Is the "residency shortage" false?

[bluepeach9]

I just read this short article about the residency shortage, and it says that this won't be a problem. The article also goes on to say that students should not be scared away from Carib schools because of the residency argument.

Does this mean that IMGs/FMGs will not face significant problems getting a residency in the US? Was all that talk about future residencies rejecting foreign MDs and even US trained docs false and unnecessarily anxiety-inducing?

http://www.kevinmd.com/blog/2016/05...nt-enough-to-fill-the-physician-shortage.html

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[WheezyBaby]

If med school spots increase at a faster rate than residency spots, it doesn't take much thought to see who's going to get shafted for residency spots

 

[Psai]

Look at how many DO schools are opening. The number of us seniors (md) is growing too with new schools and bigger class sizes. The funding for residency spots isn't increasing and there is a lot of anecdotal evidence about the increasing competitiveness of residency spots in desirable fields/locations.

The article is written by a person who is now the dean of an offshore school that has a poor reputation. Of course she's going to be a proponent of caribbean schools, it's job security for her. Overall there are more spots than applicants. But if you want to do derm or ent you're facing an enormous uphill battle. You might soap into a decent program but why take the chance after 4 years and 300k of debt? That's a huge gamble.

 

[SuperGrover44]

Deleted

 

[username456789]

Residency spots are not and should not increase significantly. Medical schools are being irresponsible in trying to force the hands of medical residencies/the ACGME into expanding when it is a bad idea.
These medical schools need to stop sprouting up out of nowhere, and existing schools should temper their eagerness to expand their class sizes.

 

[toddgurley]

Residency spots are not and should not increase significantly. Medical schools are being irresponsible in trying to force the hands of medical residencies/the ACGME into expanding when it is a bad idea.
These medical schools need to stop sprouting up out of nowhere, and existing schools should temper their eagerness to expand their class sizes.

What are the arguments for/against expansion of residency programs? Especially when we hear so much about primary care physician shortages - who/what body of people are responsible for dealing with this?

 

[terra330]

There are more residency spots than US medical students, so in that sense there isn't a shortage.

However, there are more medical schools opening up (especially from the DO side). So the chance of you getting into your top choice residency does get smaller.

 

[darkjedi]

Residency spots are not and should not increase significantly. Medical schools are being irresponsible in trying to force the hands of medical residencies/the ACGME into expanding when it is a bad idea.
These medical schools need to stop sprouting up out of nowhere, and existing schools should temper their eagerness to expand their class sizes.

Med schools are expanding at the behest of the AAMC, who set a target to increase US MD slots by 30% by 2019. As it currently stands, there are around 30,000 residency slots in the US, with less than 20,000 US MD graduates each year.

If anything it's a good thing because it allows more qualified US MD graduates to fill residency slots that would otherwise be filled with IMGs. The AAMC is just trying to produce more US MDs as we won't run out of residency slots for them in the near future. There is little to no pressure to increase residency slots due to US MD graduates as of yet.

 

[username456789]

Med schools are expanding at the behest of the AAMC, who set a target to increase US MD slots by 30% by 2019. As it currently stands, there are around 30,000 residency slots in the US, with less than 20,000 US MD graduates each year.

If anything it's a good thing because it allows more qualified US MD graduates to fill residency slots that would otherwise be filled with IMGs. The AAMC is just trying to produce more US MDs as we won't run out of residency slots for them in the near future. There is little to no pressure to increase residency slots due to US MD graduates as of yet.

Oh, it's coming.

There is no shortage of physicians, but that's the rhetoric the AAMC is pushing. Aggressively. Then it will be used to try the ACGME in the court of public opinion (won't someone think of the children???). Just as Caribbean schools twist facts to their advantage, so too will the AAMC.

 

[username456789]

What are the arguments for/against expansion of residency programs? Especially when we hear so much about primary care physician shortages - who/what body of people are responsible for dealing with this?

There is no shortage. There is a distribution problem. Trying to force more and more new doctors through the play-do squeeze contraption in the hopes that "eventually someone has to end up doing primary care in the middle of nowhere" is a terrible idea. The market everywhere else would be beyond flooded years and years before that would ever be achieved in a manner even close to the level of satisfaction of those pushing that agenda.

Medicine risks going the way of the lawyer in the not so distant future.

 

[Dr.Wink]

^^^ **shivers**^^^

 

[Lucca]

Something has got to give somewhere. Either the AAMC Changes nothing and "somebody somewhere" has to practice PC in the middle of nowhere - which I don't think is the right way of going about it, for physicians or patients. Or someone anyone else shows up to fill the healthcare need in currently underserved, mostly rural, mostly poorer areas. The latter most likely involves the expansion of scope of care for non-physician providers, which is also not in the physicians best interest because it will only mean that mid levels with expanded scope will begin to enter competitive markets willing to work for lower wages than physicians. Not good for doctors or patients either.

My opinion: it's in the best interest of American physicians, and society in general, to institute real incentives and ways for physicians to practice where they are needed without making sacrifices to their career. Debt repayment is one such current mechanism, but that clearly doesn't interest most since debt is not a very serious enough issue for most physicians to make other lifestyle/career sacrifices. In fact I don't think there exists an external incentive adequate to solving this problem. It will require a serious government intervention: as in, requiring a year or more of rural service in exchange for debt forgiveness for not only a self selected crowd but most if not all medical graduates. I suspect this idea won't be popular with SDN, but either something radical is done to protect physicianhood and address the nation's healthcare need or one or both causes are compromised in the future. Thoughts?

 

[Law2Doc]

1. As mentioned above, there is no shortage. There's a distribution problem. Everyone wants to do plastic surgery in Beverly Hills or urology in Boston and nobody wants to do FM in Fargo. This results in gluts in popular cities and other places having to pay a premium to attract mediocre applicants. But maldistribution is not the same as a shortage because nationally the number is approximately what's needed. And you can't fix this by opening more residency slots because the new people you add also all want to specialize and work in popular cities - so the glut worsens.
2. A decade back the head of the AAMC issued a press release stating that US med schools should fill all US needs, and requested US med schools to voluntarily increase enrollment. The number of US grads has since been growing faster than residency spots, which should cause concern to offshore grads, although the growth hasn't been as rapid as some anticipated. Until US seniors approximate residency slots the AAMC will only offer lukewarm lip service for the need for additional residency slots -- they are seeking market share and trying to drive out competitors and not very subtly.
3. Osteopathy, presumably seeing the writing on the wall, has essentially capitulated and the two branches of US medicine have been in merger talks which once accomplished would ensure that the growing number of compliant DO schools would be lumped into the US seniors category. This should help US numbers meet residency numbers even sooner.
4. A few years back the "all in" rule and replacing the scramble with "soap" dealt significant blows to a portion of offshore applicant who used to take some advantage of being outsiders to the process. Now they have to compete on a more head to head basis which hasn't really worked in their favor.
5. Residency slots and funding are creatures of public money. So to add lots of residency slots you have to divert taxpayer money. It's not cheap and spending money to finance the training of future "rich" doctors is a hard sell to voters. So I wouldn't expect any big jump in residency spots.
6. Midlevels have been anointed by our government to fill a lot of the so called shortage voids (starting with HRC while First Lady and continuing in Obamacare). Lots of underserved people already see unsupervised NPs or midwives these days. So for this reason the shortage is overstated (though the continued existence of a shortage is touted not in small part by midlevel groups as well as the offshore deans).

At any rate don't expect residency spots to grow much and expect offshore placement statistics to continue to worsen over time.

 

[Law2Doc]

Something has got to give somewhere. Either the AAMC Changes nothing and "somebody somewhere" has to practice PC in the middle of nowhere - which I don't think is the right way of going about it, for physicians or patients. Or someone anyone else shows up to fill the healthcare need in currently underserved, mostly rural, mostly poorer areas. The latter most likely involves the expansion of scope of care for non-physician providers, which is also not in the physicians best interest because it will only mean that mid levels with expanded scope will begin to enter competitive markets willing to work for lower wages than physicians. Not good for doctors or patients either.

My opinion: it's in the best interest of American physicians, and society in general, to institute real incentives and ways for physicians to practice where they are needed without making sacrifices to their career. Debt repayment is one such current mechanism, but that clearly doesn't interest most since debt is not a very serious enough issue for most physicians to make other lifestyle/career sacrifices. In fact I don't think there exists an external incentive adequate to solving this problem. It will require a serious government intervention: as in, requiring a year or more of rural service in exchange for debt forgiveness for not only a self selected crowd but most if not all medical graduates. I suspect this idea won't be popular with SDN, but either something radical is done to protect physicianhood and address the nation's healthcare need or one or both causes are compromised in the future. Thoughts?

You can't easily force people to move to and stay in certain parts of the country away from family, friends etc. if you make it a condition of debt you'll just drive more people to private lenders. Best you might do is reallocate more residencies to these locales and increase years of needed specialty residencies such that more people will have put down roots by the end of their training. But post residency? Nobody is going to choose debt forgiveness in booneyville over a shot at a salary in a popular city. And you can't legally force fully trained people to live someplace they don't want.

 

[Lucca]

You can't easily force people to move to and stay in certain parts of the country away from family, friends etc. if you make it a condition of debt you'll just drive more people to private lenders. Best you might do is reallocate more residencies to these locales and increase years of needed specialty residencies such that more people will have put down roots by the end of their training. But post residency? Nobody is going to choose debt forgiveness in booneyville over a shot at a salary in a popular city. And you can't legally force fully trained people to live someplace they don't want.

There will always be more residents. And if you have a good supply of physicians in training moving in and out of an area, the area itself will reap the benefits, including more senior physicians willing to contribute to an important and underserved population when they see that real resources are being directed to addressing the healthcare need.

If someone wants to assume a greater interest rate and pay more on their debt because they don't want to serve in the boonies for a couple of years, they can go ahead and do so. As far as I'm concerned, there are probably 100 more physicians perfectly willing to pay back debt with service. Better yet, don't give people a choice and make them do it. The healthcare need has to be met somehow, the way I see it we should engineer a solution that advances the interests of the profession and the population and doesn't sacrifice neither just because everyone wants to live on a coast.

 

[Law2Doc]

There will always be more residents. And if you have a good supply of physicians in training moving in and out of an area, the area itself will reap the benefits, including more senior physicians willing to contribute to an important and underserved population when they see that real resources are being directed to addressing the healthcare need.

If someone wants to assume a greater interest rate and pay more on their debt because they don't want to serve in the boonies for a couple of years, they can go ahead and do so. As far as I'm concerned, there are probably 100 more physicians perfectly willing to pay back debt with service. Better yet, don't give people a choice and make them do it. The healthcare need has to be met somehow, the way I see it we should engineer a solution that advances the interests of the profession and the population and doesn't sacrifice neither just because everyone wants to live on a coast.

First, numerous attempts to incentivize people to underserved locations, ranging from debt forgiveness to high residency/fellowship salaries have been tried and haven't worked. Your notion that for every person who won't relocate for debt forgiveness, there's 100 who will simply hasn't played out in the real world.

Second, you can't mandate that people take on debt in order to force them to pay it back with service. So I am not sure what you mean by not giving people a choice. One could allocate more residency slots to these underserved areas, but that only keeps people there for 3-7 years, and you will still have a tough time recruiting doctors to train them. Nobody cares about seeing that there's "real resources directed toward the underserved" when they choose their job -- they want to be near family and airports and nightlife and shopping and sporting events and the arts -- all the things these underserved regions can't offer. Until you build that kind of infrastructure it's a tough sell. There are places in this country which routinely advertise very high doctor salaries and never fill, because of geographic undesirability and money doesn't seem to fix this, even if these underserved areas had infinite funds.

 

[Mansamusa]

There will always be more residents. And if you have a good supply of physicians in training moving in and out of an area, the area itself will reap the benefits, including more senior physicians willing to contribute to an important and underserved population when they see that real resources are being directed to addressing the healthcare need.

If someone wants to assume a greater interest rate and pay more on their debt because they don't want to serve in the boonies for a couple of years, they can go ahead and do so. As far as I'm concerned, there are probably 100 more physicians perfectly willing to pay back debt with service. Better yet, don't give people a choice and make them do it. The healthcare need has to be met somehow, the way I see it we should engineer a solution that advances the interests of the profession and the population and doesn't sacrifice neither just because everyone wants to live on a coast.

Imagine the pr: Gay and URM students forced to work in locations where they are uncomfortable or actually unsafe. Low-income students forced to uproot their lives to work in the boonies while their rich colleagues have the freedom to live wherever. Med school graduates forcibly removed from their families who are unable to relocate to the middle of nowhere. Skill attrition from low workflow. Rural patients seen by bitter doctors who would rather be elsewhere and who care/know/understand little about the social determinants of the community. Increase in incidences of physician suicide and burnout as rural isolation kicks in Etc.

Requiring the service won't work.

Have more rural residencies, fund mobile medicine programs and reduce medicolegal/administrative barriers to setting up and running clinics, specifically mobile clinics, improve telemedicine, improve infrastructure. There was the suggestion to require non-emergent surgeries to be performed by someone who has done X number of those surgeries in the past year just to improve quality. This could also have the effect of forcing many rural patients to have their surgery done in non-rural hospitals which aren't underserved, so we can create social programs that will provide transport and lodging for these patients. Create network/financial agreements between rural and non-rural hospital so that non-rural specialist can review, consult, and advise rural physicians and their patients. Be like Australia and require that all foreign physicians must serve 10 yrs in an underserved area (hospitals could use privately funded residencies to poach the top foreigners who will not be required to work in a rural area).

Rural health will be addressed by creativity. Not force (and financial incentives won't get us further than they have already)

Edit: I think you also grossly underestimate people's desire to not live in a rural area. Before I got off a waitlist to a school that was $20K/yr cheaper, I very seriously considered turning down med school completely because the debt overwhelmed me, and I still would refuse to move to a rural area for debt forgiveness for many reasons. I'm incredibly debt adverse, but it is still not worth it. I could do a suburb (within a 1.5hr drive from a city), but not rural

 

[RogueUnicorn]

What are the arguments for/against expansion of residency programs? Especially when we hear so much about primary care physician shortages - who/what body of people are responsible for dealing with this?

more residents = less stuff per resident to do = less stuff per resident to learn = crappier training. It's not linear but there's definitely a relationship to balance. ACGME handles whether a program can expand based on the cases/logs

If anything it's a good thing because it allows more qualified US MD graduates to fill residency slots that would otherwise be filled with IMGs. The AAMC is just trying to produce more US MDs as we won't run out of residency slots for them in the near future. There is little to no pressure to increase residency slots due to US MD graduates as of yet.

One caveat I want to add is that quality training isn't an infinite resource. The more US MDs we churn out the less qualified they will be after a certain point IMO. Clinical training in MS3-4 is already tight in a lot schools. I've worked with some serious scrubs as an intern and shudder to think of what would happen if they were even less trained...

There will always be more residents. And if you have a good supply of physicians in training moving in and out of an area, the area itself will reap the benefits, including more senior physicians willing to contribute to an important and underserved population when they see that real resources are being directed to addressing the healthcare need.

If someone wants to assume a greater interest rate and pay more on their debt because they don't want to serve in the boonies for a couple of years, they can go ahead and do so. As far as I'm concerned, there are probably 100 more physicians perfectly willing to pay back debt with service. Better yet, don't give people a choice and make them do it. The healthcare need has to be met somehow, the way I see it we should engineer a solution that advances the interests of the profession and the population and doesn't sacrifice neither just because everyone wants to live on a coast.

You can't make me do sh1t. You will find soon enough that humans don't take well to "engineered" solutions.

 

[piii]

The doom and gloom in this thread is sensationalistic at best. It's mostly just premeds speculating. Take it with a grain of salt.

 

[darkjedi]

One caveat I want to add is that quality training isn't an infinite resource. The more US MDs we churn out the less qualified they will be after a certain point IMO. Clinical training in MS3-4 is already tight in a lot schools. I've worked with some serious scrubs as an intern and shudder to think of what would happen if they were even less trained..

That's true, but when the alternative is for-profit offshore medical schools, I'd rather they graduate from a school that is state-side and accredited by the LCME. Especially considering that Caribbean schools are already buying up slots for their medical students in the US, pushing out local schools.

 

[dafuturesurgeon]

So what would do you think the situation will look like in 4-8 years?

 

[Lucca]

Imagine the pr: Gay and URM students forced to work in locations where they are uncomfortable or actually unsafe. Low-income students forced to uproot their lives to work in the boonies while their rich colleagues have the freedom to live wherever. Med school graduates forcibly removed from their families who are unable to relocate to the middle of nowhere. Skill attrition from low workflow. Rural patients seen by bitter doctors who would rather be elsewhere and who care/know/understand little about the social determinants of the community. Increase in incidences of physician suicide and burnout as rural isolation kicks in Etc.

Requiring the service won't work.

Have more rural residencies, fund mobile medicine programs and reduce medicolegal/administrative barriers to setting up and running clinics, specifically mobile clinics, improve telemedicine, improve infrastructure. There was the suggestion to require non-emergent surgeries to be performed by someone who has done X number of those surgeries in the past year just to improve quality. This could also have the effect of forcing many rural patients to have their surgery done in non-rural hospitals which aren't underserved, so we can create social programs that will provide transport and lodging for these patients. Create network/financial agreements between rural and non-rural hospital so that non-rural specialist can review, consult, and advise rural physicians and their patients. Be like Australia and require that all foreign physicians must serve 10 yrs in an underserved area (hospitals could use privately funded residencies to poach the top foreigners who will not be required to work in a rural area).

Rural health will be addressed by creativity. Not force (and financial incentives won't get us further than they have already)

Edit: I think you also grossly underestimate people's desire to not live in a rural area. Before I got off a waitlist to a school that was $20K/yr cheaper, I very seriously considered turning down med school completely because the debt overwhelmed me, and I still would refuse to move to a rural area for debt forgiveness for many reasons. I'm incredibly debt adverse, but it is still not worth it. I could do a suburb (within a 1.5hr drive from a city), but not rural

You are right about the PR. I would be more comfortable if every graduate had to do it, regardless of debt load, but it doesn't remove the other problems you brought up. And I don't have a great answer for that, those are legitimate structural problems to be concerned about.

I'm skeptical about creativity solving this problem. I have no doubt that telemedicine and other new forms of upstream care will improve to the point where they are common place, and, if we're lucky, at least as effective as what is currently available. I am skeptical, however, that whatever options do arise will be a available for the uninsured and the poor. Should they succeed, as I'm confident many solutions will, they will most likely be tied to existing payment and insurance structures which I posit are the center of the problem. "Tele-Doctor" but for the poor won't exactly do very well on Shark Tank.

However, the point I wanted to make is that I don't see a way to address the healthcare need now without doing something that will basically piss everyone off ; you can't have your cake and eat it too. Requiring everyone to do a "rural" is not an original idea, many countries do it. I don't mean to sound like a cynic, but it's discouraging that actually requiring service professionals to do a serious kind of service in exchange for their training is basically unpalettable and the alternative - the underserved just continue to not receive care - is an acceptable alternative.

The binary in my original post has still yet to be answered: if the answer to this does not come from physicians, then there is no way to answer the healthcare need without throwing physicians under the bus;namely, other providers will step in and receive more rights because they are willing to meet the healthcare need and eventually they will encroach into the cities and more saturated markets we value so much at a lower labor cost. I don't mean to go down the slippery slope, but I don't think any of us want a world where the physician is either a super-specialist or a CEO of a practice that manages mid-levels and that's it, but that seems to be the road we are heading down.

 

[Lucca]

First, numerous attempts to incentivize people to underserved locations, ranging from debt forgiveness to high residency/fellowship salaries have been tried and haven't worked. Your notion that for every person who won't relocate for debt forgiveness, there's 100 who will simply hasn't played out in the real world.

Second, you can't mandate that people take on debt in order to force them to pay it back with service. So I am not sure what you mean by not giving people a choice. One could allocate more residency slots to these underserved areas, but that only keeps people there for 3-7 years, and you will still have a tough time recruiting doctors to train them. Nobody cares about seeing that there's "real resources directed toward the underserved" when they choose their job -- they want to be near family and airports and nightlife and shopping and sporting events and the arts -- all the things these underserved regions can't offer. Until you build that kind of infrastructure it's a tough sell. There are places in this country which routinely advertise very high doctor salaries and never fill, because of geographic undesirability and money doesn't seem to fix this, even if these underserved areas had infinite funds.

I understand the points you are making but I'm having a hard time processing a response to a solution to helping the underserved that merely reiterates the conditions that created a massive population of "underserved" communities to begin with. I understand you are saying my solution does not directly solve the conditions that caused the problem to begin with, what I said in my first post is that those conditions are essentially insoluble unless there is a significant intervention, a la mandated service. @Mansamusa 's post was much better.

Making people take on debt just to pay it back is silly though, I'll agree. So I'll go one further: med school is free but service is required of everyone. would this be more palatable?

 

[Mansamusa]

You are right about the PR. I would be more comfortable if every graduate had to do it, regardless of debt load, but it doesn't remove the other problems you brought up. And I don't have a great answer for that, those are legitimate structural problems to be concerned about.

I'm skeptical about creativity solving this problem. I have no doubt that telemedicine and other new forms of upstream care will improve to the point where they are common place, and, if we're lucky, at least as effective as what is currently available. I am skeptical, however, that whatever options do arise will be a available for the uninsured and the poor.

However, the point I wanted to make is that I don't see a way to address the healthcare need now without doing something that will basically piss everyone off ; you can't have your cake and eat it too. Requiring everyone to do a "rural" is not an original idea, many countries do it. I don't mean to sound like a cynic, but it's discouraging that actually requiring service professionals to do a serious kind of service in exchange for their training is basically unpalettable and the alternative - the underserved just continue to not receive care - is an acceptable alternative.

The binary in my original post has still yet to be answered: if the answer to this does not come from physicians, then there is no way to answer the healthcare need without throwing physicians under the bus;namely, other providers will step in and receive more rights because they are willing to meet the healthcare need and eventually they will encroach into the cities and more saturated markets we value so much at a lower labor cost. I don't mean to go down the slippery slope, but I don't think any of us want a world where the physician is either a super-specialist or a CEO of a practice that manages mid-levels and that's it, but that seems to be the road we are heading down.

The problem with that logic is that mid-levels are humans too. They will have the same location biases as physicians. My sister is a suburban NP. Before graduating, she was offered a $140K starting salary and relocation funding for a job in upstate NY. Her response, "Upstate NY? F that. I'm not living in the middle of nowhere." NPs don't miraculously flock to rural areas.

Service professional provide lots of services in exhange for their training and we buy our training with our own money, sweat, and work. And people don't all care for the same things- and that's not discouraging. I care about reaching non-English speaking patients in cities. I don't care about rural health (yes I think it should be addressed, but it is not something I want or feel equipped to work on). If you split your care between too many causes then you end up giving substandard attention to each cause. And I don't think physicians who aren't happy will give great care. And having rapidly changing hospital staff when people do not stay after after their service prevents long term care relationships

Why wouldn't telemedicine or mobile clinics be available to the poor?

And the having foreign physicians- and even just all non-US grads- serve a 10 yr obligatory rural service period would shunt a lot of people into those areas. Physical, fully functional physicians

Med school being free would not be enough for me. It would have to be med school free and we start right out of high school and the service somehow be built into residency. Then there is the fact that universities set their own costs so if the gov't is footing the bill, they would keep raising the tuition even if the gov't limits how much they would cover. It might be because I have been out of undergrad for a few years, but I have a good appreciation for how much time this med school + residency/fellpwship process is going to take. Requiring more of my time is just crazy

 

[Lucca]

The problem with that logic is that mid-levels are humans too. They will have the same location biases as physicians. My sister is a suburban NP. Before graduating, she was offered a $140K starting salary and relocation funding for a job in upstate NY. Her response, "Upstate NY? F that. I'm not living in the middle of nowhere." NPs don't miraculously flock to rural areas.

Service professional provide lots of services in exhange for their training and we buy our training with our own money, sweat, and work. And people don't all care for the same things- and that's not discouraging. I care about reaching non-English speaking patients in cities. I don't care about rural health (yes I think it should be addressed, but it is not something I want or feel equipped to work on). If you split your care between too many causes then you end up giving substandard attention to each cause. And I don't think physicians who aren't happy will give great care. And having rapidly changing hospital staff when people do not stay after after their service prevents long term care relationships

Why wouldn't telemedicine or mobile clinics be available to the poor?

And the having foreign physicians- and even just all non-US grads- serve a 10 yr obligatory rural service period would shunt a lot of people into those areas. Physical, fully functional physicians

Sure, mid levels will have the same biases but it is just a fact that as their number increases they will fill the gaps where there are not any physicians first, I don't think that's a controversial thing to say I think it's self evident.

Telemedicine wouldn't be available to the poor for the same reason normal medicine isn't available to the poor: cost and insurance. Would it be cheaper than a normal visit? Maybe. If any tests or prescriptions are required, then we just run into the same problem as before. Where do they go to get those tests? How do they afford those prescriptions?

You don't see a problem with saying: send doctors to rural areas, as long as those doctors aren't American graduates? It's kind of silly. There are international doctors here on the faculties of the best medical schools because they were recruited, it would be sort of absurd to expect them to spend a whole decade of their lives, not to mention careers, caring for people who ostensibly should have been the responsibility of the domestic healthcare establishment. In other words, the American people pay taxes to train doctors, but doctors don't really have any real responsibility towards anyone after graduating, but then foreign doctors would even after completing their own training and service in their own country? Sort of absurd. Like I said to L2D, would it be more palatable if medical school was free and all students were required to serve in some capacity for a number of years upon graduation?

I'm not saying every single physician dedicate their career to the underserved, I'm saying that caring for the underserved becomes a natural stepping stone in a career that is still otherwise fashioned entirely by the physician. You can specialize in Derm, move to LA and never have to drive more than an hour from the nearest opera house if you want to after that but the point is that the service is rendered. Isn't that a better alternative than just increasing then number of medical students until some students have to settle for the backwater forever?

 

[Mansamusa]

Telemedicine wouldn't be available to the poor for the same reason normal medicine isn't available to the poor: cost and insurance. Would it be cheaper than a normal visit? Maybe. If any tests or prescriptions are required, then we just run into the same problem as before. Where do they go to get those tests? How do they afford those prescriptions?

You don't see a problem with saying: send doctors to rural areas, as long as those doctors aren't American graduates? It's kind of silly. There are international doctors here on the faculties of the best medical schools because they were recruited, it would be sort of absurd to expect them to spend a whole decade of their lives, not to mention careers, caring for people who ostensibly should have been the responsibility of the domestic healthcare establishment. Like I said to L2D, would it be more palatable if medical school was free and all students were required to serve in some capacity for a number of years upon graduation?

I'm not saying every single physician dedicate their career to the underserved, I'm saying that caring for the underserved becomes a natural stepping stone in a career that is still otherwise fashioned entirely by the physician. You can specialize in Derm, move to LA and never have to drive more than an hour from the nearest opera house if you want to after that but the point is that the service is rendered. Isn't that a better alternative than just increasing then number of medical students until some students have to settle for the backwater forever?

I added a paragraph about free medical school to my last post after you responded

The cost of medicine isn't rural-specific, so that's a different issue.

I said that top international faculties can receive privately funded residencies from the universities who want to recruit them. Most foreign physicians here were not recruited to be faculty. And they have the freedom to decide to come the US and to decide whether or not to practice medicine when they come to the US. It is completely different than tying a required service to a degree and not allowing students to get a degree if they aren't willing to provide that service..


And can rural areas even remotely accomodate all the medical grads for a service stint? There probably aren't even facilities that could hold everyone and if an area produced enough patients to support a facility then those facilities would probably already exist. Rural physicians already see less and now you divide all that work up between thousands of more people. Why not have a rural health scholars program like the HPSP? Or create a rural mission schools where all students must agree to serve a rural community for a set period- there would be applicants desperate enough for that. Have one DO school do that and you'll be pumping out 1,000 new rural physicians every 4 yrs

 

[Cotterpin]

Ok, maybe I'm crazy but I want to do FM in an underserved area, even if that means living in the middle of nowhere. I just wish they awarded more NHSC scholarships.

 

[Lucca]

I added a paragraph about free medical school to my last post after you responded

The cost of medicine isn't rural-specific, so that's a different issue.

I said that top international faculties can receive privately funded residencies from the universities who want to recruit them. Most foreign physicians here were not recruited to be faculty.

The cost of medicine is not rural specific but it does seriously hamstring the possibility of telemedicine being effective for the underserved and poor doesn't it who face the double problem of not only not being able to afford the care but have nowhere to get downstream care (acute care, imaging, etc) even if they were able to afford it. Not being able to solve one of two problems is not an excuse for not trying to solve either


Making it be prt of residency and thus making residency longer is precisely my suggestion. I disagree about needing to start right after high school. Our training pipeline is not appreciably longer compared to physicians everywhere else, and training is sort of creeping to become
Longer and longer all of the time. I don't think sacrificing undergrad to save maybe one or two years is really worth it, undergrad has other purposes. Although, I might add, that should be free for everyone too.

I didn't read that bit about foreign physicians the first time, my bad for misrepresenting your post. I'll concede that sounds fair to me but I still think American grads should have some indebtedness to the public that trains them.

 

[Mansamusa]

The cost of medicine is not rural specific but it does seriously hamstring the possibility of telemedicine being effective for the underserved and poor doesn't it who face the double problem of not only not being able to afford the care but have nowhere to get downstream care (acute care, imaging, etc) even if they were able to afford it. Not being able to solve one of two problems is not an excuse for not trying to solve either


Making it be prt of residency and thus making residency longer is precisely my suggestion. I disagree about needing to start right after high school. Our training pipeline is not appreciably longer compared to physicians everywhere else, and training is sort of creeping to become
Longer and longer all of the time. I don't think sacrificing undergrad to save maybe one or two years is really worth it, undergrad has other purposes. Although, I might add, that should be free for everyone too.

I didn't read that bit about foreign physicians the first time, my bad for misrepresenting your post. I'll concede that sounds fair to me but I still think American grads should have some indebtedness to the public that trains them.

Sorry, I added more to my last post again. I didn't even realize I posted it before I added the stuff, haha.

The point with the cost is that that would be an issue regardless of the solution. If there were no undersupply of physicians in rural areas, rural people still would have trouble paying for care.

It may not be considerably longer, but other places do not require you to involuntarily relocate. Which is a huge sacrifice. You can't just keep piling on sacrifices without making some kind of reasonable concessions (debt isn't a reasonable concession because many people would take the debt over the service). And people are advocating for shortening things now without the idea of service time.

And everyone who practices serves the public that funding their residency training- you don't need to go to rural areas. Plus, technically many underserved medicaid patients did not fund our training (I know a single person doesn't pay federal taxes if they make under $30K- don't know how it is for families), which is to say that we would be more indebted to the middle class if we were being precise. I will also be paying more for my schooling than I will be paid in residency so we really aren't indebted.

It should always be an option: you have the gov't pay for your education and then you have a service option or you pay yourself

 

[numbersloth]

However, there are more medical schools opening up (especially from the DO side). So the chance of you getting into your top choice residency does get smaller.

This really depends on what residency you are applying to. I think the US's biggest problem right now is that people have the wrong incentive to go into fields like derm and ENT. If we leveled the playing field for specialties I think that the spread of residency applications would also even out.

 

[numbersloth]

Something has got to give somewhere. Either the AAMC Changes nothing and "somebody somewhere" has to practice PC in the middle of nowhere - which I don't think is the right way of going about it, for physicians or patients. Or someone anyone else shows up to fill the healthcare need in currently underserved, mostly rural, mostly poorer areas. The latter most likely involves the expansion of scope of care for non-physician providers, which is also not in the physicians best interest because it will only mean that mid levels with expanded scope will begin to enter competitive markets willing to work for lower wages than physicians. Not good for doctors or patients either.

My opinion: it's in the best interest of American physicians, and society in general, to institute real incentives and ways for physicians to practice where they are needed without making sacrifices to their career. Debt repayment is one such current mechanism, but that clearly doesn't interest most since debt is not a very serious enough issue for most physicians to make other lifestyle/career sacrifices. In fact I don't think there exists an external incentive adequate to solving this problem. It will require a serious government intervention: as in, requiring a year or more of rural service in exchange for debt forgiveness for not only a self selected crowd but most if not all medical graduates. I suspect this idea won't be popular with SDN, but either something radical is done to protect physicianhood and address the nation's healthcare need or one or both causes are compromised in the future. Thoughts?

I think medical schools should also really take into account where students think they may want to end up during the process. Of course this is hard since students will game the system, but I personally am really interested in possibly working rurally and with underserved populations and I feel like my ECs show that pretty clearly. I think the pre-med who has 200+ shadowing hours with a neurosurgeon is probably not your best bet for the primary care route.

 

[Mad Jack]

What are the arguments for/against expansion of residency programs? Especially when we hear so much about primary care physician shortages - who/what body of people are responsible for dealing with this?

There isn't a shortage, there is a misallocation. For the love of God, when will this meme die?

 

[Lucca]

Sorry, I added more to my last post again. I didn't even realize I posted it before I added the stuff, haha.

The point with the cost is that that would be an issue regardless of the solution. If there were no undersupply of physicians in rural areas, rural people still would have trouble paying for care.

It may not be considerably longer, but other places do not require you to involuntarily relocate. Which is a huge sacrifice. You can't just keep piling on sacrifices without making some kind of reasonable concessions (debt isn't a reasonable concession because many people would take the debt over the service). And people are advocating for shortening things now without the idea of service time.

And everyone who practices serves the public that funding their residency training- you don't need to go to rural areas. Plus, technically many underserved medicaid patients did not fund our training (I know a single person doesn't pay federal taxes if they make under $30K- don't know how it is for families), which is to say that we would be more indebted to the middle class if we were being precise. I will also be paying more for my schooling than I will be paid in residency so we really aren't indebted.

It should always be an option: you have the gov't pay for your education and then you have a service option or you pay yourself

You are required to involuntary relocate in several South American countries. It's literally called "doing a rural", just a stepping stone in one's career like any other.

It costs more to train a physician than it costs for you to pay your medical education dollar for dollar. I'll concede the very poor might not pay taxes but you don't have to be in grinding poverty to be underserved, as is the case for many rural populations. In any case, I don't expect people to share my view on this but I think serving the neediest is more important than serving the wealthy and better for society if our system were structured to be accessible to everyone, everywhere, and better positioned to actually prevent the problems that cost our society so much down the line.

 

[Law2Doc]

I understand the points you are making but I'm having a hard time processing a response to a solution to helping the underserved that merely reiterates the conditions that created a massive population of "underserved" communities to begin with. I understand you are saying my solution does not directly solve the conditions that caused the problem to begin with, what I said in my first post is that those conditions are essentially insoluble unless there is a significant intervention, a la mandated service. @Mansamusa 's post was much better.

Making people take on debt just to pay it back is silly though, I'll agree. So I'll go one further: med school is free but service is required of everyone. would this be more palatable?

No it wouldn't be more palatable for the simple reason that med schools and residencies aren't the same institutions in most places, though there may be affiliations. So you are robbing Peter to pay Paul here. And again no voters are going to back an idea to fund the tuitions of future "rich" doctors to the tune of hundreds of millions of dollars - that's a harder sell than adding a few hundred residency slots. You are just waving your hands saying this should be free, we should force people to do that. A free economy doesn't work that way. You create incentives or disincentives to get people to make the choices you want, but you can't force them or incur hundreds of millions of dollars of taxpayer debt.

 

[Mad Jack]

The cost of medicine is not rural specific but it does seriously hamstring the possibility of telemedicine being effective for the underserved and poor doesn't it who face the double problem of not only not being able to afford the care but have nowhere to get downstream care (acute care, imaging, etc) even if they were able to afford it. Not being able to solve one of two problems is not an excuse for not trying to solve either


Making it be prt of residency and thus making residency longer is precisely my suggestion. I disagree about needing to start right after high school. Our training pipeline is not appreciably longer compared to physicians everywhere else, and training is sort of creeping to become
Longer and longer all of the time. I don't think sacrificing undergrad to save maybe one or two years is really worth it, undergrad has other purposes. Although, I might add, that should be free for everyone too.

I didn't read that bit about foreign physicians the first time, my bad for misrepresenting your post. I'll concede that sounds fair to me but I still think American grads should have some indebtedness to the public that trains them.

Given that I'll pay enough in taxes over my lifetime to pay for my residency training many times over and that my medical education has cost me well over a half million dollars in loans and opportunity cost, I don't feel indebted to anyone. If the public paid my tuition, that'd be one thing. But even more residency just to care for people that barely pay any taxes at all? Nah. I'll do rural care of my own volition when and if it pays more.

 

[Mansamusa]

You are required to involuntary relocate in several South American countries. It's literally called "doing a rural", just a stepping stone in one's career like any other.

It costs more to train a physician than it costs for you to pay your medical education dollar for dollar. I'll concede the very poor might not pay taxes but you don't have to be in grinding poverty to be underserved, as is the case for many rural populations. In any case, I don't expect people to share my view on this but I think serving the neediest is more important than serving the wealthy and better for society if our system were structured to be accessible to everyone, everywhere, and better positioned to actually prevent the problems that cost our society so much down the line.

Lots of people agree with you. Just like lots of people agree that no one should ever go hungry, but you wouldn't require grocery stores to have yearly donations (of non-expired food). I just disagree that people should be forced to be a solution to a problem or that should be made to feel indebted or guilted into serving a population that they weren't interested in serving.

For the rural and service requirements for the South American countries I could find, the commitment ran from 3 months to 8 months and all built into the med school/residency program. Their residencies and schooling is also much shorter. So you could be done with med school at 24, finish the service require by 25, be done with residency at 27. You finish all your required stuff while still in your mid 20s. Can't do that in the US

 

[Lucca]

Lots of people agree with you. Just like lots of people agree that no one should ever go hungry, but you wouldn't require grocery stores to have yearly donations (of non-expired food). I just disagree that people should be forced to be a solution to a problem or that should be made to feel indebted or guilted into serving a population that they weren't interested in serving.

For the rural and service requirements for the South American countries I could find, the commitment ran from 3 months to 8 months and all built into the med school/residency program. Their residencies and schooling is also much shorter. So you could be done with med school at 24, finish the service require by 25, be done with residency at 27. You finish all your required stuff while still in your mid 20s. Can't do that in the US

I concede you the point, I just expect more from physicians than grocery stores/other private businesses ya know? On that, I know I am nearly alone unless almost every other premed I've met has been lying to me.

Yah like I said, over there it's just a part of your career. I didn't say people had to commit to service for a decade, my point is that people are not currently incentivized to dedicate a serious amount of time to service because it presents a speed bump on their career trajectory. If it was just a part, even a small part, of a regular career trajectory we could do a lot of good fr the people of this country, and, yes, I believe our physicians as well.

You can totally finish by mid 20s, you just can't super specialize or take time off. Personally, I don't think the training pathway length is a problem because there are ways to be supported throughout it. The most difficult part is supporting yourself through college and gap years (if you take them) if you are from a disadvantaged background. Otherwise, loans and a paycheck are essentially guarantees.

 

[Law2Doc]

...If it was just a part, even a small part, of a regular career trajectory we could do a lot of good fr the people of this country, and, yes, I believe our physicians as well...

Problem is to have more residents do a "small part" of their career in an underserved area, you need to attract many good attendings to spend an even larger part of their career in this area to train them. You can't just send an intern unsupervised to the Dakotas or wherever and say "figure it out". Residents work under close supervision so for every few residents you divert to this region you need to divert attendings as well. And eventually some of these attendings will have already been diverted as residents, so it's a double whammy.

And additionally while a small amount of one's career might not seem like a big deal because "you can totally finish by mid 20s", an ever growing percentage of nontrads are starting this game AFTER their 20s and they (not to mention attendings needed to train any such residents) already are more likely to have spouses and family and other entanglements that make spending a few extra years working in an underserved area a much much bigger deal than perhaps you are contemplating of your young single straight outta college 20 year old. You are perhaps extrapolating your own situation onto a very diverse group, many of whom would be impacted in much more significant ways.

Again it's a lot of hand waving about what "should be" without really thinking through the details and impact. If it was actually an easy fix it would already have been fixed.

Finally, this whole "doctors ought to want to do this" notion is wrong on many levels. This path, for most of us, is about finding a satisfying career, not trying to be a Mother Teresa. If you are trying to "save the world" in some sense that's admirable, but IMHO that's also an extremely superficial reason to have gone down this path (equally as superficial as being in it for the money). "Helping people" is what we allow 18-20 year old applicants coming straight out of college with no world experience to say when initially applying to medicine, but we hope the notion of what one actually expects to do with their career matures a lot and is refined to reflect the role and tasks shortly thereafter. Most of us find "helping people" just a happy byproduct of what we really want this career to entail, not the driving force.

 

[musicalfeet]

This might be off-topic, but it's really depressing to see the realities that those in underserved areas and those that don't have the economic means basically get the lowest level of care possible. I've lived in an underserved area for the past few years, and it was really hard to be able to see an actual physician for primary care needs. Like, month-long waits. So...I saw NPs because they were the only ones who could see me within 2 weeks for anything that I needed. Honestly, I wouldn't/still don't know what people who need specialists do if they can't find any within their area.

It'd be wonderful if everyone had access to physicians but...the problem is a lot more complicated than it seems and I have no idea what would be good solutions to fix that.

 

[Law2Doc]

This might be off-topic, but it's really depressing to see the realities that those in underserved areas and those that don't have the economic means basically get the lowest level of care possible. I've lived in an underserved area for the past few years, and it was really hard to be able to see an actual physician for primary care needs. Like, month-long waits. So...I saw NPs because they were the only ones who could see me within 2 weeks for anything that I needed. Honestly, I wouldn't/still don't know what people who need specialists do if they can't find any within their area.

It'd be wonderful if everyone had access to physicians but...the problem is a lot more complicated than it seems and I have no idea what would be good solutions to fix that.

I think the answer has got to start with building up the neighboring infrastructure. If you want to attract doctors you need to create a thriving nearby metropolis with restaurants and airports and shopping and theatre and museums and golf courses and country clubs and sports teams. That's the kind of place that has the ability to attract young doctors and their families. They aren't going to relocate just for a slightly higher salary or loan forgiveness in most cases.

 

[Skittsie13]

You don't see a problem with saying: send doctors to rural areas, as long as those doctors aren't American graduates? It's kind of silly. There are international doctors here on the faculties of the best medical schools because they were recruited, it would be sort of absurd to expect them to spend a whole decade of their lives, not to mention careers, caring for people who ostensibly should have been the responsibility of the domestic healthcare establishment. In other words, the American people pay taxes to train doctors, but doctors don't really have any real responsibility towards anyone after graduating, but then foreign doctors would even after completing their own training and service in their own country? Sort of absurd.

It's not a silly idea. Other countries do it. Any foreign-trained doctor moving to Australia, for example, has to practice in an underserved (not necessarily rural, could be underserved urban) area for 10 years.

 

[Law2Doc]

It's not a silly idea. Other countries do it. Any foreign-trained doctor moving to Australia, for example, has to practice in an underserved (not necessarily rural, could be underserved urban) area for 10 years.

Not only that but you only want to import foreign workers to fill a need. We do this in many fields, and it's part of the US success story and why we have pockets of certain ethnicities in random cities across this country. There isn't a need for more specialists in popular cities, the amount of "recruitment" that occurs is actually pretty insignificant. Someone wants to do plastics in LA -- "no thanks we are good." But someone wants to do FM in Boise -- "why didn't you say so! Come on in!"
So when we import anyone it should really be to fill jobs we aren't able to fill locally. In return, these foreign trained people get the opportunity for a better future. So it's win win. That's kind of the history of immigration in America. I am not sure why this is even controversial.

The idea of US grads filling US needs and importing foreign grads to fill the shortfall isn't new or hard to grasp, and the notion that those being imported should be allowed to compete for the choice spots already being adequately filled is bizarre and out of step with every other nation.

 

[Lucca]

Not only that but you only want to import foreign workers to fill a need. We do this in many fields, and it's part of the US success story and why we have pockets of certain ethnicities in random cities across this country. There isn't a need for more specialists in popular cities, the amount of "recruitment" that occurs is actually pretty insignificant. Someone wants to do plastics in LA -- "no thanks we are good." But someone wants to do FM in Boise -- "why didn't you say so! Come on in!"
So when we import anyone it should really be to fill jobs we aren't able to fill locally. In return, these foreign trained people get the opportunity for a better future. So it's win win. That's kind of the history of immigration in America. I am not sure why this is even controversial.

The idea of US grads filling US needs and importing foreign grads to fill the shortfall isn't new or hard to grasp, and the notion that those being imported should be allowed to compete for the choice spots already being adequately filled is bizarre and out of step with every other nation.

It's not a silly idea. Other countries do it. Any foreign-trained doctor moving to Australia, for example, has to practice in an underserved (not necessarily rural, could be underserved urban) area for 10 years.

I understand it happens, but the idea is a little silly.

First of all, it's out of step with the free market which apparently is important enough to maintain that we can't force junior physicians to serve in underserved areas If their training is fully paid for. It's one thing to go to another country and say "we are looking for physicians to work in these areas, anyone down?" and quite another to exclude physicians from entering the market should they be completely trained. It's also not how the US market works. You can come here from another country with a medical degree, take the exams, go to residency (perhaps for the second time in your career) and then compete in every market as if you were a US trained physician because, ostensibly, you are a US trained physician. That is actually how we do it, that is actually a free market. So the free market is important as long as keeping it means people don't need to go help poor people or people in rural
Mississippi, until it isn't because our graduates are the only ones who deserve to compete for competitive locations/positions????

By the way, in every other profession an international person with better credentials and strong English is going to be competing toe to toe with Americans. That is what it means to be in a globalized economy. Nowhere is this more apparent than in biomedical science where probably half the labor if not more is imported, many of those being physicians.

Second, L2D says "the idea of US grads filling US needs and foreign grads filling the shortfall isn't new or hard to grasp".

That is not what is happening. US grads are filling the needs of the middle, upper and urban classes in America and then nobody is filling the shortfall everywhere else, at least, not enough people. Residencies out in the middle of nowhere may have more IMGs, perhaps the easiest way for a foreign doctor to get to America is to retrain and start out a practice in a rural area (Abraham Vergheese did just that coming from Ethiopia and he's at Stanford now so it seems to work), and as long as the need is being filled I'm somewhat satisfied BUT it would really be much better if US physicians were actually being allocated to meet our greatest healthcare need.

 

[Lucca]

I think the answer has got to start with building up the neighboring infrastructure. If you want to attract doctors you need to create a thriving nearby metropolis with restaurants and airports and shopping and theatre and museums and golf courses and country clubs and sports teams. That's the kind of place that has the ability to attract young doctors and their families. They aren't going to relocate just for a slightly higher salary or loan forgiveness in most cases.

There are no market incentives to create this infrastructure because 1) population density and 2) the people who live in some of these areas are way outside of the income range to afford most of those things. Something else would have to happen in the area before the physicians came, like they struck oil or something or maybe there's a couple of manufacturers that movie in for some reason (LOL American manufacturing). You run into the same problem you already admitted to earlier, and I concede to, when discussing with me: you can't force the market to do something it has no incentives to do(unless you have a radical government intervention, cough)

 

[Law2Doc]

There are no market incentives to create this infrastructure because 1) population density and 2) the people who live in some of these areas are way outside of the income range to afford most of those things. Something else would have to happen in the area before the physicians came, like they struck oil or something or maybe there's a couple of manufacturers that movie in for some reason (LOL American manufacturing). You run into the same problem you already admitted to earlier, and I concede to, when discussing with me: you can't force the market to do something it has no incentives to do(unless you have a radical government intervention, cough)

I said before it wasn't an easy problem or we would have already solved it. To some extent it's like the notion of building a baseball stadium in a cornfield in the movie "Field of Dreams" -- "if you build it they will come". Except instead of luring dead baseball greats we are trying to build infrastructure to lure young doctors. I agree that it's a bit of a chicken and egg problem -- until they are there you can't justify the infrastructure but until you have the infrastructure they won't come. So it's going to take some ballsy people with money to risk and a dream... Or striking oil.

To be honest though it's not going to be all that much more expensive than subsidizing all med school and underserved residency, like you were postulating.

 

[Lucca]

I said before it wasn't an easy problem or we would have already solved it. To some extent it's like the notion of building a baseball stadium in a cornfield in the movie "Field of Dreams" -- "if you build it they will come". Except instead of luring dead baseball greats we are trying to build infrastructure to lure young doctors. I agree that it's a bit of a chicken and egg problem -- until they are there you can't justify the infrastructure but until you have the infrastructure they won't come. So it's going to take some ballsy people with money to risk and a dream... Or striking oil.

To be honest though it's not going to be all that much more expensive than subsidizing all med school and underserved residency, like you were postulating.

If you get doctors to come in, some infrastructure will follow. Having a constant stream of young professionals in an area will require the area to adapt. I don't think it'll mean we get LA in Kansas, but I do think it will mean that local economies might become a teeny bit more diverse. That is a secondary concern to me, secondary to ensuring that people A) don't die from treatable illness, B) are able to manage their health problems and prevent larger (more expensive) ones down the line

 

[Law2Doc]

If you get doctors to come in, some infrastructure will follow...

Nope, not gonna happen. You have to build it FIRST. Otherwise people forced to go there will always scream bloody murder, and everyone will leave quick as they can after their time of servitude. And you'll never ever entice good attendings to stay and train these people. Why would I, an attending, ever go work someplace underserved with no infrastructure when my friends, family, nightlife, theatre, sports teams, airport, shopping, etc are all much more easily available elsewhere? You've got to entice me by how good my life will be there or its a waste of breath. Paying a little more hasn't worked, and debt forgiveness hasn't worked, but these things plus an equivalent lifestyle in a thriving nearby metropolis with lots of infrastructure is going to lure some people.

So no, sorry, it's clear to me that the infrastructure has to be there first. That's the foundation you need to build on, the bait. If you think doctors will come in a constant stream and stay, hoping the areas will adapt around them, I'd say you are wishful thinking.

And again, it's not an easy or cheap fix, and it won't work to try and force people.

 

[Danny L]

Do you guys think the next generation of doctors are going to get shafted by this increase in med school/residency spots? For the current generation doctors/med students, there seems like there will be a large demand for doctors, especially as the baby boomer generation is aging (I think someone mentioned this earlier in the thread). However after that the population seems a lot smaller. The US has the benefit of immigration (vs Japan which is shrinking significantly) but it seems the demand for doctors will decrease in the future. There might be too many doctors and too little demand although I don't have time to pull the numbers for this (so someone who knows could step in here)

 

[Lucca]

Nope, not gonna happen. You have to build it FIRST. Otherwise people forced to go there will always scream bloody murder, and everyone will leave quick as they can after their time of servitude. And you'll never ever entice good attendings to stay and train these people. Why would I, an attending, ever go work someplace underserved with no infrastructure when my friends, family, nightlife, theatre, sports teams, airport, shopping, etc are all much more easily available elsewhere? You've got to entice me by how good my life will be there or its a waste of breath. Paying a little more hasn't worked, and debt forgiveness hasn't worked, but these things plus an equivalent lifestyle in a thriving nearby metropolis with lots of infrastructure is going to lure some people.

So no, sorry, it's clear to me that the infrastructure has to be there first. That's the foundation you need to build on, the bait. If you think doctors will come in a constant stream and stay, hoping the areas will adapt around them, I'd say you are wishful thinking.

And again, it's not an easy or cheap fix, and it won't work to try and force people.

Okay: then what is the alternative to the current road we are currently on? Do you have a rebuttal to the situation as I presented it earlier; namely, that if we just continue to do nothing then other forces will step in to try to meet a need that, by all accounts, must be met (unless you would like to argue that we should just leave underserved areas underserved) and those forces will include the expansion of rights of mid-level providers (a process already underway) which will eventually enter other, more competitive markets at a lower labor cost, crowding out physicians and driving the physician market up towards sub specialization or, in the long term, creating a two tiered system where only the very well insured and willing-to-pay-out-of-pocket see physicians and the rest don't or only see physician extenders for the majority of their care?

Personally, I don't think the current system is sustainable if the profession is to thrive. Survive it will but thrive? The current system does not provide for the healthcare need of the country, is needlessly expensive because of its focus on downstream, acute, and chronic care and unwillingness to expand the responsibility of the physician beyond the short horizon of an individual patient. Further, it does not have incentives to nor is it geared to (profitably) create incentives for the free exchange of patient information which is the backbone of and a necessary requirement for a healthcare system committed to the improvement of the standards of care. Physicians would thrive in a system that would commit itself to universal access, service, and the free exchange of patient information. That is the system that has a need for a healthcare provider trained in the scholarly approach. The system we have now, one based on individual transactions, that treats patient information as proprietary and as an asset, that is not universally accessible, that has a varied and uneven standard of care depending on geography and tradition, that has no incentives to simplify and streamline access to preventative and primary care, is wasteful, inhumane and immoral. This is a massive problem. That is why I think force is the only answer left us to try to move the system in a more productive direction. The problem of the underserved is the most pressing and basic problem to solve because we can't have all of the downstream benefits of a more efficient healthcare system committed to continuous improvement without universal access. If force gets us a quarter of the way there, I don't care how many residents leave as soon as possible (hell, I would imagine some of them would end up liking the lifestyle and stay anyways), as long as people are getting out there and doing what needs to be done.

I'll admit I have no idea what it would take for attendings to get to these places. That's a real problem, very difficult. I don't think infrastructure will make it out to these places before there are people there to use it. I really don't. I also have no idea how to make it so they would within the current economic ecosystem. I wish I knew how it was that other countries managed to do such a thing so that we could mimic their system. Maybe it just comes down to picking the right people in admissions.

 

[Law2Doc]

Okay: then what is the alternative to the current road we are currently on? Do you have a rebuttal to the situation as I presented it earlier; namely, that if we just continue to do nothing then other forces will step in to try to meet a need that, by all accounts, must be met (unless you would like to argue that we should just leave underserved areas underserved) and those forces will include the expansion of rights of mid-level providers (a process already underway) which will eventually enter other, more competitive markets at a lower labor cost, crowding out physicians and driving the physician market up towards sub specialization or, in the long term, creating a two tiered system where only the very well insured and willing-to-pay-out-of-pocket see physicians and the rest don't or only see physician extenders for the majority of their care?

Personally, I don't think the current system is sustainable if the profession is to thrive. Survive it will but thrive? The current system does not provide for the healthcare need of the country, is needlessly expensive because of its focus on downstream, acute, and chronic care and unwillingness to expand the responsibility of the physician beyond the short horizon of an individual patient. Further, it does not have incentives to nor is it geared to (profitably) create incentives for the free exchange of patient information which is the backbone of and a necessary requirement for a healthcare system committed to the improvement of the standards of care. Physicians would thrive in a system that would commit itself to universal access, service, and the free exchange of patient information. That is the system that has a need for a healthcare provider trained in the scholarly approach. The system we have now, one based on individual transactions, that treats patient information as proprietary and as an asset, that is not universally accessible, that has a varied and uneven standard of care depending on geography and tradition, that has no incentives to simplify and streamline access to preventative and primary care, is wasteful, inhumane and immoral. This is a massive problem. That is why I think force is the only answer left us to try to move the system in a more productive direction. The problem of the underserved is the most pressing and basic problem to solve because we can't have all of the downstream benefits of a more efficient healthcare system committed to continuous improvement without universal access. If force gets us a quarter of the way there, I don't care how many residents leave as soon as possible (hell, I would imagine some of them would end up liking the lifestyle and stay anyways), as long as people are getting out there and doing what needs to be done.

I'll admit I have no idea what it would take for attendings to get to these places. That's a real problem, very difficult. I don't think infrastructure will make it out to these places before there are people there to use it. I really don't. I also have no idea how to make it so they would within the current economic ecosystem. I wish I knew how it was that other countries managed to do such a thing so that we could mimic their system. Maybe it just comes down to picking the right people in admissions.

I don't disagree with your sentiments but have told you the only approach I think could ever work. Without the infrastructure already there you are basically trying to force people into a situation they won't want, against their will, and that won't work. So until someone or the federal or state government builds the infrastructure, these places will be forever stuck overpaying for under qualified healthcare providers. Again no easy fix and no good saying "shouldn't be this way".