Torn from the Headlines: Medical Schools Can’t Keep Up

As these pages have warned, giving 30,000,000 new people health insurance may sound like a great accomplishment.  However, insurance is a mechanism of funding, it does not represent health-care.   This distinction was blurred very effectively over the last year by proponents of a plan which concentrated power over the health care delivery system in Washington D.C.  Of course now that the dust is beginning to settle, the logistical limitations are starting to gain attention.  One key problem has always been how the health care system in America would cope with millions of new patients seeking primary care in the absence of new facilities or professionals to provide the service.

The above referenced article quotes data from the Association of American Medical Colleges which forecasts a shortage of ~150,000 Physicians over the next 15 years at current rates of training.  One would surmise that the solution would be to merely increase the acceptance rate of trainees to meet this need.  Unfortunately, prior government policy makes the logical impossible. In 1997 Congress imposed a cap on funding of Residency programs which train Medical School graduates to actually practice medicine.  This funding cap has prevented programs from increasing the number of slots available for trainees, limiting the number of physicians America can produce.  The logic behind this move was that the more Doctors there are practicing, the more care they provide.  So, by limiting the ability of residency  programs to mint new MDs, Congress hoped to control increasing medical expenditures.  It was an intentional attempt to create bottlenecks and it worked in that limited sense.  Of course the true desired effect of controlling costs failed.  However, we are left with a limited training pipeline, a problem that will take many years to correct.

Representatives from Physician groups and Medical Schools had been assured that increasing the number of funded residency positions would be part of the grand  compromise called HeathCare Reform.  Alas, these measures were not included in the final bills.   The American Medical College spokesman states that it will take 10 years to “even make a dent in the number of doctors we need out there”, a relatively optimistic assessment given that Medical School and Residency training programs run for an average of 8 years ( for primary care physicians, longer for many specialties).  Certainly there will be additional time required for the programs to bulk up their staff to handle additional demand.

As is universally acknowledged, a shortage of primary care Physicians will lead inexorably to “more limited access to care and longer wait times”, even for those who now have insurance.  A rational approach might have increased the supply before increasing demand, but such is the pretzel logic of Washington.

Unaddressed is the freedom medical trainees have in selecting a specialty.  The HCR bills envision an ever greater role for primary care Physicians in both delivering and coordinating care.  Yet the percentage of trainees selecting residencies in  Family Practice, GYN and other areas of “primary care” has remained stable or fallen over the last 30 years, despite efforts to encourage these choices.  Perhaps the $30 office visits, the need to see 50-60 patients a day, or the high debt burden most medical school graduates carry can explain the trend.  An additional consideration is the ever increasing “oversight” that primary care physicians face.  When was the last time you heard of a GP delivering a baby, or performing an appendectomy?  These procedures have fallen from the scope of family doctors due to the requirements for certification and the risks of lawsuits which make such procedures impractical.  Did HCR address ANY of these structural issues?  Of course not!

In the brave new world of Obamacare Physicians face increasing oversight, “pay for performance” which in practice means algorithmic medicine without individualization, and increased documentation thereof, all in a setting of markedly decreasing reimbursement.  Medical School costs continue to escalate (at a rate faster than the overall spending on medical care I might add) leading to ever increasing debt burdens on new grads.  A potential flood of demand from newly entitled people will place far greater time pressure on an already chaotic practice environment.  This hardly seems a setting which will encourage high quality applicants or care, even if the training spots were available, which they are not.  At this point all one can say is “we were warned”.