A Doctor Shortage or an Uncompetitive Industry?

In their article “Doctor Shortage Likely to Worsen with Health Law,” Annie Lowrey and Robert Pear report on claims of a future shortfall in the number of doctors. I was thinking about this recently when, for the first time ever, a dermatologist offered to have a nurse perform my checkup. In all likelihood, this nurse did as good a job as the doctor, perhaps even better; she certainly took more time. I’m sure she got paid less, though I’m not sure that costs passed along to the insurance company were any lower.

Is there really a doctor shortage? Or does the Lowrey-Pear article reveal one of the major problems with health care in this country: that if this were any normal industry or market, nurses and other providers would be competing with doctors to fill needs and provide services at a lower cost.

Despite its title, the article actually cites professionals making three different claims. First, there will be a shortage of doctors, presumably nationwide. Many more people will become insured under the new health laws, and the baby boomers are aging, so demand is up. The Association of American Medical Colleges estimates that in 2015 the country will have 62,900 fewer doctors than needed.

Second, mismatches abound. Although in great demand, primary care specialists get paid a lot less than specialists; as a result, medical schools are producing fewer general practitioners as more students choose to specialize. Some regions and localities have far fewer doctors per capita than others.

Third, we’re going to have to allow nurses to provide more care. As one doctor notes, we’ll have “to use the resources that we have smarter.”

Think of any other sector of the economy that experiences an increase in demand. For instance, we decide we want more heirloom tomatoes (or early childhood education, or, at one time, cars). Initially, there aren’t enough heirloom tomato growers (or early childhood teachers or steel mills to provide metal for the cars). Suppliers of goods and services respond in various ways, including providing alternatives: other vegetables, noncertified teachers, aluminum. At the same time, competition usually leads to cheaper ways of providing services to these markets. Indeed, in just about every industry except health, above-average growth in the quantity of goods and services provided is accompanied by below-average growth in prices or even price declines. Think of computers or cell phones.

So it’s hard to assess the first claim of an overall shortage. Relative to what? Every market makes adjustments all the time. That doesn’t mean there’s a shortage, unless we think we have to do things the same way and at the same price that we used to—which is the opposite of progress. I suppose if the old, landline phone companies could require that all phone services be provided over wires, there would be a shortage of telephone service as well.

As for mismatches, some exist in any industry and market. But they are especially out of whack in health care because of the crazy way we compensate. The government is clearly a partner here, given its 60 percent share of the market once we count Medicare, Medicaid, tax subsidies, and other subsidies, including for medical students and hospital training. In any case, educating more specialists who settle in popular cities where the ratio of doctors to patients is high won’t do much about the shortage of primary-care physicians or doctors in remote regions.

The third claim—that nurses may have to provide more care—is quite on the mark. But this is a plus, not a minus. Alternative providers of medical goods and services can extend well beyond nurses. What about allowing competitive offices to use yesterday’s MRI machines that have slightly less than the latest gadgetry? Making even greater use of generic drugs? Giving greater leeway to the Walmarts of the world to provide health care checkups? Converting more routine tests into procedures handled by well-trained and specialized, but lower-cost, technicians? Making medical student subsidies exchangeable for years of providing services for less compensation in poor communities or places with a shortage of health care providers? Heck, why not expand the skin cancer checkups being offered at baseball games?

Another way to save money would be to lower America’s high ratio of specialists to primary-care physicians. About a third of all doctors in the United States are primary-care physicians, compared with half of doctors in other industrialized countries. The abundance of specialist doctors in the United States has sometimes been referred to as an “artificial shortage of doctors.” Specialists are also more costly than doctors with general practices.

While we’ve already made headway on some of these alternatives, they are only harbingers of what must come so we can both rein in health costs AND get maximum care out our health care dollars.

What prevents these competitive forces from coming into play? Several things. The inaccurate notion that we all will receive the maximum amount of the best health care available, no matter what the cost. The threat of us suing doctors for malpractice if they don’t give us every possible treatment. The open-ended nature of our government health care budgets. The denial to most workers and Medicare recipients of the ability to save some cash by choosing a lower-cost insurance plan. The perverse incentives created by fee-for-service medicine. The monopolization of certain markets by some hospitals and providers.

Yes, many forces are blocking progress. But their day is coming to an end. When it comes, we will see a lot more care provided nontraditionally. Often it will be less costly. Sometimes it will even be better. That day will not see the end of the eternal (and necessary) debate over building an even better health care system, but it will likely open us up to fresh ideas. Regardless, I doubt that our future health care will be stymied by a shortage of people being paid several hundred thousand dollars a year through the fees and taxes of the average worker and taxpayer.

28 Comments on “A Doctor Shortage or an Uncompetitive Industry?”

  1. Bill Spencer says:

    Using the example of cell phones or other manufactured items as proof of decreasing costs with increased demand does not apply to people in a service industry. People are paid more to work when there is a shortage of labor. The key to decreasing medical provider costs is encouraging more individuals to see it as a desirable career. Changes such as less legal liability, fewer hours, less expensive education and a quicker path to career initiation might make a real difference in the number of students choosing to pursue this field.

  2. Doug says:

    Doctors are effectively a monopoly. The number of medical school slots is smaller than dictated by need. The evidence is doctors coming from overseas to fill the demand despite the tremendous hurdles put in place by the medical establishment. The reason for the low numbers higher salaries.

    • Josh says:

      This is exactly the problem, there are no shortage of talented folks that would be thrilled to be a doctor, even a general practitioner, but cannot get into medical school because the number of slots is low and competition is fierce. More slots will result in more doctors without any reduction in quality because they will still have to pass medical school and boards – right now we don’t even let those people try. People will happily pay full price to go to medical school so it doesn’t cost schools or the government anything to increase enrollment either – the only thing in the way is doctors lobbies like the AMA.

      Increasing the supply of doctors will results in reduced doctors salaries and an increased willingness for them to live in less glamorous areas. That will result in less expensive care, more available care, and better care.

      • This poster brings about the need in the USA for capacity building in medicine. It takes no less than about 12 years to produce a physician through the education and training system.

        In traveling to more than 50 countries and vetting the training and education of physicians in 92 countries, I know what other schools produce as physician product for less money.

        I also see these schools supported by grants and funds such as WMF, IMF IRDB, WB, ADB, and others that support capacity building and institutional strengthening. Why the USA continues to limit seats and charge so much for physician education is perverse, given our current situation.

        Are we to try to spin straw into gold? That’s a fairy tale.

  3. Dr Rosemary Eileen McHugh says:

    As a family physician who trained in Ireland and England and the US, I agree with much that this writer says. As a professor in a medical school, I find that many medical students enter medical school to be primary care doctors who are able to treat the whole patient. They are discouraged from doing this by the other types of doctors, who encourage them to narrow their field of interest. I agree that incentives are very important. In Britain, my classmates that chose to go into family medicine were given higher salaries than those who wanted to be specialists in the medical centers. There is a real problem in the US, where business has been hiring nurses to do the work of physicians. The US has a real shortage of real nurses and yet, in my experience, academic nursing centers are making nurses feel guilty for being nurses and the academic center pushes them to be nurse practitioners, who are wannabe doctors and they want to compete for patients with physicians. There is so much need for nurses as well as a need for primary care doctors. It is sad that nurse academic centers in the US want to train nurses to do the work of a doctor. Nurses are proud to be nurses in my experience in England and Ireland. I think more programs are needed to praise the work of nurses. We need well trained nurses, as well as more primary care physicians.

    • Jalynn says:

      You state “The US has a real shortage of real nurses”. This is untrue. There may be a shortage in some rural areas, or a shortage of nurses with highly desired technical experience, but there is currently no shortage of ADN and BSN trained nurses. In fact, most nursing schools are reporting that a sizable number of new grads are having difficulty finding employment, particularly those with ADN programs.
      That said, demographics tell us there will be a nursing shortage in 10-12 years. That is of little help to unemployed and under employed young nurses.

    • Michelle Benrath, ANP says:

      Nurse Practitioners are not “wannabe doctors.” We are highly motivated individuals who want to provide patient-centered care. As an NP, I still practice nursing everyday, in addition, I utilize an additional skill set including diagnosis and management of primary care conditions. Instead of stating that NPs are “wannabe doctors,” try thinking about the highest quality of care for patients, which includes providing more access to care, which the addition of NPs to primary practice has accomplished.

  4. Michael Bleich says:

    This is quite a supposition, that NURSES want to be PHYSICIANS? That the discipline is about “wannabes?” Simply, nursing is a holistic discipline and the training incorporates the patient/individual, FAMILY, and COMMUNITY. The focus is NOT just on disease and its treatment, but also on health promotion and disease management and abatement. And – there is actually science to support how to handle issues like fatigue, grief, and other human conditions that complement medicine. So, yes, we nursing lens is sometimes helpful in handling primary care. And nurse practitioners can do this very well, with evidence to support positive outcomes. But really, we’re not competing with physicians. Last I checked about 45 million people and more have NO access to primary care. Seems like having a nursing lens to help with that would be a great thing!

    • Anonymous says:

      I would compare a nurse practitioner’s level of functioning close to a 3rd year medical student (may be even less). Of course, many nurse practitioners are doctors wanna be. It is quite dangerous to have NPs diagnose. There is no such thing as “routine medicine”. A simple flank pain can either be cancer or mechanical back pain. There is no way that the diagnostic skills if an NP will ever come close to that of the most low functioning doctor.

      And frankly, more time does not equal quality. A doctor’s training is far far, did I say far? superior. Doctors are trained to scrutinize and purify their history taking skills and are taught to think outside the box. Where as nursing education follows protocols and miss the “holistic” aspect of a person regardless of the fact that they may spend more time.

  5. AL says:

    It is interesting to note that the comments related to nursing comes from someone whose country has given the world one of the best models of ‘nursing’ via the work and writings of Florence Nightingale, whose purpose was to influence policy and provide evidence-based healthcare practice to enhance the lives of patients and communities – to wit: long before any healthcare profession, nurses had evidence that aseptic technique led to decreased morbidity and mortality. This evidence was summarily discarded by the reigning physician figures of the day, until one of their own decided to do research, come up with the same conclusions, and ‘voila’, physicians then decided that they would wash their hands between patients and procedures..Mmm. So, please do not infer that nurses want to do the work of doctors…nurses do the work of ‘nursing’, using a nursing model to provide care…if a nurse wanted to be a doctor he/she would go to medical school, but, instead nurses keep to the ‘bottom line’ of providing care that encompasses the ‘whole being’, and nursing education programs educate nurses in order to promote and provide communities with a professional whose skillset, as noted by Michael, is to not to focus only on the diagnosing of disease, but to augment by providing care that encompasses more than the physical. Nursing education does not educate in the medical model that has caused, and is still causing, so many of our citizens to not receive timely, efficient and cost-effective health care. US Nurses are proud to be nurses who have the education and knowledge-base to provide patient-centered care. Advanced Practice nurses continue their education and training to broaden and deepen their nursing skills and must take advanced course work (much of which is in the same classes as medical students) and be able pass the same kind of certification as physicians in order to be licensed to practice. It intrigues me that the writer believes that businesses are “hiring nurses to do the work of physicians”. She need only look at some of the research that shows nurse-run clinics at worksites results in decreased sick day absences, increased indicators of wellness, and increased collaboration with the patient leading to greater personal responsibility for one’s health and well-being. Businesses are hiring nurses to do the work of ‘nursing’, and they are reaping the benefits. Instead of promoting the differences and providing gaps in healthcare delivery, let us instead promote physician/nurse collaboration and join together to provide a healthcare system that will deliver safe, quality, effective and efficient care for all our citizens.

  6. “In all likelihood, this nurse did as good a job as the doctor, perhaps even better; she certainly took more time.”

    Why would you make this assumption? Nurses are caring and may be great at their jobs, but never assume they are as capable as a highly-educated, specifically-trained, and skilled physician in diagnosing and treating patients.

    It’s a mistake believing that nurses can compete with physicians and provide the same level of care.

  7. Dave Thomas says:

    Why in the world would we want fewer specialists? The survival rate from all kinds of cancers is higher in the United States than in those other industrialized countries, and without a doubt it is because we have more specialists.

    Why would anyone advocate have fewer highly trained professionals? An oversupply would bring the price down as a matter of fact.

    The author misses the clear problem with our health care system. Prices are high because far too many patients do not pay for they care they receive out of their own pockets. Far too many patients have no idea what their care costs. Far too many patients believe that they must consumer health care or they lose out.

    Why? Because we have too many third parties, Insurers and government, paying for way, way too many procedures.

    You have insurance on your car, but not for oil changes or tire rotation because it isn’t cost effective. We shouldn’t have insurance or government programs that cover anyting but catastrophic care. People should pay for office visits and other normal care out of pocket so that they reestablish their understanding of the cost of their care.

    If you send me to the grocery store and tell my to buy whatever I want and an insurance company will pick up the tab, and then send me another time and tell me I’m paying for the groceries the quality and amount of groceries will be entirely different.

    Why do intellectuals ignore this central fact and argue about what are totally trivial points in comparison.

  8. Susan Hassmiller says:

    In the spirit of innovative solutions, let’s think about roles that nurses can play. The days of just taking temperatures have long passed. In a transitional care model, a nurse would meet with a patient during hospitalization to devise a plan for managing chronic illnesses and then follow him into his home setting. A nurse would coordinate various care providers and services, and check on the patient at home to ensure they are taking medications. This type of thorough follow-up is something a nurse is able to provide, would prevent patients from reentering the hospital, thereby freeing physicians to attend to patients with complex conditions. Nurses are care coordinators, manage chronic conditions, and are critical to transitional care.

    I applaud the author for raising the issue of nursing, if we are to truly move forward, it is critical that we are maximizing the potential of all health professionals. Based on an Institute of Medicine report, The Future of Nursing: Campaign for Action will continue work to elevate nursing’s role in a transformed health care delivery system.

    • Pat Barnett says:

      In a true market driven approach it should be patients deciding – with the best peer reviewed information available – what their needs are, what they can afford and who to see for their care based on skills required and cost.
      In New Jersey one large pharmacy chain has established 20 employer based APN run clinics in their facilities. The employees have access to primary care when they need it, they do not have to take time off of work and their families can also come to the clinic for care. The outcomes (reduced hospitalization, emergency room visits and duplication of care) has saved those employers money. In addition the employees are delighted with the care.
      APNs are not the only solution – a team based approach has shown excellent outcomes where everyone is allowed to practice to their highest level of education and training. I worked on a eye health screening on the Mexico border area of Texas. The team included a retinal specialist, nurses, Texas Dept. of Rehabilitation staff to help identify resources for people with visual impairment, volunteers from Prevent Blindness USA who did basic screenings and Promoteras – lay health workers who were trained to work in their community to provide basic health education, monitor compliance with treatment plans and help get patients to appointments. It was this group of women that impressed me most. Everyone brought tremendous skills to the effort but it was the lay health workers who knew the questions and concerns that the patients had and they made sure those were answered by the appropriate people if they did not have the answers.
      There was no “Captain of the Ship” central decision making it was a real team.
      We cannot afford to say only doctors may diagnosis and treat patients. PAs and APNs are both qualified to to care for most primary care patients at a fraction of the cost. Technicians and lay health workers are needed to do tasks that doctors and nurses do in some cases out of custom, not need. When every one is invited to the table to help reform care based on true need and ability to do the task, outcomes improve and costs are stable. It si time to let go of “We have always done it this way”

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  15. Susan Reinhard says:

    We know that implementation of the ACA will extend health coverage to over 30 million more Americans. It is inevitable that nurses will need to take on more. For more than 40 years, consumers have been receiving health care from advanced practice registered nurses. And there are unique aspects of advanced practice nursing that validate nurse practitioners can reduce the number of hospital days for patients, and improve quality of care.

    This issue is not about nurses wanting to be doctors, or nurses wanting to tackle patient care that they are not trained to do. State Nurse Practice Acts and regulations are preventing nurses from providing patient care, not a lack of training and skills.

    I agree with the author, this is the time to get serious about this issue, and to encourage fresh ideas. Let’s seriously look at outdated and unnecessary regulations that prevent patient access.

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  21. Anonymous says:

    First of all, there is no dispute in the fact that the caliber of intelligence b/w the fields of nurses and doctors varies massively. Anyone can get into nursing. Whereas, to get into medical student, you can not just be a hardworker, you have to have a level of innate intelligence to compete and get in.

    Just because a nurse can prescribe medication does not mean they are doing a good job at it. There have been studies that show somehow that NP level of functioning is same as a GP. How in the world can that even be studied? To perform such research would require billions of super computers and even then the validity of the study would be questioned when taking such a complex and daunting task.

    For example, statins have been used to control cholesterol for decades, but every year a study is published that changes the guidelines for use of statins. And guess what, statin is ONE DRUG and even then the studies are frustrating to conduct. Now compare that ONE DRUG to the thousands of variables involved b/w NPs and Doctors. How can you even conduct a study?

    How do you know that a nurse practitioner will know about regularly checking Creatinine, thyroid function, ECG and liver enzymes for someone who is on Lithium for bipolar and the pathophysiology behind that. How can I believe that a nurse practitioner will know that treatment of migraine can cause retroperotineal fibrosis. How can I believe that a nurse will realize that pupil constriction, unilateral anhydrousis and ptosis patients should be screened for lung cancer. How can I believe that a patient with low sodium and low osmolality should be screened for lung cancer. How can I believe that a male with decreased labido and gynocomastia be screend for prolactinoma, how can I believe that a pt presenting with slight neck pain and lacrimation be sent in for urgent angio CT to rule out vertebral artery/carotid artery dissection.

    You never knew what long term damage an NP may be doing. Therefore, it is foolish to think that the studies that say that NP’s and GP’s management outcomes are similar. The fact is you will never know. The outcomes of NPs may be better in terms of better rapport with patients as they may spend more time, but I didnt go into medical school to just spend time with patients. I went to medical school so that I could effectively diagnose, appropriately investigate and treat a patient in a timely fashion which would ultimately benefit the patient way more than simply spending more time.

  22. Anonymous says:

    Must of the nursing education follows a knee jerk reflex. For example, patient has UTI so lets give antibiotics.

    Whereas physicians are taught to think outside the box. They will be thinking about the cause of the UTI and not the treatment.
    -vesicloreflux disease, polycystic kidneys, urinary retention, fecal impactation, spinal disorders, ESBL, patient on anticholinergic medications, detrusor insuficiency and the list goes on. An NP may treat your UTI by giving you an antibiotic, but what if the underlying cause is polycystic kidney disease (which is 10% of the time associated with brain aneurysms and is followed in an autosomal dominent fashion, these patients need head CT). Most medical students will have learned this fact but I can not say the same for nurses.

    I can go on and on and on. Sure the NP would’ve given antibiotics and the “outcome” in management will be the same because the UTI will get better, but what about the bigger picture and thinking outside the box that is not done? Do you not think that that is dangerous?

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