As I pulled into the parking lot across the street from the large urban hospital where I now work, I considered the number of cars in the physician parking lot. Could there really be a physician shortage when the lot borders on full by 8am? While I fully believe that there is a maldistribution of physicians in the United States, my mind took off pondering what the parking lot would’ve looked like 50 years ago.
The older physician who served as medical director at the rural hospital where I started my private practice could have been one of them. Starting his practice in 1963, he practiced family medicine — working in the clinic and hospital, delivering babies vaginally, by forceps or c-sections, doing open tubal ligations, appendectomies and cholecystectomies. There was a single general surgeon in the town who took care of the “hard surgeries,” and oversaw the quality of the surgeries and anesthesia (although it would be another 15 years before an “anesthetist” was hired, since each of the doctors conducting surgery took turns filling this role for each other). One can argue about the quality, lifestyles, etc. of this now seemingly ancient practice of medicine, but I believe it underscores our perception of a physician shortage.
While the statistics about numbers of physicians produced seem to indicate growth, the perception of a physician shortage and difficulties with access to care are worsening, particularly in rural areas. This is because, in medicine, one no longer equals one. While I have a broad scope of practice by modern standards (clinic, nursing home, hospital, operative OB, colposcopy), I could not replace the services that my predecessor provided. To replace the one physician providing those services required three people: two physicians (family med and general surgery) and one Anesthetist.
The discussions about physician shortages are misplaced if all we do to address the problem is try to make more physicians. Trends towards increasingly limited scopes of practice (voluntary or not) work to exacerbate the problem even more — making the old 1 now equal to 4 or even 5. This would be a physician shortage insurmountable in our lifetime. There was a time when physicians were trained to meet the needs of their communities, as broad or narrow as needed. However, if the scope of education, training and practice continues to decrease, that will become a quaint relic of the past, like the black bags for house calls. I still have my black bag and still make house calls. I’ll never have the skills to be a 1, but part of the effort to address physician shortages must be to continue to learn and fight for the skills that keep us from being a 1/4.
Russell W. Kohl is Associate Professor, Paul E. Tietze, MD Chair in Family Medicine, Univesity of Oklahoma School of Community Medicine.
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