Why are there so few doctors?

[FarmerD]

This isn't a slam on doctors but a question I've been debating with a couple friends lately about why medical care is so expensive.

Doctors, especially specialists, make a lot of money.  This leads to a lot of people to try to enter medical school.  However, medical schools only admit a tiny fraction of people applying, turning aways thousands of qualified candidates.  And according to studies I've read, once in medical school, only about 0.4% of aspiring doctors actually fail out of medical school, meaning virtually everyone admitted to medical school graduates. 

If true free market capitalism was at work, wouldn't you expect the supply of doctors to rise until it meets demand thus lowering costs to consumers?  What exactly allows this perpetual situation to occur where medical schools do not turn out enough doctors to meet demand. 

Is there some sort of Medical cartel which limits the number of graduating doctors?  Since there is such a limited number of medical school students, I also assume that allows medical schools to get away charging astronomical prices to medical school students. 

I haven't been able to figure out how this situation came to be and why it persists.  Help me out here.

[Gumby]

I don't know the answer, but I found one possible answer (written 6 years ago) here:

Actually, that is a very good question.

In the USA a few years back there was actually a little surplus of doctors (the USA has only 4.5% of the world population, but we have over 10% of the doctors). So, for a while there were some plans to start some new medical schools but they were put on hold. I read just recently that Virginia Tech is starting a med school next year and there are about four or five other schools starting up in the next two or three years.

You can't just start a med school like you would open a new restaurant. You need a lot of equipment and classroom space. and you need very well qualified faculty. It costs a lot to educate a doctor, way more than they pay in tuition. So a med school is a losing proposition for any university that starts one. And, the new doctors have to have a place to practice - they have to be able to go into a hospital and see patients. So, you can't just march 1000 new student doctors into a hospital - you have to have a proper setup in the hospital... that takes a lot of planning.

And, the other answers are right. You can't just say, who wants to be a doctor!? -- you can only take in kids who are well qualified! There might be an unlimited supply of people who want to be doctors, but there is not an unlimited supply of QUALIFIED people.
Source: http://answers.yahoo.com/question/index ... 751AAbt2lW

[MomTo2Boys]

You can build as many medical schools as you want, but there are only so many residency spots...

[Benko]

"The marketplace doesn't determine how many doctors the nation has, as it does for engineers, pilots and other professions. The number of doctors is a political decision, heavily influenced by doctors themselves.

Congress controls the supply of physicians by how much federal funding it provides for medical residencies — the graduate training required of all doctors."

http://usatoday30.usatoday.com/news/hea ... htm?csp=34

This looks llike it might be of interest, to you:

The Complexities of Physician Supply
and Demand: Projections Through 2025

http://www.innovationlabs.com/pa_future ... 202008.pdf

And Obamacare or no, I would suspect medicine is not as attractive an area to go into as it was.

[FarmerD]

Benko,
Thanks for the links!  I'll obviously have to look into residency funding issue more.

I guess I just get frustrated when I meet so many engineers, chemists, and biologists, who had scored very high on the MCAT and tried to get into medical school but failed.  Undoubtably these people would sail through medical school but are kept out because a certain quota has been met.  Then I have to wait 6 weeks to get an internal medicine appointment, then sit in the waiting room for 2 hours past my appointment time, then have to pay insane amounts of money for a 15 minute appointment. 

I suspect AMA and their ilk got the govt to heavily regulate (and heavily underfund) the residency program in such a way so as to keep the number of medical practitioners down. 

From the article:
“In 1997, to save money and prevent a doctor glut, Congress capped the number of residents that Medicare will pay for at about 80,000 a year.”?
Prevent a glut of doctors?  That's a stunning statement.  A glut of doctors is bad for doctor's income but the rest of us would have to pay less for medical care.  I don't begrudge any doctor from making whatever the market pays, but I have a problem with government tilting the playing field in favor of doctors at the expense of patients. 

[Benko]

Waiting 2 hours for an internist apt?  Find another internist. OTOH 2hours is kinda routine wait for an ortho apt.

If I think about it, waiting time (phone call to being seen) to get a primary care apt (cepting emergencies) has increased, but decreased to get an apt with a specialist.  THIS WILL GET FAR WORSE if Obamacare stays in place.

This issues you raise are not simple.

[stone]

I think it is important not to have too many doctors because it is important that all doctors have a full workload otherwise they would not have the immediate experience that is neccessary for them to instinctively pick up on what is going on. For the same reason I also think it is important that doctors are only dealing with truely sick people rather than wasting time with people who should be sent away. I also think it is pointless paying doctors more than necessary. It is never going to be a free market because the information asymetry is always going to mean that very heavy regulation is required. "Price discovery" of doctors pay is a nonsense in such a situation. As such I don't see why insurance companies/government don't curtail doctors pay by a lot.

[MachineGhost]

Its all a collusion/cartel/racket.

Free market my ass.

[AgAuMoney]

Its all a collusion/cartel/racket.

Free market my ass.

This.

Yes, there is a cartel.

But before that there is all kinds of hazing and abuse.

A surgeon friend moved after residency to the city his wife was from.  After a couple of years there he ratted out another doctor who was addicted to painkillers and writing prescriptions under patients names who never received the meds.  This other doctor had friends on the medical board in that state.  Those friends made life hell for my friend with complaint after complaint.  Then he'd be put on probation while the investigation happened, then he was cleared, then back to work.  Finally he had to move to another state to escape it, but of course had to get a license in the new state which requires a clean history...  It took almost 5 years before all the trash on his record could be expunged as erroneous "record keeping errors" and he could be fully licensed again.  (He spent much of those years as an emergency room "nurse" in a remote hospital just to make ends meet.)

And then at the other end when a doctor decides as an individual practitioner that it is time to slow down, maybe work part time, there is no way.  The malpractice insurance costs so much the doctor has to either continue working long hours and seeing as many patients as possible or quit cold turkey.  There is no "slow down" or "part time" possible when it costs $100,000 to $500,000 per year for insurance.

My wife's Ob/Gyn for the first kids wanted to quit taking new patients, drop most of the existing, but at over $200,000 per year for insurance couldn't make it work.  So my wife had to find a new Ob/Gyn.

That doctor had a son, an ENT, who 3 years after starting practice just couldn't take it any more.  Had to just quit.  Did other jobs (sales, marketing) for a couple of years.  Med school debt forced him back into practice.  As good a guy as he is, knowing that makes him really low on my preferred list.  But I wonder how many others are in the same boat?

The system is pretty much broken and I think the proximate cause is the insurance industry both medical insurance and malpractice insurance.  The medical insurance then goes back to federal regulations on wages and taxable vs. not taxable "benefits."  And of course the cartel is entirely due to state and federal law.  The more the gov't pokes at things, the worse it gets.

[AgAuMoney]

Freedom is not free. Free men are not equal. Equal men are not free
Jerry Pournelle

I used to really like Jerry Pournelle (Chaos Manor, several of his sci-fi books) until I started running into him at conferences.  Just, ICK.

So here is the quote your free men quote brings to mind, from another sci-fi author:

You can't conquer a free man; the most you can do is kill him.

[MediumTex]

Freedom is not free. Free men are not equal. Equal men are not free
Jerry Pournelle

I used to really like Jerry Pournelle (Chaos Manor, several of his sci-fi books) until I started running into him at conferences.  Just, ICK.

I'm always incredible disappointed when I meet someone famous or semi-famous of whom I'm a big fan and I find that they are a jerk (or worse) when you see them up close.  I always want to say to them: "I wish I could un-meet you."

This has only happened a few times, but it's always a jarring experience.  I'm not talking about bothering someone who is having dinner with his family; I'm talking about being at a reception or other event where the purpose of the event is to meet the person.

[Benko]

The words are the important things, I don't care what his personality is like.

We as a society put far too much importance into persona.  Choose the slick e.g. salesperson, presidential candidate at your peril.  But this is what we do,and we suffer the results.

[FarmerD]

The system is pretty much broken and I think the proximate cause is the insurance industry both medical insurance and malpractice insurance.  The medical insurance then goes back to federal regulations on wages and taxable vs. not taxable "benefits."  And of course the cartel is entirely due to state and federal law.  The more the gov't pokes at things, the worse it gets.

I have a hard time blaming the insurance industry for high malpractice premiums.  Let's face it, doctors often get sued for big bucks.  When that is the case, malpractice premiums will be high by necessity.  I think a better concern is medical malpractice lawsuit reform.  I've had a lot of doctors complain to me about juries who constantly keep finding doctors liable for patient outcomes they could not possibly forsee or have prevented.  Medical lawsuits have become a sort of Vegas lottery for far too many people. Of course, those high premiums doctors pay in malpractice is passed on to patients, which jacks up our cost. 

Unfortunately, the monsterous costs of malpractice insurance will remain in place as long as trial lawyers have such a powerful lobby in Washington.   

[Xan]

But why couldn't malpractice insurance scale with the number of hours worked, or patients seen, or some kind of other metric?  It must be possible.  Anybody want to start an insurance company and try it?

[swank]

we could allow MANY thousands of them to immigrate, but our "policy" is to not let in such highly skilled people, as it lowers the ridiculous salaries charged by those already here. Many of the MD's from overseas are AT LEAST as "qualified" as many here, whom the OTHER MD';s know about but whom they refuse to censure or expose.

[hpowders]

Potential MDs choose to go to business schools instead-make a lot of money without the enormous student loans and endless training.

[hpowders]

My son-in-law grew up packing meat at the supermarket for chump change. No med school for him. He got a business degree and has worked at Goldman Sachs and Bank of America as a bond trader: multimillion $$$ salary and no student debt.

[Tortoise]

Agree with hpowders. Before you criticize the 'ridiculous salaries', consider what is involved to get there in terms of time, hard work and expense.

MDs aren't the only degrees that require immense investments of time, hard work, and money. Many PhD students--especially in STEM fields--invest similar amounts of time, money, blood, sweat, and tears in their doctoral and post-doctoral programs. So if you're going to use the argument that certain professions deserve high pay to compensate for the up-front investment, the argument at least needs to be applied consistently.

And if you want to talk ridiculous salaries, do you buy tickets to concerts, movies and sporting events? The completely insane ticket prices go to support the notion that entertainers and athletes deserved to be paid $millions / year. Who do you think is more deserving: a cardiac surgeon or a baseball player? Please.

The situation you're describing in sports is largely a result of government interference in the market. Most pro sports teams do not have to pay for their stadiums; the local government typically donates them. If the sports teams had to pay for those stadiums, they would have far less money with which to bid up the superstar athletes' salaries. So in a sense, those astronomical salaries that the top-paid athletes receive are effectively coming from local taxpayer dollars.

[BearBones]

Agree with hpowders. Before you criticize the 'ridiculous salaries', consider what is involved to get there in terms of time, hard work and expense.

MDs aren't the only degrees that require immense investments of time, hard work, and money. Many PhD students--especially in STEM fields--invest similar amounts of time, money, blood, sweat, and tears in their doctoral and post-doctoral programs. So if you're going to use the argument that certain professions deserve high pay to compensate for the up-front investment, the argument at least needs to be applied consistently.

Some MDs are indeed paid very high salaries, perhaps even "ridiculous" (subjective of course; see below). But for many, the salary is actually ridiculously low, IMO, especially for all the time put in to training, the long hours at work and on call, and all of the increasing hassles/headaches of running a practice. Many pediatricians, family practitioners, and internists would not recommend their profession or choose the same path if they were to do it over again. In fact, when you look at the folks entering primary care residencies where I am, they are largely foreign medical grads (will withhold judgement as to whether this is better or worse).

I'd agree that most PhD students are looking at even less pay per time spent training. Relative to other careers, they should probably be earning more. Unfortunately, we do not live in a world where standards are applied consistently.

Finally, one of the top paid sub-specialties is that of vascular surgeons. I watch these folks work, and you could not pay me enough to do it. Long hours, no life, high stress, high divorce rates. Money is probably a factor why some people do this. But I suspect it is a minor factor.

[hpowders]

Let's not forget about the unbelievably high malpractice insurance premiums. I don't blame anyone for not seeking an MD degree, what with high student loans and malpractice premiums.

If I was to do it all over again, I would study to become an optometrist-well-respected, high demand, decent pay, limited malpractice worries, no emergency calls and plenty of time to check my PP.

[Pointedstick]

Aren't these things ultimately determined by supply and demand? Governments always distort things, but I bet you that athletes wouldn't get paid so much if people weren't willing to pay hundreds of dollars for tickets to see them play. Same goes for movies, although the prices are lower since more people see them. On the other hand, I believe most musicians don't actually make much money at all, and the ones who do are the ones who sign up for huge deals because millions of pre-teens can cajole their parents into buying their music. Again, supply and demand.

[notsheigetz]

I'm a free market person all the way but I think the reasoning that a free market in medicine will give us more doctors is fallacious. First of all, the idea discounts human ability. Not everyone can become a doctor no matter how much it pays. It requires a certain level of intelligence, not to mention the ability to withstand a rigorous process to prove oneself worthy of the title.  Only a certain percentage of the population will ever fit in this category no matter how much it pays. And I really don't think that with this profession, financial gain is the ultimate motivation. Considering everything they have to go through I think they have to view it as a sort of "calling" like those going into the ministry or they wouldn't do it (I am not a doctor or involved in the medical profession in any way, BTW).

Having said that I do believe that government can do what it does best in regards to the medical profession and that is to destroy what incentive there is.

[Pointedstick]

"The free market" isn't just about money, it's about freedom. I would venture that most people don't choose their professions based on the money, or else more people would train to become software architects, petroleum engineers, and actuaries! I think most choose their career path first, and then think about how to maximize their income within the nexus of the career path they've already determined.

A "free market in medicine" doesn't just mean salaries can adjust to incentivize more people to become doctors (though that's a part of it); it also means an end to cartels, protectionism, and mandates that prevent qualified people who wouldn't care about the money from entering the field. As some of those here on this board involved in medicine have discussed, there are a great many aspiring doctors who end up leaving the field or being unable to enter it to begin with for a variety of reasons connected to government involvement.

I'll just leave this here: http://www.truecostofhealthcare.org/

[AgAuMoney]

But why couldn't malpractice insurance scale with the number of hours worked, or patients seen, or some kind of other metric?  It must be possible.  Anybody want to start an insurance company and try it?

I'm sure it could scale.  I don't believe it could scale very significantly.

Conceivably the odds of experiencing a problem go down with fewer patients, or if you select only patients with which you already have a long history.  But how is the insurance company going to judge that, especially on an ongoing basis when the problems are really unforeseeable?

Then the cost of a problem, should one occur, do not reduce.

The net risk to the insurance company is then not reduced very much, therefore premiums can not be reduced very much.

[AgAuMoney]

I will gladly pay the price to have the best and brightest minds working to solve my family's health issues.

Really?

I'm skeptical.  We are not talking some technical surgical procedure.  99% of those do not require the best and brightest, just a skilled technician.  You can get great work for such in India or many other places (see medical tourism).  If you have health issues that need the best and brightest minds, you are talking extensive experience to make good judgment, continual learning and extensive research to maintain that mind and resolve your issues.  That does not come cheap.

Say your doctor were to make $250,000 per year (which is far from the best and brightest) and they work 50hrs per week for 48 weeks per year (trying to be conservative, I think that is a lot of hours for most doctors especially if they really are the best and brightest).  That comes to 2,400 hours per year at about $105 per hour.  Most of these best and brightest are contractors with the hospital as the billing agent.  Those arrangements usually charge 50% to 100% over what they pay the contractors, so you would be billed $150 to $200 per hour.  That is not just for the hours you see the doctor, but for any hours necessary on research, consultation with other experts, etc.

Now if you really were going for the best and brightest, it could easily double those costs at every level.  Plus you then need to add the costs of the library with access to the latest journals, equipment and other facilities needed for them to perform and perform at a level for the facility to attract and justify having access to the best and brightest.

If you were personally paying for it, not via insurance or some other health plan which hides the cost, how many hours at $500+ per hour are you buying?

Speaking from personal experience within my extended family, not many.  Especially when you have a condition which is rare (a few hundred cases in the U.S., maybe that many more documented in the world) and serious (life may never be the same) but not urgently critical (life will go on).  This will require indefinite time to resolve.  If like most in that situation, even insurance will not cover very much time with the best and brightest.