State lacks practicing physicians

40% of Md. doctors don’t treat patients, report says

By M. William Salganik | Sun reporter
http://www.baltimoresun.com

Although the state has plenty of doctors, it doesn’t have enough who actually see patients — a situation that creates “a silent and growing crisis,” the head of the state medical society said Monday.

The shortages are greatest in rural areas “but are likely to affect most of us by the year 2015,” said Dr. Martin Wasserman, executive director of MedChi, the professional society for the state’s doctors.

MedChi and the Maryland Hospital Association released a study Monday showing that the state has 179 doctors delivering care for every 100,000 residents. That is 16 percent below the national average of 212.

While the state has about 25,000 licensed physicians, the second-highest rate per capita of any state, nearly 40 percent are engaged in teaching, research and administrative duties, according to the study, and some of the rest spend part of their time in such nonclinical work. Many of those doctors work at the state’s two large medical schools and at federal facilities such as the National Institutes of Health.

The study comes as medical groups nationally also say that more doctors will be needed — a reversal of past warnings of impending oversupply and accusations of trying to limit competition.

Still, some scholars are skeptical about shortages. They argue that more physicians does not necessarily mean healthier people and reason that improvements in efficiency and technology can cut future personnel needs.

“Just having more doctors doesn’t necessarily mean better care,” said Katherine Baicker, a professor of health economics at Harvard.

The greatest shortages in Maryland, according to the study, were found in rural areas and in certain specialties — primary care, emergency medicine, anesthesiology, hematology and oncology, thoracic and vascular surgery, psychiatry and dermatology.

The study predicts a worsening shortage by 2015 as an aging population requires more care. At the same time, the physician force will experience more retirements. A quarter of the state’s surgeons are 60 or older, the study found.

There is a growing national consensus on the need to produce more doctors. During the past few years, more than 30 studies have projected shortages in specific regions and in certain medical specialties, according to a compilation in August by the American Association of Medical Colleges.

The AAMC is calling for a 30 percent increase in medical school enrollments during the next decade. That’s a 180-degree switch from a decade ago, when many of the same medical groups were warning of an impending oversupply of physicians.

While the Maryland study doesn’t look at whether patients are suffering because of the doctor supply, Wasserman said there is anecdotal evidence in crowded waiting rooms, lags to get appointments with specialists and difficulty finding obstetricians.

Dr. Carol Paris, a psychiatrist in St. Mary’s County, said she’s so busy that new patients have to wait six weeks to see her. Those with more urgent problems are directed to the hospital emergency room.

Paris said she was the only private-practice psychiatrist in the county until two years ago, when, after an 18-month search, she attracted a colleague to practice with her. At age 55, she said, “I’d like to start cutting back.” But Paris worries that she could lose her associate because of high demand for psychiatrists elsewhere.

Calvin Pierson, president of the Maryland Hospital Association, said hospitals and physician practices have reported increasing difficulty in recruiting new doctors.

MedChi and the hospital association are recommending steps to make Maryland a more attractive place to practice medicine, chiefly increasing the rates that insurance companies pay doctors. They also are calling for lower caps on medical malpractice judgments to cut liability premiums.

With malpractice premiums dropping in the state, the legislature has indicated little interest in reforms this year. Wasserman and Pierson said Monday’s report was directed primarily at a state task force studying access to care; it is due to report in June.

They also propose an expanded loan-forgiveness program to encourage doctors, particularly those who do their residency training in Maryland, to practice here. Competition to recruit doctors who are completing their residency is intense.

Dr. Michael Abraham, in his last year of residency in emergency medicine at the University of Maryland Medical Center, said: “I get two or three e-mails a day” from recruiters, particularly from rural areas. “They’re paying a ton of money in the middle of nowhere.”

Still, he and his girlfriend, a resident in pediatrics at Johns Hopkins, have decided to stay in this region. “I like to be in an area where I can see a lot, do a lot and still be around academic medicine,” he said.

Nationally, too, the reports find the greatest shortage away from urban centers and in certain specialties. “General surgery in rural areas is becoming a national disaster,” said Dr. Richard A. Cooper, a former medical school dean who is now professor of health economics at the University of Pennsylvania.

What is needed, he said, is a national push to expand medical schools to add more residency slots. The country is now training about 25,000 doctors a year, he said, and needs to train 10,000 more than that within 20 years.

But researchers such as Baicker of Harvard argue that there’s no clear evidence that more physicians make people healthier. Baicker was co-author of a 2004 study in the journal Health Affairs, using Medicare data, which concluded that states with high proportions of medical specialists scored worse on measures of quality care.

“It’s hard to know for sure how many doctors we need,” she said.

The Maryland study projected physician need by looking at the state’s population by age and calculating how much care would be needed, based on national benchmarks, said David Boucher, a partner in Boucher and Associates, the Syracuse, N.Y., firm that crunched the numbers. The national doctor supply figures aren’t calculated the same way, the study’s sponsors said, so the comparisons might not be exact.

Jonathan Weiner, professor of health policy and management at the Johns Hopkins School of Public Health, said warnings a decade ago about an oversupply of physicians — he was one of those issuing the warnings — led to a capping of medical school and residency slots.

Although there might be about the right number of doctors overall, he said, “I definitely agree we have real challenges of access, particularly in rural and inner-city areas.”

He said policy fixes should be targeted to areas of greatest need; it makes no sense “to give the same subsidy to a plastic surgeon in Potomac that we do to an inner-city primary-care doc.”
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