Medical prime

Ezra asks how we can make it more attractive to become a primary care physician:

The problem they're responding to is real. We're about to face an epic shortage of primary care doctors -- we're talking 44,000 or 45,000 too few docs -- which will ensure massive disruption for patients. The problems for primary care are basic: Fewer graduates, more patients. As I understand the issue, there are two problems here. The first is lifestyle. Primary care doctors have too many patients, too little time, too much paperwork, too much administrative hassles, too little satisfaction. The other is money. Primary care doctors make far less than specialists, even though they go through a similarly expensive and rigorous training process. It's no surprise, then, that most doctors opt to become specialists, where they have better incomes and more control over their lifestyle. The famous stat here is that the highest MCAT scores are now to be found among dermatologists. Great money, nice lifestyle.

The money fix being proposed comes on the payment side. How can we make it lucrative enough to be a primary care doctor? The answer is increase the pay of primary care doctors. And there's an argument for this: More primary doctors would probably make the system cheaper, even at higher reimbursement rates. Specialist medicine is expensive. But you could also examine the problem on the training side: How can we make it cheaper to become a primary care doctor?

It's not quite true that there's no relationship between training and earnings in medicine:  surgeons go through the most gruelling residencies, and also tend to make the most money (it does depend on the specialty).  But the relationship between the two is out of whack.

The relationship is out of whack because there's no real market for these services.  A shortage of primary care doctors should send a price signal that we need to pay them more, or make their lifestyle more attractive.  But both Medicare and private health insurance have thoroughly stupid reimbursement policies for their physicians.  Doctors make money off procedures, not visits or health, which means that critical specialties like primary care and geriatrics are woefully understaffed.  Medicare could fix this by giving a bonus to primary care physicians and geriatricians, raising the reimbursement for their office visits.  But it can't, for several reasons:  it's already out of money, and trying to cut, not spend more; and the powerful medical lobbying groups that "help" set Medicare reimbursements are dominated by surgeons.

The insurance companies have just as little incentive to fix the problem.  After all, if it's hard to find a doctor, and your doctor makes you wait a long time for your appointments, you use less healthcare.  Brilliant, eh?

Ezra suggests opening up the field to nurse practicioners.  I don't know enough about primary care practice to comment one way or another (I'm sure my readers do, and will).  Anecdotally, however, I will say that every time I've had a nurse practicioner rather than a physician, I've ended up very, very happy with my experience.  I can think of two or three doctors in my lifetime who have given me the kind of personal, attentive care that I've gotten from every single nurse practicioner who has ever taken care of me.  I presume this is a cultural difference between medical school and nursing school, which has been described to me thusly by a midwife (nurse practioner):  doctors learn how to treat diseases; nurses are trained to take care of patients.