects our healthcare system and causes medical students to pursue specialties other than primary care. The responsible approach is to address the perverse incentives that de-value primary care. Delivery models that remove the third payer from the examination room, reduce the administrative burden, and improve income, and allow the primary care physician to practice the kind of medicine he or she learned in medical school would achieve this.

  • http://twitter.com/Cascadia Sherry Reynolds

    Most people don’t realize that CMS (medicare and medicaid) pay for the majority of graduate school training in this country about about 100k per resident/ intern a year for from 4 to 11 years. There  is a very simple fix.. double the salary for the primary care specialties and cut the funding for those specialties that we don’t need more of..  If you want to become an orthopedic surgeon you can pay for it.

    Just as an FYI – the CMS funding is also why doctors are expected to treat medicare and medicaid patients for less. They are in effect paying back a 400,000 to 1,100,000 cost of their training. If this was a loan with interest at a minimum doc’s would be expected to provide at least 4,000 a month in uncompensated care to medicare and medicaid patients.