Posted by: notdeaddinosaur | March 8, 2015

Shortage of Logic, Not Doctors

In news to absolutely no one with an iota of common sense, the purported physician shortage isn’t actually one of numbers, but rather a problem of distribution. Per this article by Lenny Bernstein in the Washington Post:

[C]ritics of doctor shortage projections have argued for years that the problem is actually poor distribution of physicians, with too many clustered in urban and affluent areas and too few in poor and rural areas.

Doctors prefer to live in affluent urban areas instead of rural poor ones. This is a surprise…why? Doctors are people. There are more people in urban and suburban areas than in rural ones. It’s, you know, part of the DEFINITION. Therefore there are going to be more doctors where there are more people.

Sure, there are doctors who love the rural lifestyle. Hats off to them. However apparently there aren’t enough of them. Then again, rural areas, by DEFINITION, have relatively few people scattered over a wide area. In order for doctors and patients to get together, someone’s gonna have to travel. (Yes yes yes, there’s always telemedicine. Doesn’t help much when you need an actual procedure like surgery, or help delivering a baby. No matter how you cut it, there are times when you and your doctor need to be in physical contact.)

So obviously there are going to be more doctors where there are more people. But why might they cluster in affluent areas? Contrary to popular belief, lots of us feel strongly that everyone deserves medical care. Unfortunately, we are faced with the realities of making a living in a profession that requires a truly obscene up-front investment. I am personally aware of numerous students who would make fabulous primary care physicians who feel they won’t be able to pay off their loans unless they go into more lucrative specialty fields. I’ll bet that distribution problem would sort itself out in a hurry if we overhauled the financing of medical education.

Imagine what public transportation would look like if all the operators had to purchase and maintain their own vehicles, and if they all had total freedom about what routes and vehicles they were going to run? If I’m going to be forced to buy a bus, you’d better believe I’m going to choose the best paying routes in the nicest parts of town. Then again, why bother? How about if I just get a Mercedes limousine, and limit my practice to shuttling rich folk back and forth wherever they wanted, almost like a “concierge”?

And no, Nurse Practitioners and Physician Assistants are not the answer either. In the first place, despite their lofty opinions of themselves, as a group they are not capable of replacing primary care physicians. I think that non-physician providers should care for healthy people and doctors should take care of sick people. Let the NPs do well baby and preventive care til the cows come home. Most of it is education anyway, which is their alleged forte. (Spoiler alert: It’s mainly because they have more time to spend with patients.) And in the second place, it’s just as hard to get NPs and PAs to set up shop in poor, rural areas as it is to attract doctors. Hell, most of them avoid primary care as well, and why? It doesn’t pay well enough. What a surprise.

Here’s a thought: make medical school (college too) affordable to everyone qualified who wants to go. Then see what that physician distribution issue looks like in ten to fifteen years.



  1. Totally true and exactly what Sydney talked about in her MDTalk. Same issues with dentists. The licensing of dental health practitioners is a scary one! Right out of high school with two years of training doing irreversible procedures including “easy” extractions. What is an easy extraction? BTW, loved your Inquirer article today!

  2. Loved this!

  3. How do you propose to make medical school more affordable? Shorten it or have it heavily subsidized by the government? No, let the free market set the price of school, our pay and govern our competition with less trained NPs and physicians using PAs.

  4. […] Closing: Oops; she’s at least partly right; poverty and wages; TLDR veggies are good for you; […]

  5. So true. I’m in the process of applying to medical school after several years in the medical field and a non-linear path to choosing to study medicine, and I really want to go into primary care. As an older student with a family to support, I’m honestly concerned that I’ll still be paying off student loans when I should be retiring!

  6. All true. It’s very hard to keep anybody in a rural area. A guy in a clinic in one of the underserved areas told me they never could keep an MD once he’d done his time to pay back for school. The bottom line, every time, was “my wife hates it here.” And that, my friends, is the other reason for maldistribution.

  7. As a sub-specialist working in a rural area, it’s harder. We don’t have access to all the subspecialists, the socio-economics are worse (more un-insured and underinsured, etc). In general, patients with means go to the big city. My colleagues in the big city don’t have to take care of uninsured because they can just send them to the Big City County Hospital. For some reason, medicare chooses to pay more for patients seen in the big city because of that cost of living fudge factor (when they aren’t taking care of uninsured…..). I certainly wish we could get credit for our work for the uninsured and under-insured. If you want to look at ease of practice, stay in the city for sure (and the economics will be better as well). It is far more than just the cost of medical school.

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