Residency Cap Legislation Introduced

[NotAProgDirector]

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The AAMC announced legistlation introduced into both chambers of congress to increase the GME cap by 15%

I may be eating my prior predictions, that Congress would never do this due to the cost. Plus, it's not so clear that there even is going to be a physician shortage. Not too many years ago, policy hacks were all bemoaning the impending physician oversupply and that there would be unemployed physicians. More importantly, research suggests that we have more of a physician maldistribution than a shortage, and that when more physicians are trained they tend to go to oversupplied areas.

Regardless, I think there is a real chance this might pass. Mostly because it costs "nothing" to Congress to do so. All of the costs come from Medicare, which is outside the budgeting process. Sure, this will simply bankrupt Medicare faster, but that will be someone else's problem 10 years from now.

 

[dragonfly99]

Lifting the GME cap doesn't automatically create more residency spots, though, right? It just leaves open the possibility that there will be more spots created.

Personally, I don't see any evidence of an oversupply of physicians in any of the areas where I've lived, except perhaps the large city where I did med school (and even there, if you go 1 hour away, outside the city, there are definitely not too many docs). It seems like we still need quite a few more docs in a lot of areas on the South and Midwest, particularly in primary care adult medicine, peds and psych.

I don't have a strong opinion about the overall physician supply in the future...in the past it has been notoriously hard to predict how many we will need in future years.

 

[dragonfly99]

Thanks for the very interesting post.

 

[GeraldMonroe]

This is big news. THIS will fix the primary care shortage, assuming those new residency spots mainly go to primary care. It'll also take a little bit of the pressure off those of us wanting ENT or urology or neurosurgery : there's probably a shortage of physicians in some of those ultra-competitive specialties, and now more slots can be opened.

Finally, it un-shaft's our Caribbean brothers. I may be a minority when I say this : but I think Americans who go to a Caribbean school and do well should get a residency spot.

 

[niranjan162]

This is big news. THIS will fix the primary care shortage, assuming those new residency spots mainly go to primary care. It'll also take a little bit of the pressure off those of us wanting ENT or urology or neurosurgery : there's probably a shortage of physicians in some of those ultra-competitive specialties, and now more slots can be opened.

Finally, it un-shaft's our Caribbean brothers. I may be a minority when I say this : but I think Americans who go to a Caribbean school and do well should get a residency spot.

From my understanding there are plenty of FP spots that go unfilled. I think creating more specialty residency spots would actually hurt FP shortage since people wouldnt get shunted into FP.

 

[DarthNeurology]

The AAMC announced legistlation introduced into both chambers of congress to increase the GME cap by 15%

I may be eating my prior predictions, that Congress would never do this due to the cost.

Not too many years ago, policy hacks were all bemoaning the impending physician oversupply and that there would be unemployed physicians.

Regardless, I think there is a real chance this might pass. Mostly because it costs "nothing" to Congress to do so. All of the costs come from Medicare, which is outside the budgeting process. Sure, this will simply bankrupt Medicare faster, but that will be someone else's problem 10 years from now.

I had a strong feeling that this would happen as President Obama and many politicians are aware that there aren't enough physicians to *meet* future healthcare needs. This is not about if there are enough physicians now, certainly there are areas where there are not enough physicians and there are reported shortages in certain specialties in several states. This is about making sure there are enough physicians down the line.

It is misleading to talk about Medicare becoming "bankrupt" as Medicare does not operate like a private trust. Medicare was predicted to be bankrupt by 2001 several years ago, . . . it didn't happen. These projections are based on a scenario where by Congress doesn't do anything to "fix" Medicare. It can change the benefits and reimbursements or up the hospital payroll tax. The increased projected cost of Medicare is increasing costs per enrollee mostly, not the increased number of enrollees, so yes, changes will be made in Medicare to keep it "solvent" although such economic terms don't apply to programs like Medicare as they operate differently than other types of trusts.



Sure Medicare is financed "outside of the budget", but this makes no sense if you think about it, what an enrolle withdraws from Medicare is unrelated to their payroll tax, very different from social security. The real reason that Medicare is kinda-sorta outside of the general budget and supposedly "self-supporting" is so costs of the program don't explode. There was always the fear that without being in a separate system that the cost of Medicare if covered via general funds of the government then there would be no incentive to keep costs down. This is why Medicare undoubtedly will go through cycles of being in "bankruptcy", to force in a way the politicians to reign in costs. Now, nobody ever talks about the military being "bankrupt", which is what would happen if the military wasn't paid via general funds.

Medicare won't ever likely be allowed to go "bankrupt", rather it could drastically reduce benefits, but there isn't political will much for this . . .

In general, Obama is focusing on improving, i.e. increasing funding for healthcare, infastructure, and education, and some for alternative energy. This means increasing the physician supply by increasing residency spots as there are tons of unserved areas and the bill will allow for perhaps some more ambulatory heavy residencies to be created. While yes the budget of Medicare is setup specially, there can be many hundreds if not thousands of changes to tweak it, and no matter what the funding mechanism, if Obama and Congress want to make sure there are enough physicians to meet future/current demands then that will happen.

The total Medicare budget is around 386 Billion dollars, of which perhaps 6-8 billion goes to residency training programs, but also these funds prop up hospitals serving indigent populations. Adding a measley 2-3 billion to up residency programs by 15% is not a problem at all. . . compared to the derivatives bubble and several pretty pricey military projects that could go either way in upcoming years, this is chump change.

 

[GeraldMonroe]

From my understanding there are plenty of FP spots that go unfilled. I think creating more specialty residency spots would actually hurt FP shortage since people wouldnt get shunted into FP.

It's my understanding that this is not true. During the scramble, I think that IMGs and the occasional AMG who had to repeat boards and years of medical school take the remaining spots.

There are plenty of IMGs who never manage to scramble even into an FP spot, and an occasional AMG who posts here who says they never got a spot.

I'm reasonably certain that nearly all of the actual medicare funded residency spots get taken by someone. After all, it's $100 grand a year and some cheap labor. Very few institutions are going to pass that up, no matter how bad the candidates who want the spot look on paper.

Some evidence : http://www.imgresidency.com/Statistics.html
249 family practice spots, 107 internal medicine spots are actually left unfilled after the main match.

6914 IMGs failed to match in 2008. I'll bet $1000 that all of the actual primary care positions offered are filled in the scramble. Some of those preliminary spots won't be filled, for obvious reasons.

 

[DarthNeurology]

This is big news. THIS will fix the primary care shortage, assuming those new residency spots mainly go to primary care.

It looks like hospitals doing primary care will get some favoritism in the process, but by no means will it mean only primary care spots are increased. Considering that there are perhaps 40 million uninsured people in the U.S. (probably more, especially considering current economic times, though I don't know how many exactly?), there is both a shortage of healthcare coverage for people and a great shortage of primary care physicians in many areas.

IF, there is increased coverage of folks who couldn't afford healthcare insurance, then there will continue to be a shortage of primary care physicians for many years. I think the crisis reached epidemic proportions when people with good health care insurance were waiting 6 months to see a primary care physician or perhaps small towns had several vacancies for primary care physicians. Likely the primary care shortage won't be fixed by this, and if the retirement of the baby boomers in primary care pans out then all this does is keep things from getting worse.

 

[NotAProgDirector]

Lifting the GME cap doesn't automatically create more residency spots, though, right? It just leaves open the possibility that there will be more spots created.

....

I don't have a strong opinion about the overall physician supply in the future...in the past it has been notoriously hard to predict how many we will need in future years.

If the feds increase the cap, hospitals will likely increase the number of residency slots. However, it depends on how the legislation is written. Many programs are already over their cap. If the cap goes up for hospitals, perhaps they will simply get paid more for training the same number of residents? I assume the legislation will be written such that only truly new spots are actually funded, but we will see.

I agree that it is notoriously hard to predict how many docs we will need. However, many of the predictions being floated are based upon the baby boomers retiring. While this is a challenge, let's not forget that once they expire, the need will be gone. Also, there is quite a bit of interesting research suggesting that the more physicians there are in an area, the more work is generated (and more money spent) without an increase in quality (and in fact perhaps a decrease in quality).

 

[medicinesux]

Oh goody, now we can open up even more DO schools and offshore med schools! This is no different than when institutions of higher learning jack up tuitions to astronomical levels whenever the govt lowers interest rates on student loans and raises the amount you can borrow each year.

 

[jiy76]

Oh goody, now we can open up even more DO schools and offshore med schools! This is no different than when institutions of higher learning jack up tuitions to astronomical levels whenever the govt lowers interest rates on student loans and raises the amount you can borrow each year.

The offshore grads and the FMG's are the most likely to go work in these underserved areas as they don't have tons of options. A well qualified AMG has many opportunites he will rarely if ever work in the boonies of arkansas or north dakota unless hes from the area and wants to stay there. Although regulation is in order there is a benefit to keeping some of these offshore programs alive.

 

[GeraldMonroe]

Oh goody, now we can open up even more DO schools and offshore med schools! This is no different than when institutions of higher learning jack up tuitions to astronomical levels whenever the govt lowers interest rates on student loans and raises the amount you can borrow each year.

Nothing in life is ever perfect. This is an improvement over the alternatives.

 

[ThinkTooMuch]

neat. wonder how this will affect me when i start, myself willing, residency in 2015?🙂

 

[LADoc00]

Sigh...this is such failure. Just reading the responses makes me depressed about the intelligence level of my fellow physicians..

Increasing the number of training slots for primary care does NOTHING to actually increase the number of practicing primary care doctors. It only serves to increase the number of foriegn trained/born refugees that draw money from medicare.

Increase PAY for primary care docs, not training positions.

 

[DOCTORSAIB]

Sigh...this is such failure. Just reading the responses makes me depressed about the intelligence level of my fellow physicians..

Increasing the number of training slots for primary care does NOTHING to actually increase the number of practicing primary care doctors. It only serves to increase the number of foriegn trained/born refugees that draw money from medicare.

Increase PAY for primary care docs, not training positions.

I agree.

The only way increasing PC spots and actually increasing PCPs is if you restrict FMGs from taking those spots and/or leaving the country once they're done with their training. Not an easy task.

The better thing to do would be to increase reimbursement for PCPs (without stealing from the specialists!) and make the field more attractive to medical students. Then lower the cost of medical education.

If you built it, they will come.

 

[UMED122]

I agree that this isn't a very well thought out solution. An unspecified increase in the number of med school/residency slots is likely to exacerbate oversupplied areas/subspecialties while doing very little to help the undersupply in underserved areas/specialties. Until people recognize the fact that this is more about distribution than sheer supply, the problem is likely to get worse. Rather than simply throwing money around haphazardly, how about something more targeted. Just a few of my thoughts:

-If we are going to increase the number of med school spots, increase them with people likely to practice in those underserved areas. For example, if Iowa needs physicians, expand enrollment with people from Iowa at nearby institutions. I'm guessing these students would be more likely to stay than someone from a big city on the coast.

-Increase funding for the NHSC. Last I checked, this is a very competitive program with many more applicants than scholarships. Probably one of the most direct ways to bring help to underserved areas. Plus, it also helps out medical students with the burden of tuition.

-As mentioned by LADoc, it wouldn't hurt to increase primary care salaries. I know this isn't the only problem that the field has, but it would certainly help make the field more attractive to interested graduates that are, unfortunately, also burdened by debt.

I know these solutions aren't perfect, but in my opinion they address the core issues more directly than the vague 15% GME increase being discussed, or some of the newer med schools which have seemingly been built for profit rather than to serve our nation. Hopefully our leaders will examine the problem more closely in the near future and see this.

 

[Acherona]

I'm pretty sure most of the FMGs who do residency in the US end up staying here and practicing as PCPs. If they wanted to practice in their home countries why would they even bother with the cost/effort of coming to the US.

I'm not convinced there is really a shortage rather than maldistribution. If the gov't wants family docs in rural areas they should simply start offering monetary incentives like higher salaries and debt forgiveness. In Canada, docs will go to rural areas for weeks-months at a time, supplement their income while providing care to underserved populations and maintaining their university affiliations/lifestyle in the city.

 

[SocialistMD]

I agree that this isn't a very well thought out solution. An unspecified increase in the number of med school/residency slots is likely to exacerbate oversupplied areas/subspecialties while doing very little to help the undersupply in underserved areas/specialties. Until people recognize the fact that this is more about distribution than sheer supply, the problem is likely to get worse. Rather than simply throwing money around haphazardly, how about something more targeted. Just a few of my thoughts:

Did you read the link?

The majority of the new and redistributed training slots would be targeted preferentially to institutions that increase the number of residency positions in primary care, general surgery, and those that train physicians in non-hospital settings.

 

[GeraldMonroe]

Sigh...this is such failure. Just reading the responses makes me depressed about the intelligence level of my fellow physicians..

Increasing the number of training slots for primary care does NOTHING to actually increase the number of practicing primary care doctors. It only serves to increase the number of foriegn trained/born refugees that draw money from medicare.

Increase PAY for primary care docs, not training positions.

-
Ok, so right now there's 6,000 more people who apply for residency spots than there are available positions. All these folk have gone to medical school, and passed the boards. Nearly all the people who fail to match are foreign trained docs, IMGs, or folks who didn't do too well in medical school - but all of them finished. All these folk who fail to match have undergone far more training the PAs/NPs.

Right now, the AMA and other major organizations claim there is a growing shortage of physicians. They have hard numbers to back up these claims, based upon
1. Increasing U.S. population size
2. Aging population
3. Current medical school graduates working fewer lifetime hours than their cohorts 20 years ago

As well as other factors. I've never read evidence suggesting there are enough doctors but they are poorly distributed : references, please? In any case, I see no reason to believe such claims : in order for there NOT to be a shortage of doctors in 15-20 years, there has to be a large (20%+) surplus of doctors right now overall. Sure, in a few wealthy cities there are lots of doctors, possibly more than the minimum needed, and it's harder for a doctor to get a job there. That doesn't equate to a huge surplus. If there were a surplus, physicians working 40-50 hour weeks because they couldn't get enough patients would be common. I've never met an attending anywhere that had this problem.

Credible evidence says there's a looming shortage of doctors and of PCPs. Now, there's several thousand (~6000) folk who would probably go to work for a mere $140k a year who are willing to become PCPs if there were enough training slots. Just because foreign grads want specialties doesn't mean they won't take a PCP residency spot : all of them fill every year.

Seems straightforward enough to me.

Maybe LADoc0 doesn't want an immigrant who's working for peanuts and barely speaks English as the PCP who calls him up to perform a referral. I'm sure it's quite frustrating, having to deal with someone you can't even understand who calls him/herself a physician. But it's better than nothing.

 

[NotAProgDirector]

I've never read evidence suggesting there are enough doctors but they are poorly distributed : references, please?

Take a look at this:

David C. Goodman, MD, MS; Kevin Grumbach, MD. Does Having More Physicians Lead to Better Health System Performance? JAMA. 2008;299(3):335-337.

He has a nice summary of the situation, and the possible poor downstream effects of simply increasing physician supply.

Also:

David C. Goodman, MD, MS. Improving Accountability for the Public Investment in Health Profession Education, It's Time to Try Health Workforce Planning JAMA. 2008;300(10):1205-1207.


All one author, so hard to know who's doomsday predictions are correct. Still, simply generating more physicians may not solve our problems, and could even worsen them.

 

[GeraldMonroe]

How are these articles relevant? The goal is to at least make sure there are enough doctor hours/ diseased patient. If more patients become diseased (obesity, aging baby boomers) we need more doctors. If doctors work fewer hours, we need more of them.

At the very least, a nominal decision making strategy would be to ensure that we have the same availability of doctors that we had in the past.

Are you saying that there isn't going to be changes that cause there to be fewer doctors available (thus creating a shortage) over the next 30 years? (assuming total number of residency positions remain constant)

Or that currently we have too many doctors, and we need to have fewer of them? Interestingly enough, when I googled for that article, I found several arguing that more total doctors are needed.

 

[dragonfly99]

It looks like the legislation, as introduced, seeks to increase the number of residents in certain specialties (like primary care) in certain geographic regions. I think this could be helpful in certain areas of the country. Certainly we probably don't need more plastic surgeons in LA, but probably could use some more general surgeons and primary care docs in middle and smaller sized towns in the Midwest in some areas. However, I generally agree with the above comments that state that what is really needed is to fix primary care and general surg. as careers/occupations...reimbursement and lifestyle and the general place/position of these specialties vis a vis other specialists are all factors. Primary docs get very frustrated that the majority of the BS paperwork gets dumped on them (often uncompensates for time spent dealing with it), and they have probably the most onerous gov't regulations and insurance company "performance measures" imposed onthem, but yet still they often get less respect from patients and other specialist docs than one of those "superspecialist" docs.

 

[Taurus]

While the bill doesn't fix the reimbursement problem, I support it. We need more physicians to defend medicine from the encroachment of NP's. If we allowed an acute shortage to exist, the nurses would use it to argue for expanded scope.

 

[dragonfly99]

I support it too. A lot of bills never make it out of Congress though...or even out of committee to get voted on. The majority never do...it'll be interesting to see what happens.

I also support the recent careful and gradual increases in med school enrollment in the US. The system we had/have is illogical. We keep out qualified students b/c there isn't enough room for them in med schools, and then we bring in people from other countries every year (and not a few...a LOT of people) just to fill up our residencies b/c we aren't graduating enough med students. It's silliness.

 

[Acherona]

We keep out qualified students b/c there isn't enough room for them in med schools, and then we bring in people from other countries every year (and not a few...a LOT of people) just to fill up our residencies b/c we aren't graduating enough med students. It's silliness.

yea but FMG's have no debt. I think I'd rather get rejected from med school than get accepted only to find out 4yrs and 250K later that I'm forced into primary care because I don't have the grades to get the specialty I wanted.

 

[DarthNeurology]

Interestingly enough, when I googled for that article, I found several arguing that more total doctors are needed.

There are also articles saying that more physicians are needed, and not just in primary care (see below). The majority opinion right now is that the AMA in decades past predicted a glut of physicians, which didn't happened, but this lead to frozen medical school enrollments and no increases in residency positions. Now people feel that the AMA goofed. But there is a more self-centered reason for the AMA wanting to decrease the supply of physicians, with fewer physicians the only practicing doctors in all specialties can charge higher fees, demand more respect from employers and see as many patients as they want.






-----------------------------------------------------

Health Affairs, 28, no. 1 (2009): w91-w102
(Published online 4 December 2008)
doi: 10.1377/hlthaff.28.1.w91

[FONT=Arial, Helvetica, sans-serif][SIZE=-1]Web Exclusives[/SIZE].

States With More Physicians Have Better-Quality Health Care

Richard A. Cooper As efforts begin to expand the physician workforce in response to deepening shortages of physicians, attention has focused on the value of what physicians do. There is a widely held belief that states with more specialists have poorer-quality health care, while quality is better in states with more family physicians. This is myth. Quality is better in states with more physicians, both specialists and family physicians. Access depends on total physician supply, irrespective of specialty. Population density, per capita income, and regional factors all influence this relationship, but the data are unequivocal.

 

[UMED122]

Did you read the link?

No I didn't, but I'm glad to see that they are intended to be targeted increases. The other points I made still stand. There should be additional policies in place (scholarships, salary increases) for primary care and other areas of need.

 

[GeraldMonroe]

There are also articles saying that more physicians are needed, and not just in primary care (see below). The majority opinion right now is that the AMA in decades past predicted a glut of physicians, which didn't happened, but this lead to frozen medical school enrollments and no increases in residency positions. Now people feel that the AMA goofed. But there is a more self-centered reason for the AMA wanting to decrease the supply of physicians, with fewer physicians the only practicing doctors in all specialties can charge higher fees, demand more respect from employers and see as many patients as they want.

Yes, that's the article I saw when I googled around. If it's correct, then more physicians are needed today so that every state can have high quality health care, not just the ones that can pay enough.

And yes, the AMA being self-centered seems exceedingly obvious. True or not, I would bet that 90% of the general public believes that this is true. This is why arguments to increase the pay of some physicians without cutting the pay of specialists fall on deaf ears.

 

[nlax30]

It's H.R. 2251 in the house and S. 973 in the Senate for those who like to track these things. I recently started using http://www.govtrack.us/ to track specific bills I'm interested in, I think opencongress.org does the same thing.

Looks like the house had a similar bill during the last session but it never went anywhere. Wonder if all the interest in health reform will give these more traction this go around.

 

[Taurus]

I support it too. A lot of bills never make it out of Congress though...or even out of committee to get voted on. The majority never do...it'll be interesting to see what happens.

True. That's why I never get my hopes too high. I wait to see the ink dry on the signature before I get excited.

 

[NotAProgDirector]

How are these articles relevant? The goal is to at least make sure there are enough doctor hours/ diseased patient. If more patients become diseased (obesity, aging baby boomers) we need more doctors. If doctors work fewer hours, we need more of them.

At the very least, a nominal decision making strategy would be to ensure that we have the same availability of doctors that we had in the past.

Are you saying that there isn't going to be changes that cause there to be fewer doctors available (thus creating a shortage) over the next 30 years? (assuming total number of residency positions remain constant)

Or that currently we have too many doctors, and we need to have fewer of them? Interestingly enough, when I googled for that article, I found several arguing that more total doctors are needed.

My point is simply that it is not clear that more doctors is necessarily better than less, or what we have now. Your statement that as more baby boomers retire we will need more doctors assumes that we actually have the right number of physicians now, which is unclear. Perhaps we need more, but perhaps not. In addition, if we train lots of docs to deal with the baby boomers, when they all die off we may end up with a serious glut of physicians (pure speculation on my part, no data to support this statement)

Put another way, simply increasing residency slots may not fix the problem. As others have mentioned in this thread, other changes will likely be needed to fix the problem -- addressing compensation / work issues for primary care for example. Without those changes, increasing the physician pipeline could worsen the current situation.

The story behind the article quoted above by Richard Cooper is very interesting. If you have access to the Health Affairs journal, I suggest you read the dueling articles by the Harvard/Dartmouth group (who state that quality decreases with increasing physician supply) and the Penn group (who state the opposite). Reading all of this:

1. The Dartmouth/Harvard group does a much better job of defending their work. Basically, they used multiple regression to assess the effects of each variable on quality which allows them to correct for correlated inputs. The Penn group seems to use simple 1:1 correlations, which could easily be confounded. I admit that my statistical skills are less than ideal, but in general a multiple regression is a strong tool than a simple correlation.

2. The Penn group reports correlations, which is misleading. Correlation measures how tightly two variables are related to each other, not how much a change in one affects a change in another. For example, let's say I decide to study the relationship between the value of pi around the world and the GDP of various countries. Since pi is exactly the same everywhere, the correlation between the two will be 1.0 -- a perfectly straight, flat line. However, the effect of GDP on pi is zero. Hence, just because something has a high correlation doesn't mean that it really matters.

3. The Penn group does make one good point -- that parts of the country with high concentrations of PCP's (or low concentrations of physicians in general) are demographically different than other parts of the country, hence this might explain the differences seen. However, that should theoretically be corrected for in a multiple regression.

The dueling articles are really amazing. They basically call each other idiots in print.

Here's the editor's summary of the story:

...As Deputy Editor Philip Musgrove points out in his Preface, these papers and Perspectives come from two camps taking decidedly different views. The first camp, led by Richard "Buz" Cooper of the University of Pennsylvania, contends that the nation needs many more physicians of all types—generalists and specialists. Cooper’s papers in this package argue that states with more doctors and higher health care spending have better-quality health care. The second camp, consisting of researchers at the Dartmouth Institute for Health Policy and Clinical Practice and Dartmouth Medical School (including Elliott Fisher, David Goodman, Jonathan Skinner, and John E. Wennberg) and at Harvard’s School of Public Health and Kennedy School of Government (Katherine Baicker and Amitabh Chandra), asserts that the nation does not need more doctors overall but rather a relative shift to more general practitioners and fewer specialists. Their papers in this package also argue another perspective that is dramatically different from Cooper’s: that high spending is associated with lower-quality health care, not better care.

Publishing these papers and Perspectives as a package is in keeping with Health Affairs’ editorial mission: to bring a broad swath of peer-reviewed research and high-level thinking to health policy debates. This is why we were disappointed to learn that one of the authors, Cooper, prematurely released his papers to parties actively involved in the policy debate. At the time that this occurred, Cooper’s papers were no longer "working papers" that were being shared with his colleagues for comment prior to submission, as is often done in the scholarly publishing process. Rather, they were full, completed papers that had been submitted for publication, had gone through peer review, and had been accepted by Health Affairs for publication.

On four separate occasions, we notified Cooper of our standard embargo policy: that "the information in your manuscript not be distributed or released in hard copy or electronic form while under review, revision or production at Health Affairs." Nonetheless, Cooper sent copies of the accepted papers in advance of publication to an official of the Association of American Medical Colleges (a fact confirmed by both Cooper and the AAMC). Copies of electronic correspondence also show that the papers went from Cooper through a separate channel to officials in leadership positions at the American College of Surgeons, among others, as well as to U.S. congressional staff. This advance distribution came at a time when the AAMC is urging a 30 percent increase in medical school enrollment, and when it and other physician groups are seeking federal legislation to increase the number of Medicare-supported residency programs at the nation’s teaching hospitals.

For violating Health Affairs’ publication policy, we will not ask Cooper to serve as a peer reviewer for journal articles and will not accept any submissions from him for five years, until 4 December 2013. This decision follows the lead of other journals, such as the New England Journal of Medicine, that have responded to similar breaches of their standards.

 

[GeraldMonroe]

aProgDirector : For that very reason, I said "nominal" decision making strategy. Maybe we need more doctors, maybe it doesn't matter, maybe we need more PCPs and fewer specialists. If it's debatable, then the safe move is to ensure we have the same number of doctors/ill patient that we have now.

The aging baby boomers mean more ill patients. The demographic shift in medical school admissions (to 50% women) means that the current class of doctors work fewer hours, on average. (women as a group aren't going to sacrifice reproducing in order to be doctors, that would be evolutionary suicide. It obviously takes a little more work for a woman to have a baby than a man. I'm not being sexist : there's research showing women work fewer hours. Non-traditional med students, changing admissions policies, and changing work ethics of the current generation also reduce the hours that the current crop of medical students work.) The predictions of a glut of doctors were made in the early 90s when they thought that HMOs could reduce usage of medical services.

So is there any debate that if residency spots are kept constant, then there will be fewer doctors per ill patient than we have today? That's the question at hand, not whether we need more or less, since as you point out, it's debatable.

As for a future glut after the baby boomers die : well, I predict that advances in medicine will have the opposite effect. Stem cell treatments routinely cure diabetes, paralysis, heart failure, parkinsons, and other illnesses in laboratory animals today. Progress moves glacially slow in medical research because of all the obstacles, but I think stem cell treatments will be available within 30 years. Those treatments will create more work for physicians.

The reason is easy to understand. Suppose you have a patient, Bob, who is developing heart failure. Now, normally Bob would have had his last heart attack at 65 and needed the services of an undertaker. But instead, you replace the lost muscle from Bob's first MI with stem cells, and Bob's heart lasts until he dies of something else. Well, doing that treatment will be a complex set of procedures. Furthermore, Bob will live on, and develop some other disease at, say, age 75. By that age, Bob will be even more complicated a patient to diagnose and treat due to all the commorbidities. And if you somehow save his life, and he lives to 85... The point is, improved medical care begats more work for doctors and healthcare providers of all stripes.

Back in the day, Type 1 diabetics weren't patients, because they all died in childhood. Now they are common.

And assumptions about how many doctors are needed per capita are based upon estimates made in the 1980s. Medicine is going to become more and more complex (and effective) in the future.

 

[ThinkTooMuch]

aProgDirector : For that very reason, I said "nominal" decision making strategy. Maybe we need more doctors, maybe it doesn't matter, maybe we need more PCPs and fewer specialists. If it's debatable, then the safe move is to ensure we have the same number of doctors/ill patient that we have now.

The aging baby boomers mean more ill patients. The demographic shift in medical school admissions (to 50% women) means that the current class of doctors work fewer hours, on average. (women as a group aren't going to sacrifice reproducing in order to be doctors, that would be evolutionary suicide. It obviously takes a little more work for a woman to have a baby than a man. I'm not being sexist : there's research showing women work fewer hours. Non-traditional med students, changing admissions policies, and changing work ethics of the current generation also reduce the hours that the current crop of medical students work.) The predictions of a glut of doctors were made in the early 90s when they thought that HMOs could reduce usage of medical services.

So is there any debate that if residency spots are kept constant, then there will be fewer doctors per ill patient than we have today? That's the question at hand, not whether we need more or less, since as you point out, it's debatable.

As for a future glut after the baby boomers die : well, I predict that advances in medicine will have the opposite effect. Stem cell treatments routinely cure diabetes, paralysis, heart failure, parkinsons, and other illnesses in laboratory animals today. Progress moves glacially slow in medical research because of all the obstacles, but I think stem cell treatments will be available within 30 years. Those treatments will create more work for physicians.

The reason is easy to understand. Suppose you have a patient, Bob, who is developing heart failure. Now, normally Bob would have had his last heart attack at 65 and needed the services of an undertaker. But instead, you replace the lost muscle from Bob's first MI with stem cells, and Bob's heart lasts until he dies of something else. Well, doing that treatment will be a complex set of procedures. Furthermore, Bob will live on, and develop some other disease at, say, age 75. By that age, Bob will be even more complicated a patient to diagnose and treat due to all the commorbidities. And if you somehow save his life, and he lives to 85... The point is, improved medical care begats more work for doctors and healthcare providers of all stripes.

Back in the day, Type 1 diabetics weren't patients, because they all died in childhood. Now they are common.

And assumptions about how many doctors are needed per capita are based upon estimates made in the 1980s. Medicine is going to become more and more complex (and effective) in the future.

youre becoming one of my favorite posters! lucky you are not a women, i would totally hunt you down and make you marry me. 😀

 

[ThinkTooMuch]

does the pcp have to handle all the paper work him/her self? i mean lets say getting rid of all the paperwork wont work, but why cant it be legally delegated to someone else? I honestly don't know exactly how it all works. what if the government guarantees they will pay for PA type person to work for all primary care physicians and take care of all/most of their paper work?

 

[dragonfly99]

does the pcp have to handle all the paper work him/her self? i mean lets say getting rid of all the paperwork wont work, but why cant it be legally delegated to someone else? I honestly don't know exactly how it all works. what if the government guarantees they will pay for PA type person to work for all primary care physicians and take care of all/most of their paper work?

There is some paperwork that can be delegated, but a significant amount has to be filled out by the doc himself/herself. Otherwise, we are committing fraud and the gov't will come after us. Actually eliminating some of the paperwork would be better than giving us another person to do the paperwork. Also, some of the paperwork is just the writing of very long progress notes about patients due to the risk of medical liability if we don't document everything that was done and said and planned for the patient...in the old days, outpatient docs wrote notes of a few lines "Mrs. M was here for her chronic back pain and upper respiratory infection...gave reassurance and prescribed naproxen". Now, you have to document multiple parts of the physical exam (Even if they were normal, etc.) and history/story she tells you, or you won't be paid, and write that you warned Mrs. M about the risk of bleeding and heart attacks, etc. from taking a nonsteroidal drug. Otherwise, even if you'd talked to her about the risk/benefit of the drug, you could be sued b/c if you didn't write it in the chart, then legally speaking you can't prove you did it.

 

[Reimat]

The points aProgDirector makes are solid - the Dartmouth Atlas is a great resource that focuses in on regional variations in healthcare. A good example from the group is that end of life care (last six-months) in LA costs twice as much as end of life care at the Mayo - controlling differences in patient health, choice of care, access to care, etc. The difference was that patients in LA saw 1.5 times more physicians during their last 6 months than those in MN - and in fact, patients in MN actually were slightly more satisfied with their care than those in LA.

My point is that there is very good evidence out there that more physicians may not equal better care. However, it has been well documented that more physicians means healthcare costs will rise.

Also, while I don't disagree with the research done by AAMC, I do think you have to take it with a grain of salt since they directly benefit by increasing medical school enrollment/creating new medical schools.

My point is simply that it is not clear that more doctors is necessarily better than less, or what we have now. Your statement that as more baby boomers retire we will need more doctors assumes that we actually have the right number of physicians now, which is unclear. Perhaps we need more, but perhaps not. In addition, if we train lots of docs to deal with the baby boomers, when they all die off we may end up with a serious glut of physicians (pure speculation on my part, no data to support this statement)

Put another way, simply increasing residency slots may not fix the problem. As others have mentioned in this thread, other changes will likely be needed to fix the problem -- addressing compensation / work issues for primary care for example. Without those changes, increasing the physician pipeline could worsen the current situation.

The story behind the article quoted above by Richard Cooper is very interesting. If you have access to the Health Affairs journal, I suggest you read the dueling articles by the Harvard/Dartmouth group (who state that quality decreases with increasing physician supply) and the Penn group (who state the opposite).

 

[GeraldMonroe]

My point is that there is very good evidence out there that more physicians may not equal better care. However, it has been well documented that more physicians means healthcare costs will rise.

This statement makes me angry. You're essentially saying that supply and demand are meaningless in the medical marketplace. I find that offensive, much as I would find an educated person trying to sell me a perpetual motion machine. Physician lobbies have an obvious agenda in claiming that training fewer doctors will be cheaper for society in the long run.

I wrote a whole rebuttal, but I don't fully understand a couple of weird effects like more doctors generating more consults and somehow creating their own demand. Still, supply and demand are a fundamental law of human interaction : how is it possible that it could not apply to the business of healthcare?

Even in Soviet Russia, the government could not completely abolish supply and demand. They fixed prices, and had massive shortages and surpluses as a result. The shortages and surpluses are because when you fix the price at a different level than set by supply and demand, you inevitably cause one or the other. Thus, supply and demand was affecting the Russian economy, despite attempts to ignore it.

 

[Reimat]

This statement makes me angry. You're essentially saying that supply and demand are meaningless in the medical marketplace. I find that offensive, much as I would find an educated person trying to sell me a perpetual motion machine. Physician lobbies have an obvious agenda in claiming that training fewer doctors will be cheaper for society in the long run.

In the current environment, supply and demand are distorted within healthcare. Both patients and doctors often have little knowledge of how much procedures cost, and patients tend to seek care based on hospital location, not based on pricing because they are rarely directly responsible for costs. One of the big movements I stand behind is a push for greater transparency in healthcare - something the medical marketplace sorely lacks right now.

I agree that it is a troubling concept - but honestly, just think about most medical procedures. Assuming a stable condition, do patients shop around when choosing a cath lab, pricing DE vs Bare metal stents? No, because they don't pay for it so they don't care about cost - hardly a normal marketplace. Lasik surgery, on the other hand, I can do a google search and get competiting offers including discounts, 0% financing for 12 months, etc, etc... All because I'm paying out of pocket and those docs have to compete for my business. I'm not saying supply and demand are meaningless, just distorted.

 

[GeraldMonroe]

In the current environment, supply and demand are distorted within healthcare. Both patients and doctors often have little knowledge of how much procedures cost, and patients tend to seek care based on hospital location, not based on pricing because they are rarely directly responsible for costs. One of the big movements I stand behind is a push for greater transparency in healthcare - something the medical marketplace sorely lacks right now.

I agree that it is a troubling concept - but honestly, just think about most medical procedures. Assuming a stable condition, do patients shop around when choosing a cath lab, pricing DE vs Bare metal stents? No, because they don't pay for it so they don't care about cost - hardly a normal marketplace. Lasik surgery, on the other hand, I can do a google search and get competiting offers including discounts, 0% financing for 12 months, etc, etc... All because I'm paying out of pocket and those docs have to compete for my business. I'm not saying supply and demand are meaningless, just distorted.

I thought of this in my original angry rebuttal. The supply and demand element is in negotiations between insurance companies and hospital systems. If an insurance company won't pay a high enough rate, the hospital will refuse to agree to take those patients without 'balance billing' the difference to patients, and taking patients to collections if they don't pay the bill.

In turn, hospitals negotiate with doctors. Supply and demand comes into effect : if you're a specialty that there is high demand for, and fewer physicians relative to demand, you can hold out for a better offer and collect a higher salary.

Even medicare isn't omnipotent : part of the reason they keep reneging on the "sustainable growth formula" every year is because 40% of physicians won't take medicare NOW. If they cut reimbursements further, almost NO ONE would take it, and they'd be forced to raise reimbursements.

All these layers in negotiations and all the government regulation and Medicare interference do distort the supply : demand element. But it's there : this is part of the reason that some specialties are paid so much.

If you're a doctor now, especially an attending, then you have a strong interest in making sure there remains a shortage of doctors in your specialty. Pure self interest dictates you have to lobby for that, and come up with reasons to justify it to yourself. (such as "what I do is so specialized that if they let more people train in my specialty, the average applicant will be lower quality and worse than me, therefore we should keep up an artificial shortage")

There are so many factors beyond an attending's control in this screwed up healthcare system that one would have a very strong desire to be on the strong end of the bargaining table. It would be horrible if the market were flooded with doctors, and you had to suck up to corporate hospital systems and grovel for a 70 hour a week high stress job.

So I fully understand LADoc00's position (see his post up above, with the picture of Ronald Reagan). That doesn't mean his position is intellectually honest or correct, however.

 

[NotAProgDirector]

So is there any debate that if residency spots are kept constant, then there will be fewer doctors per ill patient than we have today? That's the question at hand, not whether we need more or less, since as you point out, it's debatable.

I certainly agree with this statement. However, I still worry that simply raising the GME cap is the wrong way to deal with the problem. Although congress seems to be trying to "direct" the increase to primary care fields, I worry we will simply see further specialty slots created, which I do not see as addressing the situation and only worsening costs.

As for a future glut after the baby boomers die : well, I predict that advances in medicine will have the opposite effect. Stem cell treatments routinely cure diabetes, paralysis, heart failure, parkinsons, and other illnesses in laboratory animals today. Progress moves glacially slow in medical research because of all the obstacles, but I think stem cell treatments will be available within 30 years. Those treatments will create more work for physicians.

The reason is easy to understand. Suppose you have a patient, Bob, who is developing heart failure. Now, normally Bob would have had his last heart attack at 65 and needed the services of an undertaker. But instead, you replace the lost muscle from Bob's first MI with stem cells, and Bob's heart lasts until he dies of something else. Well, doing that treatment will be a complex set of procedures. Furthermore, Bob will live on, and develop some other disease at, say, age 75. By that age, Bob will be even more complicated a patient to diagnose and treat due to all the commorbidities. And if you somehow save his life, and he lives to 85... The point is, improved medical care begats more work for doctors and healthcare providers of all stripes.

This is the same logic (which I mostly agree with) that suggests that screening will save money -- i.e. if you spend money to screen people for colon cancer, you'll save in the long run because you'll avoid treating for colon cancer. The argument fails to consider that as those people grow older, they will get sick from something (perhaps more expensive) and still generate costs.

Still, if we do see a large contraction of the population as the baby boomers die, I think that will likely offset the "increased illness burden" you suggest. Can't prove that, of course, this is all theoretical.

This statement makes me angry. You're essentially saying that supply and demand are meaningless in the medical marketplace.

Looks like someone else beat me to the punch, but yes, supply and demand are not effective in the medical marketplace as it is currently designed in the US. The lasik vs stent example above is classic. Patients are 1) often unable to completely understand their problems, tests, etc; 2) are insulated from costs by insurance; and 3) unwilling to compromise on quality. If you need a new car, you can get a cheap but functional one, or a snazzy sports car. Both get you from here to there, at a very different cost. Do we want a medical system where, if you need a pacemaker, you decide if you want a new model for $5000, or a leftover model from 2 years ago for $3000? Perhaps we should, but this would involve a major shift in how health insurance works.

 

[NotAProgDirector]

The supply and demand element is in negotiations between insurance companies and hospital systems. If an insurance company won't pay a high enough rate, the hospital will refuse to agree to take those patients without 'balance billing' the difference to patients, and taking patients to collections if they don't pay the bill.

I am not really involved with contract negotiations, but there are several problems with this model. First, balance billing is illegal in many states regardless of what a contract says. Second, most hospital systems cannot afford to not take a specific insurance company because many companies have merged into "mega companies" that own too much market share. In my area virtually all patients are covered by one of two plans (not including medicare). If the system were to refuse one of them and really follow through, they would then lose half their business and would need to lay off staff, etc. Third, if you take patients to collections frequently, you wont have many repeat customers. The medical insurance system has created a monopoly of sorts, where insurers get to define payment rates. Hospitals are certainly guilty of overcharging like crazy, so there is no good guy in this battle.

In turn, hospitals negotiate with doctors. Supply and demand comes into effect : if you're a specialty that there is high demand for, and fewer physicians relative to demand, you can hold out for a better offer and collect a higher salary.

This is not really how things work. Some physicians are hospital employees. If that's the case, then salary is usually fixed within some range and is not very negotiable. Specialists who perform procedures are paid very highly because, currently, reimbursement for those procedures is huge and generates large incomes for the system.

Also, the system does not seem to saturate. If you open a new cath lab, you'll end up doing more cardiac caths. It's not clear that more caths were needed -- what happens is that the indications for cath get looser as the availability gets better. This drives systems to hire more and more proceduralists. That type of supply/demand could be very harmful to the overall health care system.

Even medicare isn't omnipotent : part of the reason they keep reneging on the "sustainable growth formula" every year is because 40% of physicians won't take medicare NOW. If they cut reimbursements further, almost NO ONE would take it, and they'd be forced to raise reimbursements.

All these layers in negotiations and all the government regulation and Medicare interference do distort the supply : demand element. But it's there : this is part of the reason that some specialties are paid so much.

I guess I see this as a great example of why supply/demand doesn't work. medicare is so huge / complex and changes so slowly that it's driving the whole market. Meidcare reimburses really well for procedures, so hospitals are ramping up procedures, building ambulatory surgicenters, etc. By it's nature, medicare is distorting the marketplace.

If you're a doctor now, especially an attending, then you have a strong interest in making sure there remains a shortage of doctors in your specialty. Pure self interest dictates you have to lobby for that, and come up with reasons to justify it to yourself. (such as "what I do is so specialized that if they let more people train in my specialty, the average applicant will be lower quality and worse than me, therefore we should keep up an artificial shortage")

There are so many factors beyond an attending's control in this screwed up healthcare system that one would have a very strong desire to be on the strong end of the bargaining table. It would be horrible if the market were flooded with doctors, and you had to suck up to corporate hospital systems and grovel for a 70 hour a week high stress job.

So I fully understand LADoc00's position (see his post up above, with the picture of Ronald Reagan). That doesn't mean his position is intellectually honest or correct, however.

I agree that there is a conflict of interest here. In a free market, less physicians would equal more pay. Still, the pay difference between an internist and a cardiologist is huge and I'm not convinced it's because there is a lack of cardiologists. It's because of payment for procedures, which is again not subject to supply/demand, as insurance companies set those payment rates, usually basing things of a medicare payment system.

It's wicked complicated, and I certainly don't understand it. I am highly suscpicious of the idea that more "free market" in the healthcare system is going to help bring costs down.

 

[DarthNeurology]

I certainly agree with this statement. However, I still worry that simply raising the GME cap is the wrong way to deal with the problem. Although congress seems to be trying to "direct" the increase to primary care fields, I worry we will simply see further specialty slots created, which I do not see as addressing the situation and only worsening costs.

There are some projections that show a shortage of specialists, such as adult cardiologists etc . . . This is different from the 1990's where the thought was the more primary care physicians will be needed and that there are/would be too many specialists. In some parts of the country there are already a shortage of specialists in cardiology, pulmonology/critical care and even neurosurgeons.

In the next years, because the President and his staff's view of the situation, there will likely be an increase in the number of ALL residency positions. I think residency positions should be pegged to roughly increase each year with population growth.

The real shortage that I think will be a crunch is a lack of well trained and qualified academic physicians. I have seen plenty of residency programs and been on clinical rotations where there is a marked lack of attendings who are not only good role models (what attending would say they aren't a good role model?), but also dedicated to teaching the next generation of physicians.

There are states where there are a lack of cardiologists (and I'm not talking about the northeast where I believe institutions like Harvard/Darthmouth have it wrong as there are surpluses there), but who will train additional cardiolgists and critical care doctors? Medical schools needed to do more to encourage and give resources to students who want to be the future PDs and fellowship directors and academic attendings. The situation right now is pretty bad education wise and will get worse as you can't create these residency programs out of thin air.

Believe me, ten years ago one institution I know had pretty strict rules about who they wanted to teach their IM residents in terms of teaching attendings, but now it is pretty much who they can get to do the job as they have problems attracting the best and brightest to teach their IM residents now and settle for anybody.

Specialties outside of IM should increase their retention and support for academically oriented students/residents/ and attendings or face what happened to IM where a lot of the big names have retired and there is no one to fill their shoes.

 

[GeraldMonroe]

aProgDirector : all good points. And honestly, there's some complex funny business going on in some professions.

I mean, why does this country have so many lawyers? One would think there would only be a market for so much legal services, beyond which any new graduates wouldn't have a job. One would think that saturation point would have been reached long before the United States trained more lawyers than anywhere else in the world.

The answer is that the lawyers create work for each other. If I sue you, you have to hire a lawyer. If I sue you and hire a legal team of 10 lawyers, you have to consider hiring a comparable armada of hired guns, or risk losing in court. Moreover, since the judges who decide which cases have merit are also lawyers, and so are the legislators writing up the very laws in question...it's one big racket. Only problem is that as parasites, the lawyers are one of the first to suffer when the host blood pressure begins to drop, such as during the current economic crisis.

And yes, it's easy to throw darts at lawyers - but consider this. If courts were remotely fair and just decision making bodies, it wouldn't matter if one hired a cheap lawyer or an expensive legal team. Countries that have fewer lawyers but are higher rated on the UN human developement index (such as Sweden) run their courts very differently than ours. Among other things, they don't let a randomly selected group of people who can't get out of jury duty make the key decisions. (they randomly select educated experts to serve temporarily on judging panels instead, with a few ordinary citizens to prevent the experts from closing ranks)

 

[DarthNeurology]

Meidcare reimburses really well for procedures, so hospitals are ramping up procedures, building ambulatory surgicenters, etc. By it's nature, medicare is distorting the marketplace.

There is a perception outside of cardiology and surgery that the surgeons are doing procedures on patients who don't need them, and certainly this does happen, but usually this is somewhat rare, at least where I have trained. The vast majority of surgeons and cardiologists will NOT put a patient through an unecessary operation. There are quacks who do multiple surgeries on patients or even fake when a surgery has been done to make money, but often they are caught and perhaps even become the subject of a television magazine show.

As surgery and cardiac procedures become more advanced, then more can be done for patients, it is always correct to question whether a surgery/procedure is necessary, and this is done on a daily basis by many surgeons and cardiologists. Most cardiologists I know are so busy given the huge disease burden of cardiovascular disease in the U.S. that they make highly ethical decisions about whether a procedure would benefit a patient or not. There are more ambulatory centers because more surgical procedures than ever before can be done on an ambulatory basis.

Winged should weigh in on whether surgeons often do unecessary surgeries just for the reimbursement or if this is more just a fluke. While I think that randomized trials and studies are the gold standard for everything in medicine, the issue of physician shortage is *so* political and every study is written is so biased as everyone in healthcare has a strong opinion or a stake in it that currently they are worthless.

While I am not a cardiolgist or plan to be one, it takes a lot of skill and knowledge and dedication to be a cardiologist and frankly there are a lot of general internists who wouldn't be capable of doing the work at a competent level. It make sense that if they do a fellowship and sacrifice to be a cardiologist that they be compensated more than internists I guess. Most don't care about the salary, at least the really good ones. I worked with a world famous cardiologist who was probably a millionaire many times over, and could have retired decades ago but loved his work and was still plugging away. So I think it is unfair to think that procedure based specialties are so heavily influenced by medicare.

 

[GeraldMonroe]

They make an attempt to measure how difficult something is to do versus something else. That's what the "RVU" is about. In theory, the reason a heart surgery is worth a ton more RVUs than an hour talking to a patient is that it's a lot harder to do the surgery for an hour. I've heard complaints that the board of physicians who cook up these formulas is stuffed with proceduralists...but the scale is probably not completely unfair.

 

[Reimat]

There is a perception outside of cardiology and surgery that the surgeons are doing procedures on patients who don't need them, and certainly this does happen, but usually this is somewhat rare, at least where I have trained. The vast majority of surgeons and cardiologists will NOT put a patient through an unecessary operation.

I don't think any (or at least most) doctors do unnecessary procedures as a way to generate revenue. I DO think that a lot of doctors practice based on their experience - i.e. my patients seem to do better with X procedure rather than just staying on meds and so I recommend X procedure to all my patients. I believe these docs honestly believe X procedure is better for their patients. However, since X procedure involves expensive single use equipment from Y company, they utilize a combination of advertising, reps, research, etc. to support the use of their product. Patients don't question the use of X procedure, a) because their doctor recommends it, b) cost isn't a factor to them.

The result is:
1) Patient is happy because they got "best," most expensive procedure at little/no direct cost to them.
2) Doctor happy because they provided the highest quality care (in their mind) to the patient.
3) Device company happy because they made a strong profit off the transaction.

At first glance - everyone wins. But this scenario doesn't account for if the patient actually fared better in the long run with vs. without procedure X, or where the money to pay for it came from. Which is why evidence-based medicine is so important because it addresses the first issue. Insurance companies like it because it allows them to compare relative cost-benefit ratio of doing different procedures. Doctors generally dislike it, because it takes away the autonomy of being able to say "I like procedure X and even though a big study shows it has little benefit, I feel like it does produce a benefit in my patients."

Anyhow, the short summation of my post is that I think most procedurists do procedures with the best of intentions. However the evidence they are using to validate their use of certain procedures is often very biased (personal experience or industry run trials).

 

[DarthNeurology]

I DO think that a lot of doctors practice based on their experience - i.e. my patients seem to do better with X procedure rather than just staying on meds and so I recommend X procedure to all my patients.

I think most cardiologists and surgeons are well aware of the current literature in terms of benefit for their patients. I don't know what specific specialty/procedure you are talking about, but I think that a lot of cardiologists who do stents are up with the current thinking, which hasn't been well defined yet. And industry sponsored trials often do show that their products are inferior to traditional therapy. Even for more complex coronary vascular disease good old bypass is proving better than stents, although perhaps past 12 hours in certain cases medications work well. I haven't seen a lot (any) cardiologists who use their own anecdotal evidence to justify procedures, cardiologists are pretty well read and make pretty informed decisions.

 

[SocialistMD]

I don't think any (or at least most) doctors do unnecessary procedures as a way to generate revenue.

While it is true that most physicians won't perform a procedure without good cause, what they do once they've decided the patient needs to go to the cath lab/OR isn't always medically necessary. I mean, seriously, how many people really need a CABGx8 or how indicated is it to put stents in the 3 main vessels? Some surgeons will still take out the gallbladder when doing a right colon simply because "they're there" and the patient has stones.

 

[Reimat]

I think most cardiologists and surgeons are well aware of the current literature in terms of benefit for their patients. I don't know what specific specialty/procedure you are talking about, but I think that a lot of cardiologists who do stents are up with the current thinking, which hasn't been well defined yet. And industry sponsored trials often do show that their products are inferior to traditional therapy. Even for more complex coronary vascular disease good old bypass is proving better than stents, although perhaps past 12 hours in certain cases medications work well.

You would think most cardiologists and surgeons are well aware of the current literature. And if you are currently working in an academic setting, most probably are fairly up to date with the literature because they have to teach. However, most physicians are in private practice where their main source of education is CME - often provided through industry sponsored events. I don't want to argue about industry influence, but an article came out recently in the New York Times about how many medical organizations are no longer letting CME be directly funded by industry because of the undue influence it causes.

For anyone interested, here is a great article summarizing outcomes research that appeared in Circulation:
Outcomes Research
Generating Evidence for Best Practice and Policies
Harlan M. Krumholz, MD, SM

I haven't seen a lot (any) cardiologists who use their own anecdotal evidence to justify procedures, cardiologists are pretty well read and make pretty informed decisions.

I would say the same thing about the handful of cardiologists I've spent time with too. But, my opinion is anecdotal based on an N=5 or so. Regional variation research would suggest that as a specialty, practice patterns among cardiologists vary widely, which is why outcomes research is so important.

 

[DarthNeurology]

However, most physicians are in private practice where their main source of education is CME - often provided through industry sponsored events.

Regional variation research would suggest that as a specialty, practice patterns among cardiologists vary widely, which is why outcomes research is so important.

I have known private practice generalist and specialty surgeons, and just because they are in private practice their main source of education is NOT just CME. They regularly read journals and attended conferences, like many private practice physicians do. I believe you have made a very false generalization saying that private practice docs get the bulk of their education via CME, far from it actually as plenty of physicians and surgeons in private practice keep up to date by reading journal articles and other sources. CME is a joke and not nearly enough to stay up to date in fields such as cardiology and surgery.

I think there is a difference between outcomes research and practicing evidence based medicine and providing standard of care in that if cardiologists are *practicing* differently then if there is a single standard of care (often not the case as the research has not been done), then all cardiologists should be educated as to the standard of care.

Outcomes research is more focused on seeing, in a policy sort of mindset, exactly what happens in a more real world environment instead of the confines of a more controlled clinical trial with the assumption that real world conditions are much different. Outcomes research isn't "important" because cardiologist practice differently in various locales, this is an evidence based medicine issue as all cardiologists should be practicing evidence based medicine.


Each patient case is complex and just because physicians approach the patient differently, and may offer different treatment strategies doesn't mean that one is clearly better than the other or even that one approach is better. Sure protocols are great for EBM, when available, even so the physician must tailor the treatment to the specific patient and no doubt different areas of the country report regional differences based on local occurrences, one state may have histo higher on the differential etc . . . and workups may procede in different orders. Ask 12 internists how to treat a standardized patient and you will get 12 different answers.