Physician Shortage and Decreasing Admission Rates

[mimelim]

Thanks for clarifying the data. So, residency spots are not the bottleneck for US grads, but are a bottleneck for the total number of doctors entering residency.

This appears to have been the case since around 1981. In the late 1970's, there were enough spots for US grads, and all the FMGs who wanted to apply, with some unfilled spost. That seems to have changed around 1982.

See the chart on page 12. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata1984.pdf

So, there has been a bottleneck for FMGs since 1981, but still an excess of residency spots for US grads.

Page 29 was very interesting. In 1984, Plastic surgery, Derm , and Ortho were the most competitive specialties, contrary to the myth that back then, if you wanted to go into ortho, all you had to do was apply. Derm, had 0.47 spots per applicant, Plastic surgery 0.28 spots, and ortho had 0.56 spots per applicant.

For all practical purposes, the only way to practice medicine in the US is to complete a residency. That is our true "quality control", not where you went to medical school. Our physician work force is only replenished via this pathway. Does increasing the number of US MD students affect our physician work force? No. The number of additional residency spots that would fill would be negligible. On the other hand, if we had more residency spots, almost assuredly they would be filled. The problem is that we can't just wave a magic wand and create residency spots, unlike medical school seats. There is a reason that we use residency as our quality control. You can't simply add residents to existing programs or create new residencies without significantly impacting the training of others. Sure, every surgery program could probably use more surgical interns, but at the chief level, there are only so many cases to go around and even adding one resident per year can drop experience and numbers significantly. The same holds for virtually every other specialty. Sure, we could increase the number of AMG in our match pool, but would that actually help with our physician shortage? No. I can tell you that in my specialty, the only graduates of residency and fellowship that go to underserved areas are the IMGs that have to for visa reasons after graduation. The same holds true in pediatrics and neurology (per residents/fellows that I know). So, I think that there is an argument that increasing the proportion of AMGs matching may actually hurt our physician shortage.

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[ZPakEffect]

For all practical purposes, the only way to practice medicine in the US is to complete a residency. That is our true "quality control", not where you went to medical school. Our physician work force is only replenished via this pathway. Does increasing the number of US MD students affect our physician work force? No. The number of additional residency spots that would fill would be negligible. On the other hand, if we had more residency spots, almost assuredly they would be filled. The problem is that we can't just wave a magic wand and create residency spots, unlike medical school seats. There is a reason that we use residency as our quality control. You can't simply add residents to existing programs or create new residencies without significantly impacting the training of others. Sure, every surgery program could probably use more surgical interns, but at the chief level, there are only so many cases to go around and even adding one resident per year can drop experience and numbers significantly. The same holds for virtually every other specialty. Sure, we could increase the number of AMG in our match pool, but would that actually help with our physician shortage? No. I can tell you that in my specialty, the only graduates of residency and fellowship that go to underserved areas are the IMGs that have to for visa reasons after graduation. The same holds true in pediatrics and neurology (per residents/fellows that I know). So, I think that there is an argument that increasing the proportion of AMGs matching may actually hurt our physician shortage.

Wouldn't decreasing the length of post-secondary education and increasing the length of residency training allow us to open up more residency spots without affecting the quality of physicians? In fact, I would think that a neurosurgeon who has 4 years of post-secondary education and 9 years of residency training would probably be better trained than a neurosurgeon with 8 years of post-secondary education and 7 years of residency training.

 

[Goro]

Profit?? What profit??? A single Physiology or Pathology department can pull in more money in indirects from R01 grants than an entire Class of student tuition. As gyngyn mentioned, most MD schools lose money on tuition.

With the amount of profit that med schools generate from the current process, i hardly believe that changing the process even in the slightest will happen. Note: this is not a rant, and doesn't express an opinion, but is merely an observation.

 

[Goro]

OK, will you be happy if we say that there are regional shortages of physicians?

But nationwide, and per population, the US has enough clinicians.

So just because the United States has equal numbers of physicians per capita to other countries, does not mean that there is no physician shortage in the US. You are making the assumption that Canada and the UK have sufficient physicians. This is a terrible assumption. In fact, both of these countries also have physician shortages and medical services shortages in general. In a market at equilibrium, no buyer would have to wait months in line to obtain the goods or services they desire. Having queues for goods and services is the classic presentation of a market that is suffering from a shortage in supply.

The supply curve in the physician services market in the urban/suburban areas of the country keeps moving to the right, yet physicians are still flooding into those markets. By definition, this means that the market has yet to reach equilibrium in even the most desirable locations in the country. Ergo, there is still a shortage of physicians.

 

[ZPakEffect]

OK, will you be happy if we say that there are regional shortages of physicians?

But nationwide, and per population, the US has enough clinicians.

I don't think you read my post or you did not understand it.

 

[Goro]

I read it alright. You're still trying to make the same argument from a classic microeconomic standpoint.

Let me ask you this: the states of CA and CO are currently experiencing a drought. Does the USA have a water shortage?

Doctors can't be compared like you would cans of peas in the Walmarts of TX vs WI.

I don't think you read my post or you did not understand it.

 

[bc65]

Let me ask you this: the states of CA and CO are currently experiencing a drought. Does the USA have a water shortage?

Point taken. But if the drought got bad enough, that water would move ( be shipped) , at great expense, from the rest of the US to California. It's about the money. If there's a big enough financial gradient, doctors will move too.

For all practical purposes, the only way to practice medicine in the US is to complete a residency. That is our true "quality control", not where you went to medical school. Our physician work force is only replenished via this pathway. Does increasing the number of US MD students affect our physician work force? No. The number of additional residency spots that would fill would be negligible. On the other hand, if we had more residency spots, almost assuredly they would be filled. The problem is that we can't just wave a magic wand and create residency spots, unlike medical school seats. There is a reason that we use residency as our quality control. You can't simply add residents to existing programs or create new residencies without significantly impacting the training of others. Sure, every surgery program could probably use more surgical interns, but at the chief level, there are only so many cases to go around and even adding one resident per year can drop experience and numbers significantly. The same holds for virtually every other specialty. Sure, we could increase the number of AMG in our match pool, but would that actually help with our physician shortage? No. I can tell you that in my specialty, the only graduates of residency and fellowship that go to underserved areas are the IMGs that have to for visa reasons after graduation. The same holds true in pediatrics and neurology (per residents/fellows that I know). So, I think that there is an argument that increasing the proportion of AMGs matching may actually hurt our physician shortage.

That's interesting. But the point I was trying to make was that if enough qualified practitioners flooded the market, eventually some would go to the less desirable areas. It seems that I was wrong when I said that residency slots weren't the bottleneck, but I still maintain that when the relative number of practicing doctors reaches a certain number, they will eventually move to fill all the available jobs. I'm not advocating that, I'm not predicting it, I'm just saying that the economics dictate that for some percentage of oversupply of doctors, that will be the outcome.

You can't simply add residents to existing programs or create new residencies without significantly impacting the training of others. Sure, every surgery program could probably use more surgical interns, but at the chief level, there are only so many cases to go around and even adding one resident per year can drop experience and numbers significantly.

I have always heard that the limiting factor in residency spots is funding, not that availability of clinical material. The growth rate of clinical material should parallel the growth of the population. As the population grows, and with increased availability of insurance, there should be more patients every year, and thus more cases for more residents.

Also, I would think that 80 hour work week limits makes room for some more residents. On paper, at least in surgery, there should be room for 20-25% more residents to work the extra hours, since residents are in theory no longer working 100 or 120 hours weeks. Someone has to do the night floats, even at the chief level. Also, I would assume that if funding were available for more spots, (and apparently it's not ), more affiliated and community hospitals could be utilized for additional resident rotations without diluting the residency experience. More rotations in non-tertiary care centers would be good experience for most residents, except for those in the most rarified specialties.

Your thoughts?

 

[gyngyn]

I have always heard that the limiting factor in residency spots is funding, not that availability of clinical material. The growth rate of clinical material should parallel the growth of the population. As the population grows, and with increased availability of insurance, there should be more patients every year, and thus more cases for more residents.

The things you need for a quality residency are: capable, intelligent medical school grads, a sufficient number of patients with challenging problems who will let residents take care of them, and a sufficient number of well trained physician-teachers to supervise them in spite of the lost productivity associated with teaching.

Merely increasing population does little to expand any of these.
Insurance coverage effectively increases the proportion of patients who feel entitled to refuse care by those in training.

 

[bc65]

physician-teachers to supervise them in spite of the lost productivity associated with teaching.

Well, I confess to being part of the problem. We had residents at one time and don't any longer. They took call for us but were more trouble and work than we could deal with. Top program, too. I do, however, give thanks daily to all the attendings who put up with me during my training. As residents, we thought we were helpful, even essential. Now I realize we just got in the way.

Insurance coverage effectively increases the proportion of patients who feel entitled to refuse care by those in training.

I encountered very little of this, if any, as a resident or fellow, but this may vary by specialty.

 

[gyngyn]

Well, I confess to being part of the problem. We had residents at one time and don't any longer. They took call for us but were more trouble and work than we could deal with. Top program, too. I do, however, give thanks daily to all the attendings who put up with me during my training. As residents, we thought we were helpful, even essential. Now I realize we just got in the way.

Residents need a lot of care. They require a lot of patience. Many excellent physicians are not able to tolerate the inefficiency and can't afford the loss of income.

 

[Lucca]

Wouldn't decreasing the length of post-secondary education and increasing the length of residency training allow us to open up more residency spots without affecting the quality of physicians? In fact, I would think that a neurosurgeon who has 4 years of post-secondary education and 9 years of residency training would probably be better trained than a neurosurgeon with 8 years of post-secondary education and 7 years of residency training.

They would be more technically skilled surgeons. They would not necessarily be better physicians ready to fill the 100 other roles that are demanded of them provided they are not simply in private practice doing surgery all day and every day. Even then, would they have been prepared for their training in such a way that they could reach residency? Difficult to say. Read the response I gave you earlier in this thread.

Also I don't think residency training works in the linear way you are suggesting but I'll let the physicians respond to that.

 

[mimelim]

Wouldn't decreasing the length of post-secondary education and increasing the length of residency training allow us to open up more residency spots without affecting the quality of physicians? In fact, I would think that a neurosurgeon who has 4 years of post-secondary education and 9 years of residency training would probably be better trained than a neurosurgeon with 8 years of post-secondary education and 7 years of residency training.

This is an entirely different issue. I used to be a big fan of the European model, but then I started working with European medical students and residents (we have 5-6 with all the time). They have their own issues and neither system inherently trains people better. I don't think that this would have an effect on opening up more residency spots as residency spots are a function of several other variables (see below). Having helped select pre-meds for medical school, I have a hard time believing most (not all) 21 year olds that say that they know that medicine is the right path for them. I can only imagine the problems with forcing people to commit at age 17. I also think that it would give a further 'advantage' to those of higher SES to force commitment earlier. Less of an issue in Europe where countries are 'more' homogeneous than the US.

That's interesting. But the point I was trying to make was that if enough qualified practitioners flooded the market, eventually some would go to the less desirable areas. It seems that I was wrong when I said that residency slots weren't the bottleneck, but I still maintain that when the relative number of practicing doctors reaches a certain number, they will eventually move to fill all the available jobs. I'm not advocating that, I'm not predicting it, I'm just saying that the economics dictate that for some percentage of oversupply of doctors, that will be the outcome.




I have always heard that the limiting factor in residency spots is funding, not that availability of clinical material. The growth rate of clinical material should parallel the growth of the population. As the population grows, and with increased availability of insurance, there should be more patients every year, and thus more cases for more residents.

Also, I would think that 80 hour work week limits makes room for some more residents. On paper, at least in surgery, there should be room for 20-25% more residents to work the extra hours, since residents are in theory no longer working 100 or 120 hours weeks. Someone has to do the night floats, even at the chief level. Also, I would assume that if funding were available for more spots, (and apparently it's not ), more affiliated and community hospitals could be utilized for additional resident rotations without diluting the residency experience. More rotations in non-tertiary care centers would be good experience for most residents, except for those in the most rarified specialties.

Your thoughts?

The things you need for a quality residency are: capable, intelligent medical school grads, a sufficient number of patients with challenging problems who will let residents take care of them, and a sufficient number of well trained physician-teachers to supervise them in spite of the lost productivity associated with teaching.

Merely increasing population does little to expand any of these.
Insurance coverage effectively increases the proportion of patients who feel entitled to refuse care by those in training.

You need the following:

#1 Capable medical students
#2 Patients with pathology
#3 Available educators

I don't think that anyone can dispute that we have enough of #1 and #2. By virtue of our growing population, we have plenty of sick people. I don't really see the issue that @gyngyn mentions about insurance. While patient entitlement can be a problem, I don't think that it substantially decreases the pathology available. I am in a field/location where virtually every single patient is insured, 30% ESRD (auto-medicare), non-trauma, elderly (medicare) etc. And while it happens on occasion, it is certainly not the norm.

The crux is as you put it, funding. As @gyngyn points out, there is inherent lost productivity when you have residents around. It is hard to ask people who have spent 15 years in school/residency post high school to take a pay cut to help train others. Certainly there are those that will take academic jobs anyways (including myself) because there are other tangible benefits of it, but it just isn't enough for most people to welcome residents/fellows and take on a smaller volume. So yes, if we increase funding toward opening up new training sites with people who are amenable to the academic responsibilities because they are being paid more (or at least enough to make up for what they will lose in productivity), I think that we will increase our overall output.

Regarding the hour restrictions, just because there are less hours to cover doesn't increase the available pathology. There are a lot of issues surrounding the hour restrictions, but I'll hold them back from this thread since I really don't think that it impacts our overall ability to churn out more capable physicians.

 

[deleted718115]

General question: if there's a predicted physician shortage in America, then how is it that these days competition to get into medical school has risen so much?

I would think that I natural solution would be to accept more applicants. Anyone have any explanation or theories?

Sorry if the question has an obvious answer. This was just something that I'd been thinking about recently.

There is no shortage. Only shortage in underserved areas.

 

[NeuResurgens]

One thing to consider is that in a field like medicine, where mistakes can literally kill people, you don't want to just accept more people who may or may not be required. Part of why getting into medical school is hard is because you need people who will be good at the job.

 

[Seth Joo]

Thanks for clarifying the data. So, residency spots are not the bottleneck for US grads, but are a bottleneck for the total number of doctors entering residency.

This appears to have been the case since around 1981. In the late 1970's, there were enough spots for US grads, and all the FMGs who wanted to apply, with some unfilled spost. That seems to have changed around 1982.

See the chart on page 12. http://www.nrmp.org/wp-content/uploads/2013/08/resultsanddata1984.pdf

So, there has been a bottleneck for FMGs since 1981, but still an excess of residency spots for US grads.

Page 29 was very interesting. In 1984, Plastic surgery, Derm , and Ortho were the most competitive specialties, contrary to the myth that back then, if you wanted to go into ortho, all you had to do was apply. Derm, had 0.47 spots per applicant, Plastic surgery 0.28 spots, and ortho had 0.56 spots per applicant.

FMGs and IMGs have been entering the US with few problems for years, its only been since the 2008 GFC and the introduction of the Affordable Care Act that things have changed and become more difficult for foreign trained doctors, that and the increase in the number of DO schools which is now helping to supply primary care physicians.

 

[bc65]

FMGs and IMGs have been entering the US with few problems for years, its only been since the 2008 GFC and the introduction of the Affordable Care Act that things have changed and become more difficult for foreign trained doctors, that and the increase in the number of DO schools which is now helping to supply primary care physicians.

Let me try to clarify my statement. Currently there are enough residency spots so that almost all US seniors are able to match, but only some of the FMGs will match, because there are more FMGs who apply than there are available residency spots. That's what I'm calling a bottleneck, because if there were more residency spots, more FMGs would be available to fill them. That wasn't true in the 1970's . Back then, after the match and the scramble, there were still empty spots available. So, in 1975, every qualified US senior and FMG and IMG had a residency spot, with plenty more left over. Today, there are plenty of spots for qualified US seniors, and extra spots for some, but not all, foreign-trained doctors.

 

[Seth Joo]

Let me try to clarify my statement. Currently there are enough residency spots so that almost all US seniors are able to match, but only some of the FMGs will match, because there are more FMGs who apply than there are available residency spots. That's what I'm calling a bottleneck, because if there were more residency spots, more FMGs would be available to fill them. That wasn't true in the 1970's . Back then, after the match and the scramble, there were still empty spots available. So, in 1975, every qualified US senior and FMG and IMG had a residency spot, with plenty more left over. Today, there are plenty of spots for qualified US seniors, and extra spots for some, but not all, foreign-trained doctors.

Today its pretty bleak for foreign trained physicians so much that I see many offshore schools that used to recruit US students closing down or cutting enrollments.

Also this talk of doctor shortage is a myth, if it were true, physician incomes would increase along with the increased cost of education for physicians, the cost of medical school has more than doubled over the past 20 years, the average salary of most physicians has been stagnant.

 

[deleted718115]

Today its pretty bleak for foreign trained physicians so much that I see many offshore schools that used to recruit US students closing down or cutting enrollments.

The Carib schools are still not closing down or cutting down class sizes...

 

[NickNaylor]

So just because the United States has equal numbers of physicians per capita to other countries, does not mean that there is no physician shortage in the US. You are making the assumption that Canada and the UK have sufficient physicians. This is a terrible assumption. In fact, both of these countries also have physician shortages and medical services shortages in general. In a market at equilibrium, no buyer would have to wait months in line to obtain the goods or services they desire. Having queues for goods and services is the classic presentation of a market that is suffering from a shortage in supply.

The supply curve in the physician services market in the urban/suburban areas of the country keeps moving to the right, yet physicians are still flooding into those markets. By definition, this means that the market has yet to reach equilibrium in even the most desirable locations in the country. Ergo, there is still a shortage of physicians.

1) Then where do we say, "ok, we have enough physicians?" When people can walk in and get any procedure they'd like done in a few days? When we have achieved the exact labor supply at which there are no firms looking for workers (good luck with that)? I use those examples because they are often used as models for the US healthcare system by those seeking to "reform" it. There is no perfect system, but those are the systems typically considered "superior" by those that take up the "we need more doctors!" argument.

2) In your second paragraph you assume that people continue going to these oversaturated markets for economic reasons. The market isn't going to reach equilibrium - in fact, that's exactly why physician wages tend to be worse in urban centers vs. rural areas: because there's such a large supply. Yet people keep going there. There is more to it than simple economics. At the end of the day, even in those areas physicians get paid well compared to the average worker, and clearly there are other non-economic forces at work to cause people to go to those areas and not others. If there weren't, everyone would be readily moving to rural areas where they might make double or more compared to what they might make in an urban center, and with increased purchasing power at that.

To add to the second point, often patients commute long, long times to go to those urban centers to receive care because that care is simply unavailable wherever they're from. When I was up in Chicago, it wasn't uncommon to have people drive 1-2 hours or even more for people to come to the medical center for their appointments. Large medical centers provide care not only to their local population but also the population surrounding that area - often quite a large area - exactly because there are no providers in their home areas.

 

[ZPakEffect]

1) Then where do we say, "ok, we have enough physicians?" When people can walk in and get any procedure they'd like done in a few days? When we have achieved the exact labor supply at which there are no firms looking for workers (good luck with that)? I use those examples because they are often used as models for the US healthcare system by those seeking to "reform" it. There is no perfect system, but those are the systems typically considered "superior" by those that take up the "we need more doctors!" argument.

2) In your second paragraph you assume that people continue going to these oversaturated markets for economic reasons. The market isn't going to reach equilibrium - in fact, that's exactly why physician wages tend to be worse in urban centers vs. rural areas: because there's such a large supply. Yet people keep going there. There is more to it than simple economics. At the end of the day, even in those areas physicians get paid well compared to the average worker, and clearly there are other non-economic forces at work to cause people to go to those areas and not others. If there weren't, everyone would be readily moving to rural areas where they might make double or more compared to what they might make in an urban center, and with increased purchasing power at that.

To add to the second point, often patients commute long, long times to go to those urban centers to receive care because that care is simply unavailable wherever they're from. When I was up in Chicago, it wasn't uncommon to have people drive 1-2 hours or even more for people to come to the medical center for their appointments. Large medical centers provide care not only to their local population but also the population surrounding that area - often quite a large area - exactly because there are no providers in their home areas.

1) Yes, precisely. All of those are good targets. Can we reach those goals? Very unlikely. However, to say that we have a sufficient number of physicians is to ignore economic reality.

2) All reasons are economic reasons. If I want to sacrifice monetary income so that I can easily go to the Met and watch the latest production of La Boheme, it is because the economic utility of La Boheme at the Met outweighs the economic utility of the extra dollars I could earn working in Bum****, Idaho. However, if the difference in compensation is large enough, there will come a point where it begins to outweigh the utility of living in NYC. THAT is the point at which enough supply will start to overcome the problem of unequal distribution.

 

[ZPakEffect]

Deleted.

 

[Lucca]

1) Yes, precisely. All of those are good targets. Can we reach those goals? Very unlikely. However, to say that we have a sufficient number of physicians is to ignore economic reality.

2) All reasons are economic reasons. If I want to sacrifice monetary income so that I can easily go to the Met and watch the latest production of La Boheme, it is because the economic utility of La Boheme at the Met outweighs the economic utility of the extra dollars I could earn working in Bum****, Idaho. However, if the difference in compensation is large enough, there will come a point where it begins to outweigh the utility of living in NYC. THAT is the point at which enough supply will start to overcome the problem of unequal distribution.

You are looking at this problem too narrowly. It's a proper context to apply an economic lens but if you are a hammer then every problem looks like a nail. If your goal is to understand why schools/the government/physicians do what they do and propose how they could accomplish their goals more effectively then you have to accept that this problem is more complex than it looks on the surface. You are not living in reality if you think this is a 'throwing more money' problem.

 

[ZPakEffect]

You are looking at this problem too narrowly. It's a proper context to apply an economic lens but if you are a hammer then every problem looks like a nail. If your goal is to understand why schools/the government/physicians do what they do and propose how they could accomplish their goals more effectively then you have to accept that this problem is more complex than it looks on the surface. You are not living in reality if you think this is a 'throwing more money' problem.

Of course it's a difficult and complex problem. I have never intimated otherwise. My only argument is that there is a real shortage of physicians, and that it's not just a matter of distribution as some posters in this thread believe.

 

[Lucca]

Of course it's a difficult and complex problem. I have never intimated otherwise. My only argument is that there is a real shortage of physicians, and that it's not just a matter of distribution as some posters in this thread believe.

Then I fail to see how your posts have made a convincing argument to that effect.

 

[ZPakEffect]

Then I fail to see how your posts have made a convincing argument to that effect.

I am sorry for your failure.

I live in a metropolitan area of several million people, and yet my father has to wait a month to see his gastroenterologist and 2 months to see his neurologist. Meanwhile, organizations such as the AAMC and the AMA have published studies on the shortage of physicians in the US. I have both anecdotal and published evidence that tells me there is a shortage. Excuse me if I not persuaded by random SDN posters who lack understanding of basic economic principles.

 

[Seth Joo]

The Carib schools are still not closing down or cutting down class sizes...

They probably should, but they are run by unethical profiteers who target gullible people.

 

[NickNaylor]

I am sorry for your failure.

I live in a metropolitan area of several million people, and yet my father has to wait a month to see his gastroenterologist and 2 months to see his neurologist. Meanwhile, organizations such as the AAMC and the AMA have published studies on the shortage of physicians in the US. I have both anecdotal and published evidence that tells me there is a shortage. Excuse me if I not persuaded by random SDN posters who lack understanding of basic economic principles.

What is the evidence that there's a shortage? That people have to wait a month to see someone? In a non-emergent situation, that seems completely reasonable to me.

Also, economics are one but not the only factor that plays into this. As @Lucca said, you're approaching the problem far too myopically and are overly focused on the economics of the situation. There is some data via APNs to suggest that training more providers will do next to nothing in terms of addressing shortages - providers simply continue going to areas where there are already tons of providers. They don't go to areas where there are legitimate shortages. Also, the AAMC and AMA are hardly non-biased sources to receive data from about this topic. That doesn't mean that their findings should be dismissed completely, but they should be looked at carefully because they both have political interests in the issue. Regardless, I would be interested in seeing these sources which are so convincing to you.

 

[Lucca]

What is the evidence that there's a shortage? That people have to wait a month to see someone? In a non-emergent situation...@Lucca said, you're approaching the problem far too myopically and are overly focused on the economics of the situation. There is some data via APNs to suggest that training more providers will do next to nothing in terms of addressing shortages - providers simply continue going to areas where there are already tons of providers. They don't go to areas where there are legitimate shortages. Also, the AAMC and AMA are hardly non-biased sources to receive data from about this topic. That doesn't mean that their findings should be dismissed completely, but they should be looked at carefully because they both have political interests in the issue. Regardless, I would be interested in seeing these sources which are so convincing to you.

https://www.aamc.org/download/426260/data/physiciansupplyanddemandthrough2025keyfindings.pdf

May be referring to this

 

[molarmom]

For all practical purposes, the only way to practice medicine in the US is to complete a residency. That is our true "quality control", not where you went to medical school. Our physician work force is only replenished via this pathway. Does increasing the number of US MD students affect our physician work force? No. The number of additional residency spots that would fill would be negligible. On the other hand, if we had more residency spots, almost assuredly they would be filled. The problem is that we can't just wave a magic wand and create residency spots, unlike medical school seats. There is a reason that we use residency as our quality control. You can't simply add residents to existing programs or create new residencies without significantly impacting the training of others. Sure, every surgery program could probably use more surgical interns, but at the chief level, there are only so many cases to go around and even adding one resident per year can drop experience and numbers significantly. The same holds for virtually every other specialty. Sure, we could increase the number of AMG in our match pool, but would that actually help with our physician shortage? No. I can tell you that in my specialty, the only graduates of residency and fellowship that go to underserved areas are the IMGs that have to for visa reasons after graduation. The same holds true in pediatrics and neurology (per residents/fellows that I know). So, I think that there is an argument that increasing the proportion of AMGs matching may actually hurt our physician shortage.

Why not do both? Ie. How has residency position increases kept up with the population growth rate?

 

[mimelim]

Why not do both? Ie. How has residency position increases kept up with the population growth rate?

It hasn't. That is the point.

 

[Goro]

This is a an insurance/payment issue, not a shortage in specialists.

I live in a metropolitan area of several million people, and yet my father has to wait a month to see his gastroenterologist and 2 months to see his neurologist. Meanwhile, organizations such as the AAMC and the AMA have published studies on the shortage of physicians in the US. I have both anecdotal and published evidence that tells me there is a shortage. Excuse me if I not persuaded by random SDN posters who lack understanding of basic economic principles.

 

[ugagrad1116]

AAMC posted this recently, and it made me think of this thread. It's basically saying, like most of you, that the problem is funding. Before the link, it said, "Myth: More medical school graduates will fix the doctor shortage." It's a pretty basic explanation that they give, but it's a very valid one.

http://www.thedoctorshortage.com/pa...=facebook&utm_campaign=20150523haventkeptupfb

 

[Affiche]

@ZPakEffect you're confusing the issue of physician distribution to be an issue of physician shortage. As Goro stated, you're also confusing an insurance issue to be a shortage issue.

 

[Seth Joo]

AAMC posted this recently, and it made me think of this thread. It's basically saying, like most of you, that the problem is funding. Before the link, it said, "Myth: More medical school graduates will fix the doctor shortage." It's a pretty basic explanation that they give, but it's a very valid one.

http://www.thedoctorshortage.com/pa...=facebook&utm_campaign=20150523haventkeptupfb

Ever heard of propaganda, that is exactly what that webpage is, propaganda, there is no physician shortage. The reality is that there is a issue of distribution, not a shortage of physicians.

 

[ugagrad1116]

Ever heard of propaganda, that is exactly what that webpage is, propaganda, there is no physician shortage. The reality is that there is a issue of distribution, not a shortage of physicians.

That's fine, and there is very much a poor distribution of physicians now. I completely agree. My hometown is one of those places in need of physicians. But this article or whatever is mostly talking about the future when the baby boomers will have grown to be older, and there will be a greater need for physicians.

 

[Seth Joo]

That's fine, and there is very much a poor distribution of physicians now. I completely agree. My hometown is one of those places in need of physicians. But this article or whatever is mostly talking about the future when the baby boomers will have grown to be older, and there will be a greater need for physicians.

My hometown of Boston has absolutely no shortage of physicians, in fact having a Harvard MD and residency training from Mass General does not mean anything because they are a dime dozen there. As a DO I know my chances of practicing Medicine there are very slim. If you discount the weather, Boston is the finest large US city.

The reason why certain regions have a shortage of doctors and others have an oversupply, and hence you have a distribution problem in this country is that certain places are more desirable to physicians than others.

Many doctors would easily leave Fargo North Dakota to move to San Diego CA in a second if given the chance.

 

[bc65]

What is the evidence that there's a shortage? That people have to wait a month to see someone? In a non-emergent situation, that seems completely reasonable to me.

This is a an insurance/payment issue, not a shortage in specialists.

My group had patients waiting a month or more for non-urgent consults, and months for highly elective surgery. We all thought that was fine, business as usual. If it's not an emergency, patients can wait. But as competition heated up, we lost patients. It turns out that "business as usual" wasn't good enough. So, more doctors were hired, everyone got more efficient, and now consults are seen the same day, surgery within a week or two. Now we have more patients and more salary. So, what seems reasonable to us may not seem reasonable to our patients ie customers.

In any case, nothing we conclude here will affect the number of residency slots or med school seats, so we can all relax. However, it's my opinion, based on a certain amount of experience, that medicine is not immune to the laws of economics, although there are unique aspects to medical economics that distort the system ( eg: the people who consume the product ( the patients ) are not the people who select the product (the doctors) who in turn are not the ones who pay for it (the insurance companies)). I would just advise medical students and younger doctors to be aware that economic forces, including the supply of trained doctors, will affect their income in the future. Why do you think that there are so few solo practitioners or private practice groups these days? It's not a changing culture, it's all due to economic pressures.

And I repeat, distribution problems are economic problems. If there are no more jobs in the big cities, then doctors will move to where there are jobs. Different people will make different decisions based on their preferences, but to assume that only lifestyle matters when looking for a job and not salary is just misguided. In fact, there was a recent discussion of this on the whitecoatinvestor website, where doctors were discussing the problems with practicing in high cost of living areas. Everyone agreed that while for most professions, salaries were higher in high cost areas, for physicians, they were generally lower in high cost areas. When this gradient gets steep enough, there will be no distribution problem. I don't want that to happen, but if there are enough doctors, or perhaps I should say, when there's a big enough oversupply of doctors to overcome the "inertia" or "friction", that will happen.

Now, if there's no increase in residency spots, there won't be any oversupply any time soon. But if more residency spots are funded, watch out.

 

[Law2Doc]

The Carib schools are still not closing down or cutting down class sizes...

It's the slot machine effect. As long as there's enough lucky winners each year, people will keep playing (even if most lose). Don't read much into that.

 

[deleted718115]

They probably should, but they are run by unethical profiteers who target gullible people.

It's the slot machine effect. As long as there's enough lucky winners each year, people will keep playing (even if most lose). Don't read much into that.

and because New York is still having a contract with them. It's all about profits.

 

[Seth Joo]

and because New York is still having a contract with them. It's all about profits.

Yife Tien whose family once owned the American University of the Caribbean now owns Rocky Vista University and is opening a second Osteopathic Medical school in Utah, he sold AUC to Devry several years ago. It really bugs me that people like this are now involved in Osteopathic Medicine because DO schools were making so much forward progress.

I would not be surprised if Devry themselves open a DO school in the near future.

And I am not the only person who has a bad feeling about RVU:
http://jaoa.org/article.aspx?articleid=2093567

The article is old, the LCME wound up approving a for profit school as well, amazing how higher education is becoming more and more a business.

 

[Goro]

I remember a doctor who once joked that U Minnesota has trained more doctors in practice in Florida than all the Florida medical schools combined!

My hometown of Boston has absolutely no shortage of physicians, in fact having a Harvard MD and residency training from Mass General does not mean anything because they are a dime dozen there. As a DO I know my chances of practicing Medicine there are very slim. If you discount the weather, Boston is the finest large US city.

The reason why certain regions have a shortage of doctors and others have an oversupply, and hence you have a distribution problem in this country is that certain places are more desirable to physicians than others.

Many doctors would easily leave Fargo North Dakota to move to San Diego CA in a second if given the chance.

 

[Seth Joo]

and because New York is still having a contract with them. It's all about profits.

I was trying to look up Yife Tien's net worth, I could not find anything, but his family is very wealthy.

I read Charles Modica, the head of St. George's University, has a net worth of $100 million.

 

[deleted716403]

Yife Tien whose family once owned the American University of the Caribbean now owns Rocky Vista University and is opening a second Osteopathic Medical school in Utah, he sold AUC to Devry several years ago. It really bugs me that people like this are now involved in Osteopathic Medicine because DO schools were making so much forward progress.

I would not be surprised if Devry themselves open a DO school in the near future.

And I am not the only person who has a bad feeling about RVU:
http://jaoa.org/article.aspx?articleid=2093567

The article is old, the LCME wound up approving a for profit school as well, amazing how higher education is becoming more and more a business.

Sadly, education has become a business model... When students at a for-profit school do well on the Boards, people praise the school and look past its for-profit nature, but truth is that the same students would do well at most schools. It's the students' success more than the school.

 

[Seth Joo]

Sadly, education has become a business model... When students at a for-profit school do well on the Boards, people are gonna praise the school and look past its for-profit nature, but truth is that the same students would do well at most schools. It's the students' success more than the school.

There is a website that has satellite photos of Yife Tien's and Charles Modica's homes, actually mansions, both of them are very wealthy men. Modica at least has the decency to stay out of Osteopathic education, Tien has gotten involved with the AOA, opened a DO school and is now opening a second DO school, the people who were in uproar over RVU were right, this is not a good sign, watch for DeVry or other for profit schools to open up DO schools as well.

 

[cantankerous]

There is a website that has satellite photos of Yife Tien's and Charles Modica's homes, actually mansions, both of them are very wealthy men. Modica at least has the decency to stay out of Osteopathic education, Tien has gotten involved with the AOA, opened a DO school and is now opening a second DO school, the people who were in uproar over RVU were right, this is not a good sign, watch for DeVry or other for profit schools to open up DO schools as well.

lmao are these people you aspire to be? Why do you know so much about them?

 

[Seth Joo]

lmao are these people you aspire to be? Why do you know so much about them?

No, I mention the wealth of these individuals to give people an idea of the scale of profit of these schools and size of of their operations, which is substantial, this is very big business. I do not admire them at all.

 

[novemberskyline]

Everyone agreed that while for most professions, salaries were higher in high cost areas, for physicians, they were generally lower in high cost areas. When this gradient gets steep enough, there will be no distribution problem. I don't want that to happen, but if there are enough doctors, or perhaps I should say, when there's a big enough oversupply of doctors to overcome the "inertia" or "friction", that will happen.

Sorry if I'm misunderstanding what you're saying, but why wouldn't you be for more doctors serving in areas of healthcare shortage as opposed to abundance (larger cities)?

 

[Mad Jack]

This statement flies in the face of basic economic principles. If the supply of doctors is large enough and the competition in desirable locations is great enough, then eventually doctors will be forced to go to underserved areas to find any work at all. Of course, in such market conditions, the average salary for all doctors will be much lower than what they are at now. This outcome is undesirable for doctors but would probably be very good for patients.

Economics is a poor predictor of human behavior. Plenty of people are willing to take a 50% (and sometimes even more) pay cut for the perks of living in a desirable area. A hospitalist in NYC will generally pull 200k, while in the sticks, you can easily make 300k. The other issue is that procedural specialties require volume that just isn't there in rural areas. No amount of saturation will make it worth it for a hand surgeon to relocate to an area with 80,000 people spread over 6 counties in NoDak.

 

[bc65]

t why wouldn't you be for more doctors serving in areas of healthcare shortage as opposed to abundance (larger cities)?

What I'm saying is that the distribution problem will be solved with an oversupply of doctors that will force salaries so low that doctors will have to leave San Francisco, Manhattan, and Hawaii and move to rural Wisconsin and South Dakota. but I don't want that to happen, because salaries will then be very low across the board and we will all be very unhappy.

A hospitalist in NYC will generally pull 200k, while in the sticks, you can easily make 300k

Right, he'll stay in NY for 200k. But if there were so many hospitalists in NY that there were absolutely no jobs, or if NY jobs were now paying only 100K, and rural jobs 300k, or maybe 200 k, he'll have to move or he won't be able to pay his bills. So there is a gradient now, but at some greater gradient, or at some level of salary so low that you can't live comfortably, doctors will have to move.

I'm saying that it's a mistake to think that doctors are somehow magically immune from economic pressure. They are not. Why do you think doctors sign up for IPOs and PPOs and take deeply discounted rates from insurance companies? Because otherwise they will lose the patients, not because they want to help the insurance companies out. When there's enough pressure, doctors close their practices and take jobs as employees. They move to where the jobs are.

No amount of saturation will make it worth it for a hand surgeon to relocate to an area with 80,000 people spread over 6 counties in NoDak.

Actually, there's probably plenty of work for a hand surgeon in rural areas, due to agricultural trauma.

More importantly, specialists will revert to a more generalist practice if it will get them a more lucrative practice. So, if that ortho hand surgeon is offered a better job somewhere else for general ortho, the hand surgeon will take that job and do general ortho. I know lots of doctors who don't use their fellowships, because they can get a better job if they do the specialty and not the subspecialty. I'm in a large multispecialty group, and the nature of the practice requires many subspecialists to take call and do cases that are in the specialty, and not subspecialty, because of the needs of the group. They would never do those cases in their own practice, but in order to have this otherwise desirable job, they compromise. Similarly, doctors even now move to undersirable or 3rd or 4th choice locations because the job is otherwise desirable. If economic pressures get larger, they will be more willing to move.

Economics is a poor predictor of human behavior.

Old-fashioned economics made incorrect assumptions. Modern Behavioral Economics is a great predictor of "irrational" behavior. I highly recommend books by Dan Arielli, Levitt and Dubner, and Daniel Kahneman, who won the Nobel Prize in economics for developing the field of behavioral economics.

 

[username456789]

Sorry if I'm misunderstanding what you're saying, but why wouldn't you be for more doctors serving in areas of healthcare shortage as opposed to abundance (larger cities)?

Have you ever worked a job in your life?

He's not saying he doesn't want people in underserved area to receive medical care. But the way things are heading now, with the ridiculous misrepresentation being pushed by the AAMC, we are apparently actively trying to sabotage our own profession and go the way of the lawyers. The blind idealism on this board continues to astound me.

This " keep cranking out more and more doctors at a higher rate until the overflow has no recourse but to go to underserved areas " idea is terrible for physicians, and by the time it would make any appreciable difference in physician distribution, we would have lost control long long before then.