FYI.  Based on a recent Times article.


Subject: Re: [HLTHPROF] Too Many Doctors in the House

Simple answers make the most sense. Medical students born, raised, and
trained in major medical center locations (zip codes with 75 or more
physicians) stay there for practice. They choose specialties that allow
them to maintain major medical center location and concentrate over time in
major medical centers. This has grown to a formidable group of over 70% of
total recent medical school graduates.

The United States has had an unprecedented progressive increase in
admissions of the medical students who have been born and raised in closest
proximity to medical schools and major medical centers. This increase
includes massive increases in the most urban (90% urban, 60% born and
raised in areas over 1 million), Asian (2% to 23%), foreign born (2% to
16%), and highest income students (53.5% over $100,000 in parent income).
Medical students from physician or professional families dominate. Those
most likely to distribute and choose family medicine and primary care and
rural practice have been replaced by those most likely to choose major
medical center practice. Anyone who is distant or different in income,
geography, culture, education, or background is being displaced. For all US
physicians from all medical school sourses over 40% were born in other
nations or are Asian, a population that is foreign born or at least on
parent is foreign born at 90% levels. Asian and foreign born physicians are
the most associated with major medical center locations of all populations
and this has to do with the highest levels of urban origins, parent
education, and parent income.

Those with 30 years of strong connections in major medical centers
involving location, parents, colleagues, private schools, school mates,
colleges, medical schools, residency training, institutions, and
fellowships are unlikely to depart from major medical centers. They are
unlikely to choose a career such as family medicine which is 60% outside of
major medical centers.

Those born and raised near medical centers are also the most unaware of the
living conditions and health situations of those living outside of major
medical centers. (AAMC Minorities in Medicine reports)

The nation's major urban areas are also very different, particularly those
that can be deemed "major medical center cities."

Major medical center cities have driven off the middle income types who are
most likely to choose serving careers such as family medicine.
Major medical center cities have driven off the lower income types who have
few connections to family or poverty contacts.
Major medical center cities cannot support those without huge incomes of
(perhaps $150,000 or more), especially those that do not own property to
save costs or that have secondary sources of income in these major cities.

Major medical center cities have all of the parameters for highest health
care costs
1. populations with less than high school education plus populations with
"excessive" education and professional degree and medical training
2. highest income levels
3. most subspecialists
4. greatest concentrations of physicians
5. monopolies in many if not most medical services, especially the most
dramatic that the public and media find very difficult to challenge
6. multiple layers of assistants between physician and patient
7. Crushing federal regulations that prevent efficient care
8. Most costly tuition and cost of living, all that will be repaid through
future increased  health care costs
9. Most costly real estate and cost of living impacting all facilities, all
personnel, and all who pay for health care

The physicians in major medical center cities will do what they can to
train and stay in major medical center locations and have developed a style
of practice and reimbursement and salary structures that facilitate this.

The nation's health policies support major medical center practice:
1. the highest reimbursement rates go to major medical center physicians
2. 99% of NIH funding goes to major medical centers
3. 97% of GME funding goes to major medical centers
4. City, county, and state health funding projects, programs, medical
education, graduate education, and public health all support major medical
centers
5. purchasing power supports large major medical center practices with
numerous physicians and penalizes smaller groups of physicians and those
not in major centers
6. negotiating power supports large major medical center practices, not the
smaller groups or individual physicians

Office general internal medicine and office general pediatrics are located
in major medical center practices at 70% levels. This is a birth origin
issue and also a health policy and low reimbursement issue. Office general
internal medicine is basically gone, victim of sad national health policy.
Pediatrics survives with major medical center support but is limited to
major medical center location.

It is doubtful that the nation's primary care can survive without the
significant adaptations offered by family medicine and even in family
medicine the choice has suffered greatly. In the concentrated inequitable
major medical center areas of the nation, the lower income groups are
ignored and get more and more cuts in health care, the middle income groups
are suffering in coverage, the higher income groups see subspecialists and
pay huge amounts for care and extra care, etc. Family medicine is not
faring well in this health policy environment that supports the higher
income patients of other physicians and penalizes the lower and middle
income patients more common to family physicians.

In the midwest and in the west where income and education and jobs are more
equitable, family medicine is doing better and sometimes very well. The
education distribution also favors choice of family medicine and the child
health coverages and other health policies are better, favoring medical
student choice of family medicine and better support of family physicians.
But some areas are highly dependent on Medicare and Medicaid and these are
troubled and uncertain areas.

Finally, major medical center areas of the nation are dying. At the county
level these locations are losing 5 - 15% population a year. By focusing on
the top levels of income, they have neglected the lower and middle income
groups that are their future. The lower and middle income groups are the
ones that become teachers, firemen, police, counselors, family physicians,
small business people, and the others that are the basic building blocks of
education, health, public safety, and economics. What services that they
have in these areas often commute in from other locations and the best of
them are quick to take jobs away from major metro areas to save on
commuting and other costs.

At the current time the nation is tolerating the waste that results and the
major urban center theft of serving professionals from all other states and
nations across the planet. But eventually the nation will realize what is
happening. Whether the nation chooses to take on these areas will be one of
the greatest debates in history. It will be some battle since nearly all of
the wealth, the income, the college positions, the professional school
positions, the leadership, and the economics will be pitted against most of
the population.

Medicine will get to choose between those who note that physicians are the
advocates of the poor (Virchow), those who promote better distributions of
education and income and health care, and those who promote expansion of
physicians to "improve the economics of the nation"

By the way, any economic improvements that the nation will realize from the
current mostly undisciplined expansion, will be limited to major medical
center locations.

Robert C. Bowman, M.D.
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