Cupcakes, Patty-Cake, and the Physician Shortage

Photo by zigazou76 via Flickr

In a recent New York Times op ed, anesthesiologist and mother of four Karen Sibert argues that physicians have a moral obligation to practice medicine full-time, an obligation that arises out of (1) the fixed (or even falling) number of slots in residency programs  and (2) the growing shortage of doctors, particularly primary care doctors.  It is fair, Dr. Sibert argues, to ask students who aspire to go to medical school “to consider the conflicting demands that medicine and parenthood make before they accept (and deny to others) sought-after positions in medical school and residency.”  “Women especially” should consider whether they are willing to fulfill the “real moral obligation to serve” that a medical education confers.  Those who cannot put aside their naïve “rosy vision of limited work hours and raising children” should choose another profession.

Unsurprisingly, Dr. Sibert’s salvo in what Michelle Au terms “The Mommy Wars, Medical Edition” swiftly inspired a vigorous and thought-provoking debate.  Dr. Au — like Dr. Sibert, an anesthesiologist and mother — calls Dr. Sibert’s “views sexist, inflammatory, and frankly discouraging” and argues that “medicine needs to catch up with the rest of society, and as such adopt some of the models other industries have created to recruit and retain the best and the brightest, regardless of gender.”  While conceding that part-time work is not possible during the “grueling training years,” Dr. Au notes that there are already “fields that present different structures to the workday and different practice models to recognize the full potential of modern physicians while also making the practice of medicine less inimical to family life.”  Others have taken Dr. Sibert’s side (see the letters and emails summarized here and here), with some making the additional argument that diagnostic acumen and surgical skill can decline with lack of use.

The relationship between the physician shortage and the increasing number of physicians who choose to work part-time may not be as straightforward as Dr. Sibert presumes. Several commentators have pointed out that an expectation that every physician practice medicine full-time for as long as he or she is physically able could actually exacerbate the physician shortage.  Carolyn Anderson, an ophthalmologist who works three long days per week, contends that discouraging part-time alternatives could deter entry into the field and make retention of older doctors more difficult.  Discouraging women from entering medicine could also backfire, because, although women physicians are more likely than men to work part-time, they are also more likely to go into primary care, and it is primary care physicians that are desperately needed.  More pointedly, it seems unfair (and likely ineffective) to try to solve a complex, multi-factorial, societal problem by asking individual young women — at the outset of their careers, typically before they have had children — to make morally-binding choices about balancing their work with parenthood.

Lastly, it would be easier for physicians and others to hear and understand Dr. Sibert’s arguments if her penultimate paragraph did not include the condescending concession that she “never took cupcakes to my children’s homerooms or drove carpool[.]“  Dr. Megan Duffy, who wrote into the Times in response to Dr. Sibert’s op ed, was similarly dismissive of the work of parenting, noting that she could not fathom putting her “lucrative career on the shelf to play patty-cake.”  It should not be necessary to diminish what parents who work part-time do in their “free” time to make the case that, when it comes to their careers, “women especially” should lean in, not back.

PPACA and the Growing Shortage of Pediatric Subspecialists

Photo by roen via Flickr

Over the course of this year, a spate of articles and op eds have highlighted a growing shortage of pediatric subspecialists.  Earlier his month, Amy Mansue, CEO of Children’s Specialized Hospital here in New Jersey, addressed the problem in a very interesting post on the National Association of Children’s Hospitals’ With All Our Might blog.  Ms. Mansue describes a recent visit to Capitol Hill during which she discussed the implementation of the Patient Protection and Affordable Care Act, explaining to the staffers that:

[t]he differences between strategies to address the needs of the newly insured children versus strategies to address the needs of adults couldn’t be more different.  Start with the basic fact that there is a critical shortage of specialists in pediatrics, where the biggest issue facing adults is how to access primary care. There can be a utilization of physician extenders in the short run until more primary care physicians are trained; there is no similar ‘quick fix’ in pediatrics.

Pediatric neurologists and developmental-behavioral pediatricians are in especially short supply.  A survey of children’s hospitals conducted by the National Association of Children’s Hospitals and Related Institutions in December 2009 revealed average wait times of 9 weeks for an appointment with a pediatric neurologist and 13 weeks for an appointment with a developmental-behavioral pediatrician.  An earlier study published in Pediatrics found that, in addition to enduring long waits, parents and children also travel long distances to see these specialists–on average 73 miles to see a subspecialist in neurodevelopmental disabilities and 44 miles to see a developmental pediatrician.

This is concerning for a host of reasons, including the importance of early, appropriate intervention to the future success of children with developmental delays.  As I discussed previously here and here, the “right” medical diagnosis can be key to accessing needed services, as can a thorough written evaluation and a doctor willing to advocate on a child’s behalf.  This is true whether a family is fighting for publicly-provided disability benefits or special education services or to get a private insurance plan to pay for medically necessary therapies.

What explains the subspecialist shortage?  As Ms. Mansue puts it, “it is all about math.  There is no incentive to go through an additional decade of training to get paid less than what a pediatric nurse practitioner is now demanding in my home state of New Jersey.”  Congress has tried to change the equation.  PPACA provides for loan forgiveness of up to $35,000 per year for up to three years for pediatric subspecialists who “work for a provider serving in a [Health Professional Shortage Area] or medically underserved area, or among a medically underserved population that has a shortage of the specified pediatric specialty and a sufficient pediatric population, as determined by [HHS], to support the specified pediatric specialty.”  But funding for this measure has not yet been appropriated.  The federal government has also attacked the problem through its Children’s Hospitals Graduate Medical Education Payment Program, which provides funding for specialty training for pediatricians.  According to a recent New York Times op ed, however, this program’s funding is also uncertain, suggesting that an end to the shortage of pediatric subspecialists may not be in sight.

Doctors’ Debts Are Clear; What About the Subsidies?

Today’s NYT story “New Doctors Awash in Debt” paints a grim picture for physicians. It graphs ever-increasing educational costs and salaries that fail to keep pace–at least in terms of percent-increase per year. But there are a few parts of the graph that need to be better explained. First, what exactly is the median compensation for specialists and primary care physicians (PCPs)? More importantly, what are the current subsidies that the federal government provides to medical education? Consider this passage from an article in the Chronicle of Higher Education by Katherine Mangan on an apparent physician shortage:

A larger number of graduating physicians also does not guarantee that the physician work force will be appropriately distributed among specialties. In the future, the nation is likely to need more geriatricians and primary-care physicians, for instance, but may need a smaller proportion of surgeons or other specialists. . . . Jonathan P. Weiner, a professor of health policy and management at the Johns Hopkins University[, says that] [t]axpayers end up paying $500,000 to $1-million to train each new doctor through programs such as Medicare and subsidies to state medical schools. . . .
Admittedly, Weiner’s estimate is for new doctor education, not present programs. But it highlights a dimension of current health policy debates that few are discussing presently: what is the stake of taxpayers in the current system? As I explain at the end of this post, the challenge for health reformers may be getting pols to recognize the public’s already enormous investment in health care–and mustering the courage to use that leverage to improve care.