Dartmouth work force study seeks better system, not more doctors

The United States needs to improve its health care delivery system, not add physicians, a study says. Several work force leaders disagree.

By Myrle Croasdale — Posted April 10, 2006

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A controversial new physician work force study says the United States doesn't need to expand the physician supply, it just needs to be more efficient in how it uses what it has. But critics say patients might not want a more efficient health care system if it means restricting access.

The study, by Dartmouth's Center for the Evaluative Clinical Sciences, examined how much time a physician spent in treating Medicare patients during the patients' last six months of life. It found that some of the 79 academic medical centers studied relied on a much higher number of physician consultations, referrals and evaluation procedures, such as diagnostic imaging, than others.

The study measured physicians' labor in full-time equivalents.

According to the study's data, if hospitals were to emulate the Mayo Clinic in Rochester, Minn., with its equivalent of 8.9 physicians per 1,000 patients, there would be no need to increase the physician supply to meet patient demand. But if hospitals modeled the New York University Medical Center, with 28.3 physicians per 1,000 patients, the country would need 111,558 more physicians by 2020.

The data led report authors to conclude that emulating efficient academic medical centers would be a wiser use of limited health care funds than spending it on expanding medical school enrollment or residency positions.

"Adding more physicians to the work force doesn't necessarily lead to better outcomes any way that it's measured," said the study's lead author, David C. Goodman, MD, a professor of pediatrics and community and family medicine at Dartmouth Medical School in Hanover, N.H. "If you're going to spend more money, where are you going to spend it? We would argue it should not be spent on increasing physician training."

The study challenges rising opinion in organized medicine that a doctor shortage will be felt by 2020 unless more physicians are trained.

Ed Salsberg, director of the Center for Physicians Workforce Studies at the Assn. of American Medical Colleges, agreed there were variations in efficiencies at academic medical centers, but he disagreed with the study's conclusions.

The physician-to-population ratio will peak in 2015, Salsberg said. By 2020, the U.S. population will be increasing 8.3% a year. Meanwhile, if the U.S. allopathic medical school supply is expanded by 5,000 students or 15% as the AAMC has called for, the total physician supply will increase just 6% annually, leaving the physician-to-patient population on the decline even if there is an increase in physician training.

On top of that, Salsberg said a significant portion of the nation's 700,000 practicing physicians are nearing retirement age.

"We have 250,000 physicians over the age of 55 who are active in medicine, 100,000 over the age of 65. These people are going to be retiring, and younger doctors don't want to work the longer hours. When you put it all together, we think we have to increase medical school enrollment just to keep up," he said.

David Blumenthal, MD, director of the Institute for Health Policy at Massachusetts General Hospital and a physician work force expert, agreed greater efficiencies are needed, but practically speaking, he doesn't expect this to gain public support.

"It would behoove us to make academic medical centers more efficient, but voters don't tend to advocate to reduce supply," he said. "No state government is going to say we need fewer doctors to reduce health care costs."

Yet spending more on medical schools and residencies is prohibitively expensive.

"This is a very complicated process," he said. "We have not come up with good solutions that are politically palatable. We could restrict doctor supply or the supply of hospital beds or new technologies, but every solution tends to fall apart politically, as it actually decreases people's access to care. That's the conundrum we've been facing all along. How do we control costs in a system that has no political will to do it?"

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