How many doctors do we need?

This isn’t really about pediatric critical care, but it’s a topic that once again has come up for debate: how many doctors do we need? Do we already have enough? Is the problem mainly one of distribution, both in the sense of having too many specialists and a geographic maldistribution of doctors? A little over a decade ago the received opinion was that we were heading for a doctor glut, and should cut back on the number we trained. Now many predict we will not have enough doctors, especially with the progressive aging of our population. Several states have made plans for expanding the sizes of their medical school classes, and, for the first time in decades, new medical schools are opening. You can read a good discussion of this trend here.

On the other hand, some say the statement that we will be short of doctors is false. For one thing, we already have more doctors now than ever before — in 1950 we had 145 physicians for every 100,000 persons, and now we have 280 per 100,000. By 2020, even without expansion of medical schools, we are projected to have 294 doctors for every 100,000 citizens. The problem, some say, is a maldistribution of doctors and too many specialists. You can read a good summary of that argument here.

A major problem in all these discussions is that we really don’t know what the optimal number of doctors is. There is also vigorous debate over whether many things doctors do could be done, often more cheaply, by others, such as nurse practitioners and physician assistants. There is also the real probability that having more doctors will actually drive up demand for what doctors do, thereby increasing the costs of medical care even higher than they already are.

One thing most people don’t realize is that the federal government is the de facto gatekeeper for the number of new doctors we train because it controls much of the financial support for training of resident physicians, the next step after medical school. So it is residency slots, not medical school class size, that determines things. Currently we have more residency slots than we have medical school graduates — the balance is filled out by residents who went to medical schools in other countries. If we have more domestic graduates there will be less foreign residents, but the total won’t change unless the cap on residency slots is lifted.

What do I think? I think health care is not like other parts of our economy, and trying to use simple market-based reasoning will not work. In many ways, doctors drive the demand for our services. We do things, order things. This means, at least in our present system, having more doctors will stimulate more demand, demand which is in some ways insatiable.

There are many debates around the blogosphere about this complicated issue. You can follow a good discussion of it here.