Do we really need more physicians?

The goal of the Affordable Care Act is to make affordable, quality health care coverage available to more Americans. But how many physicians will America need to satisfy this new demand?

The debate over doctor supply rages on with very little conclusive evidence to prove one case or the other.

Those experts who see a shortage point to America’s aging population — and their growing medical needs — as evidence of a looming dearth in doctors. Many suggest this shortage already exists, particularly in rural and inner city areas. And still others note America maintains a lower ratio of physicians compared to its European counterparts.

This combination of factors led the Association Of American of Medical Colleges to project a physician shortage of more than 90,000 by 2020.

On the other side of the argument are health policy experts who believe the answer isn’t in ratcheting up the nation’s physician count. It’s in eliminating unnecessary care while improving overall productivity.

The solution, they say, exists in the shift away from fee-for-service solo practices to more group practices, away from manually kept medical records to electronic medical records (EMR), and away from avoidable office visits to increased virtual visits through mobile and video technologies. Meanwhile, they note physicians could further increase productivity by using both licensed and unlicensed staff, as well as encouraging patient self-care where appropriate.

The doctor divide: Global and domestic insights

Among the 34 member countries of the Organization for Economic Co-operation and Development (OECD), the U.S. ranks 30th in total medical graduates and 20th in practicing physicians per 1,000 people.

Despite these pedestrian totals, there is one area where the U.S. dominates. It ranks first in the proportion of specialists to generalists– and there’s not a close second.

These figures don’t resolve the debate on America’s need for physicians but they do reveal an important rift in the ratio of U.S. specialists to primary care practitioners.

And while these totals shed some light on where the U.S. stands globally, there’s still widespread disagreement within our borders on a very straightforward question: How many practicing physicians are there in America?

The cause of confusion is that not all licensed physicians practice clinical medicine and, among those who do, the number of hours spent in clinical practice is unknown.

In California, for example, the AMA and the Medical Board of California disagree heavily on the number of practicing physicians. The difference in their estimates is nearly 20 percent.

Further, the distribution of licensed doctors varies significantly within and across our states. California’s greater Bay Area hosts approximately 30 percent more medical specialists than Los Angeles. And the number of active physicians per 100,000 population in Massachusetts is roughly twice that of Mississippi.

In the absence of conclusive data and in the face of so much uncertainty, is it possible to determine whether we have too many physicians, too few or just enough?

Turning the debate upside down

As the number of insured people in the U.S. grows rapidly, our nation will face a shortage of physicians — unless there’s (a) an immediate uptick in their numbers or (b) a drastic change in how the majority of physicians practice.

For this reason, it may seem logical to begin training some 90,000 new physicians.

But the costs would be too enormous and the lag-time too substantial to meet America’s pressing demand. Not to mention the costs created by more physicians, more offices and more support staff.

To put it bluntly, the U.S. can’t afford the number of physicians it would need in today’s inefficient health care delivery system.

If we want to address the increased demand for health care services while keeping health care affordable, we need to make our system 10 to 20 percent more efficient. Once we do that, we will have enough physicians — not only for today but for tomorrow, as well.

As a nation, we can continue to debate whether or not we need more physicians. But we’d be better off transforming the process of care delivery. In reality, that’s our only choice.

Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com.

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  • NPPCP

    I have a question – if we as primary care clinicians (I am an NP in private practice) see 25-30 patients in a 10 hour day without a lunch, that seems pretty darn efficient. What patient would want someone to see them and care for them who has already seen 30 other people? So, with or without the medical home (we still have to evaluate the patient, consider the ancillary diseases and medications, and take into account social and economic factors) how can a human being be expected to manage more than 30 people a day in ANY setting? Even in a medical home – a physician manages 4 NPs who are seeing 30 patients per day. Does that mean they are “responsible” for 120 patients per day? In Texas, a terrible NP state and last for healthcare outcomes in the country, physicians can manage up to 7 NPs!! Really? So they are responsible for 210 patients per day or 1,050 patients per week? What physician in their right mind would do this? What NP would continue in this type of setting? The ANSWER to the health care crisis is to can the PCMH and let physicians and other business minded clinicians do what they do best. INNOVATE. The health policy experts are not on the right track. Maybe they can help with population based health care, but not with real physician/NP to patient healthcare. That relationship can never be replaced by anyone.

    • guest

      This is also happening in psychiatry, where some people are very excited about a model of “integrated care” which means that a primary care practice gets a psychiatrist for three hours. In one hour, he or she “supervises” the psychiatric care of 50 patients being seen by other providers, in the remaining 2 hours, sees five or six new or complicated patients who have illnesses beyond the scope of “supervised” treatment. My question is, why are the patients not screaming about this?? Why is psychiatry holding it up as the next great thing??

    • buzzkillersmith

      How can you see that many pts? One word: amphetamines.

      Nothing says pt-centered like a provider on speed.

    • PrimaryCareDoc

      I wish I could “like” this post a thousand times! I think the PCMH may very well be the nail in the coffin for primary care. When I went into primary care, it was because I wanted to have a one-on-one relationship with patients. I wanted to care for them over their adult lives- through sickness and health.

      I DIDN’T go into primary care to sit around and “supervise” a bunch of other clinicians. That’s administration. Not medicine.

  • PoliticallyIncorrectMD

    I think we can easily afford training more physicians if we cut down the number of CEOs!

    • Kristy Sokoloski

      I have to agree with you on this.

    • cynholt

      And if we can’t cut down on the numbers of CEOs, we can certainly cut down on their pay. That alone would greatly improve the efficiency of our healthcare system.

  • buzzkillersmith

    Shorter Pearl: We are Kaiser and everyone should have to work for Kaiser. He only wants to serve us–like the Kanamits.

    • Deceased MD

      mmm.. Time for dinner. No need to watch TZ anymore. Medicine is the Twilight Zone.

  • guest

    Personally, I think our patients would rather see us train more doctors than hospital administrators, but I could be missing something here…

    • Deceased MD

      Haha. But there was a paper written about administratium: a chemical compound heavier than any other that impedes every reaction it comes in contact with. It causes one reaction to take over four days to complete when it would have normally occurred in less than a second.

  • Lacie Lynch

    How about this strategy: Let’s all (vocally) support the forgiving of (a significant) % of federal student loans for primary care givers? This would inevitably help keep & attract the best/brightest (doctors) to the field. Also…take out the middle man (for profit insurance companies) & it would free up frivolous admin costs/red tape. These billions (insurance co profits) could go directly to the cost of covering all the new patients/paying doctors.

    • swatdoc

      When I graduated and finished post grad training I went to a small town and my public health scholarship was forgiven after 30 plus years two of us who started on that same program are still here. Don’t see many more who want to replace us most are being hired by larger town hospitals as hospitalists. And who could blame them they have more time off and get paid more money. This more modern grad wants time off wants to work less and most lack the work ethic to go to a small town and really build a practice.