nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
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Thursday, April 15, 2010

Poison Pill Of The Day: Not Enough Doctors? Shorten The Training

My name is Doc D and I am a three-year MD.

This is like deja vu all over again:  Back in the mid-seventies there was a perception that the country needed to increase its supply of doctors.  That coincided with my years in medical school.  Baylor began a program to offer the medical degree in 3 years.   But there were a couple of caveats:  you had to be in the top half of your class, and you had to attend school 12 months out of the year (ie., 3 yrs of 12 mo versus 4 yrs of 9 mo--both 36 months).  I went for it.

Now the shortage of primary care physicians, which health care reform makes critical, is being addressed by increasing the number and scope of practice of non-physician providers (nurse practitioners and physician assistants), and by experimenting with cutting the medical school curriculum by one year.

Both strategies will require more people coming out of training.  Some doctors see non-physician providers as a threat, or unsafe, but many others work closely with them.  Patients are variable:  many prefer them, particularly for common, acute care illnesses.  Some other patients think they are getting "less" than a doctor.  When I joined the Air Force in 1980, enlisted technicians did simple suturing and casting.  That went away (without cause) when the malpractice lawsuit explosion occurred, and a lot of talent was wasted by keeping them from doing what they had trained to do.

With all types of providers following their skill sets, the system can expand somewhat to meet the care requirements of millions of new patients.  But it will take time--more for physicians than other providers: 7-8 yrs v. 2 yrs.

But, if medical schools are cutting the fourth year just to reduce cost and get people out the door quicker, I'm not sure that will accomplish the same degree of preparation required to treat patients safely and effectively.  In medical education, time is needed to absorb a mountain of material, then digest it and chew on it and apply it, in order to be good at it.  Many say that happens AFTER school is over.  That's true, but you have to have a solid foundation to build on.

If I had it to do all over again, I would do the same.  But at the time, I had been in grad school first, had a wife and growing family, and felt the pressure to git 'er done.



Dr William J McKibbin said...

Here's an idea, why not commit out nation to tripling the number of physicians coming out of medical schools during the next 10-15 years! The US graduated an average of only 15,800 new physicians each year since 1981 (see chart at link below). Why is this so? Why is it that there has been no growth in the number of physicians coming out of medical school despite the increase in demand and the growth of the general population? Is someone of the mind that there are not enough "smart people" in the US to make it through medical school? The truth is we do not need to waste any more time studying why we are short physicians, because the reasons have nothing to do with the solution. We as a nation (with or without the support and consent of physicians at large) should commit to the impossible and train more of our sons and daughters to become physicians -- many more -- the need is urgent and morally justified by society's needs. Indeed, we may have to convert the medical profession from private enterprise into public services -- if that is what it takes, then so be it (I have known plenty of physicians who serve in the military on government salaries). I call on the nation to do whatever it takes to expand the capacity of our healthcare system in the coming 10-15 years! No more sending people to the moon -- it's time to prevail over the shortages of medical care in this country with whatever means are necessary. More at:

Thank you for the opportunity to comment...

Doc D said...

Dr. McKibbin,
Thanks for your thoughtful comment. By coincidence, I served most of my career in the AF (27 yrs). I loved it and wouldn't have it any other way.

I don't disagree with your suggestion. In fact, we must increase production. And the studies show that it's not necessarily the people with the highest MCAT scores who make the best physicians.

The key to success will be the methods we choose to accomplish that increase. The most acute shortages are in primary care in rural communities. The new health care law addresses this through scholarships to rural and low-income applicants. The expectation is that with increased income for PC, and a student pool that is more likely to serve where needed, the balance will be redressed.

I think these things will help, but they've been tried before with only partial success (late 70's). I think the *culture* of primary care v specialty has to be addressed also. See my post on this (below)

Even if we approach the need for providers through government employment as you mentioned, some care needs to be taken. I've spent time in the medical system in several countries (I'm interested in any experience you've had with single-payer). Their doctors, as government employees, have less influence over standards of care. They experience some frustration at their government agencies' regulatory power, that reaches into the examining room. Not an insurmountable problem, just one among many that would need to be addressed.

Our new health care law implemented some great things in portability, no denial of care, and coverage caps. But passage was ugly, and left a number of things to be fixed. You won't find me posting repeatedly on the good things--that's not useful. I'm spending my time poking people in the eye about what requires further work or a better answer.

Once again, thanks.

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