Wednesday, October 10, 2007

Doctor Shortage - The Physician Shortage - The Achilles Heel of Health Reform

In 1988 I wrote And Who Shall Care for the Sick? The Corporate Transformation of Medicine in Minnesota (Media Medicus, Minneapolis). At the time, I had been present at a center of creation of HMOs for 15 years.

My thesis was straightforward. Managed care would ultimately alienate doctors and make medicine so impersonal and unattractive fewer doctors would enter the profession and few would be left to care for the sick. It’s a thesis worth revisiting in view of the mounting physician shortage.

Frustrated Doctors and Busy Doctors

For almost 100 years, starting with President Teddy Roosevelt’s 1912 call for universal health reform, a progression of politicians, poets, historians, and critics have struggled to explain what’s wrong about American health care. Success has eluded them. American doctors have stubbornly refused to sit still long enough to be analyzed. They’ve been too busy.

Chances are, they’ll become even busier. Richard Cooper, MD, in a February, 2001 Health Affairs piece, projected the U.S. will be short 50,000 physicians by 2010 and 200,000 by 2020.

Phillip Miller, a principal in physician recruiting firm of Merritt, Hawkins, & Associates, captured the gravity of the doctor shortage in the title of his recent book Will The Last Physician in America Please Turn Off the Lights (Physician Support Resources, Inc, 2005). In an interview with me, Miller observed,” People need to understand the seriousness of the shortage. Believe us, based on 3000 physician researches we did last year, there’s a tremendous shortage, and it’s growing.”

Miller’s comments are germane to health reform. After all, what good is universal coverage if no physicians exist to provide the care? If universal coverage is achieved, the physician shortage will intensify. This is already happening in Massachusetts, the state farthest down the path of coverage-for-all.

A July 25 Wall Street Journal piece (“Doctor Shortage Hurts a Coverage-for-All Plan”) tells the story of Tamar Lewis, who was told by two dozen primary care groups they no longer were accepting new patients. In Massachusetts, 49% of internists aren’t seeing new patients. Boston teaching hospitals employ 270 primary care physicians, and 95% of these hospital doctor groups don’t take new patients,

The reasons practitioners are hard to find are three fold:

1) A steady fall in medical students entering primary care (the percentage fell from 55% in 1998 to 20% in 2005);

2) “too little money for too much work” (mean income for primary care was $162,000 in 2005, which may not be enough in high cost urban environments to sustain a sensible life style and family life and pay off educational debts that may exceed $200,000);

3) an increase in demand with more elderly with multiple chronic diseases or aging baby boomers seeking perpetual youth and active life maintenance seeing fewer doctors.

Physician Demoralization Factor

In addition to these factors, reformers forget the physician demoralization factor. The College of Physician Executives surveyed 1,205 MDs in 2006. They found nearly 60% had considered leaving medicine. The top five complaints of clinical practitioners were:

1. Low reimbursement

2. Loss of autonomy

3. Bureaucratic red tape

4. Patient overload

5. Loss of respect

“Sea Change” in Gender and Plans of Young Doctors

There’s another factor as well. A “sea change” in career and life plans of young physicians. I lunched the other day with Robert Gifford, MD, who serves on the admissions committee of the Yale Medical School. He observed, among other things, more than half of accepted students are now women, none of the applicants, men or women, expressed any interest in primary care, and most said they were interested in careers offering decent incomes with regular hours, such as dermatology, anesthesiology, and radiology.

The physician shortage is likely to grow even worse, especially for physicians on the frontlines of medicine. . According to Merritt, Hawkins, and Associate Guide to Physician Recruiting, searches for primary care physicians in 2005/2006 picked up most dramatically for internists ( 46%), family practice ( 55%), but were also up for certain specialists serving patients in hospital settings: general surgeons 42%, hospitalists 81%, and emergency medicine 94%.

Fundamental Questions about Physician Attitudes

Another problem with health reform is that people looking for what’s wrong and how to correct it, are so preoccupied with their pet managerial and political solutions, they never stop to ask these fundamental questions:

• What do doctors really think about what needs to be done?

• How will they react?

• And who, after the management consultants, politicians, and critics have done their work, will care for the sick?

Doctors’ attitudes are important if we are to have health reform that works. Doctors’ orders, after all, account, in one way or another, for 80% of health care costs. Also no matter what rules are set in place, doctors can choose to support, finesse, and even undermine any reform system depending on whether the system treats them with respect as professionals or as mere technicians carrying out orders from on high.


What do doctors really think? To define physician trends, a company called in Cambridge, Massachusetts, has set up a web site, funded partly by Wall Street firms tracking doctor trends and partly by a contract with the American Medical Association. Only licensed physicians can visit the site, and Sermo encourages them to write “posts” and comment on posts of others. It’s a free-wheeling discussion forum. Responses to posts are instant, and give one a clear feel of the pulse of what America’s doctors are thinking.

Ten Conclusions

The results are a mixed bag, but here are 10 conclusions I have reached.

1. Physicians are intellectually restless, politically edgy, and full of angst about their future. They have little respect for the bureaucracy of managed care organizations, and they see little forthcoming from these organizations and government but more bureaucracy in the form of clinical protocols, restrictions based on evidence based medicine, and pay-for-performance rules and regulations.

2. Physicians prefer terse brevity to verbal longevity when discussing current practice conditions or reform measures. Doctors are weary of being lectured by consultants and long-winded directives from health plans and Medicare on how to practice medicine.

3. Physicians feel most secure in telling stories of difficult diagnoses, obscure cases, and unknown clinical causes. Reformers constantly forget that doctors entered medicine because of the intellectual challenges posed by the differential diagnosis process.

4. Physicians dislike being lecturing by others about how to conduct clinical and business practices. If there’s anything that turns off doctors, it’s being judged by “experts” who have never set a foot in a doctor’s office, or spent any time following doctors during office hours and hospital rounds.

5. Physicians often express skepticism about radical health reform, either from the left or the right. When told of the glories of guaranteed health care for all in other countries or the promise of a purely market-driven solutions, doctors tend to scoff. With patients flooding into their offices, they don’t foresee any magic solutions.

6. Physicians regard information technologies – either from data mining algorithms or electronic medical records – as overrated. An emergency room physician in California once told me, when seeing a patient, he often had to enter six different software programs, give his user name and password, and wait for the download – each entry and exist requiring several minutes of his precious time.

7. Physicians distrust large integrated systems that reduce them to protocol-following functionaries. For thirty years, the Kaisers, Mayos, Cleveland Clinics, and other large multispecialty groups have been saying health care solutions lie in teamwork, scale, and infrastructure, yet 60% of doctors stubbornly remain in groups of five or less.

8. Physicians question the value of retail clinics, off-site clinics, and disease management systems in which they do not directly participate. The realities and successes of the marketplace may alter this resistance, but don’t count on it.

9. Physicians remain wary, even hostile, towards managed care, often regarding it as unwelcome, intrusive, ill-informed, and obsessed with cost not quality. This is unlikely to change because most doctors, like most Americans, are anti-authoritative.

10. Physicians, albeit heterogeneous, are a brotherhood and sisterhood, a common culture supportive and understanding of each other.

In the course of sorting through and selling some of my books, I came across an introduction to a book The American Character (George Braziller, Inc, publisher, 1983), written by William E. Bundell Staff Writer, Wall Street Journal, 1983.

The book consists of a series of Wall Street Journal stories describing energetic, sometime star-crossed, always individualistic Americans. To me it explains why the America health system is what it is and what it is likely to be.

“The manufacture of the future is the life and business of America. But it is increasingly a fragmented, specialized, and urbanized endeavor; we are becoming a nation of isolated individuals ever more dependent on each other, and at the same time ever more ignorant of how we are connected.”

“The characteristic of America that resists any attempt at a definition, lasting analysis of the nation is the constant upwelling of self-induced change in our society. We remake that society every few years, scrapping whatever isn’t working and trying something new.”

“But beneath the turmoil some things never change. We are now, as we always have been, the most individualistic of peoples. We insist on being treated as individuals and not as impersonal, faceless numbers.”

Coverage without Access is Meaningless

Governor Deval Patrick of Massachusetts noted, “Health care coverage without access is meaningless.” The shortage is likely to grow even worse as America’s 78 million babyboomers enter the Medicare in 2011.

Suggested solutions to ease the doctor shortage include:

• build more medical schools,

• change the criteria for medical school admissions, focusing on those likely to pursue careers in primary care,

• Send medical students out into the field to serve as preceptors for busy doctors,

• pay primary care physicians more,

• reduce the pay differentials between primary care physicians and specialists by placing doctor in salaried groups where pay can be controlled,

• employ more nurse practitioners and physician assistants,

• recruit more international medical graduates and make it easier for them to enter the country.

• Decrease patient demand -- shift more costs to patients, make them conscious of what health care costs, and let them spend more of their own money so they will become more prudent medical shoppers

To these suggestions I would add this one: have every pundit, every management consultant, every politician, and every health care reform, spend a month in busy doctors’ offices, walking in their moccasins, observing the patients they encounter, experiencing first hand their hassles, judging whether information technologies facilitate or hinder practice, and seeing why fewer ambitious young Americans are choosing to be practitioners.


Unknown said...

You've hit this one head on--if you get what you pay for, we're certainly not going to see much in the way of primary care medical practice as the current generation retires and has no replacements in the wings.

I'm one who left the primary care track--for multiple reasons around scope of work, intellectual stimulation, and financial prospects.

I've told more of my story in my post: "Leaving medicine for business"

Anonymous said...

One issue where I live is that physicians are resistant to change. One way to give the physicians more time during the day would be to go to a paperless system. If there was healthcare reform in the area of technology there would be no redundant testing, no handwriting of reports each day, no more waiting for results to be sent to the office, a paperless system would clear up these issues. Test results would be available to the physician as soon as the results were available. A specialist could see that Mrs. Slapherasski had a throat culture done a week ago at her primary care docs office even if Mrs. Slapherasski doesn't tell him/her because there would be one unified system. No need to waste time doing another culture and waiting for the results. Save money and time.

Docs need to be open to change. In our area that's a problem. Too much to discuss in this little narrow box.

Unknown said...

Whoami929, you're way off base in your criticisms here. Docs are open to change-- but, as with everything else, they need to be incented to do so.

Its clear from what they're doing that they're responding to incentives. In an insurance-based world of declining reimbursement on a fee-for-service basis, making the capital expenditures and spending more time only to lose reimbursement for services billed for today make about as much sense as putting a hole in their head.

Howard Luks MD said...

Well thought out, well written and a nice read. Over the last 10 years the discussion in the OR lounge has gone from a recollection of the weekend past to a litany of complaints similar to those you articulated so well. So many docs are looking for a way out and loosing their focus. Not that I blame them... It is hard to hold on to the memories of those moments that nail home why I did this in the first place.

Richard L. Reece, MD said...

Vijay: As always, I treasure your perceptive comments. If primary care doctors, who are bright people, feel overworked, understimulated, and underpaid, they will seek work and rewards elsewhere.

Richard L. Reece, MD said...

Dear whoami929: I am not sure resistance to EMRs is so much resistance to change as common sense. Why should a primary care physician who has a marginal economic existence pour $30,000 into a computer system sold by a company that may not survive, that disrupts the practice, that rewards the payer not the doctor, and that requires money for staff training and maintenance. Or should he/she bow to the expertise of IT experts who proclaim EMRs as the best thing since Ritz crackers? Most doctors are withholding judgementuntil they see if this thing is for real, or until the feveral government steps in and puts their money where their mouth is in the form of Hill-Burton subsidies.

Richard L. Reece, MD said...

Dear Westchester Orthopedist:

You and I ought to get together and issue a joint statement (pun intended) on what'w wrong with health care. I admire orthopedic surgeons. They are among the most prolific of innovators. You can never tell what they will do when left to their own devices.

ObGynThoughts said...

excellent post! thank you for correctly pointing out the many factors that make physicians unhappy and why American should care! I wish you all the publicity and exposure you can get. Everybody should read this and rethink the "rich doctors earn too much and should do more for the public" stupidity.

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