Tuesday, September 7, 2010

Staggering Physician/Patient Ratio for the United States and the Chronically Ill

I ran across some statistics today that stopped me cold...

If the population of the United States is anywhere near the 2010 estimated 307,212,123 people in this post, and the AMA's rounded off figure for the number of practicing physicians is anywhere near accurate, the scary thought for me as a chronically ill patient is - "How are we all going to be able to receive the health care we need when we need it?"

Again, using Spurtler's figures in his post in the WEGO Health group Health Activists And Public Policy 500,000 health care providing physicians to 307,212,123 people seems dangerously high.

Just how high is it? Let's take a look:

Upon further investigation the United States (#52) ranks right down there with #51 Cyprus and #53 Slovenia in terms of the number of physicians per 1000 patients (2.3:1000), and that was in 2002. For comparison, Germany ties with Austria at #23 with 3.4 doctors to 1000 patients, France is #25 with a ratio of 3.37:1000, Italy is #8 and 4.2:1000, and Switzerland is #17 and 3.6:1000.

Thinking that in a pinch you'll choose to head to Mexico or Canada to get the health care you need? You might want to think again. Even further behind us are #58 Canada and the #55 UK, and followed distantly by #79 Mexico.

On this table the 2002 research states that the US has approximately 2.3 doctors for each 1000 patients. That translates to 435 patients for each physician. Spurtler's new AMA figures drops those numbers considerably to 1.628 doctors per 1000 patients, or another way to look at it - 615 patients for each doctor. This is a 41.4% increase in patient load for our doctors in only 8 years!

Photo copyright Ellen Schnakenberg 2010 - One family of geese with 20 goslings at Greater Ottumwa Park - Ottumwa, Iowa

If you were to have a 41.4% increased work load on you over the last 8 years, what would you do? How would you deal with the increase?

This is certainly a drastic change and indicates the deficit in the number of new physicians has not been able to keep up with the number of patients they are serving. If those 2010 figures are compared to the 2002 table mentioned above, the United States would drop in rank to #73, smack between The Virgin Islands and South Korea.

Providing our population stops growing disproportionately to physicians produced (subtract physicians retiring - keep in mind that baby-boom doctors will soon be retiring by the handsful) and each patient has only a single physician, right now that is 615 patients per doctor to carry us into the new millennium - if every doctor is able to manage the same number of patients, which we know is not possible.

Add to that the large number of illegal aliens that are not being counted in these numbers...

Add to that the growing percentage of geriatric patients in need of continuing care...

Add to that, most chronically ill patients of any age have several doctors...

... and the load becomes apparent.

The numbers are not adding up to a manageable picture and I am afraid we are very quickly headed for trouble...

Were you surprised by any of these numbers?

Do these numbers give you any more or less understanding for your own health care experience?

Views: 1223
Comment by Arnon Krongrad, MD on September 8, 2010 at 12:13am
We developed a mobile model to provide surgical service to Americans using facilities abroad. It works and we have relationships in Mexico and the Caribbean. However, there are special issues and you are right for more reasons than you cited. Want to go to Monterey for a knee replacement? Do you mind driving around in a bullet proof van? It's complicated. And, as it turns out, there are ways to just lower costs here.

The broad issue is the evolution of American culture, which has transformed itself into a second-guessing army of compliance officers. Why do you think Poland beat us in getting help to Haiti? They don't have seventeen layers of compliance to go through before every decision. And why do you think anesthesiologists in Trinidad efficiently move patients out of the OR at the end of the case? They don't have to worry that a low-level insurance clerk will deny the claim if some post hoc analysis of "core measures" is imperfect. The problem is very, very broad. Medicine is just one example of the fact that we just don't trust each other.

Good news: We have more military lawyers than Europe has soldiers. We're number1. :-O
Comment by Ellen S on September 8, 2010 at 10:08am
Oh wow. More military lawyers than Europe has soldiers? That is disturbing on so very many different levels.

In order to ask ourselves how to fix the problem, I suppose the first question is - why have we transformed ourselves into a second-guessing army of compliance officers?

I hate to say it, but so many times I see people acting the part of the victim or being greedy - greedy for revenge and money - from BOTH directions.

Why does this happen? I think a lot of it has to do with time. If our doctors had/took more time to spend with patients, even when there is a mistake made there is that relationship to fall back on. There is understanding. This is one reason these figures really frighten me as a patient - we don't have enough time with our physicians for them to see the whole health picture or even be seen as a human half the time as it is now. When your case load has doubled I fear it is the chronically ill who will be left behind.

Doctors I know personally have come to this area expressly because there is a large population of Amish. Amish pay in cash and they don't sue, and especially for OB/GYN's this is very attractive. These doctors can relax and not lose sleep at night because they're worried some unhappy patient is going to try to take away their life savings.

You know, it's okay to say "I'm so sorry, I'm human". Patients forget that physicians are human beings and you are doing your best with what you have.

For some reason patients think their physicians are gods, and when their gods fail them they get angry. They have been slighted, wronged, or are otherwise the victim, but this only happens because they are not encouraged to learn about their conditions and to become proactive in their own care. From the perspective of the patient, they are being "forced" to trust the doctor, so when the doctor is wrong there is real reason for anger.

Unfortunately, as a patient who through the years has been forced to see several doctors, I have seen many who perpetuate this godlike behavior which goes far beyond simple due respect. This is discussed frequently in online support groups as well and is seen as an enormous problem across the board. Instead of our doctors acting as trusted and learned friends who are there to do their best to help us, they enjoy and perpetuate the godlike station to which patients (in their ignorance) elevate them. Physicians don't ask questions, refuse to admit they may not know every answer or that they may be wrong. They refuse to see the patient as a fellow human being who is vulnerable. Healthy relationships are not nurtured from either side. There simply isn't enough time!

Honestly, I see the lack of personal time as the big bad black evil demon here, and I see it growing exponentially in my lifetime. This is what scares me. Where is this going to leave my children???
Comment by Arnon Krongrad, MD on September 8, 2010 at 10:19am
So now ask: Why do American doctors spend less time? Why don't they take email correspondence? Why are they less and less service oriented? One reason is that they are American, not that they are doctors. America is progressively a less thoughtful, service-oriented culture.

Consider my friend the baker who had to take back 100 carrot cakes covered with coconut from a convention hotel. Why? Because somebody in event planning was told a guest had a nut allergy and absolutely -- for fear of lawyers -- refused to hear that coconut, like peanut, is not a nut. And all the assurances I helped to bring from my friend the senior rheumatologist made no difference. It's second-guessing, CYA all the time. So my friend the baker, because of meddling third parties, spent less time with her clients, children ...
Comment by Ellen S on September 8, 2010 at 10:42am
I assume one of the big reasons physicians spend less time with their patients is because of those awful numbers I listed above. You deserve a family life and when you have 50 patients in a day banging on your door, you try to get to as many as physically possible. You take time out of your family time to deal with patients, which I know is frustrating. Am I close?

As a patient, I know how difficult it already is to get an appointment. I have doctors in which I make an appointment in March to be able to get in to see them in June. And I am an established patient! To get a new appt with these doctors is nearly impossible. Additionally, I drive 4 hours to see 3 of my doctors, because either there are none in that specialty near me or those that are near me are too booked to be able to see me. My entire family sees one of them, so we carpool and every couple months he graciously schedules us together in a block of time in which he generally does not see patients at all. It's the only way he can fit us all in together without us having to schedule a year in advance.

Let me ask you this question - If you didn't have so many folks banging on your door needing to be seen each day, would you - personally - make the attempt to spend more time with the patients you see? Or would you instead choose to keep appointment times the same, squish all patients into a 4 day work week and take an extra day off? (I ask because that is what most doctors here do, usually a Thursday for golf)

I do hope that being American does not mean that we cannot be service oriented. Yes, it may make it more difficult, but here in America you can make your own choices. Each of us gets to choose how we spend our time and our day. For me, I choose to spend about 8 hrs a day in service of others. I sit here plunking away hoping to help patients find the information they are not getting from their physicians or elsewhere, so they can take charge of their care and not go blindly forth. With education comes choices and the best informed decisions. This is what I've lived, and this is the service to which I've dedicated myself, as do many other Health Activists. I assume that, as you are here taking time to read and respond to posts, you are the same. My figurative hat is off to you for those efforts. Personally, I won't get financially rich doing it, but folks are living better lives as a result, and that's what it's all about for me. That itself makes me richer than most people I know...
Comment by Arnon Krongrad, MD on September 8, 2010 at 10:55am
The issue is the illegitimate third parties who parasitise the system, taking time and money as they go. How many cents of every health care dollar go to Wall Street profits for devices and medications that bring no actual bedside value? How many to defensive medicine? How many to billboards on the highway and hospital marketing departments that send clerks to tweet from the OR? How many to insurance auditors? Considering that these parties do not actually deliver health value ... you get the point. We're focused in this thread on the health care example. The problem is much broader. The carrot cakes illustrate that well.

I really love being a doctor. I love working with my patients. They have my direct email, which I answer any time, any day, right from my Blackberry. But do I have any patience for an insurance clerk who calls to authorize a CT scan for new onset back pain and vomiting and asks: "Doctor, is there a differential?" You want two minutes of my time? Sorry, they go to that clerk.
Comment by Ellen S on September 8, 2010 at 12:00pm
Aaah, see? I knew you were one of the good ones :)

So, 615 patients per physician (provided each patient only has one doctor) does not seem excessive to you? An increase over 8 years that is estimated as 41.4% doesn't bother you at all? Granted not all patients seek medical attention every year, but many should and I think with the new health care system about to take effect, they will. I hear you on the *parasites* with their hands out, and this too is wrong. My shock is still those numbers - 615 patients per doctor and an increase of 41.4%. I just don't know how we can keep this up...

Insurance is saving me and killing me at the same time. I could never afford my treatments without it, but it is almost literally a full time job dealing with them and their manipulation just so I can get my doctors paid. For me, my next step is taking it to the insurance board of our state to see if we can get some action. I doubt that will make a difference though. What's a patient to do to free up our doctor's time so it can be utilized where it is needed - with patients?! What can we as the public and as your patients do to help?
Comment by Arnon Krongrad, MD on September 8, 2010 at 12:14pm
Shut down the law schools. Get out of Afghanistan. Teach civics. Dust off e pluribus unum.

For medicine to work well, we need a cultural shift that starts with individual responsibility. Because there is no way to legislate morality, if we don't start to act like a community -- one nation, indivisible -- we'll never get doctors, who are almost on the periphery of the health care equation, back to the center. For example, fire elected officials who demand Cornhusker Kickbacks and pork. Demand that instead of having lawyers write health legislation we have patients and doctors write it. Seriously, having lawyers write health care is like having gynecologists write space exploration reform.

There are ways to save tons of money so it can be better spent at the bedside. Our mobile surgical model is one tiny example. But if we don't trust the doctors to do this ... oops, there it is again: We need a cultural shift to trust, service, accountability, civility ...
Comment by Diana Lee on September 8, 2010 at 1:00pm
Um, why demonize an entire profession to discuss this issue? I'm a lawyer and a patient and patient advocate. I actually used to write legislation and let me be clear that I did not set policy. Unfortunately that is not how it works on the federal level. Would we rather have a country where there were no legal protections? I wouldn't. I think we can reach a happy medium. But I suppose it is typical of doctors to hate lawyers. The way the cookie crumbles.
Comment by Spurtler on September 8, 2010 at 1:23pm
Thank goodness we have an MD in our midst who applies his SOAP skills both to his patients and to the community in which he lives. I won't say that I totally agree with him for, I'm sure, we haven't heard all his opinions and I can't agree to agree in the future. For the moment I'll accept his assessment of the major cause and effect arguments on our rush to litigate, a congress voted by the people and paid by lobbies and corporations (you should see my political blog to know how I feel about this one - I'm not linking because you'll throw me out of this group), our acceptance of waste, for-profit health care (another bete-noire for me), and health insurance that interferes with the therapy based on cost (who says death panels are exclusive to the government?). The one issue the good doctor cites and I can't accept is the removal of compliance. I am in the middle of composing some posts about whether or not you can trust the clinical test results that labs perform. As a former CTO of a LIS software development company I have many contacts in this niche community and there are some distrurbing issues that could be prevented with more exhaustive policing of lab practices. So I give Arnon nine out of ten for nail-head strikes.

We are becoming a nation of nut-f*ck-whackos whose model is more Gordon Gheko than St Francis of Assizzi; more Jesse James than Florence Nightingale. Sometimes I just want to bail and then the engineer in me says "Fix it!, Fit it now!".
Comment by Arnon Krongrad, MD on September 8, 2010 at 1:35pm
Diana Lee,

As noted above, the cookie also crumbles with carrot cake.

As for doctors and patients: When I can save an insurance company 40% on major surgery costs, which I do routinely for uninsured patients, and their legal teams hold up a contract for months due to undislosed deliberations and laws that may serve them but not patients, yes, I have a major problem with lawyers: They cost money and put up barriers to care.

Sure, we need some rules. Some compliance. But how much? As the world's leading producer of lawsuits, we're way beyond the "happy medium" you refer to. Can we really legislate and sue and spin ourselves into a functional, happy nation?

The fact is we have too many bureaucrats, compliance officer, lawyers, and lawsuits. Is the legal profession -- are you? -- proud of such sociopaths as John Edwards? Is he a welcome part of the "happy medium?"

The Death of Common Sense pretty well spells out what most of us already know. And as for my opinions, as reviewed above and in the recent Tony Blue Eyes, the problem if broader than just the lawyers.

Join me in calling for a law school holiday. We've got as much justice as we can possibly handle.
Comment by Spurtler on September 8, 2010 at 2:29pm
My commercial philosophy has always been that all characteristics, both good and bad, start at the top and are disseminated throughout the system. At the top of our social system are government, religion and commerce. Today, I see no evidence of any of these systems perpetuating what I call socially redemptive values. I don't think the challenges you cite are merely legally and govern-mentally spawned. I think all three societal leader groups are unworthy of their responsibilities. I also think citizens are rightly burdened with the responsibility to shout when they see wrongdoing. Not voting is a vote! We need whistle-blowers, not compliance officers (but, then we'd have corrupt whistle-blowers, sadly!).

I'm a US Resident, not a citizen, so I have lived in other societies that do not share the challenges of the US. They have their own challenges. However, you will never remove greed and fear as motivators in any type of society. You just need to hold your own character values and also surround yourself with those who share these values. Over time, society can change. Let's hope its an improvement!

Ok, now let's get back to health care activism.
Comment by Denis Van Loan D.D.S. on September 15, 2010 at 2:51pm
Thank goodness I am retired from dentistry. I only see the health care problems getting worse with the implementation of the comprehensive health care plan by the government. It doesn't target dentistry yet, but I'm sure it will follow if the process is not reversed. In my view there will be a disincentive for aspirants to become M.D.'s. Those, already doctors, will will soon be over whelmed with the millions of patients added by the government health care plan. When politics and government get involved I see a deterioration of health care. Politics have a way of trumping what is best for the patient...Denis Van Loan D.D.S.
Comment by Arnon Krongrad, MD on September 15, 2010 at 2:57pm
 Denis, of possible interest: In Defense of Physician Autonomy.

No comments: