PERSPECTIVE ON HEALTH CARE : Medicine’s Glut of ‘Fighter Pilots’ : We have far too many highly paid specialists and a scarcity of family doctors. It will take generations to undo.
During the early days of World War II, a U.S. fighter squadron was assigned the miserable duty of guarding a remote and unthreatened Bolivian tin mine. The pilots, young, eager and trained to the hilt, grew so desperate for any kind of action that they resorted to using their aircraft to hunt eagles flying among the mountain peaks around them--a highly dangerous waste of flying skill, fuel, ammunition and eagles.
Something akin to that contributes significantly to the spiraling cost of health care in this country. The fighter pilots, in this analogy, are specialist physicians with too few challenges to their hard-won skills.
No, it’s not the “doctor glut” that we were warned about in the 1980s. That never materialized. We have about 20 practicing physicians per 10,000 people in the United States--slightly higher than in England, Canada and Australia but considerably lower than in Italy, Germany, France and Scandinavia.
However, we clearly have a “specialist glut.” Generalist physicians make up 50% to 75% of the medical cadres of other developed countries. In the United States, only 30% of physicians are generalists--even stretching the definition to include general internists and general pediatricians.
Medical academia is strongly biased in favor of specialists because this nation still harbors a powerful belief that what is new and exotic is the ultimate in medical care, and because, for all our talk of healthier lifestyles, we still expect our doctors to salvage us from the inevitable effects of our excesses and follies. And because specialists tend to use high-cost technologies, they earn more than general physicians. So doctors naturally want specialties, and the process by which U.S. specialists are created is unrestricted.
Left to follow its present course, the situation isn’t likely to improve. Fewer than one-fourth of graduating U.S. medical students now intend to become primary-care physicians. That percentage has been dropping steadily for a decade.
In most countries, either a qualified regulatory body decides the number of specialist physicians or the supply is controlled by marketplace limits, such as limiting the level of government reimbursement for specialist procedures.
It is theoretically possible for the national residency review committee in each specialty to limit the number of specialists in training by decreasing the number of residency slots at a particular teaching hospital, or even eliminating whole programs. But if it does so on any ground other than program quality, it invites a federal restraint of trade investigation.
We have, as a result, exceeded the saturation point in many major specialties. The predictable effect is an excess of expensive specialty procedures.
There is, for example, no correlation between the rate of coronary artery disease and the frequency of bypass surgery in developed countries. But there is a strong correlation between the frequency of that surgery and a nation’s investment in doctors and technology to perform it. The United States has the world’s highest per-capita investment in cardiac surgeons, cardiologists, catheterization labs and cardiac operating suites, and a frequency of coronary bypass surgery to match. There are similar patterns for other high-technology services like diagnostic imaging, neurosurgery, treatment of end-stage renal disease and cancer chemotherapy.
While no one can say absolutely what constitutes the “right” number of procedures, there is persuasive evidence that anywhere from 20% to 50% of the commonly performed specialty procedures in this country could be avoided without harming the health of the public.
The economic impact of such over-performance is immense. The $30,000 it costs to perform one unnecessary bypass operation would pay the annual salaries of two badly needed full-time home health aides.
The oversupply of specialists can even reduce the quality of care if patient volume falls below the level needed to maintain a specialist’s technical skills. There is also increasing evidence that underemployed specialists who are obliged to practice more general medicine tend to provide higher-cost, lower-quality care outside their specialties.
Conversely, a nation with too few general physicians can’t provide adequate access to basic health care for its citizens--though, admittedly, the problem of access is too complex to be addressed just by increasing the percentage of primary care physicians.
There is the beginning of an effort to influence this imbalance by better compensation of general physicians under Medicare and Medicaid. That should be the first step toward a more thorough payment reform that reduces the bias in favor of high-technology specialties.
Government, which pays in large measure for the residency training of physician through fees for their services to Medicare and Medicaid patients, should use that leverage to press for more emphasis on generalist programs. Loan forgiveness for physicians training for primary care specialties should be expanded.
Even if we could change all the requisite attitudes and programs overnight, it would be decades before the physician imbalance shifted adequately. The average physician practices for 40 years after he completes his training. Two generations will live with the choices each generation of physicians makes in choosing a specialty. All the more reason to start changing now.
