No Physician Shortage Despite Dire Warnings: Zeke Emanuel

'More' Not the Answer to Distribution Problems

; Ezekiel Emanuel, MD, PhD

Disclosures

January 24, 2018

Eric J. Topol, MD: Hello. I'm Eric Topol, editor-in-chief of Medscape, and I'm delighted to have Ezekiel Emanuel with me today. He is the chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. Zeke, welcome.

Ezekiel Emanuel, MD, PhD: Nice to be here with you.

Dr Topol: We can get into so many topics because you have had a big influence on healthcare policy in the United States with the Affordable Care Act (ACA) and many other things. But today's topic, a "physician shortage," is a special interest. You have had multiple writings on this, including a notable op-ed in the New York Times back in December 2013 with none other than our current Food and Drug Administration Commissioner, Scott Gottlieb.[1]

More recently, your reaction to the Association of American Medical Colleges (AAMC) report [predicting a shortage] was published in JAMA in May,[2] with subsequent correspondence—as you might expect because of controversy—going back and forth in September. Why don't you give us your own sense about a physician shortage in the United States.

A Time Management Problem

Dr Emanuel: If you look through history, everyone is always predicting that we will have this terrible physician shortage. Yes, there are lots of problems: delays in getting an appointment and spot shortages in certain specialties, especially some pediatric subspecialties.

But if you look at the issue of primary care doctors, I think the notion of a shortage is greatly exaggerated.

How can there be a shortage? Let's just calculate how many doctors we have, how many patients we have, and what the actual match is.

Initially we did it two ways. We said, "If every doctor is going to have 2000 patients in their panel and we have 320 million Americans, how many primary care doctors are actually needed?"

Let's do the long division. This is not a complicated math problem requiring differential equations.

The other way was by imagining that we have a billion outpatient visits in the United States and each one is half an hour. How many doctors would be needed to take those billion outpatient visits? Again, this did not require a lot of math; it's basic division. It's really surprising—we have more than enough primary care docs to satisfy all of that.

We have doctors doing a lot of things that they should never be doing.

The question is: Why is everyone feeling like there is a shortage? My intuition is that we are just bad at managing time.

We are probably bad in two ways. First, we are not maximizing our doctor time. We have doctors doing a lot of things that they should never be doing. They are filling out paperwork and arranging tests and treatments that do not need an MD with at least 3 years of post-MD training to do. The second is, we have a lot of doctors seeing patients who do not require appointments for things like follow-up visits.

As a cardiologist, you can probably tell stories like this. When I was training to become a breast oncologist, I was told that for women with early-stage , you remove the lump, give them 6 months of chemotherapy, and then bring them back every 3 months for follow-up. Where did that come from? Right after finishing chemotherapy, the cancer should probably be at the lowest risk for coming back. Every 3 months sounds like overkill to me. Do we have any data? There are no data, no evidence that that is the right time sequence, etc. We ended up with this general overkill for a lot of sequences.

There is a lot of minor stuff, like for women with urinary tract infections. You treat the urinary tract infection. You do not need to see them again. You can just check in by text message or something pretty low-tech. There is a lot of unnecessary use of the physician's time.

More Doctors Not Always the Solution

Dr Topol: I understand that you are getting at paraprofessional help and current technology, like texting, that we are not using enough. I'm sure you would be supportive of telemedicine and virtual visits. The AAMC report[3] zoomed in on three things: the aging population; the aging of doctors and the fact that half of doctors are well over 50-55 years and are retiring or burned out and are reducing their effort; and the issue about lengthy work hours and how that is just unsustainable.

You underscore that [the number of] medical schools [in the United States] has increased from 125 to 145, and [the number of] medical trainees has increased almost 30%, in recent years. That is a big change. How do you square away [the AAMC's] assertions with your math and views?

The best way of attacking chronic illness and managing it may not be with more doctors.

Dr Emanuel: First of all, we have had an aging population for a long time now. We have learned that, yes, the population ages and they have more chronic illness. But the best way of attacking chronic illness and managing it may not be with more doctors but rather with more chronic care coordinators who take responsibility for reaching out to patients. Again, we will have more patients with chronic illness, but is the solution more doctor hours? That is the underlying assumption of the AAMC, and I think that assumption is erroneous.

We are moving a lot of services out of the hospital, and that is going to require more people. But I'm not sure that this is mainly a doctor problem.

When you look at the aging of the doctor population, I do think the AAMC has a point. A lot of doctors in the older generation, above my age and your age, used to work like maniacs. With my father, a 70-hour work week was normal, but the current generation does not want to work so much.

As I pointed out, we have more doctors now than we have ever had. Even when you do the math under very conservative estimates of not overworking the doctor (30-minute primary care appointments, no weekend work days, no extended hours, 12 slots a day per primary care doctor), you have more than enough slots to handle the billion appointments we have every year in the outpatient setting.

I do not think AAMC's math ever worked out. They always use docs per 1000 population, but that is not the number you want. The number you want is, how many visits do we need or have, and can we manage that with the current crop of doctors working at a reasonable pace?

Many doctors work more than the 12 slots a day that we allocated to them, and that is because they need the money or they want the money of additional appointments. That is a very different issue than a shortage based upon sheer numbers. That is about how much income doctors want to make.

'They're Never Going to Be in North Dakota'

Dr Topol: There is a maldistribution issue. One fifth of the American population is in rural areas, and adding more doctors does not seem to be the fix for that, right?

Dr Emanuel: Right. If you were an economist, you would say, "We've got to get supply to equal demand, so we will just make more docs and force them out of New York City or San Francisco and they will go to North Dakota." But we know that is garbage.

No country with big rural populations has ever solved maldistribution this way due to the fact that highly trained doctors do not want to relocate to small, rural cities. It's not just the United States. The main reason is because they want a lot of the social amenities that come along with a high socioeconomic status. These tend to be located in larger, urban areas, and getting this very talented pool out into rural areas is just not going to happen unless you literally force them, and we are against forcing doctors.

I do not think more doctors are going to solve that maldistribution problem, and so we need to address this by adding more allied healthcare professionals, using telemedicine, and finding other ways of linking rural populations with physicians at more urban centers. That is especially true for specialty care. Here we might have a genuine shortage, but that is of a different kind. There may not be enough pediatric cardiologists or pediatric rheumatologists, but they are never going to be in North Dakota. That is a problem you are only going to solve by changing the amount that we reimburse them and linking them when patients need their services in rural areas by telemedicine or MD-MD consults via the Web.

Serving the rural patient population is a hard nut to crack, but it's not going to be solved by training more docs.

Wait Times Linked to Scheduling, Not Physician Supply

Dr Topol: Another metric used a lot is wait times. Wait times to see a primary care doctor in places like Boston are more than 6 weeks, and the average is well over 3 weeks for the United States. Since wait times have been creeping up, the idea is that we do not have enough doctors. What are your thoughts about that?

Dr Emanuel: It is very interesting. They looked at wait times after Massachusetts expanded access. A large part of the fear was that if you add millions of new people with health insurance and you are not adding doctors to cover them, wait times will go up. There was no evidence that that was true. Despite the fact that we added 22 million Americans through the ACA, I do not know that anyone has seen general wait times around the country go up.

Wait time is not a function of doctor supply; it is a function of how you manage doctor time. I went around the country looking at places that provide high-quality, low-cost care, and one of the things I noticed is that they have "open-access scheduling."

At the start of the day, between 20% and 50% of the physicians' slots are open and unscheduled so that patients can walk in or call and say, "I have some free time. Can I see my primary care doctor and get my annual exam?"

That management style, ironically, opens up additional free time in doctor schedules because you have fewer no-shows. A lot of mechanisms can reduce wait time.

Your old institution, the Cleveland Clinic, went to same-day appointments, and last year I think they did a million same-day appointments. Open-access scheduling, getting people in on the same day, and fixing the no-show issue can increase efficiency and decrease wait times.

Supply Induces Demand in Healthcare

Dr Topol: That brings up the issue of healthcare costs. After hospitals, the next line item of the $3.4 trillion in healthcare costs (or whatever it is right now) is docs. The concern is: If we increase the number of doctors like the AAMC is ordering up, are we going to increase costs?

Dr Emanuel: Economists like to say that supply equals demand, and if we have this big demand of a billion office visits and these long wait times, we need to increase supply and things will even out.

We know that in healthcare, supply and demand do not work that way. We have "supply-induced demand," which is how often you are supposed to see a diabetic patient in follow-up, for example. There is no evidence-based guideline. You have a lot of doctors chasing diabetic patients. Doctors will see more patients and increase costs with no added benefit.

We have seen this over and over again. Florida has very high utilization because they have a lot of doctors down there for the old people and too many doctors given the population. You end up with very high utilization and very high costs. But there is no evidence that it leads to better care and some evidence that it actually leads to worse care because you are giving people unnecessary care and inefficiently delivered care.

One doctor who practices down there and runs a capitated system responsible for total cost of care says that what you end up seeing is relatively small community hospitals with 70 cardiologists on staff who are doing all sorts of unnecessary catheterizations, , and other things on marginal cases. He says this drives up costs because there is a big supply of doctors who produce a lot of unnecessary care because they need to meet a certain income threshold.

That is not a place to be. We made that mistake. In the 1970s, Richard Nixon thought that by increasing the number of medical schools and doctors, healthcare costs would go down. The effect is exactly the opposite: If you increase the number of doctors, you will increase healthcare costs because they write prescriptions and order services like x-rays. That is not a good way of approaching the problem.

AAMC: 'Shortage! Shortage! Shortage!'

Dr Topol: You have made a really good argument here that goes against almost every point in the AAMC report. Would you say that the AAMC has a conflict of interest?

Dr Emanuel: If you go back to their reports, it is an institution that has talked about shortage, shortage, shortage for decades. They do represent medical schools, and they want more of them, so they have increased authority. But a lot of medical schools, like the University of Chicago, have actually been shrinking. I think we really do need to be much more critical of their position.

It's not just medical schools but also postgraduate training—internships and residencies. Do we need all of those slots? We have a lot of slots. Those slots are not always geared toward the trainees; they are often geared toward satisfying hospital overnight coverage situations and services. I've always noted that places with few trainees, like dermatology or , do not have a lot of overnight coverage. In places where you have a large number of trainees, it's really about overnight coverage. That is not the way the system ought to work.

We need to rethink this. Not only do we train the doctors we graduate here, but we bring in foreign medical graduates to fill other residency slots. Is that a good use of our resources or ought we to think about overnight coverage in different ways?

Dr Topol: I see your point. For the 30 years that I have been a physician, I've heard nothing but "physician shortage." As you know, it is now projected that the shortage could be more than 100,000 doctors between now and the next 12 years,[4] which seems a little far-fetched.

Solutions to Physician Burnout?

Dr Topol: We have talked a lot about the math and the economics, but we have not really gotten into the downtrodden spirit, the deepest , low morale, suicides. What can be done to make things better for physicians? They do care for patients but they are getting burnout left and right.

Dr Emanuel: We have to look at the cause of that burnout. One of the causes, undoubtedly, is the electronic health record (EHR) and the way it works. Can a tech solution make EHRs work better for doctors so that they are not so onerous to use and do not just add time for doctors?

The second important thing is that there are a lot of administrative tasks—speed bumps—with the sole purpose of creating hassles for doctors. Insurance companies put burdens on things like ordering MRIs or CT scans. Their goal is to create an impediment to ordering these tests.

Despite working 70 hours a week, why was my father so happy? He controlled things.

If we change payment so that doctors are responsible for the money and have more autonomy in how it's spent, you may actually increase doctor satisfaction. A lot of orthopedic surgeons report that they are happier and have more satisfaction under bundled payments because they have more control over how the money is spent.

If we pay doctors differently so that they have more control over the money, are they going to be happier, and will it end some of these administrative hassles that they go through to practice? That would be my hypothesis.

Dr Topol: What if we gave all doctors a really good salary and there was no incentive to do anything but take care of their patients? Would that help at all?

Dr Emanuel: Whether or not a salary would help doctors is a good question. Places that have used salary, like the VA system, have had problems with productivity. You need to have a balance. Salary is incentive for people who are driven and passionate and not motivated by money. I do not want to say that all doctors are motivated by money, but money does play a role. When you salary doctors and there is no intrinsic motivation, you might end up with low productivity. That has been the experience of places that have done that.

I think doctors really want autonomy. "Let me practice my way. Tell me what metrics you want me to hit, and give me control over the resources." That would probably go a long way to alleviating burnout.

Despite working 70 hours a week, why was my father so happy? He controlled things. He did not have many hassles from insurance companies standing in his way of practicing what he thought was good medicine. That is the place we have to get to.

Dr Topol: He had a tight bond with his patients, and he probably had a lot more time with patients than doctors have these days since visit length is now so incredibly short.

Is There Hope for a Better Future?

Dr Topol: Getting your views has been really helpful, Zeke. Are you optimistic that things could get better or are we kind of stuck in the mud where we are right now? Where are we headed?

Dr Emanuel: I'm actually wildly optimistic about the American healthcare system. The main reason I'm optimistic is because we are a great country. We have a lot of people with great innovations and great entrepreneurial spirit. I think changes in the system, some of it possibly due to the ACA, may be driving people toward a better-performing system.

We are going to have a lot of testing of new ideas. Not all of them are going to work, and a lot of them are going to fall by the wayside. Ten or 15 years from now, we are going to have a much better system and probably more doctor satisfaction as a result. I am optimistic about the directionality of American healthcare even though some aspects of it now look like they are not doing too well.

Dr Topol: That sanguine outlook is much appreciated. I'm sure the folks listening and watching this will feel good about that. Zeke, I want to thank you. It was really great to have you on Medscape to talk about this and get your views. I look forward to watching all of the work you are doing in medical ethics, oncology, healthcare policy, and the like. Keep up the good stuff, and we will keep in touch with you and hopefully get you back again. Thanks a lot.

Dr Emanuel: Thank you very much, Eric. It was a pleasure.

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