The Two Faces of Physician Shortage

A medical residency is not easy.  Part of the coping mechanism involves complaining among your fellow residents about everything from the work hours to the deteriorating quality of vanilla pudding parfait in the cafeteria.  Generally the discussion goes something like this:

Resident A: “The vanilla pudding parfait has too much whip cream and not enough pudding.”
Resident B: “We get paid fifty-thousand dollars a year for working eighty hours a week, and they can’t even have a respectable dessert in the cafeteria.”
Residenc A: “I am going to go have a chocolate parfait.  That one comes with an Oreo.”

While Resident A is probably just partial to chocolate, Resident B’s observation begs for an obvious non-dessert-related question.  If medical residents create such immense value at a low cost to hospitals, then increasing the size of the residency program must also be highly desirable.  But the truth is even in the face of increasing demand for physicians, America is not making many more doctors to match the demand.

Over the past month, news reports of physician shortage began to bring an insidious, oft-ignored health care issue to light.  By Association of American medical Colleges (AAMC) estimates, the US will have a shortage of over 130,000 physicians by 2025 if residency capacity is not increased.  The most important physician categories among the shortage include primary care and geriatrics, where demand can quickly outstrip growth in the era of aging baby boomers.

Physician Work Force
From (source image)

While newly-minted doctors in residency may disagree, residency training is a money-losing business even after offsetting costs by value created in resident work.  Medicare funding is an important source that sustains most residency programs. (Interestingly, if a residency program manages to invest very little on the quality of its training but somehow able to recruit top students and secure its Medicare funding, residencies become a source of income.  This interesting conflict of interest creates some idiosyncrasies in hospital policy-making.)

The AAMC argues for expanding funding for physician training.  Like most things worthy of a controversy, expanding the Medicare cap on resident training – a function of the total fund available – has foreseeable pros and cons.

Reasons to Expand Residency Limit Cap

  1. Fewer Errors:  Increasing the number of residents would improve resident hours, and reducing resident work hours reduces fatigue and therefore, possibly, also reduces medical errors.
  2. Having More Doctors Matter:  Data from AAMC shows that physicians per capita for each state are widely different, and the states with higher physicians per capita also have lower mortality per capita.
  3. Quality of Applicants:  While any increase in residency training caps would be filled by both US and foreign medical graduates, studies have shown that foreign medical grads and US medical grads have similar mortality in patient care.
  4. Competition: More doctors lead to more competition, decreasing the overall cost of health care.

Reasons NOT to Expand Residency Limit Cap

  1. No Fewer Errors: Ironically, reducing resident hours has also been shown to increase medical errors.
  2. Decreased Quality of Care:  Increasing the limit cap is equivalent to arbitrarily lowering the bar for residency entry, so lower quality applicants would be allowed to become physicians.
  3. Residency Limit is the Wrong Focus:  Among US medical school graduates entering the match, 94% matched into residency in 2013.  Yet only 64% of the residency spots were filled by US graduates, the remainder by foreign medical graduates.  This implies that the real shortage is the number of medical school positions, not the number of residency positions.
  4. Costs:  With Medicare overstretched to cover its costs for the increasing number of elderly Americans, increasing the number of residency positions would further increase the cost and reduce the funds available for health care.

Ultimately the controversy will be settled at levels far above the ranks of any hospital’s residency staff.  Until then, I will keep opting for Chocolate.

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