文章來源：《經(jīng)濟(jì)學(xué)人》Nov 4th 2023 期 United States 欄目 The gilded age 鍍金時(shí)代

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According to the Association of American Medical Colleges (AAMC), in a decade America will have a shortage of up to 124,000 doctors.?This makes no sense. The profession is lavishly paid: $350,000 is the average salary according to a recent paper by Joshua Gottlieb, an economist at the University of Chicago, and colleagues.?Lots of people want to train as doctors: over 85,000 people take the medical-college admission test each year, and more than half of all medical-school applicants are rejected. And yet there is a shortage of doctors. What is going on?

據(jù)美國醫(yī)學(xué)院協(xié)會(huì)稱，美國將在10年內(nèi)面臨高達(dá)12.4萬名醫(yī)生短缺問題。這毫無道理。醫(yī)生這個(gè)職業(yè)薪水豐厚：根據(jù)芝加哥大學(xué)經(jīng)濟(jì)學(xué)家約書亞·戈特利布及其同事最近發(fā)表的一篇論文，醫(yī)生平均年薪為35萬美元。很多人都想成為醫(yī)生：每年有8.5萬多人參加醫(yī)學(xué)院入學(xué)考試，而一半以上的醫(yī)學(xué)院申請(qǐng)者都被拒之門外。但醫(yī)生仍然短缺，到底是怎么回事呢？

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For many Americans, the doctor shortage has already arrived. More than 100m people today live in an area without enough primary-care doctors (the problem is particularly bad in rural areas).?For mental health things are even worse: half of Americans live in an area with a shortage of mental-health professionals.?With less than three physicians for every 1,000 people, America is behind most other wealthy countries, despite spending vastly more on health care.

對(duì)于許多美國人來說，醫(yī)生短缺問題已經(jīng)到來。如今，有1億多人生活地區(qū)的初級(jí)保健醫(yī)生不夠（這個(gè)問題在農(nóng)村地區(qū)尤其嚴(yán)重）。心理健康方面的情況更糟：半數(shù)美國人生活的地區(qū)缺少心理健康專業(yè)人員。每千人僅有不到3名醫(yī)生，盡管美國在醫(yī)療保健方面的支出比其他國家要高得多，但醫(yī)生比例仍落后于其他大多數(shù)發(fā)達(dá)國家。

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The usual suspects have been blamed. As the baby-boomers age the need for medical care rises and the doctors among them retire.?According to the AAMC, more than two out of five practising doctors will be 65 or older within the next decade, leaving even more vacancies.?Covid-19 drove doctors away: an analysis by Peterson-KFF, a non-profit group, shows that health-care workers are quitting their jobs at a rate 30% higher than before covid (and about double the rate of all workers today).?“A majority of physicians would not encourage our?offspring?to go into health care,” says Jesse Ehrenfeld, a physician and president of the American Medical Association. “People have lost the joy in the profession.”

問題歸咎于特定人群。隨著 "嬰兒潮 "一代步入老年，他們對(duì)醫(yī)療服務(wù)的需求也隨之增加，而其中的醫(yī)生也將退休。根據(jù)美國醫(yī)學(xué)院協(xié)會(huì)的數(shù)據(jù)，未來10年內(nèi)，2/5以上的執(zhí)業(yè)醫(yī)生將年滿65歲及以上，將導(dǎo)致更多的職位空缺。新冠疫情使醫(yī)生離職：非盈利組織 Peterson-KFF的一項(xiàng)分析表明，醫(yī)護(hù)人員的離職率比新冠前高出 30%（約為目前所有工人離職率的2倍） 。美國醫(yī)學(xué)會(huì)主席兼醫(yī)生杰西·埃倫菲爾德說：“大多數(shù)醫(yī)生不會(huì)鼓勵(lì)自己的后代進(jìn)入醫(yī)療行業(yè)，人們失去了從醫(yī)的樂趣?！?/p>

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Yet there is another explanation for the doctor shortage, which has to do with the pipeline into the profession, and which the American Medical Association has played a part in creating.?It takes longer to train a doctor in America than in most rich countries, and many give up along the way.?Future physicians must first graduate from university, which typically takes four years.?Then they must attend medical school for another four years. (In most other rich countries, doctors need around six years of schooling.)?After?post-secondary education, American doctors must complete a?residency?programme, which can last from three to seven years.?Further specialist training may follow. In all, it takes 10-15 years after arriving at university to become a doctor in America.

然而，醫(yī)生短缺還有另一種解釋，這與從醫(yī)路徑有關(guān)，而美國醫(yī)學(xué)會(huì)在其中扮演了重要角色。在美國，培養(yǎng)一名醫(yī)生所需的時(shí)間比大多數(shù)發(fā)達(dá)國家都要長，而且許多人中途就放棄了。準(zhǔn)醫(yī)生必須首先接受4年的大學(xué)教育。然后，他們必須再接受另外4年的醫(yī)學(xué)院教育。（在其他大多數(shù)發(fā)達(dá)國家，醫(yī)生大約只需要6年的教育。）完成高等教育后，美國醫(yī)生必須完成為期3-7年的住院實(shí)習(xí)醫(yī)師培訓(xùn)計(jì)劃。隨后，可能還會(huì)有進(jìn)一步的專業(yè)培訓(xùn)?？傊?，在美國上大學(xué)后需要 10-15 年才能成為醫(yī)生。

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If the expense and length of the training were not?off-putting?enough, the number of places in the profession has also been artificially held down.?In September 1980 the Department of Health and Human Services released a report warning of a troubling surplus of 70,000 physicians by 1990 in most specialties.?It recommended reducing the numbers entering medical school and suggested that foreign medical-school graduates be restricted from entering the country.?Despite the shortage, doctors trained abroad must still sit exams and complete a residency in most states regardless of their years of experience.

除了醫(yī)學(xué)培訓(xùn)的費(fèi)用和時(shí)間令人望而卻步外，醫(yī)生名額也被人為地縮減了。1980年9月，衛(wèi)生與公共服務(wù)部發(fā)布了一份報(bào)告，警告稱到 1990 年，大多數(shù)科室的醫(yī)生將出現(xiàn) 7萬人過剩的情況，這令人擔(dān)憂。報(bào)告建議減少醫(yī)學(xué)生錄取人數(shù)，并建議限制外國醫(yī)學(xué)院畢業(yè)生入境。盡管存在醫(yī)生短缺問題，但無論外國醫(yī)生的培訓(xùn)和經(jīng)驗(yàn)如何，他們?nèi)匀槐仨殔⒓俞t(yī)師考試，并在大多數(shù)州完成住院醫(yī)師培訓(xùn)。

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Medical colleges listened, and?matriculation?flatlined for 25 years, despite applications rising and the population growing by 70m over the same period.?In 1997 federal funding for residencies was capped, forcing hospitals to either limit programmes or shoulder some of the financial burden of training their doctors.?Some spots have been added back, but not nearly enough. Many potential doctors are being shut out of the profession.?“Not everyone who would be willing to go through that training and could do it successfully is being allowed to,” says Professor Gottlieb, the economist.

醫(yī)學(xué)院聽從了這一建議，錄取率在25年里持平，盡管同期的申請(qǐng)人數(shù)在增加，人口增長了7000萬。1997年，聯(lián)邦對(duì)住院醫(yī)師培訓(xùn)的資助設(shè)置了上限，迫使醫(yī)院要么限制項(xiàng)目，要么自己承擔(dān)培訓(xùn)醫(yī)生的部分經(jīng)濟(jì)負(fù)擔(dān)。雖然又增加了一些名額，但還遠(yuǎn)遠(yuǎn)不夠。許多有潛力的醫(yī)生被拒之門外。經(jīng)濟(jì)學(xué)家戈特利布教授表示：“并不是所有人都愿意接受這種培訓(xùn)，并不是所有成功完成培訓(xùn)的人都能成為醫(yī)生?！?/p>

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In reaction to this artificial doctor shortage, a new type of medical degree gained popularity: DOs (doctors of?osteopathic?medicine).?In 1981, there were only 14 osteopathic medical schools. Today there are 41.?In most countries, an osteopath is someone who manipulates middle-aged spines.?In America DOs are fully-licensed doctors. They represent about 11% of the physician workforce and 25% of medical-school students.?“The American DO looks almost nothing like their international counterparts,” says Robert Orr, a policy?wonk. “They basically?mainstreamed?themselves in response.”

為了應(yīng)對(duì)這種人為造成醫(yī)生短缺的問題，一種新型醫(yī)學(xué)學(xué)位開始流行起來：DOs（整骨醫(yī)生）。1981年，整骨醫(yī)學(xué)院只有14所，如今已有41所。在大多數(shù)國家，整骨醫(yī)生給中年人做正骨整脊治療。在美國，整骨醫(yī)生是擁有完全執(zhí)照的醫(yī)生。他們約占醫(yī)師隊(duì)伍的 11% ，占醫(yī)學(xué)生的 25%。政策專家羅伯特·奧爾說：“美國的骨科醫(yī)生幾乎與國際同行毫無相似之處，他們基本上是為了應(yīng)對(duì)醫(yī)生短缺情況而把自己納入了主流?！?/p>

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Nurse practitioners and physician assistants have been given responsibilities typically reserved for doctors, such as writing prescriptions.?Foreign-trained doctors have filled some of the gap too. Yet the shortage persists.?Foreign-trained doctors have filled some of the gap too. Yet the shortage persists.?This looks a lot like a labour market that has been rigged in favour of the insiders.

執(zhí)業(yè)護(hù)士和醫(yī)師助理擁有了通常只有醫(yī)生才有的職責(zé)，如開處方。外國訓(xùn)練有素的醫(yī)生也填補(bǔ)了一些空缺。但醫(yī)生短缺依然存在。這看起來很像是一個(gè)人為操縱利于內(nèi)部醫(yī)生的就業(yè)市場。這看起來很像是一個(gè)人為操縱利于內(nèi)部醫(yī)生的就業(yè)市場。