Doctor? Doctor? Are you there, Doctor?

Big Red Car here.  Bit gloomy this morning in the ATX.  In the 50s and only a high of 72F and cloudy all day.

Ahhh, but next week — next week all cool and sunny.

So The Boss and a doctor friend are talking about all things Obamacare.  The Doc is not a fan of it all but most importantly he indicates that there is a huge problem in the making that nobody is talking about — an acute shortage of doctors.  [Or was it a shortage of “cute” doctors?  Haha, Big Red Car, STFU already and get on with the story.  Cute doctors, you wag.]

How many doctors do we have?

The pool of doctors — medical doctors — in 2012 is approximately 812,000 license holders.  This does not mean we have 812,000 “practicing” Docs as many licensed doctors are engaged in other fields like research or simply not practicing medicine.

That number is very low and surprised The Boss given the American population of 317MM folks.  Go to Population Clock — here — for up to date population information.

Do the math and see that the ratio between the folks and the Docs is approximately 390 persons per doctor.  When you look at primary care Docs, the front line of much of medicine, the ratio is about four times that number.

What are the growth numbers?

Here’s where the numbers begin to get a bit dicey and troubling.

If you start with 812,000 doctors (disregarding that approximately 10% of licensed Docs may not even be practicing medicine at all) of which about 25% are primary care Docs, you have to look at the following info.

1.  Approximately 26,000 Docs are leaving medicine annually — most via “normal” retirement but anecdotally many due to the current Obamacare furor and the contraction, mindless contraction, of Medicare reimbursement rates.  The Boss’s Doc doesn’t even see Medicare patients.  Period.

This is going to get worse as almost 30% of all Docs are age 60 or older.

2.  Approximately 15,000 new Docs are being minted each year.  [Get it together, American Medical Association, let’s get more Docs in the pipeline, eh?]

3.  Some Docs are jumping into “concierge” medicine — high annual fee, limited patients, more direct care model.  This has now become a meaningful trend.  This exacerbates and accelerates the already troubling trend line.

All of this suggests that the supply of Docs — in the face of an aging and increasing population — is going to be a problem and when one looks at the number of primary care Docs, the reasoned result is very, very troubling.

Can’t we just train more Docs, Big Red Car?

Well, Grasshopper, therein lies another set of challenges.

1.  Primary care Docs make much less ($191,000 on average) than cardiac Docs ($457,000) or dermatologists ($385,000) — these are 2009 numbers and in the last four years this disparity is even more pronounced.

[Pro Point:  These are fairly stale numbers but when you look at Docs who own a private practice the disparities are even greater.  Perhaps as much as four times more pronounced.  Docs in private practice who own their own practice, are part of a clinic or a collective practice are doing very well indeed — when they are in a specialty in particular.]

2.  The disparity between retirees v new Docs has been known for years and no effective countervailing force has appeared to reverse this trend.  The AMA does not seem to be particularly focused on the issue.  [Hey, Big Red Car, could that be because with a dampened supply individual compensation might go up in a meaningful way?  The old fashioned greed factor?  Haha, yes, Old Sport, it damn sure could.]

3.  The University of Texas — having wrestled with the issue for a couple of decades — has recently been authorized to build a new Med School in or around Austin.  Estimated time of delivery?  Who really knows but it won’t be next month, ya’ll.  [Hey, this is just another reason to love Texas, ya’ll, they deal with real stuff when it really happens and don’t wait around for the Feds to send them a suckling pig.  Texas acts on its problems.  Like a free country which it is.]

Almost 23% of all Docs are trained currently at foreign medical school and absent this phenomenon, the numbers would be much, much worse.

What’s all going to cost to fix, Big Red Car?

Therein lies the rub, Old Sport.  Even if you reverse the trend, the costs are enormous.

1.  Docs are incurring enormous debts — up to $500,000 each — to complete undergrad and Medical School.  This is a real barrier to entry.

2.  Because of the comparative income differences, Docs are not training to be primary care Docs.  Period.  Why train for the lowest paying job in the food chain, ya’ll?  You get it, right?

3.  Costs for education are rising.  And rising.  And rising.  This undermines what is eventually and essentially a NPV (net present value) issue if you take a DCF (discounted cash flow model) approach to suggesting that long term income discounted to a PV (present value) justifies making the investment.  A very tough sell these days.

This a very real barrier to entry that must be overcome.

It could be overcome by the AMA simply authorizing more students at existing Medical Schools.  [Good luck with that says the Big Red Car.]

WTF does this all mean, Big Red Car?

Well, my friend, it means that while everyone is fixated on that nasty incompetent Obamacare website — which even the Big Red Car acknowledges will be fixed sooner or later, well OK not “sooner” — the swatting of gnats has allowed some elephants to get out of the compound and roam the countryside.

We are going to have  a meaningful and critical shortage of Docs very soon.  You think that the structure of Obamacare is going to “ration medicine” by its flawed delivery system?  Wait until there are nowhere enough Docs left to operate it, ya’ll.  Within the next five years we are likely to be staring down the barrel of a 150,000 Doc problem.

There are solutions which we will discuss in the future.

But, hey, what the Hell do I really know anyway?  I’m just a Big Red Car.  Call your parents and siblings and tell them to have a nice damn day.



7 thoughts on “Doctor? Doctor? Are you there, Doctor?

  1. One of the best stop gap measures, that will at least buy us some time, is to encourage greater use of Physician Assistants and Nurse Practitioners. The training time for these professions is significantly shorter, and could expand the pool of medical providers rather rapidly. Not every sniffle someone has needs an actual MD, and adding more of these roles will create a triage process to maximize the effective use of the MD’s time to those patients who cannot be handled by a lower level of care.

  2. We need commoditized tech to redeploy doctors. For example, we can build machines to replace anesthesiologists and many radiologists. We can use predictive analytics to diagnose things before they happen using electronic data. But, Obamacare or any other health care program isn’t encouraging that.

  3. Another factor when discussing doctors is the ratio of specialists vs. general practioners/family doctors. I don’t recall the exact numbers, but I think the US has a large % of Specialists, and US patients tend to see a specialist a lot faster than otherwise.

    As you well know, specialist care costs a lot more. So, part of curbing healthcare costs is to have the right balance of GP/Specialists and encourage more preventative, earlier type of care which is cheaper, and to not always run to the specialist.

    • .
      We need prescribing senior nurses and primary care providers who can deliver diagnosis — simple diagnosis — via video. We need a splash of video medicine.


      • The other issue is that due to the fear of malpractice lawsuits doctors are practicing defensive medicine. Primary care physicians send patients to specialists and for more tests than really necessary in order to cover their bases in case of a lawsuit. This contributes to the rising cost of care in a significant way. Simpler diagnosis did exist in days past. I don’t think video medicine or even a return to simpler diagnosis can occur until doctors feel less at risk.

        • .
          Right, you are, Tom.

          The biggest missed opportunity was tort reform. Tx had it enacted and it has worked as advertised.


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