Medicine December 2007

Overdose

The health-care crisis no candidate is addressing? Too many doctors
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The second assumption underlying the push to train more doctors is that an increase can only lead to better health, so that as long as the market can support new physicians financially, we should create more of them. This idea also rests on shaky ground. A wealth of data suggests that health care is actually no better (and if anything, worse) in parts of the country, like Manhattan and Los Angeles, where we have very high numbers of doctors and, in particular, very high numbers of specialists. In a paper published last year in the journal Health Affairs, David Goodman and his colleagues at Dartmouth’s Center for the Evaluative Clinical Sciences examined care at academic medical centers—the hospitals that are associated with medical schools, considered the crème de la crème of American medicine. They tallied the number of doctors caring for Medicare recipients who were suffering from one or more chronic diseases and were in their last six months of life. The variation was enormous.

Medical centers at the high end, like UCLA and New York University Hospital, employed on average two to three times as many doctors per patient as did hospitals at the low end. But these high-end hospitals did not produce better outcomes than hospitals using relatively few doctors, like the Mayo Clinic, Duke, and Stanford. Other studies show that these latter hospitals consistently deliver higher-quality care—and not just to dying patients—using fewer physicians. And the cost of care is much lower.

Why would more doctors lead to worse care, and fewer doctors to better care? More tests and procedures always entail more risk, and for care that’s unnecessary, the ratio of benefit to risk is zero. What’s more, where numerous doctors, particularly specialists, are routinely involved in a patient’s case, the potential for miscommunication and confusion multiplies. Modern medicine should be a team sport, but it is often practiced as if everybody is running a different play. Different doctors order duplicative tests, prescribe drugs that interact poorly with what the patient is already taking, and assume another physician will attend to a critical aspect of a patient’s care. A cardiologist can be a virtuoso at slipping a stent into the coronary artery of a patient in the throes of a heart attack, but if she leaves it to another physician to prescribe aspirin to her patient—one of the most effective treatments for preventing a second heart attack—that prescription might fall through the cracks.

This is what appears to be happening in many hospitals, where the ratio of specialists to primary-care physicians is especially high. In one recent study, two Harvard economists—Katherine Baicker, of the School of Public Health, and Amitabh Chandra, of the Kennedy School of Government—examined how the quality of care in different states varied as the proportion of specialists rose. They found that measures of quality, like the percentage of heart-attack patients who received a prescription for aspirin, tended to fall in direct proportion to a rising ratio of specialists. The point, says Chandra, “is not that the specialist is inferior, but that the system is not accounting for the ‘coordination cost’ specialists are imposing.”

Medical schools are now graduating more and more specialists and fewer and fewer primary-care physicians. Between 1997 and 2005, the number of U.S. medical graduates entering family-practice residencies fell by 50 percent, as young doctors headed for more-lucrative specialties like orthopedic surgery and radiology. “The problem is, primary care has never been loved by the deans of medical schools or by the teaching hospitals,” says Dartmouth’s David Goodman. As the total number of doctors rises and the proportion of primary-care doctors falls, we’re likely to see the quality of care deteriorate further and the cost of care increase rapidly.

The imbalance between specialists and primary-care physicians could be mitigated by changes in physician pay. Medicare, for instance, could raise its low reimbursement rates for primary-care visits (and lower its rates for specialist services), so that more young doctors would view primary care as an attractive career. Two primary-care professional organizations have proposed a plan to ensure that every patient has a primary-care physician, who is paid extra to coordinate the patient’s various doctors. In the meantime, patients might want to pay attention to the mix of doctors at their local hospital and compare how the quality of care measures up.

As for the rising number of physicians being trained, the remedy is simple: Turn the spigot back off, or at least close it partway. The groups now calling for more physicians should come up with better evidence that all those new doctors are not going to simply drive up costs.

Shannon Brownlee is the author of Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer (2007).
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