As someone who spends most of the day thinking about the health problems facing developing countries, it can be a little jarring to open up the Boston Global or New York Times to learn that in fact, we in the United States are facing a "critical shortage" of doctors. These figures are a few years old, but the U.S. has roughly 1 doctor per 400 population. This of course varies regionally, but is the national average. Meanwhile, in India, where I traveled a few months ago, the ratio is closer to 1:1,700. I still can't even begin to wrap my head around Malawi, where there is one physician per 50,000 people. I have almost as many doctors in my office as they have in the entire country.
Other people have written about this subject in great depth, so I will try to restrict my comments to what I haven't seen in the literature.
One comment I want to make though: salary is obvious a huge reason for migration, but I think the issue is actually much more complex than a lot of people realize. Almost no one trains to be a doctor so that they can stand by and witness patients die. Knowing how "simple" it would be save lives with adequate tools must only make this worse. I have heard surgeons in Uganda talk about splinting broken bones with cardboard. If physicians were motivated to take up the profession because they wanted to save lives or heal people, working in a system that fails to offer them the resources to do that will not satisfy that need. Another common complaint from physicians is that in order to further their training, they have to leave, because those opportunities do not exist locally. I just point this out because these debates usually focus on the disparity in salaries, which is no doubt the primary driver of migration, but I think that a lot could be done to improve local working conditions and work satisfaction that would also promote physician retention.
I recently came across this editorial in the Lancet and the following commentary. (For a more recent and tempered piece in the Lancet, check out this article from May, 2009)
As they point out, there are various ways to deal with the issues at hand:
1. Place legal restrictions on the movement of physicians: there are probably economic concerns with this one, but the fundamental issue with this argument for me is that physicians have rights too, so it's hard to argue that the "right to health care" of a larger group trumps an individual right to seek what he or she thinks is best for his/herself and family. I don't think I can stress enough the difference of scale that we're discussing here: a successful doctor with a private practice in say Kampala, Uganda would be wildly successful if he made USD 20,000 a year. I would guess that USD 5,000 is closer to the norm (again, for an urban area; rural physicians will make much less). In the U.S., the mean salary for a primary care physician is easily over USD 100,000, with specialists making much more.
Legal restrictions on physician practices have been implemented with limited success. Many countries now have a compulsory period that all graduating medical students must spend working in the public sector--Singapore and Rwanda are two such examples. I see this as a good idea, given the amount of investment that governments put into their medical students. But I doubt that it has long term consequences on how many practitioners choose to stay in the country and practice.
In many countries, public physicians are poorly compensated, so many take up private practice as well. In some instances, countries (such as Uganda, I think) have decided that public physicians cannot have their own practices. The result was that all public physicians left. Zambia requires physicians to work in the public sector to have their own practice.
2. Address the supply created by advanced economies: if rich countries (like the U.S.) would just invest adequately in training their own human resources for health, the old adage goes, there would not be the demand for foreign physicians, de facto limiting opportunities for emigration.
If we are systematically underproducing physicians, then I do think that we're morally obligated to expand the medical education system. It seems like that would be a good investment too--a cadre of highly skilled, in demand individuals that go on to contribute greatly to tax revenue. I'm willing to bet the ROI on physician education is pretty good for the U.S. government. So why haven't we seen an increase in medical schools? It's easy to pin it on the American Medical Association (more doctors may mean more competition,i.e. lower salaries), but there must be other reasons as well. It is an issue that I think American citizens should push for greater information on--particularly as the population ages and (continues) to get fatter, our need for health services will only increase. The Wall Street Journal recently had a piece by Darrell Kirch that spells out some of the legislation around medical education, and the unaddressed challenges to increasing the output of physicians (critical as we expand insurance to populations that previously did not have good access to health services).
What I don't hear often in the dialog, and I find critical to value-based health delivery, is the need to move away from our physician-centric system and recognize that other cadres of health workers can be equally (or more) effective in delivery some segments of care. In places like Malawi, reliance on other types of workers (sometimes called task-shifting) was a response to not having any physicians. In HIV care, nurses have become the primary caretakers of stable patients; lay people trained in community health provide social support and ensure that patients have high levels of adherence to their medications (important to preventing viral resistance, which will render the medication ineffective). In other places, such as Bangladesh, lay women with only basic literacy form the backbone of the tuberculosis program in rural areas, with very limited support from physicians. The examples of effective programs go on and on. In the U.S., however, there has been great resistance to these new models. The wrath that MinuteClinic has received from the medical community is one example of our bias. MinuteClinic, which one can often find at a local pharmacy, is managed by a nurse practitioner, and addresses a lot of common ailments with fairly straightforward diagnosis and treatment: pink eye, ear infection, urinary tract infection, etc. My dad recently got his vaccinations to travel there--it's infinitely more convenient than trying to visit the doctor's office.
The first time I heard about MinuteClinic, I thought, that sounds just like community health workers in Bangladesh. The principles are the same: what conditions can we do address without doctors and/or complex hospitals? How can we set up a program to make people likely to access services here? MinuteClinic is an early mover, but there are doubtlessly many other ways that we could and should improve access, quality, and health outcomes by moving away from physicians as the primary point of care. Other innovative models in the U.S. include a heart failure program at Duke that has really adopted a nurse-centered approach to caring for patients without complications.
So, I take issues with estimates from the Health and Human Services quotes in Kirch's article--that assumes that we don't redesign our delivery system to better fit our resources--and we'd be idiots not to.
I met Dr. Simi on my trip to Mexico last year. He's the mascot for a really innovative pharmacy company in Mexico, Farmacia Similares that's making a lot of money by providing access to basic medical services and well-stocked pharmacies, particularly to lower-income Mexicans. Where's the catch, right? Sure sounds like everyone wins. . . .
Posts
No comments:
Post a Comment