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Too Few Generalist Physicians Doesn’t Necessarily Mean Too Many Specialists

It’s hard to find an article or op-ed about the implementation of Obamacare next year that doesn’t mention the looming “doctor shortage.” The reason is clear: there are too few physicians in the United States to care for today’s insured population, let alone the potential 30 million people who will be newly insured in 2014.

Aaron Carroll, MD, MS

A recently released article in Washington Monthly, “First Teach No Harm,” takes a hard look at the educational system producing our physician workforce. While addressing the issue of physician education, it takes to task residency programs in general. It’s not cheap to train a physician: most teaching hospitals are given about $100 000 a year for each resident slot, or about half a million dollars on average to train each physician. But the article’s author says the money isn’t being spent as wisely as it should be:

America does indeed face a looming shortage of medical professionals, but because of the way it’s spent, that $13 billion subsidy isn’t helping us fill the gap. The nation’s residency programs are producing too many of the wrong kinds of doctors in the wrong places, while not producing enough of the kinds of doctors we most need to sustain the US health care system.

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. Meanwhile, residency programs are producing a dwindling number of primary care physicians and other generalists, who are already in chronically short supply in most parts of the country and are desperately needed to implement the kind of reforms to the health care delivery system necessary to improve its quality and efficiency.

There is some truth to this. The United States does have a higher specialist-to-generalist ratio than pretty much any comparable country in the world. It’s also true that most specialists tend to go on to practice in areas where physicians aren’t in short supply. Furthermore, the article correctly points out that many of the top residency programs in the world are turning out very few primary care physicians, and most of these do not go on to practice in the parts of the country that need physicians most.

Some of the blame can be laid at the feet of the medical education system. The vast majority of time spent in residency education is in inpatient, often critical care, settings. People practice what they see, and when it comes to residency, most of what trainees see is hospitalized patients with a lot of subspecialty-focused issues. Given that we need many of these training to become primary care physicians, the relative lack of exposure to such clinicians is somewhat odd.

But not all of the blame can be placed on educational programs. The reimbursement system of the US health care system heavily favors subspecialty care. Given that many students graduate with a significant debt, and given the fact that in a capitalist system higher-paying jobs are more attractive than lower-paying ones, it’s not surprising that many trainees tend to gravitate away from generalist fields. It’s sometimes hard to justify the money they give up by not choosing a specialty.

It’s also important to recognize that although we may have too few generalists, that doesn’t mean we have too few specialists. Here’s a graph I made with data from the Organisation for Economic Co-operation and Development to show the number of general practitioners we have per 1000 people, compared with other similar countries.

Given the rhetoric often used, many wonder what a similar graph for specialists might look like. The results may surprise you.

The United States doesn’t have too many specialists compared with other countries. It has a rather average number of specialists. It’s just that we have so few generalists, it feels like we have too many specialists.

Many people, including the author of the Washington Monthly article, call for a reduced number of specialist training spots. What that might do, however, is give us too few specialists compared with other countries. What we may need to do is drastically increase the number of primary care training spots while not reducing our specialist capacity. Such an undertaking is sure to be expensive. That will make it unpopular. But that doesn’t mean it’s not necessary.

About the author: Aaron E. Carroll, MD, MS, is a health services researcher and the Vice Chair for Health Policy and Outcomes Research in the Department of Pediatrics at Indiana University School of Medicine. He blogs about health policy at The Incidental Economist and tweets at @aaronecarroll.
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