2009 October 21 Wednesday
Smaller Supply Of US Medical Doctors Expected

Will the number of doctors in America fall short of needs by 200,000 physicians in the year 2020?

Compared with a source of data often used regarding physician workforce supply and projected changes, data from the U.S. Census Bureau suggests that the future physician workforce may be younger but fewer in number than previously projected, according to a study in the October 21 issue of JAMA.

Recent projections have indicated that the supply of physicians may soon decrease below recommended requirements, with some projecting a shortfall as high as 200,000 by 2020. "Although debate over potential shortages has focused largely on the number and type of physicians needed in the future, concerns have also been raised about data used in physician supply estimates and projections," the authors write.

The American Medical Association Physician Masterfile (Masterfile) data, although frequently used by workforce analysts, are believed to overestimate the number of active physicians at older ages, attributed to delays in updating the Masterfile data when a physician retires or experiences a change in status, according to background information in the article.

I am skeptical because a lot of visits to a doctor's office are optional. Do you really need to see a doctor about a sprain? Odds are it will heal. Or an allergy? There are over-the-counter meds that work as well as prescription meds for most people. How about a flu? No, it is not a bacterial infection and, no, an antibiotic won't help.

In 10 years time diagnosis will be far more automated. Cheap microfluidic devices will check blood, stool, urine, saliva for orders of magnitude more indicators (e.g. gene expression levels, many pathogens, and cancer cells) and expert systems will analyze the results. We ought to embrace such a future in order to slow spiraling medical costs that are holding down living standards improvements.

You can read a lot of political rhetoric about cutting medical costs. Well, we realistically have two choices for how that'll get done: automation or rationing. If we don't automate we'll ration.

Share |      By Randall Parker at 2009 October 21 10:39 PM  Economics Health


Comments
Rohan Swee said at October 22, 2009 5:31 AM:

It'd be nice if articles like this were just harbingers of future cost-cutting technical advances in medicine requiring fewer physicians to provide adequate care. But astute Americans ought to know by now that when the word "shortage" appears in any outlet of Pravda Today, it is a signal that yet another formerly respectable and decently remunerative middle-class career is scheduled for destruction by cheaper imported labor. The medical guild is so far powerful enough to prevent this, but I won't be surprised when op-eds deploring the "out-dated", or "protectionist" or, yes "racist" medical credentialing standards in this country start appearing. (Wait a minute, I've already seen the "protectionist" wheeze floated.) This will impede, not promote, innovation.

Joe said at October 23, 2009 12:52 AM:

Are you serious? The APA racket is one of the biggest problems with healthcare in this country. It's why we pay so much more (among other reasons). Americans are traveling overseas now to get surgery done cheaper (and just as safely!). I'd welcome boatloads of foreign doctors to our country, although allowing more natives to become doctors should happen first. We could also allow people to practice only in specialized areas. Either way, I won't shed any tears for surgeons making only 100k instead of 200k.

Big Bill said at October 23, 2009 6:20 AM:

The same drill has been executed in Britain. In order to contain costs they have been importing nurses from the Caribbean and doctors from Pakistan. Dalrymple makes reference (without complaint) to the mass of foreign doctors that now provide British medical care. This trend was apparent 40years ago when underserved communities in the US started bringing in Philipino doctors to provide services to their community. The trend is clear in all professions: you will be replaced as soon as possible. For example, the secret Federal GATS negotiating team is working hand in hand with other countries to get rid of barriers to entry in every trade and profession wherever possible. Sweden had a recent taste of this in the EU context when they found they had to let a Romanian (Bulgarian?) construction company use imported labor in Sweden at cheap foreign rates that massively undercut Swedish construction workers pay scale. We can expect much of the same in the USA. Indian "hospital corporations" building facilities in the USA, bringing in doctors and nurses to live in dormitories and provide medical care at rates that are impossibly low.

Joe's dream will come true: no Americans will become doctors and he can get all his needs taken care of by inexpensive foreigners.

Truth(er) said at October 23, 2009 6:27 AM:

What the British Health Service does not tell you is that the well-educated white doctors work in private clinics. You want to go there, you pay in cash.

Rohan Swee said at October 23, 2009 10:39 AM:

Joe: Are you serious?

Yes.

The APA racket is one of the biggest problems with healthcare in this country. It's why we pay so much more (among other reasons).

Yes, there is guild protection in this field. But medicine was a lucrative profession in this country before costs began spiraling out of control. (And I'm old enough to remember when the grinding fear of being financially destroyed by medical costs was not was not a distinguishing feature of life among middle-income people with medical insurance, as it is now.) You really think turning medicine into a low-wage, low-prestige field, that can't attract talented natives, is the long-term solution to our health care woes? Full disclosure: no, I'm not a doctor, nor am I related to any. I just think disincentivizing the entry of smart, capable citizens into productive, critical fields - which has been the ruling business model in this country for the last several decades - is stupid and not in the long-term national interest. No, that doesn't mean "no immigrant doctors". It does mean that "import don't invest" is as a destructive a policy in medicine as it is in any other field.

Americans are traveling overseas now to get surgery done cheaper (and just as safely!).

And those cheaper costs are not all about the surgeon's fees.

I'd welcome boatloads of foreign doctors to our country, although allowing more natives to become doctors should happen first.

You see any serious calls (or plans) for providing more training opportunities for qualified natives? No, me neither. Everybody cries about nursing shortages,too, but "import don't invest" is the preferred, ADHD management solution there, too, as it is in, well, just about every job category. "Boatloads of foreign X" inevitably results in the destruction of X as a viable career path for natives.

We could also allow people to practice only in specialized areas. Either way, I won't shed any tears for surgeons making only 100k instead of 200k.

Yeah, really, who do those surgeons think they are? MBAs? When I think of useless overpaid people in this country, my thoughts always fly first to physicians.

Truth(er): What the British Health Service does not tell you is that the well-educated white doctors work in private clinics. You want to go there, you pay in cash.

What the NHS also does not tell you is that those well-educated native-born doctors take their talents and emigrate in droves, because over-reliance on "cost-cutting" via staffing from the Third World, the invariable preferred "solution" of ever-proliferating "management", results in degraded standards and working conditions.

Joe said at October 23, 2009 11:32 AM:

"no Americans will become doctors"

ridiculous. Just like no americans become programmers anymore?

"he can get all his needs taken care of by inexpensive foreigners."

Sure, why not?

"You really think turning medicine into a low-wage, low-prestige field, that can't attract talented natives, is the long-term solution to our health care woes?"

Again, ridiculous. Wages will go down, but being a doctor will always pay well above the average. Since there is such high demand for more doctors, this is obviously one part of the solution. If you don't like this, what do you propose? If you don't like the high prices you pay, blame all those native born doctors who keep the supply artificially low via govt force.

"Yeah, really, who do those surgeons think they are? MBAs? When I think of useless overpaid people in this country, my thoughts always fly first to physicians."

You're dodging the issue. They're still overpaid and even with boatloads of foreign doctors, will still make a lot of money.

Michael L said at October 23, 2009 2:01 PM:

what Joe said, bring it on with the cheap medical care using cheap foreign doctors. Enough of bankrupting the increasingly impoverished America to pay the AMA aristocracy. If medical school in America is so darn expensive and results in too big debts, let's send American students abroad to study medicine for less (clearly Chinese doctors don't have similarly high debts; I would imagine neither do the French). Do whatever we have to do, but the health costs need to be controlled.

sg said at October 23, 2009 2:17 PM:

Doesn't malpractice insurance account for a fair portion of doctors charges?

What value to patients get for that? Lottery jackpot if injured?

Truth(er) said at October 23, 2009 5:33 PM:

"What the NHS also does not tell you is that those well-educated native-born doctors take their talents and emigrate in droves, because over-reliance on "cost-cutting" via staffing from the Third World, the invariable preferred "solution" of ever-proliferating "management", results in degraded standards and working conditions."

Oh, of course. People actually forget what the purpose of American medical education is. It is not to teach medicine. It is to make sure only the best and the brightest practice medicine. That is why admission standards for even average American medical schools are so high.

The high salaries that doctors earn are the incentive needed to bring high IQ people into the profession because such people have other opportunities.

What the hell makes anyone think that importing Chinese or Indian doctors is such a great idea? Don't you think it is suspicious that the government-funded foreign educational system is allowing the best and brightest chinese/indian minds to simply leave? Or, are they simply letting their worst students practice medicine in the United States? Which makes sense to you?

The British NHS is full of Pakistani doctors. How wonderful are they?

not anon or anonymous said at October 23, 2009 6:58 PM:

Oh, of course. People actually forget what the purpose of American medical education is. It is not to teach medicine. It is to make sure only the best and the brightest practice medicine. That is why admission standards for even average American medical schools are so high.

Close, but no cigar. The actual purpose is to limit the supply of doctors so that the incumbents can charge a monopoly price for their services. There's no need to import more Chinese, Indian, or Pakistani immigrants; just allow more natives to become doctors and expand the range of medical services which can legally be provided by nurses, physician's assistants and other healthcare workers.

albatross said at October 23, 2009 7:17 PM:

Aren't we in the middle of basically lowering standards? We're not doing it by making it easier to become a doctor, but by allowing NPs and PAs to practice medicine more-or-less independently. (I think in most states PAs have to practice under the supervision of a doctor, so they can refer you to the doctor when they realize they're in over their heads.) I wonder if anyone has good data on how this affects outcomes of patients. Intuitively, I expect that that whole four years of med school plus three years of residency, plus really high entrance requirements (which means high IQ doctors) pays off in catching subtle problems. But that's a question better answered with data.

Randall Parker said at October 23, 2009 7:46 PM:

Joe,

High supply does not mean lower total spending on medicine. Just because the income of doctors would go down if we brought in a million foreign doctors does not mean that total health care costs will go down.

Why do I say this? Doctors can make work for themselves. They can order tests. They can ask patients to come back for follow-up visits. They can recommend surgery. A million more doctors means even more unnecessary (and in some cases harmful) health care.

We ought to use fewer service providers more efficiently rather than throw more labor at the problem. Our living standards rose because we increased labor productivity for many purposes. That's the path to greater wealth, not more labor.

Joe said at October 23, 2009 11:15 PM:

Those are good ideas, randall. But your article says supply will go down as demand goes up. So even if you don't want boatloads of foreigners, don't we need more doctors, whether native or foreign? I don't think we can innovate our way out of any problem, certainly not this one in ten years.

Truth(er) said at October 24, 2009 12:53 AM:

"Close, but no cigar. The actual purpose is to limit the supply of doctors so that the incumbents can charge a monopoly price for their services. There's no need to import more Chinese, Indian, or Pakistani immigrants; just allow more natives to become doctors and expand the range of medical services which can legally be provided by nurses, physician's assistants and other healthcare workers."

This may be the effect, but I doubt it is the purpose. The point is, the emphasis on quality means the average medical student graduating from an American medical school (assuming she is not there on affirmative action) has an IQ of at least 130. That seems like a reasonable enough IQ to have working on someone's body or making decisions about someone's body.

Expanding the number of doctors would inevitably result in compromises with IQ.

Foreign doctors who wish to practice medicine need to take the American MCAT's apply to and graduate from an American medical school, and go through the normal procedures of any other med school grad. Then they can practice medicine here.

For those who keep cribbing from Milton Friedman's "Capitalism and Freedom", keep in mind that even Friedman said he was not enough of an expert in medicine to re-organize medicine.

Joe said at October 24, 2009 9:29 AM:

Truther: sure, that's all true. But how do we know the right balance between quantity and quality? Is the AMA looking out for us, or for themselves?

not anon or anonymous said at October 24, 2009 1:15 PM:

"That seems like a reasonable enough IQ to have working on someone's body or making decisions about someone's body."

If you want to pay through the nose for gold-plated medical care, that's your choice. In case you haven't been paying attention, the most pressing issue is access to routine and basic health care, not the latest innovations in brain surgery.

Truth(er) said at October 24, 2009 6:43 PM:

1) Everyone has access to routine and basic health care. I could walk into any emergency room in the country, give them a fake name, declare that I have chest pains, and they are required to keep me over night.

Simply put, there is nobody who is not getting adequate care if they want it.

2) What makes you think even basic and routine care does not require high intelligence? General practitioners are gatekeepers to other experts. They need to have the brainpower to figure out that something requires the work of a specialist. Who else is going to do that? A nurse who graduated from the DC public school system?

3) Everyone is at the mercy of experts. Either you have to become an expert yourself, develop some external mechanism of control, or just take your chances. Sure, the AMA may be looking out for doctors' interests, but doctors are still performing a valuable and highly technical service.

In other words, I want my experts to be real experts. I don't want them to be mediocre, hostile foreigners with entitlement complexes who graduated with "bachelors of science in medicine" from Calcutta university.

After all, why do you think foreign doctors are coming here? To relieve your medical costs? No, they are coming here to make Western medical salaries and to act out whatever status fantasies they can play out. Trouble is, they are not going to deliver.

Joe said at October 25, 2009 12:04 AM:

"General practitioners are gatekeepers to other experts. They need to have the brainpower to figure out that something requires the work of a specialist. Who else is going to do that? A nurse who graduated from the DC public school system?"

This is not who the ama is keeping out of the profession.

"Sure, the AMA may be looking out for doctors' interests, but doctors are still performing a valuable and highly technical service."

No one is denying that doctors perform a valuable service. Why did you even say this?

"In other words, I want my experts to be real experts. I don't want them to be mediocre, hostile foreigners with entitlement complexes who graduated with "bachelors of science in medicine" from Calcutta university.

After all, why do you think foreign doctors are coming here? To relieve your medical costs? No, they are coming here to make Western medical salaries and to act out whatever status fantasies they can play out. Trouble is, they are not going to deliver."

Your whole strategy seems to be making dumb shit up. Foreign doctors aren't hostile and no one with a bachelor's degree will be able to practice medicine in america.

worse_than_hitler said at October 25, 2009 1:37 AM:

The question really isn't whether or not we should import doctors. It's whether we should be importing so many other people. With the Democrats acting like health care is THE MOST IMPORTANT THING IN THE WORLD right now, one obvious solution to providing more health care per citizen is to kick out all or most of the non-doctor non-citizens, or at the very least keep more from coming.

Of course, that's relying on the racist and xenophobic premise that the American government should make policies that benefit American citizens.

Truth(er) said at October 25, 2009 2:09 AM:

That's true. Running around providing medical services to the 12-30 million illegals and other foreigners sponging off the system is the bigger problem, not importing doctors.

"Your whole strategy seems to be making dumb shit up. Foreign doctors aren't hostile and no one with a bachelor's degree will be able to practice medicine in america."

The only kind of doctors who are going to make a dent in healthcare costs are the ones coming in from Third-World countries. For example, most of the doctors in the British NHS are Pakistanis. Do you honestly think Pakistan is a wealthy enough country to produce first-world standard medical schools and have their trained physicians high-tail it out of there and come to the West? Or, are we simply getting the dummies capable of passing board-certifications but not capable of attending a Western medical school?

Medical schools, nursing schools and other programs in Third-World countries are simply not to the standard of American medical schools. Do you really want to suffer through a drop in competence just to make things cheaper?

Quequeg said at October 25, 2009 4:17 AM:

The last episode of "This American Life" described some anecdotes and studies that indicate that a higher geographical concentration of doctors results in more medical care. (The episode is called "#391 More is Less").

17 minutes into the episode:
"One of the many doctors I talked to in Maine, was an eye specialist named Frank Reid and he told me this story: 'My old partner that I joined here in 1971 was asked by a friend of his, 'At what level of vision do you do a cataract operation' and he said 'well, if there's one opthamologist in town, it's 20/200.' 20/200 is pretty bad vision. 'If there are two opthamologists in town, it's 20/80.' Not so bad vision. 'If there are three opthamologists in town, it's 20/40.' Pretty good vision. ... In other words, the criteria easily shifts. ... The number of doctors in an area can influence the amount of medical services consumed. The more doctors, the more procedures, the more appointments, the more money spent."

"You could definitely see this in the 1970s. To drive down costs in medicine, the Federal Government created a program to send more people to go to medical school. The theory was that when there were more doctors, doctors would be forced to drop their prices to compete for patients - basic economics. But that's not what happened. The doctors just adjusted their criteria for doing stuff and had the patients they had, come in more often. Because in health care, supply drives demand. So, when the supply of doctors and clinics increases, the demand for medical services goes up."

"... You see the majority of doctors in this country are not paid on salary, but are paid for each thing they do, a la carte. ... If you pay people more the more things they do, they're going to do more things. ... One of the most popular operations among back doctors these days is this complicated procedure called an "instrumented fusion". ... In the old days, the doctor used a much simpler and safer operation, but the new more complicated one costs more. Surgeons could charge more, because they were doing these complicated procedures. ... So, you had a whole new high-tech procedure that was enormously attractive to spine surgeons and it literally took off in this country. And at the same time, they had no research to support what they were doing. In fact, the one high quality study that did exist showed ... that the old-fashioned non-instrumented fusion was as successful as the instrumented fusion, which was a real blow."

"A group of healthcare researchers at Dartmouth College ... estimated that about 1/3rd of medical care is unnecessary in this country."

Joe said at October 25, 2009 11:09 PM:

Many third world countries have decent medical colleges. Not only that, many third world doctors are first world trained. Americans already to to thailand, india, and other places for medical care, with good results, so why not bring those doctors over here? And you still haven't defended your 'hostile' remark.

Truth(er) said at October 26, 2009 12:23 AM:

"Many third world countries have decent medical colleges. Not only that, many third world doctors are first world trained. Americans already to to thailand, india, and other places for medical care, with good results, so why not bring those doctors over here? And you still haven't defended your 'hostile' remark."

1) Right. Third-world countries with no toilets or sewage systems have "decent medical colleges." If you want to get worked-on by a glorified veterinarian, then you can go visit as many Third-World doctors as you want. We do not need to import any more of their backward dysfunction then we do now.

More specifically, how does a poor society allocate scarce resources to something like medical schools? Do medical schools get disproportional funding just to compete with the West? Of course not. "Decent" means nothing.

2)"First world trained" huh? Ok. What percentage of foreign doctors have the following training: 1)Got a high enough MCAT score to have a shot at being admitted to an American medical school; 2) Applied, and was actually accepted, to an American medical school; 3) Entered the medical school and actually graduated; 3) Had good enough grades to be accepted to an American hospital's internship/residency program; 4) Completed said residency/internship program in good standing with offers lined up to begin private practice, barring completion of the Board Certs; and 3) Doesn't speak English like he has marbles in his mouth ("debeloper").

Any doctor with this kind of training would not bother going back to the old country. So your "first world" trained doctor probably did not complete the level of training that an American doctor did.

3) First-world countries and Third-World countries do not have the same medical problems. American doctors are trained to treat illnesses that are unique to the United States (cancers and age-related diseases) because those are the medical problems Americans face. Third-world doctors have to deal with what are essentially "human cattle" diseases: outbreaks of cholera or dysentery, malnutrition, typhus, leprosy or asses growing out of the side of their heads because such nations lack public health measures. So, even if your foreign doctor has training, the bulk of his clinical disease training is in veterinary medicine.

4) Most of the third-world doctors who come here come from the upper castes in their respective societies. Their upper classes manifest all the disdain and contempt for the lowers that has not been leavened with the thin veneer of egalitarianism that makes customer service an fairly honorable attitude. Worse, they sometimes developed an overly friendly servility that barely masks their comtempt. No, we do not need these people.

Michael L said at October 26, 2009 9:11 PM:

why is Truth(er) so obsessed with protecting our life and limb from the machinations of the incompetent foreigners who don't know how to use the toilet? Is he on AMA payroll or something? Nobody is trying to force him or anybody else to go to a doctor he doesn't like or trust. The big idea here is to give us more FREEDOM - freedom to choose another doctor who charges less if that appears to be a worthy value-quality tradeoff to the customer. If you don't trust a Chinese trained doctor or dentist, don't visit him. If I trust him enough, why this passionate desire to prevent me from using his services without shelling out the cash and the time to at least to fly to Mexico and back?

Truth(er) said at October 27, 2009 8:46 AM:

"why is Truth(er) so obsessed with protecting our life and limb from the machinations of the incompetent foreigners who don't know how to use the toilet? Is he on AMA payroll or something? Nobody is trying to force him or anybody else to go to a doctor he doesn't like or trust. The big idea here is to give us more FREEDOM - freedom to choose another doctor who charges less if that appears to be a worthy value-quality tradeoff to the customer. If you don't trust a Chinese trained doctor or dentist, don't visit him. If I trust him enough, why this passionate desire to prevent me from using his services without shelling out the cash and the time to at least to fly to Mexico and back?"

Simply put, bad doctors will crowd-out good ones. Those who have used and remembered what good doctors are like will certainly notice the lower quality doctor when they see one. Think about it in terms of the nursing profession. You have no choice over the kind of nurses you get if you are ever hospitalized. This means if you get AA Nurse LaFawnda with her bad attitude and press-on nails, there is nothing you can do. How much death is cause by nurse incompetence in the major hospitals?

This "nursing model" is moving up to affect doctors. It will eventually drive the doctors to a much lower level of quality just like it drove nurses down to a lower level of quality.

It isn't worth it.

Michael L said at October 27, 2009 10:02 AM:

ok, NOW we are getting at reasonable arguments. It's good to argue substantively and meaningfully as opposed to the "no toilets" kind of stuff.

Yes, I agree that when you put together the "no discrimination", the ethnic nepotism and the various other such unpleasant tendencies in American life, this can cause trouble. And while I don't put much stock in claims about massive difference in quality between med schools (or, more specifically, that this difference makes any difference in practice - e.g. elite Korean high schools teach math better than elite American ones, but they don't produce better engineers as a result), I can certainly buy the claim that Indians will not make as smart and competent doctors as Americans or Chinese.

Nevertheless, I think this sort of stuff can be explored as a stop-gap measure. This is not the "cheap gardeners" we are talking about, we are talking about medical services that cost massively and that are a big drag even on the young and middle aged, to say nothing of the old. Moreover, it may well be that some years from now majority of the immigrants (especially folks like doctors) are going to pack their bags and leave due to major economic and other turmoil. In other words, I don't think that any changes in this aspect of legislation would have the same kind of strategic and long term impact as we have seen with the Immigration Act of 1965. In the meantime, it might be a good idea to cut costs to some extent even at the expense of lower quality.

Truth(er) said at October 27, 2009 11:48 AM:

Michael L wrote:

"In the meantime, it might be a good idea to cut costs to some extent even at the expense of lower quality."

I don't think you understand what this really means. I think that, in the back of your mind, you seem to believe that medical school is some kind of "credential mill" where academic practices are just padding. Lowering quality seems to you quite lossless since the quality you perceive is just useless credentialism.

This is not the case.

The drop in quality to contain costs means substandard care. It means that medical mistakes, errors of omission and commission, that would not have occurred under the old system will occur under the new one. That's not acceptable.

Michael L said at October 27, 2009 12:36 PM:

Not acceptable to whom? To you? So afraid of LaTonya that you don't want to see any Chinese doctors either? :-)

Last time I checked this place claims to be a republic that prides itself on freedom, personal responsibility and desire to somehow accommodate different people and different viewpoints. Well, "medical mistakes" and "errors of omission and commission" at a higher rate is perfectly "acceptable" to millions of people worldwide. It can be made "acceptable" to many Americans as well if financial aspect of it is explained more clearly. Perhaps this would need to happen through AMA's dead body, but so what?

Truth(er) said at October 27, 2009 9:13 PM:

"Last time I checked this place claims to be a republic that prides itself on freedom, personal responsibility and desire to somehow accommodate different people and different viewpoints."

Only if you are talking to a liberal. There used to be an America that did not define itself this way.

"Well, "medical mistakes" and "errors of omission and commission" at a higher rate is perfectly "acceptable" to millions of people worldwide."

And those people can stay in their own countries, not come here and make their norms standard. we're treating an additional 30-50 million people within our healthcare system that need to be repatriated back to their own countries.

"It can be made "acceptable" to many Americans as well if financial aspect of it is explained more clearly. Perhaps this would need to happen through AMA's dead body, but so what?"

No one is going to trade-off quality healthcare to reduce their costs.

averros said at October 30, 2009 2:43 AM:

> No one is going to trade-off quality healthcare to reduce their costs.

Really? Especially those who can't get *any* healthcare except emergency?

You seem to be of very high opinion of American medical care and American doctors. Well... try living someplace outside US. It would be an eye opener to you. There's a lot of very competent people in the world outside.

not anon or anonymous said at October 30, 2009 5:09 PM:
You seem to be of very high opinion of American medical care and American doctors. Well... try living someplace outside US.
Yes, US-trained doctors in the rest of the world are good, too.

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