Too Many Doctors in the House

July 10, 2006Op-Ed ContributorToo Many Doctors in the House By DAVID C. GOODMANDavid C. Goodman is a professor of pediatrics and family medicine atDartmouth Medical School.Hanover, N.H.CAN we cure our ailing health care system by sending in more doctors? Thatis the treatment prescribed by the Association of American Medical Colleges,which has recommended increasing the number of doctors they train by 30percent, in large part to keep up with the growing number of elderlypatients. But the most serious problems facing our health care system -accelerating costs, poor quality of care and the rising ranks of theuninsured - cannot be solved by more doctors. In fact, that approach, likeprescribing more drugs for an already overmedicated patient, may only makethings worse. Many studies have demonstrated that quality of care does not rise along withthe number of doctors. Compare Miami and Minneapolis, for example. Miami has40 percent more doctors per capita than Minneapolis has, and 50 percent morespecialists, according to The Dartmouth Atlas of Health Care, a study ofAmerican health care markets (for which I am an investigator).The elderly in Miami are subjected to more medical interventions - moreechocardiograms and mechanical ventilation in their last six months of life,for example - than elderly patients in Minneapolis are. This also means morehospitalizations, more days in intensive care units, more visits tospecialists and more diagnostic tests for the elderly in Miami. It certainlyleads to many more doctors employed in Florida. But does this expensiveadditional medical activity benefit patients? Apparently not. The elderly in places like Miami do not live longer thanthose in cities like Minneapolis. According to the Medicare CurrentBeneficiary Survey, which polls some 12,000 elderly Americans about theirhealth care three times a year, residents of regions with relatively largenumbers of doctors are no more satisfied with their care than the elderlywho live in places with fewer doctors. And various studies have demonstratedthat the essential quality of care in places like Miami - whether you aretalking about the treatment of colon cancer, heart attacks or any otherspecific ailment - is no higher than in cities like Minneapolis. Studies of individual hospitals have likewise shown that while thedoctor-patient ratio varies widely from place to place, more doctors do notmean better care.The Mayo Clinic in Rochester, Minn., and the University of California, SanFrancisco, Medical Center each have about one doctor treating every 100elderly patients with chronic illnesses in their last six months of life.New York University Medical Center has 2.8 doctors for every 100 suchpatients and the University of California, Los Angeles, Medical Center has1.7. The elderly patients at N.Y.U. and U.C.L.A., as compared with those atthe Mayo Clinic and the San Francisco hospital, see more specialists and aresubjected to more imaging tests and other procedures. But the quality oftheir care, as judged by doctors, is no better.Using the N.Y.U. doctor-patient ratio as a benchmark for determining thenumber of physicians that will be needed to care for the over-65 populationin the year 2020, we can project a deficit of more than 44,000 doctorsnationwide. But if the benchmark is based on the Mayo ratio, we can projectan excess of nearly 50,000 doctors in the year 2020.How can it be that more spending and greater physician effort does not leadto better health or to improvements in patient satisfaction? One explanationmay be that when more doctors are around, patients spend more time inhospitals, and hospitals are risky places. More than 100,000 deaths a yearare estimated to be caused by medical mishaps.The association of medical colleges has argued that increasing the doctorsupply overall can remedy regional shortages. But in the past 20 years, asthe number of doctors per capita grew by more than 50 percent, according toour measurements, most of the new ones settled in areas where the supply wasalready above average - places like Florida or New York - rather than inregions that lack doctors, like the rural South. Medical training is anexpensive business, and it makes little sense to waste additional publicdollars to perpetuate doctors' preference to live in affluent places.By training more doctors than we need, we will continue to fill morehospital beds, order more diagnostic tests - in short, spend more money. Butour resources would be better directed toward improving efforts to preventillness and manage chronic ailments like diabetes and heart disease. Better coordination of care is also worth investment. Small physician groupsin disconnected offices often provide fragmented treatments, whilemultispecialty practices integrated with hospitals - prevalent inMinneapolis and some other cities - are associated with lower cost andhigher quality of care. All these strategies have been shown to improve patient outcomes withoutadding physicians. Instead of training more doctors, let's make better useof the ones we already have.