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What’s wrong with more interventional cardiologists in Miami?

An opinion piece in today’s NYT:

FOR anyone who has had to wait a long time to schedule a medical appointment, it might seem as if the world needs more doctors, and that training more of them would be a good idea. An amendment that teaching hospitals are pushing to include in the health care legislation before a final vote is taken in the Senate and the House would do just that. It would add 15,000 medical residency slots to the 100,000 residencies the federal government now finances, most of them through Medicare.


Increasing the number of doctors would make our health care system worse, not better, because the United States doesn’t actually need more doctors. What we do need is for primary care to reclaim its central role in the delivery of medicine, to provide the preventive care, chronic disease management and coordination of services that is lacking in so many parts of the country. Primary care doctors can help patients avoid unnecessary visits to specialists, hospitals and emergency rooms, thus lowering health care costs.

Granted, the teaching hospitals and others lobbying for more doctors would have Congress designate some of the new residency slots for family practice, pediatrics and internal medicine. But there are already plenty of residency openings in those areas that currently go unfilled. And since the amendment would not prohibit the positions going to specialists, that is who would fill them. If the past is prologue, these newly minted specialists would most likely gravitate toward cities like New York, Los Angeles and Miami, which already have plenty of doctors — and relatively poor care.

I have to admit, that line about “New York, Los Angeles, and Miami” made me laugh.  Visions of Mercedes-driving plastic surgeons will do that to me.

But seriously, I agree with the argument that increasing the number of residency positions won’t do much to help anyone.  Our problem is not a shortage of doctors per se, but a shortage of the right kinds of doctors in the right locations.  Specifically, primary-care doctors in lower-income regions.  Doctors, like hospitals, thrive best in our health care system when they avoid treating poor patients with typical ailments.  This leaves inner cities and rural locations short of primary care physicians, even as Los Angeles and Miami are flush with plastic surgeons and interventional cardiologists.

Funding more residency positions will not fix this problem.  Instead, here are some things that might help.

1)  Reduce the debt of graduating medical students, to induce more medical students to choose lower-paid primary care careers.  The Association of American Medical Colleges described the problem in a Feb.3 letter (pdf) to Senators Reid and McConnell:

Over 85 percent of medical students graduate in debt. The average indebtedness of that group is $155,000 and over a quarter of medical students graduate with debt levels of $200,000 or more. The nation faces a physician workforce shortage and the cost of medical education can be a daunting figure for prospective students and future physicians. Concern about managing this substantial debt burden can play a factor in career decisions or drive physicians away from primary care specialties.

2) One way to reduce medical student debt is to lower medical school tuition, especially for in-state students at state medical schools.  Sadly, we are moving in the opposite direction.  States continue to cut funding for medical schools which forces schools to make up the shortfall by raising tuition.  My own state medical school, the University of Colorado School of Medicine, exemplifies this problem.

3) Make sure every patient is able to pay for medical care.  I would prefer a simple single-payer system, but this is America, Land of Irrational Fear of Socialism, so we’re not going to get single-payer.  Hopefully, the health care bill in Congress will reduce the number of uninsured patients, making it more attractive for doctors to provide them with the primary care they need.

4) Reduce the disparity between what specialists earn and what primary care physicians earn.  Alterations in Medicare’s payment system that are included in the healthcare bill might start to make this happen.

5) Pay emergency physicians much, much more money.  Most of society’s problems would be solved if emergency physicians were more richly compensated.  So I hope that the lobbying arms of all the specialty societies representing ER doctors like myself will rededicate themselves to educating our elected officials about the urgent need to pay ER docs more money.*

*Here is the iron law that I wish to mock: every trade group lobbies the government to support policies that will enrich members of the trade group.  (Am I brilliant?)  As a new ER physician, I thought I’d better demonstrate my firm grip of political reality by jumping on this bandwagon early.

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