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Dialing For Doctors

category_bug_geriatrician.gif [EDITORIAL NOTE: The TGB Geriatrician is a bi-weekly column written by Dr. Bill Thomas (bio) for Time Goes By to give us the information we need to help us navigate the health issues of aging. Dr. Thomas also writes his own blog at Changing Aging.]

USA Today goes in depth with a front pager on the issue of physician economics and the future of the aging baby boom. The story is a follow up on this earlier report:

"Millions of baby boomers are about to enter a health care system for seniors that not only isn't ready for them, but may even discourage them from getting quality care.

"’We face an impending crisis as the growing number of older patients, who are living longer with more complex health needs, increasingly outpaces the number of health care providers with the knowledge and skills to care for them capably,’ said John W. Rowe, professor of health policy and management at Columbia University.

“Rowe headed an Institute of Medicine committee that released a report Monday on the health care outlook for the 78 million baby boomers about to begin turning 65."

USA Today, 14 April 2008

Here is the latest news:

"Medical students are shying away from careers in general internal medicine, which could exacerbate the U.S. doctor shortage expected by the time the youngest Baby Boomers head into their senior years, researchers report today.

“Only 2% of 1,177 respondents to a survey of students at 11 U.S. medical schools said they planned to pursue careers in general internal medicine, according to the new study…

“According to one estimate, the USA will have 200,000 fewer doctors overall than it needs by 2020, according to the new report. Meanwhile, the number of older Americans is expected to nearly double between 2005 and 2030.

“’Many medical students are turned off by the thought of caring for chronically ill patients and the amount of paperwork general internists must deal with,’ says lead author Karen Hauer, a general internist on the faculty of the University of California-San Francisco.

"’They rated the intellectual aspects of the field highly, and they rated continuity of care appealing,’ Hauer says. ‘When you put the whole package together, it's too hard.’"

“On top of the workload, a "research letter" in the same issue of JAMA as Hauer's study ranked internal medicine as one of the lowest-paid medical specialties…

“Radiologists topped Ebell's list, with a starting salary of $350,000, not to mention, Hauer notes, more regular hours than general internists.

“Their amount of debt [following medical school] didn't seem to influence their choice of specialty in her survey, Hauer says.

“Rather students focused more on quality of life factors such as income and work hours, which did steer them away from general internal medicine."

USA Today, 9 September 2008

The problem with a health care system that is driven exclusively by the economic interests of the participants is that what the market rewards (that is, large numbers of radiologists) and what people need (large numbers of general internists) do not match up.

I raise this issue because it is a sub-species of the more general question, "Is health care a market good (like cars and candy canes) or is it a right?"

We as a society share the conventional wisdom that people do not have a "right" to cars and candy canes. If we want to have these things we have to pay for them. Health care is, somehow, different. Who would say that a child with pneumonia should be left to suffer because his/her parents cannot afford treatment. There is a law that requires hospitals to treat any person who comes to the emergency room, regardless of their ability to pay.

This reminds me of a bit of cynical medical humor I learned in medical school: Doctors who we thought were overly concerned with a patient's ability to pay were said to demand a "wallet biopsy" before they would be willing to accept the patient."

The profit motive has contributed to progress in medicine and the healing arts. I would not want to go back to a time when medicine was a small-time cottage industry of not very well educated physicians making use of a narrow range of not very effective treatment. It is also true that the market does a terrible job of matching resources to need.

So the wealthiest nation in the world is now facing the greatest age boom and will almost certainly live through it without the doctors we need.

EDITORIAL NOTE: You can subscribe to The TGB Geriatrician column by email by clicking here. Subscribe to the daily Time Goes By blog by email or RSS in the upper right corner of this page.

[At The Elder Storytelling Place today, Tom Speaks recalls his trucking days in Hard Working '50s.]

Comments

This is not just a physician choice, but also an increasing institutional choice. Most of my doctors are affiliated with a large teaching hospital. The institution is discouraging its students from going into internal medicine. But it's also shrinking its internal medicine clinics, facuty, staff and resources. The institution is discouraging those types of regular, long-term patients in preference for quick surgery and procedures with little followup.

Years ago, I was recuperating from a spinal injury in a small hospital on the northern end of Lake Como. One of the residents would stop in my room after dinner for a chat. One night he pointed up towards the top of the mountain facing us and at a small cluster of lights blinking on the mountain side. He told me that his father had been the village doctor there for more than 40 years. He said that his patients always had absolute confidence in his father's advice and followed his instructions to the letter. In contrast, today people like me question every thing the doctors say and check out prescriptions on the web and seek second opinions all the time.
"The question is"
Are we happier and healthier today than the people in the Italian village were?
Or have we traded an upset stomach for WebMd.com?
And, if you were
making your career choices today, would you choose to practice medicine?

My eldest godson chose a specialty that offers twice the money, more regular hours, and less paperwork than a family practice physician or internist. With mountains of education debt, I could see his point.

I wonder sometimes if his decision would have been different had his education costs had been subsidized.

But the lure of big bucks would have been the same for anyone in his generation. They have had it drilled into them that money equals success, rather than service to mankind.

Maybe it's the old hippie in me that's coming out, but I was extremely disappointed in his decision. It puts money over the serving of others, which I thought was one of his reasons for becoming a doctor.

Perhaps we can get some guidance by rereading the immortal words of our fearless leader,George W. Bush who said:

"Too many good Docs are getting out of business.
Too many OB/GYNS aren't able to practice their love with women across the country."

We may all snicker at this remark but the fact remains; if you have a baby in this country and that baby is not PERFECT in every way, it is the Doctor's fault..And he/she must be sued.

No wonder our young,bright medical students all want to study Dermatology or Radiology.

Here in Canada we have tax-funded healthcare, but we have the same problem with not enough GPs (General Practitioners, aka family doctors) and lots of specialists. Specialists get paid more, that's how our system is set up. So, a medical school grad, faced with paying off huge student loans, is virtually forced into specializing because she/he needs the money to pay their debt. And, in looking at lifetime earning potential, it just makes sense to choose to specialize: fewer hours but more money. I heard recently that a specialist can earn up to three or four times what a GP can; who would choose to be a GP?!? We need to start placing more economic value on what family doctors do, and bring their potential earning power up to at least that of a specialist.

There seem to be many more specialists than GPs around here also. But the practice I go to has a couple of very smart nurse practitioners who help fill in the gaps. Thank goodness for them. They spend more time with patients and listen more carefully, even to an old lady, than many MDs are willing to do. NPs are allowed to prescribe meds in my state, although they must work in a practice with a doctor. They are a good resource for most ordinary problems. NPs may be what more older patients will have to rely on in future.

Yes, I am all for NPs! They first started appearing back in the '80s (or at least, that's when I first became aware of them), but doctors didn't like them encroaching on their turf apparently. Now they have no choice but to accept them. They are indeed 'just what the doctor ordered'! Although many doctors were/are opposed to them. I think that they are not only a good resource for ordinary problems, but they have more care and concern for their patients as people, and they are trained to recognize more serious problems and refer patients to appropriate medical help. Every NP has an MD somewhere to refer to or get to sign off on a prescription she/he is not authorized to issue alone.

I find it discouraging that our health care system has lost it's focus, which should be the patient. Doctors are so controlled by the system they only see you for 15 minutes. How can they know what is wrong with a patient in 15 minutes. It took my doctor 8 months to find my cancer. I was to young, did not fit the profile. He did not push for a simple test that would have discovered the cancer because I was not age 50. Recommended screening for colon cancer is age 50. I was 41. Our focus needs to be on preventative care. I feel my doctor was stifled by health care system . So I was diagnosed with IBS. As population grows and baby boomers enter health care system for seniors we need to allow doctors to screen earlier for preventive care. Mandate that insurance companies approve preventative care screening at earlier ages and cover those costs. Who knows, had they found my cancer earlier I may have avoided 6 months of chemo and saved the insurance company 192,000.00. Perhaps creating a preventative health care system will encourage students toward a career in Internal Medicine, they would lead the new health care system by actually following each patient early on with proper screening for many diseases, saving the insurance companies and medicare a lot of money. Live Strong!

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