Efficiency, not more doctors, is the prescription for aging population

Dartmouth research challenges calls for increases in physician workforce

HANOVER, NH – Recent news reports that threaten a shortage of doctors to treat the burgeoning elderly population are wrong, according to researchers at Dartmouth Medical School's Center for the Evaluative Clinical Sciences (CECS). In a study published in the March/April issue of Health Affairs, they argue that if employed efficiently, the current supply of physicians and medical students will be adequate through 2020.

In recent months, the Association of American Medical Colleges (AAMC) and others have called for expanded enrollments at medical schools, arguing that population and economic trends will necessitate an increased supply of physicians. But David Goodman, MD, and CECS colleagues assert that shifting the current workforce to more efficient practice styles would avert the need to train additional physicians.

"Spending millions of dollars annually to expand our capacity to train physicians will not only create an oversupply, but will also divert health care dollars from care that has been shown to improve the health and wellbeing of patients," said Goodman, professor of community and family medicine and of pediatrics at Dartmouth Medical School.

Instead of expanding the number of physicians being trained, Goodman and his team write, efforts should be aimed at increasing the efficiency of medical practice and directing resources to care that has been proven to be effective. They point to large interdisciplinary (or multispecialty) group practices, a structure that has been in place in many parts of the United States since early in the 20th century, as models of both clinical excellence and efficiency. One such practice, the Mayo Clinic in Rochester, Minnesota, is widely viewed as one of the most outstanding providers of medical care in the United States, despite using fewer doctors and fewer resources in managing of patients with chronic illnesses when compared to other academic medical centers.

Using the Medicare claims database to examine the experience of chronically-ill people who received most of their medical care at academic medical centers, the researchers calculated the physician workforce inputs per patient during their last 6 months of life. Their analysis found that the full-time equivalent physician input per 1,000 chronically-ill patients varied by a factor of five, from about 6 per 1,000 to almost 30 per 1,000.

For example, patients treated at the Mayo Clinic used fewer than 9 physicians on average, among the lowest in the country. By contrast, patients treated at New York University Medical Center, another medical school-affiliated facility, used 28.3 physicians per 1,000 in the 6 months before death.

"Both of these models can't be 'the best'" way to provide medical care to the chronically ill," Goodman said. "We believe that, in fact, less is more, and that quality of care, rather than quantity, is the critical factor"

The research focuses on the management of severe chronic illness because it is the area where health care resources are most heavily used--about half of Medicare's budget goes to the care of chronically-ill Americans. Additionally, the need for such management is expected to increase as the population ages and baby boomers acquire a growing number of ailments such as Type II diabetes, congestive heart failure, and chronic obstructive pulmonary disease.

Prior studies by CECS, published in the Dartmouth Atlas of Health Care, have demonstrated that in some parts of the country, people with severe chronic illnesses receive more physician care in visits, hospitalizations, and procedures than people who live in areas with fewer physicians per capita. But contrary to popular belief, patients who have more doctor visits and treatments do not realize a benefit. Indeed, evidence shows they may actually be harmed by unnecessary medical care, Goodman said. If all medical practices adopted the practice style and resource use of efficient providers, patient care would cost less and patients would be less subject to interventions that could do more harm than good.

The argument for expanding the physician workforce is based on a faulty assumption, according to the authors. Proponents reason that the practices of the highest-intensity medical centers where many more doctors and resources are used in providing medical services at the end of life, should be the standard for the country as a whole. "Instead of financing further growth in our medical education system, resources might be better directed to reorganizing delivery systems that have already demonstrated that they can deliver good care at relatively low cost," the authors write.

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This study was funded in part by the National Institute on Aging and by the Robert Wood Johnson Foundation. In addition to Goodman, co-authors of the study are Dr. John Wennberg, director of CECS at DMS, Chiang-hua Chang, research associate at CECS, and Dr. Therese Stukel, research director at the Institute for Clinical Evaluative Science in Toronto, Ontario.


Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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