What’s Up, Doc?

As the Affordable Care Act expands healthcare coverage (could we really add another projected 25 million to active coverage?), just about every other federal policy is working to create what is likely to become one of this nation’s most serious shortage of professionals: primary care and even more specialized medical doctors. Even as Medicare and Medicaid are contracting the permitted payments to doctors, even as the costs of attending medical school have exploded up to an untenable pricing structure, notwithstanding the disappearance of most forms of financial aid except loans with no bankruptcy escape, facing the massive reduction in federal support for the post-graduation “residency” program, and even given the graying of an increasing percentage of the population, the expected demand for doctors is growing almost exponentially.

Oh, add another factor. A very significant proportion of practicing physicians have reached or are about to reach retirement age. “Steven Berk, M.D., the dean of the School of Medicine at Texas Tech University, says that ‘the doctor shortage is worse than most people think. The population is getting older, so there's a greater need for primary care physicians. At the same time, physicians are getting older, too, and they're retiring earlier.’  Between now and 2030, the number of Americans 65 and over will jump from 12.9 percent to 19 percent.” Catherine Crawford writing for the HollywoodPatch.com (January 12^th).

While the number of nurses (from practitioners to secondary support personnel) and physicians’ assistants is growing, the topline cadre of doctors is stagnant (retirements are offsetting the rise in new medical students). Interest in medical school (a brutal process in itself) is not keeping up with demand. It’s too expensive, caps imposed by government and insurance companies are reducing earnings power, malpractice threats loom around every nook and corner, and which pay is dropping for most practitioners, workload is not. Doctor morale is plummeting.

“While it may seem like doctor burnout and a growing lack of interest in the medical profession are to blame, New York Times writer Catherine Rampell found that medical school enrollment is actually on the rise. ‘It turns out,’ Rampell writes, ‘that the real bottleneck is at the post-med-school step.’ Most residency programs are subsidized by the federal government, but the number of the subsidized positions was frozen by Congress in 1997.  On top of that, the distribution of the residencies is not regulated. Health policy professor at George Washington University Dr. Fitzhugh Mullan explains, ‘Under our current system, despite the fact that they’re getting huge amounts of federal money, there is no requirement that hospitals bring on residents in any kind of work-force-accountable way. So they’re doing what businesses do, by bringing in residents that are most valuable to them.’  Although primary care physicians are greatly needed, they aren’t greatly lucrative to hospitals, as compared to other areas of expertise like neurology.” Crawford.

In the end, we are going to be forced to shift many primary care tasks to nurse practitioners, a reality that is unlikely to appease a graying populations with increasing complexity and an extending life expectancy. We do need to address the residency issues noted above, and most of all, we really need to conduct a ground-up review on exactly how we fund the heavy burden of a full medical education. Graduating with six figures of debt, getting into a low-paid residency program (if you can get in) and facing years of additional post-graduation training is not acceptable. We need doctors, and we need to support those who wish to pursue this profession!

I’m Peter Dekom, and if you want more doctors, you actually have to act like you really do!