Doctors No One Needs

Doctors No One Needs
By SHANNON BROWNLEE and DAVID GOODMAN
Copyright by The New York Times
Published: December 22, 2009
http://www.nytimes.com/2009/12/23/opinion/23brownlee.html?th&emc=th


FOR anyone who has had to wait a long time to schedule a medical appointment, it might seem as if the world needs more doctors, and that training more of them would be a good idea. An amendment that teaching hospitals are pushing to include in the health care legislation before a final vote is taken in the Senate and the House would do just that. It would add 15,000 medical residency slots to the 100,000 residencies the federal government now finances, most of them through Medicare.

This amendment is being heavily promoted by several doctor specialty societies and the Association of American Medical Colleges, a group that represents the nation’s major teaching hospitals. But that doesn’t mean it’s a good idea. It would raise Medicare’s bill for residencies, which is already $9 billion a year. More important, since the cost of health care follows the supply of doctors, the added slots would substantially increase the national health care bill. And the measure would not address the underlying reason that patients are forced to wait to see doctors.

Over the past 20 years, the number of doctors in relation to the American population has risen by 30 percent. Yet in many parts of the country, more doctors has simply meant more doctors, not better access for patients, not better communication among a patient’s health care providers, and not better results. The truth is that regions with the highest number of doctors per capita tend to deliver lower quality care at a higher cost.

Increasing the number of doctors would make our health care system worse, not better, because the United States doesn’t actually need more doctors. What we do need is for primary care to reclaim its central role in the delivery of medicine, to provide the preventive care, chronic disease management and coordination of services that is lacking in so many parts of the country. Primary care doctors can help patients avoid unnecessary visits to specialists, hospitals and emergency rooms, thus lowering health care costs.

Granted, the teaching hospitals and others lobbying for more doctors would have Congress designate some of the new residency slots for family practice, pediatrics and internal medicine. But there are already plenty of residency openings in those areas that currently go unfilled. And since the amendment would not prohibit the positions going to specialists, that is who would fill them. If the past is prologue, these newly minted specialists would most likely gravitate toward cities like New York, Los Angeles and Miami, which already have plenty of doctors — and relatively poor care.

Our national problem is that primary care doctors are leaving their practices in droves, driven out by their low pay (relative to that of specialists), long hours and mountains of paperwork. Some of them go to work in emergency rooms or hospitals, others become specialists, and many simply abandon medicine. The idea that there’s a supply-side solution to this problem is a little like thinking you can fill a bucket with holes in the bottom by pouring in more water.

Increasing the number of residency slots would also mean that the United States would continue to rob other nations of their doctors. More than a quarter of American residencies are filled by graduates of foreign medical schools, more than half of them from poor countries. After training here, many stay, leaving the people of their own countries holding the bill for their training. In a kind of reverse foreign aid, the president’s Global Health Initiative is poised to invest millions in medical education in Africa and elsewhere, while American academic institutions expect to employ more of their medical school graduates.

Before adding residency slots, Congress should demand that academic medical centers come up with a plan to improve the disorganized, fragmented care that plagues much of the country. Insurers and Medicare should pay family-practice doctors and general internists enough to keep them in the field. And federal financing for medical education programs should hinge on their plans to train more primary care doctors and fewer specialists.

Otherwise, we’ll simply end up perpetuating a system in which too many doctors provide poor-quality care at too high a price.

Shannon Brownlee, a senior research fellow at the New America Foundation, is the author of “Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer.” David Goodman is a professor at the Dartmouth Institute for Health Policy and Clinical Practice.