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One particular issue has put Goodman in the limelight: whether the U.S. is facing a serious shortage of doctors. Goodman says no. Others say yes. The Association of American Medical College (AAMC), the Council on Graduate Medical Education, and other organizations believe there is an impending shortage and are pushing for a 30% increase in medical school enrollments by 2015.
When asked about the AAMC's position, Goodman's eyes widen and his voice goes up in pitch, belying his usual calm demeanor. In the late 1990s, AAMC officials believed the U.S. had a surplus of physicians, Goodman points out. But in 2005 they decided there was a shortage. "How did that happen so quickly?" Goodman asks. Then he answers his own question: "It happened because a small group of people [at the AAMC and other organizations] declared it so."
But policy should be based on evidence, not belief, says Goodman. "And [the AAMC] cannot reconcile [its] position" with workforce research. He quickly adds that he is friends with AAMC leaders and researchers and doesn't believe they're ill-intentioned. But he contends that there needs to be more dialogue from all points of view on the issue.
The AAMC's view—outlined in a paper in Academic Medicine by Edward Salsberg, director of the AAMC Center for Workforce Studies—is that a physician shortage will occur by 2020 because of several facts: that the U.S. population is growing quickly, especially the over-65 contingent, which uses more health services than younger people; that one-third of active physicians are over age 55 and are likely to retire by 2020; and that the next generation of physicians is not likely to work the long hours that current physicians do.
In response, many medical schools are planning to increase enrollment over the next five years. But Goodman—who doesn't argue with the paper's facts, only its conclusion—says that simply pumping out more doctors won't fix things. Many experts—physicians, patient organizations, purchasers of health care, even the Medicare actuary's office— say the U.S. health-care system is not
Grew up: Framingham, Mass.; Narberth, Pa.; and Port Washington, N.Y.
Education: University of Vermont '77 (B.A. in biochemistry), State University of New York at Syracuse '81 (M.D.), Dartmouth Medical School '95 (M.S. in epidemiology and biostatistics)
Residency: Johns Hopkins University Hospital
Early jobs: Taxicab driver on Long Island, which taught him "interpersonal communication skills and microeconomics," and chauffeur for the owner of the Chrysler Building in New York City
Hidden talent: Can translate classical Chinese
Favorite hobbies: Walking, hiking, and kayaking
Is the United States facing a serious shortage of doctors? Goodman says no. Others say yes.
functioning well and is
not financially sustainable, Goodman points out. "So why would we
plan on the assumption that [the system] is going to be the same as today,
only bigger?" he asks. There are proven ways to improve health,
he adds, but training more physicians is not one of them. He would
like to see more evidence-based health workforce planning. "We need
to hold ourselves to the same standards of evidence that we would for
a new drug or a new test. Why do we suddenly throw this all away
when we're talking about [the] health
workforce?" he argues.
In a recent essay published in the New York Times op-ed section, Goodman wrote: "By training more doctors than we need, we will continue to fill more hospital beds, order more diagnostic tests—in short, spend more money. But our resources would be better directed toward improving efforts to prevent illness and manage chronic ailments like diabetes and heart disease." His piece drew much media attention and resulted in interviews with Newsday, Business Week, NPR's Marketplace, and the like. He also received more than 50 letters in response to the piece, and half of the Times's letters page a few days later was devoted to his essay.
Goodman's op-ed piece drew on several of his studies, including a 2006 paper in Health Affairs that reported on inefficiencies in the delivery of care to elderly Medicare patients. The study found that multispecialty group practices, like the Mayo Clinic and Dartmouth-Hitchcock Clinic, which integrate their services with a hospital, use fewer physicians and do a better job.
Goodman was also the lead author of a 2005 American Academy of Pediatrics (AAP) workforce report. It recommended maintaining the current numbers of U.S. medical students and pediatric residency positions but distributing doctors differently, including to rural and other underserved areas. The AAP was the first specialty medical society in the U.S. to state that the country should not increase physician- training rates, Goodman says.
With all these activities, Goodman has "really brought an evidence base to what many people have felt to be the case for a long time—and that is that simply by producing more doctors, we're not necessarily improving the population's health," says Fitzhugh Mullan, M.D., a former assistant U.S. surgeon general who is now a professor of medicine and health policy at George Washington University. (See this article's for a Q&A on Goodman's workforce research.)
In addition to doing research, Goodman sees patients, served for several years as the chief of DHMC's allergy and clinical immunology section, and teaches both CECS and M.D. students. He is held in high regard by students. "His somewhat soft-spoken demeanor complements his intellectual rigor by drawing students into his critical thinking," says Tracy Onega, a CECS doctoral student. "Dave's like an intellectual Mr. Fix-It. If you get bogged down . . . in a conceptual conundrum, Dave will help you find clarity and resolution."
But Goodman hasn't forgotten his roots amid the rigor. Ultimately, he hopes that his research will improve the distribution of healthcare resources. That it will bring better pediatric care to underserved areas. That babies like the one who died in 1984 might live.
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Matthew Wiencke is the assistant editor of Dartmouth Medicine magazine.
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