More isn't better

So says Dr. David C. Goodman, a professor of pediatrics and family medicine at Dartmouth Medical School who wrote “Too Many Doctors in the House” printed July 10th in the NY Times.

Can we cure our ailing health care system by sending in more doctors? That is the treatment prescribed by the Association of American Medical Colleges, which has recommended increasing the number of doctors they train by 30 percent, in large part to keep up with the growing number of elderly patients. But the most serious problems facing our health care system — accelerating costs, poor quality of care and the rising ranks of the uninsured — cannot be solved by more doctors...

The writer's argument centers on the findings of The Dartmouth Atlas of Health Care study.

Many studies have demonstrated that quality of care does not rise along with the number of doctors. Compare Miami and Minneapolis, for example. Miami has 40 percent more doctors per capita than Minneapolis has, and 50 percent more specialists, according to The Dartmouth Atlas of Health Care, a study of American health care markets (for which I am an investigator).

The elderly in Miami are subjected to more medical interventions — more echocardiograms and mechanical ventilation in their last six months of life, for example — than elderly patients in Minneapolis are. This also means more hospitalizations, more days in intensive care units, more visits to specialists and more diagnostic tests for the elderly in Miami. It certainly leads to many more doctors employed in Florida. But does this expensive additional medical activity benefit patients?

"Apparently not."

The elderly in places like Miami do not live longer than those in cities like Minneapolis. According to the Medicare Current Beneficiary Survey, which polls some 12,000 elderly Americans about their health care three times a year, residents of regions with relatively large numbers of doctors are no more satisfied with their care than the elderly who live in places with fewer doctors. And various studies have demonstrated that the essential quality of care in places like Miami — whether you are talking about the treatment of colon cancer, heart attacks or any other specific ailment — is no higher than in cities like Minneapolis.

Another finding, same conclusion:

The Mayo Clinic in Rochester, Minn., and the University of California, San Francisco, Medical Center each have about one doctor treating every 100 elderly patients with chronic illnesses in their last six months of life. New York University Medical Center has 2.8 doctors for every 100 such patients and the University of California, Los Angeles, Medical Center has 1.7. The elderly patients at N.Y.U. and U.C.L.A., as compared with those at the Mayo Clinic and the San Francisco hospital, see more specialists and are subjected to more imaging tests and other procedures. But the quality of their care, as judged by doctors, is no better.

So apparently even physicians believe more doctors do not make for better quality care.

How can it be that more spending and greater physician effort does not lead to better health or to improvements in patient satisfaction? One explanation may be that when more doctors are around, patients spend more time in hospitals, and hospitals are risky places. More than 100,000 deaths a year are estimated to be caused by medical mishaps.

The writer asserts that physician surpluses do not "remedy regional shortages," a stated aim of the AAMC. "But in the past 20 years, as the number of doctors per capita grew by more than 50 percent, according to our measurements, most of the new ones settled in areas where the supply was already above average — places like Florida or New York — rather than in regions that lack doctors, like the rural South."

This seems counter-intuitive. A doctor surplus in the city would drive salaries down. Thus, many doctors wanting greater financial reward would move elsewhere. But simple supply-and-demand economic incentives is, well, just that: simple. It does not prevail over every consideration as living in the city confers advantages that money can't necessarily buy.

Coming back to his argument, the writer believes adding more doctors is like throwing more grease to take out a fire.

By training more doctors than we need, we will continue to fill more hospital beds, order more diagnostic tests — in short, spend more money. But our resources would be better directed toward improving efforts to prevent illness and manage chronic ailments like diabetes and heart disease.

Better coordination of care is also worth investment. Small physician groups in disconnected offices often provide fragmented treatments, while multispecialty practices integrated with hospitals — prevalent in Minneapolis and some other cities — are associated with lower cost and higher quality of care.

All these strategies have been shown to improve patient outcomes without adding physicians. Instead of training more doctors, let's make better use of the ones we already have.