Where are all the doctors?

Our country, and the world, has a longstanding problem with so-called physician maldistribution. As doctors, we prefer to work in wealthier areas because of the associated opportunities, amenities, and prestige. And we know that the areas with the fewest doctors – that is, poor rural and urban regions - tend to have worse health outcomes. In 2009, as one example, there were 78 deaths per 100,000 that could have been prevented with timely and effective health care in Massachusetts, versus 142 per 100,000 in Mississippi:

We talk a lot about a physician shortage on a national level in the wake of the Affordable Care Act (ACA) and the growth of our elderly population. With an additional 32 million patients insured, the AAMC estimates a shortfall of 63,000 doctors by 2015 and is pushing for medical schools to increase enrollment by 30%.

But the math isn’t as simple as more doctors = better care, and the answer isn’t as easy as augmenting our workforce across the board. Projected shortfalls, which are simply extrapolated from existing doctor to population ratios, don’t reflect the elusive “right” number of doctors per 100,000 citizens, in part because we still don’t know the true impact of physician workforce on the population’s health. Complicating this calculation is the fact we can be a lot more efficient in how we practice, especially in teams with other health care professionals. And there’s growing evidence that too many doctors can lead to the overuse of health care resources and worse outcomes.

Without targeted efforts to send doctors to where they are needed, simply increasing our numbers will continue to widen the gap between Massachusetts and Mississippi, and lead to more over- and underuse of health care resources. In Nepal, the government produced a surplus of doctors in an effort to push more of them into rural areas, but most of them emigrated instead.

Japan is another case in point: In the 1970s, the Japanese government began requiring at least one medical school to be established per prefecture (essentially, county) to counteract physician shortages in rural areas. Between 1998 and 2008, the number of practicing physicians per 100,000 rose from 188.1 to 214.0, but the inequality of physician distribution remained constant.

Like Japan, but unlike many other Western countries including Canada, the United States doesn’t require doctors to practice in certain areas. I don’t think that will, or should, change. But we can continue to study this problem and take other steps to address it.

For example, we know that doctors who were born in rural areas or have had rural or inner-city training experiences are more likely to practice in areas of need, so we can use this knowledge to target prospective trainees. A few years ago, the Pacific Northwest University of Health Sciences opened a College of Osteopathic Medicine with the mission of producing doctors to serve in rural, underserved areas. Since the ACA was passed, we have had an all time high in trainees joining the National Health Service Corps, a program which repays medical school loans in exchange for service in federally defined underserved health centers. The list goes on.

What do you think we should do in the U.S. to ensure a more even distribution of doctors?