Column: More Physicians Won’t Fix Health Care
by Elliott S. Fisher
LEBANON - In his Valley News commentary, Dr. Robert Kiefner, a Concord-based family physician, called for increasing the number of doctors — especially primary-care physicians — we train in the United States (“A Primary Role for Primary Care,” Aug. 11). I agree with Kiefner on the need for strong primary care that is accessible, timely and of high quality — both in the United States and the Upper Valley — but now is most certainly not the time to expand training programs for physicians, whether in primary care or elsewhere.
Kiefner and others have argued that more training slots are needed as the population continues to grow older and more people get access to health care coverage under the Affordable Care Act. These arguments for expansion, however, rest on flawed assumptions about the connection between physicians and health. They ignore the negative impact that expansion would have on both cost and quality. Moreover, the changes now underway in health care suggest a future in which we will need fewer physicians, not more.
Adding more physicians won’t make care better. Dartmouth research has shown that patients in U.S. regions with a greater physician supply don’t get better care. Paradoxically, primary-care physicians in high-supply regions reported having a harder time coordinating care than those in low-supply regions.
Adding more physicians also won’t save money. Most of the cost of physician training is borne by the public. Some may argue that increasing the supply of physicians will drive down the prices they charge. But when prices fall, physicians are able to offset some of their lost income by increasing volume. As a result, training more physicians will either lead to increased costs or unemployed physicians. None of us should want either.
Much of the care that we currently deliver in the United States is needlessly inefficient, uncoordinated and expensive. Many arguments in favor of expanding the physician work force — including Kiefner’s — are based on the needs of the current system. Experiments underway across the country, however, make me optimistic that this will not remain the status quo for very much longer. If the health care system changes, so, too, will its work-force needs.
First, physicians are increasingly delivering care in teams with other health care providers, including nurse practitioners, which allows the physicians to focus on patients with more complicated issues and makes care more accessible. The quality of care provided by these other health professionals is indistinguishable from the care provided by physicians. In fact, the Annals of Family Medicine, which Kiefner cited in his column, published a 2008 report that found practices that included nurse practitioners generally delivered better care for diabetics than those with only physicians. Recent work suggests that greater use of these team-based models could eliminate the projected shortage of primary-care physicians.
Second, new models of specialist care offer promise as well. When specialists design treatment plans for serious illnesses that align with the medical evidence on what works, much of the actual care can be delivered either by patients themselves or by primary-care teams, as with patient-run dialysis clinics. This allows specialists to spend more of their time on those few patients who really need their expertise. The result is better care and a need for fewer specialists.
The important challenge confronting us as people and patients is to take responsibility for our health and our health care decisions. Doctors can help: They are the experts on the science of health and disease (what’s the matter) and on the likely outcomes of different interventions. But we, as individuals, are the experts on what matters to us: Are we willing to accept a non-trivial risk of death to reduce our hip pain? Do we want a medication that might help us fall asleep more quickly but that makes us more sleepy the next day? Only when both sources of expertise are incorporated in decisions will we as patients get the care we need and want — and no more.
We — as individuals and as citizens — also need to be engaged in the redesign of our health system. Would we prefer an office visit or a phone call to handle our sore throat? (Do we want to miss half a day of work?) Would we prefer to receive care in our homes as we age, as opposed to an expensive (and sometimes dangerous) stay in a nursing home? Only when we as individuals take responsibility for our personal health care decisions and our health care system will we know how many primary-care physicians, specialists, hospitals and MRIs we actually need. The times they are a-changin’ in the health care system. The right answer to the question of how many physicians we need to train is anyone’s guess, but mine is that we need fewer than we have right now — and that health care will be both better and cheaper if we focus on getting care right, not on the numbers.
Dr. Elliott S. Fisher is the James W. Squires Professor of Medicine and Community and Family Medicine at the Geisel School of Medicine at Dartmouth. He is also the director of The Dartmouth Institute for Health Policy and Clinical Practice, as well as co-director of the Dartmouth Atlas of Health Care.