The Physician-Supply Debate
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Blumenthal's article on the physician-supply debate (April 22 issue)1 provides an excellent review of the history of workforce analyses and of the academic debates and public policies surrounding them. His conclusions, and those of other analysts in the field, focus on physician demand and supply because physicians are the common unit of measurement. It is time, however, to move beyond the physician as the principal unit of analysis in workforce studies. The more appropriate unit of measurement should be the medical services needed or demanded to meet patients' requirements. When this is the case, the analytic question becomes not how many physicians we need, or do not need, but how we can most efficiently produce the required services with a variety of different types of resources, such as physician assistants, other health professionals, and information and biomedical technology. Medical care is no longer just about what physicians do. Workforce studies in the future should focus on the production of services and not just on categories of professionals.
Stephen C. Crane, Ph.D., M.P.H.
American Academy of Physician Assistants
Alexandria, VA 22314
steve@aapa.org
References
Blumenthal D. New steam from an old cauldron -- the physician-supply debate. N Engl J Med 2004;350:1780-1787.
To the Editor: Blumenthal notes that the demand for subspecialty physicians and services is more closely linked to growth of the gross domestic product than is the demand for primary care physicians, but like Cooper, whose work he discusses, he does not specify the factors underlying this association.1 First, defensive medicine, highlighted by the current malpractice crisis, drives specialty referrals, although the magnitude of the effect is difficult to estimate.2 Second, the ever-expanding knowledge base in fields ranging from internal medicine to neurosurgery makes it less and less likely that even the most intelligent physician can fully grasp his or her entire field. Finally, the public, as medical consumer, is increasingly becoming aware of the factors that drive quality, chief among which is the volume of a given procedure performed by the physician. At the extreme, this can involve physicians' limiting themselves to one simple procedure, as exemplified by the enviable results of the Shouldice Hospital in Canada, which performs only hernia repairs.3 The causative factors behind the inexorable drive toward subspecialization among physicians, and hence the need for medical and surgical specialists, is worthy of further discussion and analysis.
Anthony A. Mikulec, M.D.
Massachusetts Eye and Ear Infirmary
Boston, MA 02108
References
Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21:140-154.
Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med 2004;350:283-292.
Gawande A. Complications: a surgeon's notes on an imperfect science. New York: Metropolitan Books, 2002.
Dr. Blumenthal replies: Drs. Crane and Mikulec raise valid points. The ultimate goal of workforce planning is to meet the demands and needs of patients, and that increasingly requires us to recognize that medical care is provided by multidisciplinary teams of professionals. Most projections of the need for physicians try to take into account the potential contributions of nonphysician clinicians. Predicting these future contributions, however, is somewhat more difficult than for physicians because the roles of nonphysician clinicians are evolving so rapidly. In addition, even after careful consideration of the roles of nonphysician clinicians, there will still be a need for workforce planning devoted exclusively to physicians. After all, physicians will remain part of the health professional workforce for the foreseeable future, their training is resource-intensive, and public and private authorities must make decisions concerning the numbers and geographic and specialty distributions of medical-school and residency slots.
Dr. Mikulec suggests that the determinants of demand for specialty services are likely to be multifactorial. This is almost certainly the case, and we know too little about those factors. Cooper has made a novel observation by noting that increasing societal wealth may constitute an independent predictor of the demand for specialty services. This suggests that specialty care, even more than other types of services provided by physicians, is what economists call a "luxury good" — a good or service for which demand increases as personal wealth increases. However, that observation by no means invalidates some of the other hypotheses suggested by Dr. Mikulec.
David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital
Boston, MA 02114
Stephen C. Crane, Ph.D., M.P.H.
American Academy of Physician Assistants
Alexandria, VA 22314
steve@aapa.org
References
Blumenthal D. New steam from an old cauldron -- the physician-supply debate. N Engl J Med 2004;350:1780-1787.
To the Editor: Blumenthal notes that the demand for subspecialty physicians and services is more closely linked to growth of the gross domestic product than is the demand for primary care physicians, but like Cooper, whose work he discusses, he does not specify the factors underlying this association.1 First, defensive medicine, highlighted by the current malpractice crisis, drives specialty referrals, although the magnitude of the effect is difficult to estimate.2 Second, the ever-expanding knowledge base in fields ranging from internal medicine to neurosurgery makes it less and less likely that even the most intelligent physician can fully grasp his or her entire field. Finally, the public, as medical consumer, is increasingly becoming aware of the factors that drive quality, chief among which is the volume of a given procedure performed by the physician. At the extreme, this can involve physicians' limiting themselves to one simple procedure, as exemplified by the enviable results of the Shouldice Hospital in Canada, which performs only hernia repairs.3 The causative factors behind the inexorable drive toward subspecialization among physicians, and hence the need for medical and surgical specialists, is worthy of further discussion and analysis.
Anthony A. Mikulec, M.D.
Massachusetts Eye and Ear Infirmary
Boston, MA 02108
References
Cooper RA, Getzen TE, McKee HJ, Laud P. Economic and demographic trends signal an impending physician shortage. Health Aff (Millwood) 2002;21:140-154.
Studdert DM, Mello MM, Brennan TA. Medical malpractice. N Engl J Med 2004;350:283-292.
Gawande A. Complications: a surgeon's notes on an imperfect science. New York: Metropolitan Books, 2002.
Dr. Blumenthal replies: Drs. Crane and Mikulec raise valid points. The ultimate goal of workforce planning is to meet the demands and needs of patients, and that increasingly requires us to recognize that medical care is provided by multidisciplinary teams of professionals. Most projections of the need for physicians try to take into account the potential contributions of nonphysician clinicians. Predicting these future contributions, however, is somewhat more difficult than for physicians because the roles of nonphysician clinicians are evolving so rapidly. In addition, even after careful consideration of the roles of nonphysician clinicians, there will still be a need for workforce planning devoted exclusively to physicians. After all, physicians will remain part of the health professional workforce for the foreseeable future, their training is resource-intensive, and public and private authorities must make decisions concerning the numbers and geographic and specialty distributions of medical-school and residency slots.
Dr. Mikulec suggests that the determinants of demand for specialty services are likely to be multifactorial. This is almost certainly the case, and we know too little about those factors. Cooper has made a novel observation by noting that increasing societal wealth may constitute an independent predictor of the demand for specialty services. This suggests that specialty care, even more than other types of services provided by physicians, is what economists call a "luxury good" — a good or service for which demand increases as personal wealth increases. However, that observation by no means invalidates some of the other hypotheses suggested by Dr. Mikulec.
David Blumenthal, M.D., M.P.P.
Massachusetts General Hospital
Boston, MA 02114