We have too many specialists and need more primary care doctors is a mantra repeated so many times that one has to doubt its veracity. What’s the metric by which we determine how many doctors we need and by which we assign their tasks? There doesn’t seem to be one separated from divination.

Consider this from Dr Dennis Gottfried. He thinks we need more doctors than we have and that 70% of them should be in primary care. He uses this distribution because it’s what other countries have. But is it right? I don’t know; but in truth neither does he. Every manpower prediction we’ve had over the past several generations has been confounded by reality. If we change our ratio of primary care doctors to specialists will medical practice get better? Again neither of us knows.

What service do primary care doctors provide that’s currently lacking? These doctors (internists, family practitioners, and pediatricians) take care of the worried well and manage simple straight forward illness that are immediately referred to a specialist when anything goes astray. Most of what they do could be provided by competent nurse practitioners or physicians assistants. What Dr Gottfried proposes to right this “problem” is not increase the number of nurse practitioners or PA’s, nor to increase the income of primary care doctors, but rather is to limit the number of specialty residency positions while increasing the number of primary care slots. Who will manage this transition? The government.

Consider these two sentences. “Our maldistribution of physicians is a major cause of our overpriced, yet underperforming, health care system. Throwing more doctors into the mix will inevitably result in higher costs since American medicine does not obey the usual laws of supply and demand.”

What is the evidence that our current standard of medical practice underperforms? There is none. Statistics like life expectancy and infant mortality are commonly used to gauge medical practice, but in a country as diverse as ours they have little to do with delivery of medical care and everything to do with differences in socio-economic and cultural background. Furthermore, different countries analyze and report their outcome data differently from the way we do making comparisons difficult

Why does medicine not obey the usual laws of supply and demand? Because the government doesn’t allow these laws to act. Read the rule book of Medicare and Medicaid. Insurance companies don’t compete because the government through mandates and suspension of anti-trust regulation allows, indeed encourages, them not do so. A diagnostic related group (DRG) is not the stuff of market competition.

Who goes into primary care practice? By and large women who want to balance the demands of family life with a practice that has regular hours and is less demanding of their time and men whose academic record is usually below that of those who enter the more competitive specialties. Dr Gottfried thinks specialist have “generally easier hours”. Tell that to an invasive cardiologist or a trauma surgeon or a nephrologist or an orthopedic surgeon. Primary care doctors no longer treat their patients when they are hospitalized. This is one of the reasons their hours are regular and not demanding. In general, they work an 8 to 5 schedule and do not work night or weekends. Those who do hospital work do so with an army of nurse practitioners and PA’s.

I was an Alpha Omega Alpha (AOA) (the medical school counterpart of Phi Beta Kappa) councilor for 24 years. Only the smallest handful of students elected to AOA went into primary care. What prevented them from becoming generalists was not greed or a desire for an easy life; it was that the specialties are more interesting and challenging than general medicine. The very best of our students end up in academic medicine where the compensation is less than they would receive in practice, but where the most professional excitement is found. Differences in income between general medicine and the specialties are only part of the reason for the greater popularity of the latter.

The level of primary practice is as good as it is because the applicant pool for medical school has been high. But the number of applicants has been falling in recent years.

If we were to follow Dr Gottfried’s advice there’s no telling what mischief would follow, but here’s one possible scenario. Remember, when you impose a top down change on a system as complex as medicine the consequences are opaque. Forcing 70% of our graduates into primary care would inevitably leave many of them unhappy. Medicine schools are not deluged with applicants, as I just mentioned, as they once were. About half of those who apply are accepted by at least one American medical school. If we force medical graduates to enter a practice they do not find attractive and which pays them less, the number of medical school applicants may fall even more than it has.

We are opening more medical schools. To maintain the quality of practice now prevalent we will need more applicants not less. That we need more doctors is an assertion, not necessarily a fact. That we need more primary care doctors is an even greater assertion. Both may turn out to be true, but based on the accuracy of past medical manpower predictions I’d bet the other way.

If we have too many specialists why are they all so busy? They don’t haul in patients from the street; they get them by referral from primary care doctors. Changing the ratio of primary care doctors to specialists is just another name for rationing. If we have more than twice as many primary care doctors taking care of more patients the number of these patients who require specialty referral will increase markedly. But we’ll only have 40% of the specialists we now have (70% of all physicians now, 30% when Dr Gottfried prevails). Draw your own conclusion about waiting lists.

I believe that medical care, if costs are to be contained, must be rationed, but that market forces and competition should be the vehicle for this rationing, ie price rationing. This requires that we accept that medical care will be unequal once we go above a generally accepted level of good care. This is not a popular position. Dr Gottfried’s view is likely to carry the day.

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