One aspect that is under weighted in the discussion on US Health Care is the focus on how our doctors are trained. When reform in the healthcare system is discussed, the main question is how the existing healthcare services should be allocated. We look to other countries for models on how health care is produced. Liberals cite the single payer systems in Europe that seem to work with relatively low expenses while conservatives often point to the public/private system in Singapore that are able to provide suitable services at a fraction of the cost of their gross national product.But the question of allocation is only half the problem. The education of healthcare workers, and more specifically physicians, is a variable that is basically ignored by almost everyone in the health care debate. A 2009 paper by the Global Knowledge Exchange Network provides an overview of differing physician training requirements.
The table above contains data from the paper, supplemented with data from the World Bank, the OECD, the Congressional Research Service, the German Medical Association, and Singapore's Ministry of Health.
A 2013 OECD study found that the United States has the third lowest proportion of general practitioners to specialists among developed economies, with only Hungary and Greece having fewer general practitioners. Looking at the above table it's easy to see why - with education already lasting over ten years, the addition of a few more years for a significant bump up in salary is a strong incentive to avoid general practice. The return on those last few years of training is quite high.
It is interesting to note that a recent study found that foreign trained primary care physicians trained abroad outperformed American born physicians. Whether that says more about industrious foreign born immigrants or burnt out Americans is an exercise left to the reader.
Longer training times restrict the supply of physicians available to treat patients. A restricted supply means that demand must be rationed. In capitalist systems, that rationing occurs with the wages of doctors and costs to the patient going up. In socialist systems, that rationing occurs via longer wait times for patients with less serious conditions. But if restrictions on doctor training were loosened then in mixed systems there would be downward pressure on both prices and on wait times.
Unfortunately, no political reform of the medical system is going to occur without the public support of physicians. And the American Medical Association, the modern guild of physicians, is not going to support policies which have any chance of creating downward pressure on the wages of its members.
While analyzing which countries are most efficient in training physicians is a fun exercise, actual reform in the medical system needs to come more from other places. Ideas to reduce the incentives of hospital physicians to practice defensive medicine, price disclosure by medical service providers and the proper implementation of technology and standardization to reduce administration costs need to be given more weight. The political question surrounding the allocation of resources gets much easier if the amount of those resources can be significantly increased.