Maybe we don't need to train so many doctors

The CEOs of two academic hospitals are upset that Congress may reduce the funding for Graduate Medical Education (GME) paid through Medicare. To fight back, they’ve written a scare story for the Wall Street Journal Op-Ed page (We Can’t Afford to Train Fewer Doctors) that’s full of omissions and misleading statements.

To summarize their arguments:

  • A cut in GME funding “could dramatically limit the ability of patients to see physicians, even for critical illnesses” by limiting the number of new physicians trained
  • Hospitals have been buying up physician practices and as a result now provide most primary care, outpatient care, and care for the indigent. Reducing funding in one area (e.g., GME) “will impact all services that hospitals provide to the community”
  • We need 90,000 more doctors by 2020 to meet increased demand and to replace doctors who retire

The authors make it sound like a cut in GME funding will doom the country to a dire doctor shortage. I think they’re being over dramatic:

  • There is serious overutilization of medical services in this country today. Reduce that and we won’t need so much physician capacity. Conversely, supply creates its own demand. Train more doctors and overall utilization and costs will rise
  • I don’t see why a reduction in GME funding will automatically lead to cuts in other programs. If their funding is fungible as the authors imply, maybe hospitals should just find other revenue sources to substitute for lost Medicare GME. Or maybe GME cuts can be offset by reductions in overhead expenses such as administrator salaries?
  • Technology and process improvement should make physicians more productive. The number of farmers has dropped dramatically as agricultural methods have improved. To get costs under control we’ll need to see some of the same effect in health care
  • Plenty of well-trained physicians from overseas are interested in working in the US. We could make up for some of the expected shortage by encouraging more immigration
  • Physicians aren’t the only medical providers out there. Nurse Practitioners and Physician Assistants are an important, growing component of the clinical work force and can continue to take up some of the slack
July 12, 2011

6 thoughts on “Maybe we don't need to train so many doctors”

  1. Make the post graduate medical training for doctors just like any other post graduate training. Something like a Masters or Ph.D program where the institutions accept tuition and fees from the trainees. Only thing is that the training institutions(hospitals) have to pay for the malpractice insurance of the trainees. I am pretty sure that would work. Take no money from Medicare. Accept tuition and fees around $50,000 a year from the trainees. They get trained at the hospital unpaid. Lift the cap on residency numbers. So many international medical graduates are willing to use this opportunity if available.

  2. Great idea Aryan. So instead of graduating 150 grand in debt in our late twenties, that number will be closer to 300 grand in our thirties, and we will be even more incentivized to choose only the well paying procedural specialties and practice boutique medicine. If you spent 10 minutes on one of these hospital wards you would realize that most of these training hospitals are basically run by the residents. These hospitals and the American public already enjoy all of this manpower at less than minimum wage, a special legal carve-out had to be made to allow this to happen. We have less rights than a person who dropped out of high school and works part time at McDonalds. Any fool should understand why continuing to disincentive the best and the brightest in this country from entering medicine is a big problem.

    Another idea: because of the flawed payment model for services rendered in health care (which in itself would be a great place to start looking at cost savings) many procedural and specialist residencies pay for themselves. It not only makes no sense to spend government money to train these individuals, but hospitals are incentivized to close or reduce the # of positions in less lucrative primary care programs (the doctors who really are in short supply) to create more speciality slots. Stop paying for residencies that pay for themselves, and start putting the money towards training the types of doctors this country has a real need for, and that have been shown to REDUCE costs and inappropriate health services.

  3. Rebecca is spot-on here. There is indeed a shortage of primary care physicians, and the reason is that it is not lucrative enough. Increasing debt loads for putative physicians or decreasing pay for primary care both strongly incentivize away from primary care–either to specialties or out of medicine altogether.

    David’s argument regarding the reduction in overutilization of medical services is odd to me. Are you arguing that, say, fewer mammograms for middle-aged women with no history of breast cancer will create more access to primary care for the indigent? Seems dubious to me.

    What “other revenue sources to substitute for lost Medicare GME” do you propose, besides reducing administrator salaries? Those two figures will not even be on the same order of magnitude.

    Allowing more immigration itself does not solve the undersupply issue, as immigrant physicians–regardless of their foreign training–also must serve American residencies. That obviously doesn’t address any GME funding issues.

  4. Jeff,

    If demand for services goes down then supply does not have to go up. No I’m not arguing your mammogram point. A more realistic example is increased availability of GI’s for colonoscopies by reducing unneeded UGI for GERD.

    Hospitals have plenty of revenue opportunities, e.g., expansion of profitable clinical services such as oncology and cardiology, enhancement of other services such as parking fees.

    On the immigration side, we could follow Aryan’s suggestion to let immigrants finance the training themselves, or Rebecca’s to shift the funding to primary care training.

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