More Physicians? Not the Answer

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I recently attended a reception for those who have served as interviewers for prospective students at the Virginia Tech Carilion School of Medicine.  When the new class matriculates this fall, the medical school will have a full complement of aspiring physicians; almost 170 in number.

Hayden Hollinsworth
Hayden Hollinsworth

VTC, as the school has become known, has had a remarkable history in the years since it first became an idea.  They have passed every benchmark for accreditation thus far.  The students have lived up to the expectations of the admissions committee.  The rising senior class was above the national average in their tests scores at the end of their second year.  The class entering this fall exceeds the national average on the Medical College Admissions Test.  Dean Cynda Johnson and her faculty have every reason to feel proud of their accomplishments. 

We now hear that there is a push for even more new medical schools.  I must admit that there was skepticism when VTC was proposed here in Roanoke.  Clearly, that has disappeared.  Now there is discussion of a new school in Abington, which seems an unlikely location, but perhaps not.  Surveys suggest that in the coming decades there will be the need for tens of thousands of new physicians.  This is particularly true of rural and underserved areas.

There is a problem with this.  Over the past decades efforts have been made to find physicians for such places.  New residency programs for primary care physicians have been developed with the hope the graduates would locate where there were few doctors.  Such has not been the case and the reasons are obvious, but not often stated.

When a graduate from medical school and post graduate training has accumulated a large amount of educational debt, often in the hundreds of thousands of dollars, is an average age of late 20s or early 30s, the pressure to earn money, and lots of it, is a practical necessity.  There are children to educate, pension plans to fund, in addition to retiring that massive debt.  Going into practice in a disadvantaged or rural area is unlikely to meet any of those needs.

After the grueling years of training the idea of being the only physician in a large area is less than appealing.  The onus of being on call every hour of the day and night is quite real.  Additionally, being the product of all the training modern medicine can offer, it takes a missionary zeal to leave that technology behind and rely on much less in available resources.

The result of these factors is that the vast majority of physicians completing their training locate in or near cities where there are the medical and social amenities to which they have become accustomed.  In my decades of involvement with medical education, I can count on one hand the number of graduates who have chosen the rarely travelled path of rural medicine.  On the other hand hundreds of our finest physicians in Roanoke are the product of training programs like Carilion or similar institutions.

The establishment of dozens of new medical schools will not address this problem.  Those new physicians will be seeking the same types of practice opportunities that have been attractive in the past decades.

The answer lies not in opening new medical schools or training more physicians but in changing the face of health care providers.  That used to mean physicians only, but if we are going to provide adequate care to underserved and rural areas, it will mean expanding the role of nurse practitioners and physician assistants.

Physicians of my generation have jealously guarded our craft.  Only MDs or DOs should deliver care, write prescriptions, and carry out the role of physician.  That model must change.  Physician extenders should work under the aegis of fully licensed doctors, a concept that nearly everyone endorses.

Their training will be rigorous, although much shorter and less expensive than the traditional MD or DO.  The Jefferson College of Health Sciences and other institutions are already in place.  Their graduates as nurse practitioners or physician assistants are more than capable of handling a large percentage of what primary care doctors are currently offering.

For those still seeking certification as primary care physicians they will need additional training in oversight of a number of physician extenders.  This will be a sea change in the professional life of such doctors but it is, I believe, the only solution to the predicted shortage of doctors in the locations where they are most needed. Hoping that the training of more physicians will eradicate the deficit in care has been a vain hope in the past decades; it will remain so until a new approach is addressed.

– J. Hayden Hollingsworth, MD, FACC