Wednesday, May 13, 2009

Do We Need More Doctors?

According to this commentary on CNN, the answer seems to be "no." Well, perhaps we should explore this a bit further. This story is written by Clayton Christensen, Dr. Jason Hwang (there's another common Asian name), and Vineeta Vijayaraghavan. Here's a bit of background:

  • Clayton M. Christensen is the Robert and Jane Cizik Professor of Business Administration at Harvard Business School, co-founder of Innosight Institute, and the best-selling author of six books.
  • Jason Hwang, M.D., M.B.A. is co-founder and executive director of healthcare at Innosight Institute.
  • Vineeta Vijayaraghavan, M.B.A. is a Research Fellow at Innosight Institute.
  • Innosight Institute is a non-profit think tank whose mission is to apply Harvard Business School Professor Clayton Christensen’s theories of disruptive innovation to develop and promote solutions to the most vexing problems in the social sector.

One point they make is this: "There is a shortage of health care services being provided, but many of them are not best offered by a doctor."

I agree with that statement. However, I also personally believe that we also have a shortage of physicians, especially when we look at rural and other types of underserved areas of this country. If you live in a major metropolitan area, then you won't have any problems finding a doctor (you may have a challenge finding one who takes your insurance, but that's another story). The authors acknowledge the fact that health care is unevenly distributed around the nation, but then they point out that "Studies of geographical disparities of care have demonstrated that more physicians will likely lead to greater intensity of care -- but not better health outcomes." So where does that lead us? What about all the incentive programs that try to drive physicians to these underserved areas? Are those failing?

The authors also argue that we need to embrace more eHealth solutions. I also agree with this point. Technology is making it easier for patients to receive some basic health services

So what's the solution? The authors propose this: "what the country really needs are policies that pave the way to more avenues of care, which is well within the government's control."


  1. Joseph, thank you for highlighting our op-ed piece on CNN.

    "What about all the incentive programs that try to drive physicians to these underserved areas? Are those failing?"

    In a word, YES. Rather than convincing doctors to go where they don't want to go, we ought to find ways to help nurses do more (and make more).

    "So what's the solution? The authors propose this: 'what the country really needs are policies that pave the way to more avenues of care, which is well within the government's control.'"

    Obviously the real answer is much more complicated, but there's only so much you can fit into an op-ed piece. For the full extent of our recommended solutions, please visit or read The Innovator's Prescription.

  2. Jason, thanks for your comments. Obviously, this is a huge issue that won't get answered in a few paragraphs. I hope to write more about this after I read your book.

  3. This conversation amuses me and at the same time scares me because it is very dangerous. It is ignoring the fundamentals, larger than ever elderly population and fewer doctors. Very simple. Geriatrics are nothing short of amazing medicine, to keep a body healthy that should be breaking down. Your common NP or PA are not trained to the standard that is needed to care for this selection of the population. To give the impression that they are is incredibly wrong. Please think for a lot longer of a time before writing gibberish like this. Think about your family and extended family and friends.

  4. An article like this seems to inspire a lot of fear from a lot of directions. Ignorance is the fertilizer of fear, and it is no different in this case. There is overwhelming evidence that expanded roles for paraprofessionals yields comparable outcomes at somewhat lower cost and greater accessibility in primary care environments. The evidence to the contrary is lacking. Much of the evidence comes from outside of the US, of course, and becomes a suspect of American exceptionalism.

    If there were truly an institutional recognition that a shortage of doctors exists, then JAMA would not publish articles and editorial pieces in virtually every issue attempting to refute the idea. The AMA and medical education organizations would not be lobbying so intensely (or successfully) to restrict visa and licensing requirements for foreign doctors (as opposed to engineering and science oriented applicants). People would begin to see through the haze that a wide array of services and skills are perfectly suited to be provided by well trained, non-doctor professionals.

    Americans (and others) are too ignorant of health care, too enamored by the apparent necessities of superhuman knowledge required to address a sore throat, too accepting of paying $180 for a povidone gauze wash kit, and too overwhelmed by the din of poor issue framing in this area to remember the three criteria of good health care: 1) outcomes, 2) outcomes, and 3) outcomes. If we focus on these relentlessly, costs will come down, more will have better access to effective care, and we will become citizens of a world that has grown up and moved on without regrets.

    If not, it will continue to remain less expensive to purchase a round trip airline ticket from Denver to British Columbia, get a simple skin check and biopsy by a dermatologist there, stay in a hotel, maybe do some shopping, and return than wait a month or more do the same here locally in any Denver area dermatology office. Everyone else outside of the US who is suffering from the evils of any one of the dozens of examples of socialized medicine with its scandalously lower costs, horrifically better access, and perhaps most distressing, the glaring improvement in outcomes will continue to regard the American health care edifice as increasingly irrelevant.

    The comments by doctors indignant over devaluation of a decade or more of training should have more to worry about as their profession goes the way of the auto manufacturers, steel workers, and other edifices of the realities of institutional quicksand. Health care cannot continue the trajectory it is on in the US- hyperinflation (with no shortage of scapegoats),worsening access,lower quality, etc. It is a bubble that will break, like real estate, steel, car making, ship building, manufacturing or any other of a hundred bubbles have broken in the US.