【每天一篇经济学人】The gilded age 镀金时代（2023年第61期）

文章来源：《经济学人》Nov 4th 2023 期 United States 栏目 The gilded age 镀金时代

[Paragraph 1]

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?

据美国医学院协会称，美国将在10年内面临高达12.4万名医生短缺问题。这毫无道理。医生这个职业薪水丰厚：根据芝加哥大学经济学家约书亚·戈特利布及其同事最近发表的一篇论文，医生平均年薪为35万美元。很多人都想成为医生：每年有8.5万多人参加医学院入学考试，而一半以上的医学院申请者都被拒之门外。但医生仍然短缺，到底是怎么回事呢？

[Paragraph 2]

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.

对于许多美国人来说，医生短缺问题已经到来。如今，有1亿多人生活地区的初级保健医生不够（这个问题在农村地区尤其严重）。心理健康方面的情况更糟：半数美国人生活的地区缺少心理健康专业人员。每千人仅有不到3名医生，尽管美国在医疗保健方面的支出比其他国家要高得多，但医生比例仍落后于其他大多数发达国家。

[Paragraph 3]

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.”

问题归咎于特定人群。随着 "婴儿潮 "一代步入老年，他们对医疗服务的需求也随之增加，而其中的医生也将退休。根据美国医学院协会的数据，未来10年内，2/5以上的执业医生将年满65岁及以上，将导致更多的职位空缺。新冠疫情使医生离职：非盈利组织 Peterson-KFF的一项分析表明，医护人员的离职率比新冠前高出 30%（约为目前所有工人离职率的2倍） 。美国医学会主席兼医生杰西·埃伦菲尔德说：“大多数医生不会鼓励自己的后代进入医疗行业，人们失去了从医的乐趣。”

[Paragraph 4]

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，医生短缺还有另一种解释，这与从医路径有关，而美国医学会在其中扮演了重要角色。在美国，培养一名医生所需的时间比大多数发达国家都要长，而且许多人中途就放弃了。准医生必须首先接受4年的大学教育。然后，他们必须再接受另外4年的医学院教育。（在其他大多数发达国家，医生大约只需要6年的教育。）完成高等教育后，美国医生必须完成为期3-7年的住院实习医师培训计划。随后，可能还会有进一步的专业培训。总之，在美国上大学后需要 10-15 年才能成为医生。

[Paragraph 5]

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.

除了医学培训的费用和时间令人望而却步外，医生名额也被人为地缩减了。1980年9月，卫生与公共服务部发布了一份报告，警告称到 1990 年，大多数科室的医生将出现 7万人过剩的情况，这令人担忧。报告建议减少医学生录取人数，并建议限制外国医学院毕业生入境。尽管存在医生短缺问题，但无论外国医生的培训和经验如何，他们仍然必须参加医师考试，并在大多数州完成住院医师培训。

[Paragraph 6]

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.

医学院听从了这一建议，录取率在25年里持平，尽管同期的申请人数在增加，人口增长了7000万。1997年，联邦对住院医师培训的资助设置了上限，迫使医院要么限制项目，要么自己承担培训医生的部分经济负担。虽然又增加了一些名额，但还远远不够。许多有潜力的医生被拒之门外。经济学家戈特利布教授表示：“并不是所有人都愿意接受这种培训，并不是所有成功完成培训的人都能成为医生。”

[Paragraph 7]

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.”

为了应对这种人为造成医生短缺的问题，一种新型医学学位开始流行起来：DOs（整骨医生）。1981年，整骨医学院只有14所，如今已有41所。在大多数国家，整骨医生给中年人做正骨整脊治疗。在美国，整骨医生是拥有完全执照的医生。他们约占医师队伍的 11% ，占医学生的 25%。政策专家罗伯特·奥尔说：“美国的骨科医生几乎与国际同行毫无相似之处，他们基本上是为了应对医生短缺情况而把自己纳入了主流。”

[Paragraph 8]

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.

执业护士和医师助理拥有了通常只有医生才有的职责，如开处方。外国训练有素的医生也填补了一些空缺。但医生短缺依然存在。这看起来很像是一个人为操纵利于内部医生的就业市场。这看起来很像是一个人为操纵利于内部医生的就业市场。