American healthcare's most fundamental problem — we don't have enough primary-care doctors because primary care simply doesn’t pay well enough — has also long been its dirty little secret. The public is only dimly aware of the doctor shortage, oblivious to its causes and solutions.
But with the Affordable Care Act’s insurance expansions and mandates coming online in 15 months, the problem is about to move to DEFCON 5, at which time there will be no hiding it. The public will see the shortage for the health crisis it truly is.
New research, meanwhile, by a pair of Yale economists offers insight into how the basic pay problem at the heart of the shortage affects women physicians especially hard — a grave problem not only because of the fundamental unfairness of it but also because women comprise the majority of American medical students and are more likely than men to choose careers in primary care. The economists found that a woman who wants to spend her career in the noble business of getting patients to say "aah" would be better off financially becoming a physician assistant than an MD.
Doctors earn more than PAs, sure, but medical school costs so much more than PA training that the long-term economic benefits must far outweigh the upfront cost difference. And since the additional costs come well before the added benefits, inflation comes into play, too. Economists Keith Chen and Judith Chevalier applied a metric called Net Present Value (NPV) to account for these factors.
"We found that, for over half of woman doctors in our data, the NPV of becoming a primary-care physician was less than the NPV of becoming a physician assistant," Drs. Chen and Chevalier (both PhDs) wrote in a summarization of their findings for The Atlantic.
For male primary-care doctors the value of an MD over a PA degree is still worth it. This is due partly to a wage gap: men earn more per hour than women, on average. But a bigger factor, the economists found, is that the female physicians are more likely to work less than full-time schedules, depressing their incomes even further.
We've long known that today's generation of doctors want different things from their careers than their doctor-fathers and grandfathers did. They want a balanced life with time for the kids. Employment is increasingly appealing to younger physicians because the terms of employment are seemingly more negotiable than the terms of ownership, and schedule flexibility is high on their list of demands. All of this is true of under-45 doctors generally and of women doctors in particular, it seems.
But the Chen-Chevalier study, beyond clarifying that the male/female wage gap exists even in medicine (where one would have hoped for a more enlightened worldview), also sheds light on the systemic challenge posed by the new generation of physicians' changing career demands. About half of all doctors responding to our Great American Physician Survey (our cover story starts on page 12) say they wish they worked fewer hours, but only among the youngest cohort was a plurality willing to sacrifice some income in exchange for schedule flexibility. Lori Schutte, president of physician recruiting firm Cejka Search, told us that women aged 35-44 make up the fastest-growing group of part-time physicians.
But if it becomes clear to women that many of their career goals could be satisfied by becoming PAs and NPs, and that they’d start working sooner and be better off financially long-term, you don’t need to be a Yale economist to figure out how that will affect our primary-care physician shortage.
Bob Keaveney is the editorial director of Physicians Practice. Tell him what you think at [email protected] or on Facebook: Unless you say otherwise, we'll assume that we're free to publish your comments in upcoming issues of Physicians Practice, in print and online.
This article originally appeared in the September 2012 issue of Physicians Practice.