A Doctor Shortage? Uh-oh!

Worry about the depleted supply of registered nurses in California? Stay cool. After all, health care professionals are merely behaving rationally.

He recommends that physicians:

• Discontinue risk assumption for professional services or pharmaceutical benefits.
  
  
• Seek actuarial advice on reasonable reimbursement rates for professional services when negotiating contracts instead of accepting discounted fee schedules.
  
  
• Let the market balance itself. Managed care will decline; sick patients will return to specialty care; and the artificial demand for primary care will collapse.
  
  

His first two recommendations merit serious attention; the last is disingenuous. Economists seem repeatedly chagrined to discover that human nature transcends economic axiom in the marketplace. (Consider the stock market.)

Economics are not part of my limited expertise, but human nature is. Physicians and nurses make personal decisions about where and how they want to practice their professions. Along with economics, they consider - consciously and unconsciously, overtly and covertly - a slew of personal values, interests and aspirations, not the least being gender and life cycle issues. With a greater proportion of female physicians, differences between how men and women make career choices will count for more than economics in predicting the distribution of supply.

When Sigmund Freud retorted to ad hominem criticisms with, "Sometimes a cigar is just a cigar," he was reminding us that the rest of the time a cigar is something else. So much for rational choices.

Advertisers frame their messages accordingly. Direct advertising of medical services and products has created images of catastrophic illnesses and emergencies, ailing children, and caring, friendly unrushed physicians armed with a panoply of technologic miracles - present and promised - all at low cost or unmentioned cost. Medical advertising has also made our patients comfortable with warm-hearted para-physicians.

A generation ago, Edward Stainbrook, then Professor of Psychiatry at USC, published a paper on "fashionable illnesses." A generation before that, when civilian physicians and nurses were scarce, stories extolling the virtues of self-care, not so much prevention as self-medication, flooded the marketplace.

Clearly, whoever can manipulate the marketplace can do so for personal profit. Add that to human vagaries, and supply and demand are not free and rational determinants of marketplace economics.

Does professional shortage affect access, availability and quality of service? Yes indeed. This issue discusses the shortage of specialists available to emergency rooms in the Sierra-Sacramento Valley area. It shows how a shortage of critically needed specialists and uncertainty about payment for emergency and post-emergency care endangers patients.

Attorneys have taught patients to sue to get services; insurers have taught patients to lower their expectations and accept what is available. The shortage has also fueled arguments to expand the scope of practice of non-medical professional providers.

Fewer physicians will not increase physician income. During past shortages, physicians have earned more not because they have charged more, but because they have worked harder and longer - sometimes so hard and so long as to put patients at risk. Those who manipulate the marketplace will teach the public that less expensive, less trained paraprofessionals are "as good, or better" and time with patients is "unnecessary." Patients will soon lose the memory of what "used to be."

Unfortunately, so will physicians. They will forget their duty to serve, even at odd hours and with payment uncertainty. They will forget to discuss diagnostic and treatment options with their patients, including financial and other costs - and disclosure of how the decision might affect the physician's income.

So far physicians profess fealty to an ethos of service - at times, self-effacing service. By contrast, the ethos of the marketplace is profit, even self-aggrandizing profit. Dr. Gibson mentions that, but drops it. Yet the ethical dilemmas posed by a shortage of physicians, nurses, pharmacists and other medical service professionals must inform our legitimate concerns and actions.

Physicians must acknowledge the public harm of a shortage and collaborate with all the stakeholders to reverse it.

Ed_Rudin@macnexus.org