There is a shortage of GENERALISTS and an oversupply of SPECIALISTS. Unfortunately you can’t force medical students or residents (american or international graduates) to go into fields they don’t want to go into. Currently, there are 24,000 first-year residency slots, which are filled by 18,000 allopathic and osteopathic U.S. graduates and by 6,000 International Medical Graduates (IMGs). In the end, it doesn’t really matter where the doctors are coming from because most residency spots get filled. Actually, many primary care residencies in less attractive, underserved areas would go unfilled if not for IMGs, because they are geographically less appealing to American grads.
But here’s the problem. Even after going into a generalist field like internal medicine, the majority still subspecialize. Initially, it was hoped that increasing the total number of physicians in the United States would increase the number of practicing generalists who would provide primary care to the majority of Americans, particularly by serving in underserved areas. Yet, while the total number of physicians has doubled, the proportions of generalist and specialist MD physicians have changed from 50% generalists and 50% specialists in 1961 to the present proportions of 32% primary care to 68% specialists.

The majority of residents (american or IMG) opt for subspecialties, and the reasons for this are many: higher financial compensation for specialists, decreased prestige for generalists, and (for physicians practicing in rural and underserved areas) isolation from technology and peer support. Just like most people in other lines of work don’t want to work in a rural, farm town in Indiana (or Health Profession Shortage Areas (HPSAs), just using an example here; please no hate mail from Indiana), neither do most doctors…and hence the disparity in access to care.

How do we fix this? I don’t know, but some measures that would definitely help take us in the right direction: the healthcare dollars that we pay for physician’s services need to be redistributed. We should pay the generalists who provide preventive care and practice cognitive medicine more. At the same time, we need to cut the salaries of some specialists who focus on the most aggressive care—especially in cases where it appears that they are talking patients into unnecessary procedures. We might consider putting a cap on how many operations they can do in a given year.

Now in terms of physician salaries, they are NOT the biggest factors for costly healthcare. About 22% of healthcare spending goes directly to doctors. The big drivers for Medical costs in the USA are : a. Ever-improving Medical Technology and Research b. Expensive, new Drugs c. Bad health choices that people make (smoking, obesity, consequent cancers, heart diseases) and d. Uninsured People [44 Million in US] ALL of which contribute to increasing Insurance Premiums and Out-of-pocket payments.

Another small detail to remember: physician salaries that are reported are never calibrated to 40-hour weeks – they mostly represent salaries for 60-hour weeks on an average, while salaries in other fields mostly are 40 – 45 hour weeks. So when salaries are compared, the hourly rates should be compared – so a $150,000 annual salary for a 60-hour week family medicine doc would mean $100,000 annually if the same physician worked 40-hours a week instead.

And finally, to clarify some numbers brought up earlier about end of life care, it’s reported that about 27% of Medicare’s annual $327 billion budget goes to care for patients in their final year of life, which is obviously a sad state of affairs.

Thus the numbers of procedures done in a certain geographical area varies directly with the number of physicians in that area. John Wennenberg, MD at Dartmouth has done four decades of research on this phenomenon. Patients in Sioux Falls, SD have an order of magnitude fewer arthroscopies, cardiac caths, etc than patients in Miami or Manhattan. This is because the latter markets have a far greater number of physicians than the former. Is this the doctor’s “fault.” Yes. Would increasing the number of doctors fix this. No. It would obviously make the problem of excessive health care spending worse.

As far as the Indian Health Care issue. The number of Indian physicians emigrating to the US has slowed to a trickle (compared to the 70s and early 80s) and many of them are considering going back because right now the opportunities are better there than they are here.

Great question. I agree with you here. Very good point. Insurance companies are impeding free-market capitalism. Instead, they are promoting predatory capitalism.

This hasn’t happened in the past and it’s not gonna happen in the future. Ultimately they will always try to make money . Enjoy this read: http://www.ncbr.com/article.asp?id=100242 and please understand that becoming a doctor is hard enough we don’t need people blaming us for being “dollar mongers” even though we have no control over it.

BOSTON_MAHESH: Hello, and thanks for your informative post. I am familiar with supply & demand. Apparently you are not. If we have more MDs, there would be a decrease in the cost of services. The markets would be more efficient. As an analogy for this: thinly traded stocks have a much higher commission for the trade associated with it, than a Blue-Chip stock, like ExxonMobil (XOM). The biggest fault for our lower number of MDs is the AMA, who artificially limit this value to about 18,000/year even though we can accomodate about 54,000 home-grown MDs a year. We can, however, increase our number of MDs who graduate to 30,000, and the quality of healthcare will not diminish, but increase.

I’m sure that the MD schools wouldn’t mind increasing their revenues by increasing their number of MD students. These types of businesses have a very high fixed cost, and the added MD students would only add very little to the fixed costs, but it would provide a lot of profit. The sunk costs have already been paid, and the marginal cost to educate the next few MDs is very little.

I understand how end-of-life care, multiple and redundant testing, neo-natal care and medical procedures add to these expenses. We spend way too much on these procedures. Who is to blame? Aren’t the MDs getting money for doing these procedures? I also realize that the insurance companies are to blame. The insurance companies are very much culpable here.

Finally, they say that malpractice only adds ~1.5% to the cost of healthcare. Do you sincerely believe that? I don’t believe that for one minute. The malpractice insurance in Florida, from what I understand, is over $100,000. Do you know how much caram boards you can buy with this?

We need to let the Indian MDs stay in India where they are better served to help the people there. The people of India deserve excellent healthcare, and they are more underserved than us.

BOSTON_MAHESH: You’re flat wrong. If there are more doctors, than the insurance companies have more bargaining power against the MD’s salaries. Another words, the doctors would now compete with one another on price. You mention that this would translate to no savings for the patient. You’re flat wrong again. The insurance companies would have to lower price or be more efficient with their capital that they have, and this means passing the savings to the consumer.

WE NEED MORE MDs, LESS BUREAUCRACY, AND ALLOWING CAPITALISTIC/MARKET FORCES TO COMPETE. CURRENTLY, MARKET FORCES ARE BEINGS STIFLED BY THE RACIST AND MONOPOLISTIC AMA.

We must kill the Indians and civilize and modernize the country. After we kill the Iraqis. And the Afghans. And Chavez.

You’d have a right to speech whether the police exist to protect it or not, hence they exist to protect rights, not generate them.

How are you going to have a right to an MRI, however, if the MRI machine hasn’t been invented? It can’t be a natural right if the very existence of the good depends on production and distribution.

What we need is the ability to talk about and advocate for things because they are simply good or useful things to do without having to pretend it’s the end of the world or some grave violation of human rights if it doesn’t happen. Not every political issue has to be the GREAT BATTLE OF OUR TIME UPON WHICH THE FATE OF THE HUMANITY RESTS! Every time someone starts fabricating new “rights” as a justification to do something it strikes me as an argument from emotion rather than a positive case as to why we should do something.

What makes access to healthcare a “right” exactly?