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The Supply Side of Medicine
How many doctors does the U.S. need? Many more, say some policy-makers, to address access problems and population trends. Not so, says a Dartmouth researcher, who argues that simply churning out more doctors won't fix the problems and may make them worse. He and others call instead for a more rational payment system and better-organized workforce planning to rectify current imbalances in the physician supply.
By Amos Esty • Photographs by Jon Gilbert Fox
There were days when Dr. David Goodman felt like he was making a real difference in the lives of his patients. It was the mid-1980s, and Goodman was serving as a National Health Service Corps physician in the rural town of Colebrook, N.H. "I was the only pediatrician in the county," he recalls.
But other days, he wondered how much good he was actually doing. "The biggest needs in that community were not medical," Goodman says. "They were mental and dental." Another problem was that the focus of the local health-care system was always on treating the next patient in the waiting room. No one was thinking about how to improve the overall health of the community. For Goodman, the experience raised "these sorts of heretical questions about, well, how much influence do we have as primary-care doctors?"
He began trying to answer those "heretical questions" when he arrived at Dartmouth in 1988. Before long, he was working with Dr. John Wennberg, a pioneering health-outcomes researcher, and other DMS faculty interested in such topics. It was a momentous experience. "I left my first meeting with my eyes wide open," Goodman says. In the 20 years since then, he has studied the association between physician supply and health outcomes as a researcher at the Dartmouth Institute for Health Policy and Clinical Practice (TDI). He's now one of the nation's leading voices calling for a reevaluation of physician workforce policy.
At the moment, U.S. medical schools are in a period of rapid expansion. Last fall, more than 18,000 students began working toward their M.D. degree—the largest first-year class in history. In coming years, class sizes are likely to grow still more as existing schools increase their enrollments further and several new schools open their doors.
This expansion is part of an effort to avoid what some believe could be a health-care catastrophe. According to the Association of American Medical Colleges (AAMC), by 2025 the country could face a shortfall of more than 100,000 physicians. The organization points out that 30 million Americans live in areas that have been designated by the federal government as medically underserved, and that state agencies and academic researchers in more than 20
states have issued recent reports detailing local physician shortages. If nothing is done about the supply of physicians, the AAMC argues, the nation's health will be at risk.
David Goodman doesn't buy the AAMC's reasoning. He agrees that there are widespread problems with health-care delivery, but he contends that increasing the number of doctors will actually make things worse. "While what doctors do is very important,
the number of doctors that are doing it doesn't make that much of a difference," he says. He even argues that the push to expand the physician workforce isn't about improving health care—it's largely about the money academic medical centers could stand to make if federal funding for physician training is raised.
The debate has grown increasingly heated. "People have called it trench warfare," says Dr. Jonathan Weiner, a professor of health policy and
Amos Esty joined the Dartmouth Medicine staff as a senior writer last May and was recently named managing editor. He was previously an assistant editor at American Scientist magazine.
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