The United States healthcare system is in crisis. Even prior to the COVID-19 pandemic, many physicians were working fewer and fewer hours due to systemic burnout across the profession, working an average of 51.4 hours per week in 2018, a one-hour decrease from 2016. An NIH study found that the COVID-19 pandemic exacerbated this issue, with many more physicians leaving the profession or working even fewer hours.
This has done nothing to improve the already existing shortage of healthcare workers, with an AAMC report projecting a drastic shortage of as many as 122,000 physicians by 2032. This same report coupled this prediction with the declaration that the entirety of the Baby Boomer generation, a population comprising 21.16% of the U.S. population and many of our physicians, will become over 65. This entails a 48% increase in the amount of individuals over 65 in our country.
The issues with the U.S. healthcare system range far beyond just physician and patient numbers, and the effects of our deeply flawed system are showing in harrowing ways. The U.S. is lagging far behind its equally-developed counterparts. A 2021 Commonwealth Fund study found that among some of the world’s leading healthcare providers, seven of them European nations, the U.S. consistently ranked last in all but one of the five categories assessed. An additional study compiling data from 2015 found that among the world’s most developed nations, eight of them European, the U.S. had a significantly higher mortality rate per 100,000, especially in regard to circulatory disease, which accounts for about a third of all deaths in the United States.
The United States also ranked second worst in respiratory disease mortality rates, by far the worst in nervous system mortality rate and external causes of mortality (overdose, suicide and assaults), second worst in Endocrine disease mortality rate and had five times the maternal mortality rate per 100,000 live births. Among equally-developed nations, the U.S. also sports the highest percentage of obesity prevalence, a staggering 41.9% in 2017.
As a result of all of these disastrous deficiencies, the U.S. had twice the average of years lost to premature death. Even more worrisome, these issues show no signs of improving, as the index for healthcare quality and access has plateaued completely over the last decade. While a solution to all of these issues will require years of activism and significant legislative action, one aspect in which the U.S. is lagging behind most seems relatively straightforward. Physician numbers per 10,000 in the United States average at some of the lowest in the developed world, 26.1, while most European nations average around 40. We are in dire need of more physicians.
If you want to become a physician in the United States, there are a number of challenging hurdles that you must clear. Firstly, you’ll spend four years earning an undergraduate degree, then four more years at medical school and, lastly, three to seven years of residency depending on the kind of specialty, upon which an aspiring physician can finally become certified. Some may also choose to complete a one to three year fellowship for even more specialized training, meaning that many physicians don’t start practicing until their early 30s. While this ensures that U.S. physicians are among the most highly trained in the world, only about 25,000 were certified in the last year, nowhere near enough to meet the current demand.
Two major factors in why this demand hasn’t been reached are rates of medical school acceptance and graduates being matched into residency programs. During the 2021 application cycle, 62,443 U.S. applicants competed for 22,666 spots, filling out a total of 1,099,486 applications — an average of 18 schools per student and a 3% acceptance rate. According to some experts, applying to just 15 schools can cost a student up to $10,000. Especially for low-income students, such costs implicate a significant risk in applying to medical school, possibly discouraging some who would be well-qualified. This creates a significant barrier to entry entirely dependent on economic standing, on top of the artificial barriers placed on prospective students during the application process, due to its extremely selective nature. The aggregation of all of these factors results in an inequitable system which may only be selecting the “best” third of applicants but is denying us many good doctors which could be employed to save many more lives.
A University of Michigan Medical School student in the class of 2024 argues that the amount of residency spots available is the bigger issue in terms of the number of physicians available to treat patients: “Right now we have, every year, people going through four years, five years of medical school, and sometimes they don’t match into a residency spot … So adding more medical school spots wouldn’t alleviate this problem.” In 2021, 7.2% of graduates didn’t match into a residency spot — an uptick of 1.5% since 2017. Elaborating on the process of entering residency, the student said: “There’s so much pressure as medical students, especially nearing the end of medical school. There’s stress about where you’re gonna match, and if you’re gonna match — competitive specialties match at lower rates … But a lot of that is also government funding, so a lot of these positions it depends on the funding level.”
A study found that residency programs are actually overfunded in some places, with $1.28 billion allocated by Medicare to GME programs. 47% of hospitals reported their system received more than the needed $150,000 per resident, and this resulted in many other areas being underfunded. Better allocation of funds could lead to residency programs which use their funds more effectively, leading to more well-trained and an overall increase in the number of doctors.
Meanwhile, the situation in Europe is much different. Costs are far lower, and acceptance rates tend to be much higher. For the class of 2020, with an average yearly tuition up to $63,370, the average U.S. medical student incurred up to $337,000 in debt over their time in medical school. Conversely, medical school in Europe is significantly less expensive. For example, public universities in Spain charge a maximum of 3,500 euros for European students, with some programs upcharging international students up to two to three times the regular rate, which still entails far less debt after receiving a degree. Rather than receiving a medical degree after eight years of both undergraduate and graduate education, most European medical schools offer an integrated program, which means one can receive your medical degree in only six years.
Contrary to popular belief, shorter, cheaper medical education doesn’t lead to worse doctors. In fact, an NIH study determined that among their surveyed population of 1,215,290 hospital admissions, treated 44,227 internationally-educated physicians in the United States, they actually had very slightly lower mortality rates of their patients when compared to U.S. educated physicians.
The same study found that those internationally-trained graduates also saw higher rates of patients with chronic conditions. As of 2013, foreign-trained immigrant doctors make up about 25% of the U.S. physician workforce, with 11% of those doctors trained in Europe. A factor which may have impacted the results is that internationally-trained physicians go through a very stringent process to obtain certification in the U.S., so the additional hurdles produce an even more qualified immigrant physician population, contributing to slightly better outcomes.
It is clear that while more physicians wouldn’t necessarily solve all of the issues surrounding the U.S. healthcare system, it would go a long way to ensuring that patients receive more rapid and high-quality care, as has been shown to be the case in Europe.
Maximilian Schenke is an Opinion Columnist and can be reached at maxsch@umich.edu.