It is 2025, and somewhere in rural Vermont a child gets hurt.
Big deal. Kids get hurt every day. This kid's mother drives him to the hospital emergency room or perhaps to the office of the family's own health care providers.
Either way, they walk in and are…given a number and told to sit down. It will take awhile. There aren't enough doctors.
Good thing this kid isn't so badly hurt that he needs emergency surgery. In that case, they'd have to rush him to Fletcher-Allen in Burlington or Dartmouth Hitchcock over in New Hampshire. The nearby hospital hasn't had an emergency surgeon on the staff for decades. To put it bluntly, by 2025, Vermont will not have enough doctors.
Actually, according to most experts, Vermont already doesn't have enough doctors. Or at least it doesn't have enough primary care physicians in most of the state.
"We're probably short 25 FTEs (full-time-equivalent) when it comes to family practitioners," said Dr. Charles MacLean, a primary care physician who is also Associate Dean for Primary Care at the University of Vermont's College of Medicine, where he heads Vermont's AHEC (Area Health Education Centers). AHEC was created by Congress 40 years ago to try to increase health services in poor and rural areas.
Twenty-five is not a big number, but according to the State Health Department there are only 492 primary care physicians to begin with, so Vermont is already about five percent short of the family practitioners it needs.
"The number of primary care physicians falls short of the number needed to care for all Vermont residents," said a report released in August by the Association of American Medical Colleges. The report found shortages "in all counties," but Dr. Harry Chen, Vermont's Health Commissioner, said, "there is a maldistribution of physicians," with doctors "more available" in Chittenden County and a few other pockets of the state.
Elsewhere, then, the shortage would be greater than 5 percent.
That shortage is likely to grow, and not only for primary care physicians. The doctors said they also expected shortages in general surgery and mental health care, where the state needs more doctors but also more physicians assistants, nurses, and other therapists.
Vermonters are getting older, and older people need more medical services. Furthermore, Vermont doctors are getting older, meaning many of them will be retiring. Furthermore, if the new national health care law is not repealed, more Vermonters will be able to afford health care. And if the projected state health care plans take effect, even more people - especially lower-income Vermonters who tend to have more health problems - will have access to the system.
If the system can accommodate them.
"If we cover everybody," said Dr. MacLean, "the shortfall would probably double." The potential shortage of primary care physicians, he said, could be "severe."
In Vermont, at least, the medical establishment does not disagree.
"We have a shortage of physicians especially in primary care, and also general surgeons and orthopedic surgeons and it's only going to get worse," said Paul Harrington, the Executive Vice President of the Vermont Medical Society. Harrington listed the same three reasons - older doctors, older patients, more patients with health insurance - to explain why the doctor shortage would get worse.
So what, exactly, is Vermont doing wrong?
Probably nothing. The doctor shortage is a nationwide problem, worse in many other states than in Vermont. According to the Organization for Economic Cooperation and Development, the United States has 243 physicians per 100,000 people, substantially lower than the 298 average for all OECD countries. One of the few countries with fewer doctors per person is neighboring Canada, which has only 218 physicians per 100,000 people. France, whose health care system is considered the world's best by many international health care experts, has 337 doctors for every 100,000 people.
States in the U.S. don't compile statistics allowing a precise comparison with the OECD's. For Vermont's 630,000 or so people, Harrington said, about 1,880 physicians practice in the state.
Both Dr. MacLean and Dr. Chen said that the physician shortage was less severe in the New England and Northeastern states than in most of the rest of the country, especially the Southeast.
That would seem consistent with the answer given by the two doctors to the question of why the doctor shortage is worse in rural areas than in and around cities. To some extent, they acknowledged, money might be a factor; perhaps doctors earn more in metropolitan areas. But mostly, Dr. MacLean said, in and near cities is simply "where people want to live."
Or at least where doctors want to live. Being educated, physicians tend to have high- (or at least middle-) brow taste. They want to live and raise their families where there are good schools, gourmet restaurants, theaters (and not just for movies), concerts, and like-minded neighbors, all more common in larger cities or university towns. In Vermont, Burlington is both. Many out-of-staters come to Vermont to attend UVM's highly-rated College of Medicine, fall in love with the state and the city, and never leave. Enticing a young doctor to open a practice in Burlington is easy; convincing one to move to the Northeast Kingdom or the White River Valley is not.
So the state and the doctors are trying harder. Dr. Chen described a process a bit like a college coach who is tipped off about a hot basketball prospect in eighth grade and keeps tabs on him through high school.
"We take a multi-faceted approach," Dr. Chen said. "For instance, if someone who's interested in being a doctor grows up in the Northeast Kingdom, we'll follow them (through college and medical school) and focus incentives" designed to make it more appealing for the young doctor to open a practice or join a hospital near his or her home town.
Those incentives include partial loan repayments, which the state has been making for some young doctors with the help of money from both the federal government and private foundations.
Student debt is no small consideration for young doctors, many of whom emerge from their 10 or more years of training (college, medical school, residency) owing $150,000 or more, and almost 30 years old before starting their careers. It's one reason many young physicians choose a specialty such as cardiology or ophthalmology, where they can earn twice what a family practice primary care doctor earns.
There is some dispute about the root cause of the nationwide doctor shortage. Some critics argue that over the years the American Medical Association has deliberately held down the number of medical school openings to control the supply - and therefore prop up the price - of providing health care.
The AMA was formed in 1847, partly because some of the then 400 medical schools were diploma mills churning out unqualified graduates. Today's 133 medical schools graduated 16,838 students in 2010, a small increase over the 15,676 who graduated in 2002. Thousands of applicants, many of them presumably capable, are turned away every year for lack of space.
Whatever the reason, US doctors do earn substantially more than their counterparts elsewhere. According to a chart posted by economist Greg Mankiw, physicians in the U.S. earned an average of just under $200,000 in 1996, roughly twice the average income of a Canadian doctor and almost four times the average in France.
Another reason for the doctor shortage is that even if there were more medical school graduates, there aren't enough intern slots to handle them. One reason for this is federal budget cuts. Most of those intern positions are funded through Medicare, and in the 1990s Congress started cutting back on those expenses.
One way or another, Vermont's ability to attract new doctors will depend on how the new Green Mountain Care Board chooses to revamp the state's health care system under the sweeping law the Legislature passed earlier this year. At the Medical Society, Paul Harrington worries that if the Board does not heed the recommendations of "the physicians actually providing care, it will create a system with too much uncertainty to attract new doctors."
Dr. Chen, though, thinks that "medical students overwhelmingly support" Vermont's effort to change a "clearly dysfunctional" health care system, and that the kind of system envisioned by the new law can attract young physicians from around the country.