Doctor Shortage

People have been reporting about this for quite a while, but a friend just recently forwarded me this NY Times article about how there will be a severe shortage in doctors in the future, especially in the primary care field. It seems many people, including the current Obama administration are becoming increasingly worried about this problem. While some steps are being taken to try and delay this crisis, there are many many roadblocks.

Of the ideas that have been proposed or already instituted to try and solve this problem, one includes increasing the sizes and numbers of medical schools. Medical schools may have to admit more students that don't have science backgrounds - while some worry that this may decrease the quality of medical students and eventual doctors, I don't think this is a problem and may even be of benefit. Medical schools already admit plenty of students with non-scientific backgrounds and as long as they can build up a significant fund of knowledge either in medical school or in a year of study before entering, I think it's not a problem. In fact, it may even build diversity and bring new ideas and perspectives to the table, which is definitely a good thing.

Another idea is to increase the use of non-MD sources of health care, including nurses and other health care professionals, which I think is a great idea. However, there is also a nation-wide shortage of nurses, so this avenue may be limited as well. Finally, it has been suggested that we use more minority as well as international doctors as there are many MDs from other countries who would like to practice in the U.S. Obviously this presents many problems as training in other countries can be vastly different than training in the U.S. and currently, depending on the country they come from, international doctors often have to retake licensing exams, as well as complete full residencies (after having already completed residencies or full training programs in another country) in the U.S. This is a huge deterrent for MDs coming from other countries to try and become MDs in the U.S. - I don't know how many international MDs I know who have instead become lab technicians or Ph.D. students or post doctoral students because the requirements for them to practice medicine in the U.S. are so overwhelming. However, I don't have a great solution for this as I do believe the training is different from country to country and that international MDs should practice in the custom of U.S. training, for legal purposes as well as medical.

Despite these efforts, I see a lot of hurdles for which there are no easy answers or solutions. One is that even though medical schools may be increasing their enrollment, there are a limited number of residency training spots available. These are being increased as well, but they cannot be increased as easily or at the same rate as medical school spots. Residencies are much more complex to set up, and must go through a thorough accreditation process every couple of years, which is not only cumbersome, but can be difficult to arrange and maintain.

Moreover, there is heavy competition for competent people by other professions, the major competitors being business and law. Now, with the economy being the way it is, business has been less attractive the last few years, and perhaps the medical pathway is getting a boost from the decrease in business school applicants or business jobs. However, law and business careers can be much more attractive than medical careers - the training is much shorter. School takes half as long, and after school you start earning a relatively good salary right away whereas in medical school, it can take 4-6 years, with 3-5 year of low-paying residency afterwards, sometimes followed by 1-2 years of low-paying fellowship. Once you finally get out of all this training, doctors (especially primary care) often still make lower salaries than lawyers and businessmen, and have to contend with other headaches and costs associated with malpractice insurance, insurance paperwork and red tape, etc. Until there is good health care reform, or salaries become more equalized (either doctors' salaries have to come up or other salaries should be lowered - probably the latter is better for various reasons), there's not much that can be done about this problem.

Finally, even with the increase in medical school admissions and residency spots, many people are still attracted to practicing in medical specialties rather than primary care, in which the doctor shortage is the most severe. Again, this likely is due to a salary differential as primary care doctors make much less than doctors in medical specialties. As with competition with business and law degress, not much can be done about this problem until the salaries equalize - in this case, I think primary care doctors should be valued more highly and their salaries increased.

Night Coverage

Clearly, doctors can't be at the hospital 24 hours a day, 7 days a week, so for at least some of the time, their patients have to be cared for by somebody else. Different hospitals handle this in different ways. At Pennsylvania Hospital, there is a night float system. Most of the interns leave the hospital at night and sign their patients out to a single night float intern who works from about 5pm to 7am. The good thing is that most interns actually get to leave the hospital at night and are refreshed the next day to do work. The bad thing is that the night float intern is taking care of probably about 80-100 patients a night, and since you get signout on so many patients, it's not that detailed and you really only remember the really sick patients or make a note of specific things you have to do for certain patients. That means that night float doesn't know most of the patients very well at all - they just handle critical issues at night. Most patients are sleeping at night, and there's not much going on, so it's manageable, but if there are quite a few sick patients that night, it can get very busy and complicated. The good thing is that there is a resident or two for backup if things do get ridiculously busy.

Some other hospitals do it differently. They have teams that round together, and at night, 3 interns will sign out to one other intern for the night. The good thing is that that since they all round together, that intern staying overnight is supposed to know all the patients relatively well. The bad thing is that one out of every 4th intern stays overnight, making 25% of the interns extremely tired and miserable the next day (since usually they get very little to no sleep) and also decreasing the work force by 25% the next day since they have to leave by noon.

It's hard to say which is the better option. It's bad to have so many interns tired working the next day as studies show that the more tired doctors are, the more mistakes can be made (not that they are common by any means). This is an argument for the first system, like at Pennsylvania Hospital. However, newer studies are starting to show that the more times care is transferred between different doctors, especially doctors who are not super familiar with the patients to begin with, the more mistakes can be made (again, not that they are common). This would be an argument for the second system.

In fact, there are rumors of new legislation in the works that forces interns to take a nap (!) in the middle of call for at least 3-4 hours. During this time, they would have to somehow sign off their patients to someone else, and then get them back at the end of their nap. This is all part of ongoing legislation reform about duty work hours (a whole other post). However, the problems with transfer of care may be an argument against doing this sort of thing. Until hospitals have more money to hire more helpers (e.g. RN's, NP's, etc) that can at least do part of the work of interns, I guess we'll have to make do.

Interviewing

It's coming to the end of the interviewing season, thank goodness. :) For the last couple of months, with a break for the holidays, Pennsylvania hospital has been interviewing candidates for next year's intern class on Wednesdays, Thursdays and Fridays, about 10-20 4th year medical school candidates each day. It's somewhat interesting to see how a program recruits good candidates.

Of course, the program reputation speaks for itself - either for good or for bad. Word of mouth goes a long way, and during the day, they give the candidates ample opportunity to speak to current residents and interns and ask them questions. I, for one, believe in being completely honest about everything, even if that puts the program in a bad light. Of course, I tend to look at things more positively than others, I think, so I may be putting a good spin on things unintentionally. I think it's a bad sign when a program doesn't give you time to spend with current residents and interns - what are they afraid of?

More interesting to me are the little things that candidates care about that draw them to or away from a program. #1 thing is the food. I can't tell you how many times the subject of food or how well candidates have been treated during the interview comes up or plays a role in their decisions. Logically, this should have nothing to do with someone's decision to join a program, or how good the program is, but if crappy food is served during the interview, candidates notice! It's worth noting that on the days that preliminary candidates come to interview (these candidates are internship candidates that, instead of staying in an internal medicine residency for 3 years, are in the program for one year and then go on to a specialty like radiology or opthalmology), the food is much better because good preliminary candidates are thought of as much more competitive and more difficult to draw to your program.

Other little things include paying for parking, taking you out that night with other residents, etc. If a program goes so far as to pay for other things, like hotel costs or travel costs, that's even more impressive to candidates. I think for most people this plays out during residency too - in the end, many people are concerned not just with the training they receive during residency, but their quality of life during residency which includes all these "little things."