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Remember back in the 1990s? Clintons were in the White House. Bushes wanted to be in the White House. Health care reform was fresh on everyone’s mind. As the French say, plus ça change, plus c’est la même chose, I guess.

The care delivery reform vehicle of the 1990s was to be Health Maintenance Organizations. Not particularly liked by physicians, these were groups of physicians and non-physician providers (hospitals and other health care entities)  who were tied by a common goal of delivering quality care at low cost. The problem is the definition of quality on the part of the HMO (low use of services that were not proven to be effective) was not the same as that of the patient (immediate access to services felt to be necessary by a prudent lay person).

In 1998, 3200 graduates of US medical schools went into Family Medicine.

The HMO movement eventually receded, as a consequence of consumer and physician revolt, although some remained (Kaiser and Group Health Puget Sound are the most well known from that era). For most Americans in the ensuing years, health care consumption was considered a matter of personal choice and, as Americans, we opted for convenience and technology. Insurance companies obliged us by limiting out-of-pocket cost. One could eat at the health care buffet and it only cost a couple of dollars.

As  physicians, we opted to provide these services in as efficient a manner as possible, with this efficiency being manifest as immediate access for folks with insurance. What happened was fairly predictable. Physician salaries skyrocketed. Health care inflation soared. Consumption was increased in areas of surgical procedures and high cost medications. Use of opiates such as Lortab dramatically increased.  If the analogy was one of restaurant dining, it is as if everyone with insurance in America got a free dining card with unlimited dessert.

For those without insurance (about 15% of adults under 65), care was not readily accessible unless they had significant cash to spend. Their dining card allowed them to stand by the dumpsters and wait for table scraps.

In 2004, only 1100 US grads went into Family Medicine.

Medical students in this country started talking about the ROAD to success, getting a position in a Radiology, Ophthalmology, Anesthesia, or Dermatology residency. Relatively easy work, really high pay. The pastry chefs of medicine.

American medical school in 2006 stood ready to respond to this new market reality, as encapsulated in this report from the era. They recommended a strategy of increasing enrollment in medical schools by 30%, supporting it with evidence of an aging workforce and the fact that physicians were not located where they needed to be (areas of shortage). In addition, they pointed to increased demand for more convenient access by an aging population.

If you fill the bucket to overflowing, they figured, student physicians could not help but go to places of need and select specialties of need. The market would sort things out. The aging population would get the doctors they needed, more Americans could catch the brass ring of “my son/daughter the doctor,” and we could continue to allow the market to set the tone. Or, to use the restaurant analogy, everyone who wants to be a pastry chef can be, and certainly someone will want to clean the dishes.

Did it work? We have increased the number of medical students from 14,000 in 2006 (the year the AAMC decided that the answer was to increase the number of doctors) to 22,500, an increase of 66%. The number of positions offered for training after medical school has increased from 24,000 to 27,000. Of those new US grads, the number electing to do radiology is up 200% and anesthesia is up 300%, Physical medicine and rehabilitation (one of the “new road” specialties) is up 300%. Family medicine, the specialty that goes to rural areas, the most rapidly aging specialty—how are we doing? Up 20%. The rest of the Family Medicine training slots? Filled by folks who went to medical school  in other countries

American students, it seems, are betting that we as a country are going to continue to allow people to eat unlimited dessert and they all want to be the pastry chef. So much for allowing our country’s workforce policy to be set by 25 year-olds. Heck of a way to run a restaurant.

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