As a current applicant to medical school in the US, it’s heartening to hear that there will be more spots for the qualified candidates who are increasingly being turned away from medicine each year. As someone who plans to go into primary care and is keenly aware of the, err, uneven distribution of human, financial, and technological resources throughout our medical system, I’m somewhat unenthusiastic about these news. Depending on whom you ask, we may or may not need more doctors in this country. The presence of more physicians in a community drives up demand for medical services and thus greatly increase health care costs in that community. However, there are many areas of the country (Indian reservations, rural areas) where physicians and health care services of any kind are severely lacking. And anyone you ask who knows anything about physician supply will tell you that we are in desperate need of more primary care physicians. This is a problem that will not be easily solved, especially as the gap between supply and demand of primary care physicians only grows larger every year.
There are currently few systems in place to encourage new medical graduates to pursue primary care, and the health reform bills in Congress (if something gets passed—please let something pass!) do not go very far in changing the incentives and expectations towards producing more primary care physicians. In many other countries, for example, the UK, the majority of medical graduates expect to go into general practice. I don’t think this is true in the US. Primary care is simply not a “sexy” field for many people interested in medicine, especially in a world where substantial undergraduate research experience is increasingly necessary for entering medical school. When I told a friend that I was probably going to pursue a career in general pediatrics, he was surprised—he thought I was “too smart” for that. Perhaps this is trite, but I love the dramas of everyday life: a child getting ready for his first day of school, one who needs help managing her asthma, or the parent dealing with a moody, secretive teenager.
According to the AAMC’s 2006 Specialty Data Chartbook, the three major primary care specialties are also the largest: they are the top three specialties with the greatest number of actively practicing physicians (those who work more than 20 hours a week). These are family medicine/general practice, general internal medicine, and general pediatrics. However, as a percentage of all actively practicing physicians, they only make up 34.4%. When you look at the number of people per active physician for these three specialties, you get 3,000; 3,000; and 5,700 for family medicine/general practice, general internal medicine, and general pediatrics. For these top three primary care specialties, only about 65% of actively practicing physicians have an MD from an American medical school. (The rest would have DO degrees and/or be graduates of a foreign medical school.) And this is all data from 2006. I’m sure the numbers are even less encouraging today. All of these statistics explain why primary care is increasingly being provided by non-physicians such as nurse practitioners and physician assistants, and in non-traditional settings such as retail medical clinics at your local chain drugstore. This practice ironically ends up hurting primary care physicians because they face competition for their already relatively low-paying services. Yet another disincentive to go into primary care.
Side note: You find out all sorts of fascinating information when you look at demographic and workforce data. For example, did you know that only about 70% of actively practicing physicians in the United States are graduates of US allopathic medical schools? Almost a quarter (!), 24%, of physicians are graduates of foreign medical schools. Forty-five percent of doctors end up practicing in the same state where they did their residency. Only about 40% of OB/GYNs are female. In most specialties, only a quarter or so of practicing physicians are female.
Still, more trained physicians could be a good thing, particularly if we are able to increase the diversity of the workforce and can encourage more of them to pursue geriatrics or family medicine and practice in rural areas. Unfortunately, physicians tend to cluster in cities and/or around large medical centers, and diversity is another supply problem that we will not be solving any time soon. In places like California, Latinos already make up 30% or so of the general population, but only 3% of physicians are Latino. For a number of reasons, including language and trust barriers, Latino patients in particular are better off being seen by providers from a similar cultural background. Say what you will about affirmative action, but it is undeniable that diversity is absolutely crucial for a vibrant, effective health care workforce. Many studies have shown that physicians who are underrepresented minorities or come from an economically disadvantaged background disproportionally serve minority and low-income/uninsured patients.
There are many great outreach programs across the country that target low-income and minority students, but I suspect that they very often see minority students who are already pretty accomplished and planning on pursuing medicine anyway. Case in point: my friend and former freshman advisee who participated in a Summer Medical and Dental Education Program, which gives students clinical exposure, MCAT prep help, various academic enrichment opportunities, and mentorship from MDs and med students. He is an MIT student with an almost perfect GPA, doubly published, and an EMT. His mom is a physician. Oh, and his MCAT score rocks. If you don’t know anything about applying to medical school, let me tell you that those are some pretty solid credentials. He is not the kind of person who needs help getting into med school. I am not saying that he didn’t deserve to do the SMDEP; in fact, I entirely supported his decision to apply and participate. Nor am I saying that SMDEP programs mostly serve people like him, but I’m sure there are more than a handful just like him, and generally the applicant pool for those programs are self-selecting. I have a fair amount of experience with academic enrichment programs for disadvantaged kids, and broad recruitment is probably the biggest challenge.
As it turns out, the United States actually has relatively few physicians for its population compared to other OECD countries. These charts are from the 2009 Health at a Glance report from the OECD, though data are from the early 2000s. The average number of physicians per 1,000 people is 3.1 across OECD countries, but in the US, there are only 2.4 physicians per 1,000 people. The OECD average number of medical graduates per 100,000 people is 9.9, whereas the US figure is 6.3.
Number of physicians per 1,000 population:
Medical graduates per 100,000 population:
I guess we do need more doctors after all?
