Where Did All the Doctors Go?

Thirty percent of Americans do not have a primary care doctor.?

Why is this? Too few doctors in training despite a growing population.

We need to care about this topic for many reasons, not the least of which is because people deserve access to thoughtful professional medical opinion.?

Also because the physician shortage is grossly underestimated. Generally a doctor shortage is determined by the U.S. Dept. of Health and Human Services when there is less than one physician per 3,500 persons. One doctor every three to four thousand people? That seems insanely low.?

Even affluent areas like Beverly Hills, with one doctor per 500 persons, have a low physician per capita ratio. Of course more physicians does not equal better health, but it is a start to have access to a physician.?

A brief historical perspective as to why medical school numbers have not risen since the 1900s:?

In 1910, Andrew Carnegie, in conjunction with the U.S. Congress, hired a high-school teacher named Abraham Flexner to evaluate U.S. medical schools and provide standardization recommendations. The Flexner Report led to numerous medical school closures, I assume so that there was some control over this branch of the educational system.?

Today there are three more medical schools in the United States than in 1910 (158 today compared to 155 in 1910).

While there were likely too many apprenticeship style medical schools without standards at that time, we are now in dire need of better quality schools with shorter times to graduation and more numerous medical student positions.

As it stands, new residents (doctors who just completed medical school) need intense supervision, which is not really acceptable after four years of training. Partly the reason is that there is too little practical teaching in medical school, with the two years of basic science courses likely superfluous. A cursory knowledge of subjects like chemistry and biology is required (believe it or not) to be a world-class, top-tier doctor.

A four-year program is also completely unnecessary. Three-year medical program students like those at NYU do just as well on exams as those in four-year programs. Still, there were only 150 students in 3-year medical schools as of 2020. I would push for two year programs with a focus on actually examining, working up, and treating patients.?

In addition to shortening medical school program length, more paid residency positions would open up the path for medical students to continue their training on the way to becoming independent practitioners.?

In residency, immediately post medical school, new med student graduates obtain their specialty certification to independently practice. During this time they receive approximately a minimum wage pay from the Center for Medicare and Medicaid Services (CMS).?

This means hospital departments and clinics aren’t paying a single penny for the more than 140,000 resident doctors working throughout the nation. It also means that the CMS does not have much incentive to pay more residents. CMS residency funding was capped in 1997 and has only been raised once in 2021 to support a measly one-thousand more residents.?

Maybe hospitals should pay residents? Seems fair.?

To the hospital residents are not just cheap labor, they are free labor. Maybe the hospital would feel more comfortable paying them if they were trained better.?

Better training does not necessarily mean “harder”, more challenging schooling, it just needs to be different. I believe it should be revamped to focus much more on actual patient care and mastery of identification and treatment of common problems like coronary artery disease instead of attempting to teach a bit of everything. Leave diagnosis of rare phenomena to seasoned specialists.?

Similarly, I have no issue with the fact that medical administrators are making med school testing easier. In 2022, the United States Medical Licensing Examination (USMLE) Step 1 exam became a pass-fail test.?

However, there needs to be more stringent teaching of clinical diagnostic skills at the bedside. Even so called soft skills like communication need to be better taught so that clinicians can more readily navigate patients through their healthcare experience. Delivering tough news and developing therapeutic relationships is essential to being a great doctor, however these skills are are almost never included in any medical school curriculum.?

Finally, for the time being it may make sense to increase the acceptance rate of med students, which is around 50%. There is a severe waste of medical student applicants, who have devoted themselves to a life of improving the human condition through science and medicine. Contrary to common belief being a physician does not require significant intellect. It’s more about grit and character than factoid recollection, and the quality of the physician pool will not suffer with a less stringent admission process. What will contribute to a continued lack of quality among U.S. physicians is a basic-science based and impractical med school curriculum.