Medicine’s Creepy Problem – Part 2: The Congressional Tango

We continue our discussion on exploring the topic of the NP/CRNA/PA scope creep from Part 1: Turf Wars. Here, we discuss the origin of the debate and the societal forces for why such issues exist to begin with.

The (Absolute) State 

There is a proverb in Chinese: “Birds die for food and humans die in pursuit of money.” It highlights the idea that the ultimate driver of conflict between people is often financial. No other time in American history has the questions of the costs of healthcare come under the scrutiny of the public eye as today, and I believe that the financials of this particular turf war illuminate much more than the surface-level disagreements.

The case brought forth by Nurse Practitioners is as follows: wait-times are spiraling out of control, with 6-month waiting periods to see family doctors and primary care physicians, while preventative care is being completely ignored as patients are turned off by the costs and waiting times for ominous signs and symptoms that don’t yet affect their daily living. If we’re talking about patient safety, shouldn’t we give the American public the choice of going cheaper?

So… Are They?

The United States spends a total of 17% of its massive GDP on Healthcare. Compared that to averages of other nations, which is 8.6% one by OECD countries (Organization for Economic Co-op and Development, sort of a stand-in for statistics relating to the global economy). Now we can 

Figure 1: Pictures, Yay! [Citations]

Now, there is a discussion about the quality of the care derived, we won’t get into that here, but it matters little to those struggling in the system how high quality the care that can be delivered is if one cannot afford it. If studies are finding that medical costs are contributing to at least 46.2% of all bankruptcies (compared to say, nations with nationalized healthcare where that number would be 0%), we begin to understand how much of a luxury being sick is.

Despite these exorbitant costs, hospitals still seem to be running on razor thin margins, with 673 hospitals at risk of closing in rural regions. 

How is care so expensive and yet hospitals make so little money? Well, there’s some bad news…

Out of the many anchors weighing down the costs of healthcare, everything from drug pricing to the insurance circus is certainly omnipresent, but a factor we certainly don’t bring up very often is…and please don’t hurt me… the cost of physician services.

My Mind on The Money and The Money On My Mind

We already know about many of the big culprits of medical care costs that are unfair and should be addressed accordingly. This article is also not to argue that physicians in the United States are overpaid (nonono), but are rather forced into a situation of overwork, and being stretched out too thin, and thus costs have to rise naturally in response to scarcity. 

Here is the documented change in physician salary over the years:

Figure 2: (note the equally rising salary of nurses, who are also in high demand)

What changed between the 1960’s and now? Is it the same in other nations? Survey says no, the average salary for US physicians is also #1, with a significant gap over the next best (Germany) as well.

Why do physicians refuse to accept less than competitive pay, especially when it comes to living in less than desirable places outside of the comfort of large cities and away from the allure of academic centers? This fact has not come under as much scrutiny precisely because we are well familiar with the reason. With physicians, the difficulty of getting into medical school, financial costs, and opportunity costs have long been well-known and extensively calculated. This median of $250,000 debts is already widely known as the driver of a general increase in specializing, and with a scarcity in place, market economics leads us to the conclusion that the natural result is rising costs of labor that is exclusively done by a group limited to just over 26,641 graduates a year (MDs + DOs). With residency salaries paying a median of only $64,000 annually, physicians have become the ultimate masters of delayed gratification, waiting an absurd number of years until they become attendings to finally plug the financial wound that they’ve inflicted upon themselves. Studies looking at the finances of a physician across their careers conclude that physician pay has mostly kept pace with inflation since the 60’s but with the added burden of increased education costs, thus lowering overall lifetime physician compensation compared to the past. 

Thus, these “unavoidable societal factors” leave us with an estimated 37-124 thousand estimated physician shortage. Especially in the areas of primary care in rural areas, and the effects are crushing all Americans, especially those of lower income. As such, we’ve found ourselves in a full nelson of cost increases.

I have personally gotten tired of chanting “increase telemedicine” in our healthcare administration class, and I suspect administrators have too…

Image not related to anything in particular. (credit for original meme: owlturd)

Given the increasing quality of education for both professions, it is understandable why I suspect many administrators begin to view a redefinition of the two roles as necessary. Motivated by the thought of an Excel budget sheet finally in the black, decision-makers in the industry seem to want to nudge the physicians further towards climbing higher in the ivory tower and becoming academics responsible for the development of basic science while carving out a new role in primary care for nurse practitioners and physician assis-sociates.  

The Original Sin (of Medical Education)

Why not just increase the number of trained physicians? If the issue of increasing costs of medical education stems from market forces related to the scarcity of medical school spots, the issues involving physician burnout and overwork, and the shortening of clinic visits related to the lack of physicians available to perform them, why not simply increase the number of residency spots available in the country? Doesn’t this kill two birds with one stone?

Well, as Allie from The Notebook would say, “It’s not that simple.” 

In 2010, Smith et al. published a study forecasting the expansion of radiology oncology as a field, and now it has become one of medicine’s “cautionary tales.” Over 10 years, there has been a 50% increase in residency positions being added;  meanwhile the reality of the field went against the original prediction. Rather than expand, the need for radiologists contracted creating a market situation where the ratio of residents to cases increased dramatically. Right now “word on the street” for those wishing to specialize in rad onc is to go big or bust and that they would face more uphill battles in their coming years to find competitive jobs with salaries nowhere near as competitive as their predecessors. “Word on the street” is that the same might be happening to Emergency Medicine (EM) now. [Myself and the Pulse take no responsibility for SDN prediction accuracy, we are not career advisors, and this is not meant to be career advice]

These so-called cautionary tales highlight the deepest fears of physicians and those going through training. These are the fears that all the sacrifices they have made up to now will be rendered useless by a simple stroke of the pen. That the expansion of more fellow practitioners into their field isn’t “lightening the load” and allowing one to focus more time on providing quality, personable treatment to fewer patients, but something that adds competitors who are taking away business and decreasing their yearly salaries.

The Great Cap of 1997 (Balanced Budget Act 1997) is one of the main policies that dictates the maximum number residency spots by tying government funding (actually the funds for residency spots are funded through Medicare) to training of residents and limiting the number of doctors that could be trained (back then there was a concern there would be too many doctors). Overall, the system of residency training spots and salary can be said to have simply been “locked in place” since the 90’s, with everyone throwing up their hands and pointing to the law as the reason for why market forces have not been in play when it comes to residency. The law inadvertently created a captive workforce entirely at the mercy of the programs they matched at, whose soul-crushing debts are held over their heads as they struggle to learn with no recourse against their respective programs and the system at large. (Hey, it’s like the Squid Game!)

With the aforementioned shoestring budget of administrators, what inclination would exist to increase the pay of a workforce that holds absolutely no bargaining power? Even though residents and fellows have provided a bulk of the work in whichever center they work at, they are only paid $3/hour more than what a fresh out of college intern is paid. This is despite  a challenging workplace where lives are on the line and where the 80 hour ACGME cap is often violated.

All this comes back to the “social burden” of being a physician – where we are repeatedly reminded that physicians are public figures that must exemplify the peak of everything. Only the cream of the crop may exist as a “doctor” and treat patients. This is the justification given for the absurd working conditions of residency, its length, and the cost of medical school. Thus, exists the deep bitterness of physicians whose expertise and competency are now called into question as waiting times grow and visit times shrink. At the very heart, I choose to believe both sides really care about patient safety, with physicians concerned for the traditional model of having all patients seen by the highest quality of expertise in order not to miss diagnoses and mid-levels arguing that half-year waiting times, sub-15 minute visits, and massively overworked residents are safety concerns in and of themselves.

So, where do we go from here? We’ll try to take a stab at that next time on, Medicine’s Creepy Problem- Part 3: Where Do We Go, Cotton Eye Joe?