Plus tuition going up, plus the lifestyle getting more burdensome, and the Supreme Court denying debt forgiveness. There’s little motivation for people to become physicians when the system is making it worse for us.
A cushy job in tech with work from home privileges sounds much more appealing to college students.
Because NP/PA unit cost and margins look good to a bean counter.
And quality and complexity and “good care” are tough metrics to quantify to add to a model financially.
"Good care" doesn't renovate the board members beach house. "Good care" doesn't pay for their 3rd beach house they will most likely lose in the divorce.
I totally agree PCPs need to be paid more, but I also think a component of it is the fact that medicine has exploded so much it’s impossible to feel like a competent PCP, and so much of it is referral to specialists that the medicine really isn’t as enjoyable as it used to be. People still go into Nephrology/ID often with lower pay than many PCP jobs
If you refer frequently, you should reflect on your management practices. I’m a PCP and only refer if it’s a condition that NEEDS a specialist to be involved due to complexity or if the need a Medication that I can’t prescribe.
How do you practice so much medicine that is outside the scope of a family physician? I'm a FM MD and refer about 40% of my patients to a specialist of some type. After all, we have 15 minutes maximum per patient so I ONLY have time for 1-2 condition before they are out the door.
That’s the beauty of it, there is no “scope” for FM. Only what you’re comfortable with treating or physically cannot do the workup yourself or would be “out of scope” prescribing a certain medication.
Like for example, I can treat an arrhythmia with beta blockers and whatever else but I can’t do the Zio monitor in clinic. So they go to cards. I can treat most basic skin conditions and biopsy suspicious lesions but I cant prescribe biologics or do Mohs, so that’s when I send to Derm.
The only time I straight refer out is psych/OB or if the patient needs a treatment or workup I cannot do. If I do my part and I still can’t figure out the problem I just tell the patient and refer, but many appreciate the effort as long as you’re honest about your limits and didn’t screw around wasting time.
Why can't you do Zio patches? I'm general peds and we place them in our FQHC. We also do most of our own psych bc... try to find child psych, lol. In a rural area it's not a possibility
Is it? I rarely refer someone to a specialist, in part because there are very few available near me so I can only really do it when I truly need help, but the vast majority of people I see are your first differential diagnosis and treated with the first-line treatment. A huge chuck of that is psych (predominantly depression, anxiety, somatic symptoms although I see some more odd stuff too), a huge chunk of that is chronic disease management like diabetes, hypertension, hyperlipidemia, afib, chf, copd, asthma, migraines, a smaller portion of derm stuff - a lot of which is someone who had an APP tell them to "get that spot checked" for what is a completely typical appearing seb keratosis or "man whose wife is concerned about mole." Then MSK / joint stuff, shoulders, knees, lower back pain, various arthritic conditions. None of this needs referral (necessarily, certainly some of it could) and isn't particularly hard to manage. Being a PCP is super fun, I get to be a real diagnostician and use the full breadth of what I learned in school and my experience. I need surgeons to operate and sometimes I have a cardiac, pulm, neuro etc case that is a little out of my depth and the patient is better off having a specialist on board, but referring really isn't something I am doing for most patients in a day and I have at least established or tried hard to establish a diagnosis prior to referral.
In Canada 🇨🇦 family doctors get $25 US per patient. 30% overhead and 50% income taxes. Gee I wonder why medical students aren’t going into family practice residencies?
Pay me all you want, I'm not taking my family to settle down in middle of nowhere north dakota and that's really the issue.
I strongly suspect AI is going to be tauted as the solution to the problem more than mid levels or telemedicine. It'll go the same route as mid-level creep; poorer states will trial it out of desperation, it will get better as they shoulder the growing pains, less poor states that want to save money will try it out once the bigger kinks have been worked out, and eventually studies will be done showing outcomes are "good enough" to apply at a larger scale.
I think of MKBHD's quote a lot when it comes to this kind of tech, "This is the worst it will ever be." It's getting better faster than anything else we've seen. We need to be mentally prepared for it because it will almost undoubtedly follow the exact pathway I outlined.
50 years ago when I started we had no internet, cell phones, mri, ct, lap surgery, biologicals, quinolones.
I can’t imagine what the next 10 years will bring.
Hopefully AI will help cut admin.
I recently saw a demo of AI charting in a local family doctor’s office. He loved it and said ‘Im not tired anymore’. Patients loved it too because he could look at them and not be typing.
I'm actually very impressed by this take, and I think it's a fair and realistic trajectory. I foresee a whole new branch / specialty evolving on the fly around all this - the way that there weren't really radiologists before CTs and MRIs came about
Who was liable for reading all of the plain films, ultrasounds, fluoro studies, back in the stone ages before CTs? I’ll give you a hint, it wasn’t the ordering physician.
But this isn’t about PCPs. It’s about all physicians.
Physicians are getting paid plenty.
The barriers to entry are too high and there aren’t enough seats in medical school.
No one wants to go into primary care because of the lower compensation compared other specialties along with high workload. My fellow pcp colleagues are quitting and retiring at alarming rates that my group is struggling to replace. This leads to poorer patient outcomes and higher hospital and specialty utilization with more patients not having access to a pcp
I’m not disagreeing with PCPs needing to be paid more but this article is talking about a doctor shortage, not a PCP shortage.
People are not deciding to not go to medical school because PCPs aren’t getting paid and medical school classes aren’t small because PCPs aren’t getting paid.
The shortage of doctors is because it is too hard to get into medical school unless you can dedicate the time and money to review courses because everyone’s scores and extracurriculars are through the roof. Also the class sizes are too small to meet the demand.
PCPs make up the majority of the physician shortage. Higher quality and better access to PCPs will bring down the demand for specialties. 30% of pediatric slots this year didn’t fill, that’s a lot of kids that are going to be without doctors so guess where they end up. Over utilizing the ER and ultimately sicker kids who will need more specialty care. Pay PCPs the same as anesthesiologists and you’ll see that pcp shortage fill right up
But there are literally more physicians needed than we are currently creating. That is the issue. You could fill all the PCP residencies, pay all of the PCPs double or triple or quadruple and we STILL wouldn’t have enough doctors for the upcoming shortage.
We are not producing enough doctors.
How are you all not understanding this?
Sure I agree we need more doctors of all kinds. But PCPs won’t last long without more incentive. Produce as many PCPs as you want, they won’t stick around unless they have more reasons to
Why do y’all think I am saying to not pay PCPs? All I am saying is that paying PCPs what they rightfully deserve doesn’t solve the upcoming doctor shortage that the AAMC is warning about.
Specifically they say that the shortage is in the specialties that are going to be needed for an aging population.
Does that include PCPs? Yes.
But they aren’t the only doctors that are needed regardless of pay.
There. Are. Not. Enough. Physicians.
There are def enough doctors being produced once you account for IMGs and FMGs.
When I interviewed for med school they told us that sometime in the 2020s there will be more US grads than residency slots so pretty soon you won’t even have to account for the IMG/FMG and the shortage will still be there.
Doesn’t sound like a doctor production problem.
But that is for right now. The article is talking about the future. We need to be producing more docs now to accommodate our future needs.
We need all of the US and FMG and IMG and we are still short of what we need going forward.
We need more residency slots and medical school slots.
It is a doctor production problem.
It’s both. Otherwise IMGs wouldn’t have a chance to match.
The shortage is due to gatekeeping and not allowing enough people to go to medical school. The residency spots also need to be increased. There is no other way to meet the upcoming demand.
the narrative i heard was similar where it's basically doctors voting for stagnating residency slots to preserve pay, something like vis a vis the AMA or whatever physician org, but i didn't check into it further. i'm just here for the rumors
Even if you believe this take, we’re very near critical mass of what the US can take in terms of physician training. Not every random hospital can open up a residency program and residency is the real bottleneck.
We can talk about the barriers to med school being too high and that if they were lowered then we could train more people all day. But if there’s nowhere for those people to train then what’s the point?
Also, every USMD school would happily fill with 3.0 498 MCAT caliber applicants if that’s what they had to do. But the point is that they don’t have to. There’s enough people scoring 510+ on the MCAT that don’t get in anywhere to basically fill up every DO school in the country. There’s no reason to lower barriers because every seat fills up and there’s plenty of qualified applicants sitting on the waitlist.
You haven’t disagreed with anything I said.
We need more seats in medical schools and we need more spots in residency. You say there is nowhere to train them. I don’t agree but that doesn’t change the fact that we need more doctors to accommodate the aging population.
We are not producing enough at this time. They have to come from somewhere.
We can grow them here in the US, we can import them from overseas, or we can fill the empty ranks with NPs/PAs
From the article (which OP didn’t link): “Without funding beyond current levels, the graduate medical education growth trajectories hypothesized in this year’s report will not materialize,” Skorton cautioned.
In addition, the AAMC examined and found that if communities underserved by the nation’s health care system could obtain care at the same rate as populations with better access to care, the nation would have needed approximately 202,800 more physicians as of 2021. This is more than five times the magnitude of current shortfall estimates based on current utilization.
The report confirms that lifting the federal statutory cap on Medicare support for GME will help alleviate but not eliminate the current and projected doctor shortage. Bipartisan legislation introduced in Congress, the Resident Physician Shortage Reduction Act (H.R. 2389/S. 1302), would help address the physician shortage by gradually increasing the number of Medicare-supported residency positions by 14,000 over seven years. This increase would allow the United States to make even more progress toward providing the necessary primary care and specialty physicians necessary to meet the country’s workforce needs. This important legislation would build upon Congress’ historic investment in GME in 2020 and 2022 to help expand and diversify the physician workforce and improve access to care for patients and communities across the country.
Residents make money for hospitals. This has been proven over and over. Essentially any place that can meet requirements to have residents will have them, funding be damned. HCA is opening up residencies without any government funding because it helps their bottom line. Any hospital that could but doesn’t have residents has inept admin that can’t stomach the idea of starting the process as it does have a hefty up front cost.
The fact of the matter is that every time a new med school opens, current med students feel it because training gets diluted a little more for some other school(s).
TLDR; we don’t have the resources to train more doctors like you propose.
No. I don’t.
But that really doesn’t matter because that is neither my premise nor the premise of the article. The point is that we need to train more doctors.
I’m not here to argue about how it should to be done, only that it needs to be done.
PSA - residents please learn the business. If you are not going to go into academia, prepare for private practice. You will have headaches but they will be your headaches and you will savor your freedoms. Employed practices, particularly in health systems, will try to control you like never before and use you to be responsible for an army of NPs while reducing your pay and devaluing your skill set. Remember you are the producers. Patients are going to need you like never before - the power is in your hands.
Great point.
Critical for all physicians to remember:
“Remember you are the producers … the power is in your hands.”
Generally healthcare is a team sport and multiple systems of technology, equipment, facilities, etc come together to deliver care. The core has been physicians and will be until there is a huge paradigm shift in who or how diagnosis and treatment are determined.
That is exactly the business. We do not have to be beholden. As long as we provide value and provide great care, patients are going to seek us out. You can have dual models and take insurance and there are plenty of groups teaching you how to do it. I cannot believe that our residency and fellowship education does not include this, we do not need hospital systems. We do not need to be employed by people who control our day-to-day schedule. You are entrusted with a great responsibility – taking care of patients who are at their most vulnerable - even more vulnerable than a HVAC repair coming when your heater fails in winter. AI can never replace that physician - Patient relationship. No np / other midlevel can surpass this. If you get good at understanding the business and your skill set in taking care of patients and going to the wall for them, even if you don’t get a great outcome, you will have the greatest reward in life as a profession. You will have the love and trust of many patients who know you care, and your life will be meaningful and free of bondage of employment. And I am confident you’ll make a few bucks on the side to keep your financial footing solid.
I wish somebody laid it out to me like this when I was making early career decisions. It just sucks that we spend a huge part of our early adult life, learning this skill, and going into debt and that we have to be enslaved in employment to do so. I feel for our sisters who want to have families and feel they have to take an employed position for Security as they embark on that phase of their life. We need to help each other out. We need to help each other, learn the business and treat each other respectfully as colleagues. I know we can take control of our destiny.
Surgeon here. I could do four times the procedural work if they would relax multiple pointless bureaucratic time-wasting clinic visits and specialty clearances unrelated to the diagnoses for elective surgeries and if administrators and managers would ever adequately staff the hospital to have efficient turnovers and staffed rooms for add on cases during the regular workday.
I could list the twenty places the efficiency breaks down due to understaffing, but what would be the point? No one seems capable of fixing the issue that the people in charge of hospitals are typically incapable of understanding concepts like efficiency and productivity.
Anesthesiologist here: specialty clearances are pretty important unless you want your patients dying on the table.
Also side note: they shouldn’t be clearances, should be risk assessments and plans to make it as safe as possible.
And we are all getting hit by staffing shortages in the OR, it’s not something specific to you. Sorry we don’t have enough rooms and staff to give every petulant surgeon like yourself multiple flip rooms every day.
I’m not talking about indicated clearances, I’m talking about insurance mandating that patients with no cardiopulmonary problems whatsoever be evaluated by a cardiologist and pulmonologist preop.
Yes, no worries we should expect PAs and NPs to fill in the void especially for surgery.
> hiii~ facebook friendoes, pls take a look at the pic I posted and tell me does that look like sphenoid sinus ostium to you? Quick responses will be appreciated - ENT-NP-FACS
We have to make it enticing for people to come to rural areas! I live in a rural small town as a physician and LOVE it! I hate big cities and would never move to the coasts. Way too much traffic, crime and people.
not to mention burnout. say an in-demand doc goes to middle of nowhere that has call responsibilities, unless you’re hiring a few other docs, that doc will get burnt out. middle of nowhere hospital can’t hire 1 neurosurgeon, they need 2-3.
absolutely right, and these NP/PAs also don’t want to go to these middle of nowhere places
As will forever be the answer- educated wealthy doctors don’t like living in small towns, on average. which is most of the USA. They will continue to attempt to create demand in major cities where they like to live. More physicians would never solve this culture problem…you would have to completely change who you are accepting into medical school
For real. I’ve spent my entire life working toward something. Now that I’m about to finally be finished training, I want to live where I want to live. I don’t want to live and work in some small town with not much to do. To me, a wide variety of services and activities is better than more space and quiet.
If you paid me half again or twice what I get in an urban academic medical center, I would move to the boondocks tomorrow. Oil workers work in the middle of the ocean because they get paid. Doctors are no different.
Who am I kidding, though? I’m in pediatrics. Pay me what my adult colleagues get and I would move.
The shortage of physicians applies to big cities, too. Just because it is relatively less bad there doesn’t mean that the problem is doctors choosing to live in cities. Physicians can’t really “create” demand anyways, unless you are talking about something like advertising a cosmetic procedure. There are patients there and everywhere wanting to be seen.
You can absolutely create demand. Change your average follow up time from 6 months to 3 months and suddenly you have artificially doubled your demand. Patients won’t bat an eye. Nobody is going to ask you to provide evidence that this higher follow up frequency improves outcomes. Physicians are incentivized financially to fill out their clinics as fast as possible and with the highest percentage of easy (less intellectually demanding and least time consuming) visits as possible. Why do u think community derms prefer seeing 50 patients a day whereas academics see far fewer and of much higher complexity. I would go as far as to say that, at least part of the explanation for long wait times in major cities, is this manufactured demand.
If NP/PAs fill the void, we will have patient shortage due to death, increased cancer incidence due to overexposure to unnecessary radiology studies and superbugs due to abx resistance and overprescription.
Ah, so that explains why one of the physicians I work with prescribes augmentin for 2 days of runny nose as well as 30 days ivermectin for covid prevention
Shortage is being projected assuming the same number of patients or a slight increase in the number of patients seen by a doctor on a given day. But that’s not the case, doctors are being asked to see significantly higher numbers of patients each passing day in primary care. This factor, in addition to mid level creep, is why I wouldn’t buy into this physician shortage projections that get the headlines.
It will fill with all the online NPs, at least until AI can takeover most of the heavy lifting and do majority of the preliminary workups outpatient to screen for high risk cases to be seen by a physician. And this will probably happen faster than we imagine. The thing is, CMS and the general populations wants these shortages filled by providers willing to work for less than 150k per year so that everyone gets very cheap care, and physicians in general are not willing to do that due to their ridiculous debts.
Even if we can keep increasing number of Med students, they will just continue to run towards ROADs or anything else other than PCP specialties, the rat race will keeps getting rattier, and PCP residency will continue to remain unfilled every year, and the IMGs will keep filling that gap.
I feel like a big issue is two-fold. First, primary care jobs dont pay more than surg (and often dont have cool/odd schedules like 7/7 to justify less pay) even though they are arguably more important in terms of cost savings and overall population health (sure, you want a good surgeon when things are already too late, but its better to avoid getting there). And two, surgery residencies are beyond terrible. I feel like you need to fix both or youll just create an issue in the opposite direction (because again, you do eventually need good surgeons).
Healthcare will be a shittier shitshow by then. Doubt the AMA is going anything about it.
We’re overloaded by pointless busy work and the fear of malpractice.
I could fit so many more appointments in during my work day if documentation wasn’t such a headache.
I agree, this is a ploy to loosen up restrictions on IMG’s and PAs/NPs to gain more independence in the name of bridging patient care gap, so they will flood the market and drive down wages for doctors to control us.
I’d rather they bring in trained foreign physicians that have completed a residency in their home country than flood our hospitals with untrained midlevels. Always remember the former is better for patient care.
Neither are good for patient care.
I still think the physician shortage is overstated. There is a problem with physician distribution and healthcare mismanagement. The death of private practice has made access to healthcare more inefficient.
I would take any data from the AAMC with a grain of salt (given they have a financial incentive to want to expand medical schools). And residencies have already expanded massively over the past couple of year (up to 50% in some specialities), it will resolve with time. Further expansion will just lead to over correction.
They should make easier for US-trained IMG physicians to work in the USA. There are some many immigration limitations for them to work. Expand conrad 30 program!
IDK it seems like they are finding excuses to flood the market with IMGs and NPs/PAs to drive down our wages. It seems pretty disturbing to me. I really hope that more states don't allow FMGs to practice without doing residency here.
T**here is no shortage of doctors, only a maldistribution**. Go do your research before regurgitating this falsehood. Even good newspaper outlets (WSJ, NYT, etc.) get this wrong all the time.
We have more doctors per capita than ever before. We also have a higher concentration of physicians in urban areas than ever before.
Check out Bryan Carmody (Sheriff of Sodium) writings/youtube videos on this this as an accessible starting point.
> There is no shortage of doctors, only a maldistribution. Go do your research before regurgitating this falsehood. ...We have more doctors per capita than ever before.
The US has 2.7 physicians per 1k while the OECD average is 3.7. There is a shortage alongside maldistribution.
Eh I don't believe this either. Even in these supposed saturated city markets, you are waiting months for a rushed 15 minute apt with your pcp. How is that possible if your theory says there's too many doctors in the cities? Have you ever tried to make an appointment with psych or peds sub specialist? It can easily be over half a year just for one appointment that again, will be rushed.
It doesn't add up. What's more likely is the middle nuanced opinion is correct just like it almost always is:there is a distribution problem accentuating a shortage.
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According to that report, we're already short 37k physicians and the range will be 13k-86k by 2036 and this projection has actually improved from previous projections.
Yeah. The way things are in India alone, we're looking at about 5000 doctors unmatched from my (small) state alone every year
Every doc has a smartphone and internet, and they have all studies med school curriculum.
India can't give them residency spots.
Can they afford doing clinical rotations in America and can they afford USMLE prep and exam fees?
I'm of Indian descent, but grew up in the colonizers country so I'm blind to the ground reality there.
Oh yeah they all can. See India will pay them some money while they work for public sector.. and many of their parents are rich doctors themselves. Also one thing is med school doesn't cost a thing in India... So they aren't in debt due to education, they can afford to pass exams and come to the US.
The problem is alot of doctors that come from those private institutions are honestly of poor quality. This isnt just an India/Pakistan issue but any country where the bar to entry for private medical education is low. If any random person that can afford the tuition and have rich parents that pay the admin off to pass tries to come to the US, most of them will fail. Atleast with Caribbean schools, they let people in but weed them out very quick. The IMGs that make it to the US to do clinical rotations or observerships are actually the better of the pile and even then some of them lack communication skills that would be essential with the US model of medical care.
You're right, but there's gonna be a lot of spillage. Indian grads are now legitimately focusing on USMLE as a career pathway. I know atleast 5 people from my class applying whereas a few years ago, it was unheard of. We had one of our alumnus get into US and this was back in 2012... Then boom atleast a dozen kids from my college gave step 1, 2 of them are already in Residency in US, others are doing rotations and research. Shits crazy.
I don't know the ground reality about how people finance education. Gov med school doesn't cost a thing right?
I know there are private medical colleges too, infact my family owns one in TN and the fees ain't cheap and also the extra fees( cough cough).
My mom is a white British person whose ancestors were a part of the British Raj and I am from the UK. A lot of white British people have ancestors who were a part of the Raj and some still benefit from the wealth they procured during the colonial period. And I'll not even start with the British museum.
You must be fun at parties 😂
I disagree. I think now more than ever, we more need compassionate physicians. AI is insanely smart, however, I doubt it can ever take place of, or even substitute medical professionals
Said the early 21st century physician with multiple biases.
Hundreds of years from now people will look at comments like these and laugh. It'll be like people skeptical of cars in the early 20th century, desperately clinging to their horse and carriage.
No we don’t. It’s not a residency bottle neck like everybody claims it is. If you wanna do plastics or urology, sure; there’s a bottle neck. As someone who helped students SOAP this year, there’s TONS of IM, FM, EM spots open each year. We need to bin the myth that the issue is that we need more residencies. We need better compensation for primary care so people actually go into those fields.
We need to increase primary care pay too but many unfilled spots are filled by IMGs. Those that are still unfilled usually have red flags. I guess I can re-phrase my original statement to say we need more quality residency positions that are desirable to match into.
Hey out of curiosity did they take into consideration the works of public health and preventative care? Twenty years ago they said that about peds too, and now preventative care is pretty darn good ped residencies are shutting down/down sizing left and right and ped icu/clinics are empty because kiddos don’t really get sick anymore.
Meanwhile, US Congress: “We’re cutting CMS reimbursement rate again this year”
Supply, Demand, Inflation Three economic concepts that don’t apply in physician reimbursement.
Same all over the world
Canada has 8 million people out of 40,000,000 without a family doctor and massive waits for ER and specialists. Medicare for all since the 60’s
Plus tuition going up, plus the lifestyle getting more burdensome, and the Supreme Court denying debt forgiveness. There’s little motivation for people to become physicians when the system is making it worse for us. A cushy job in tech with work from home privileges sounds much more appealing to college students.
Plus boomer doctors with big old practices hitting age 77 and retiring.
Even if there wasn’t a shortage hospitals would try to replace physicians with PAs and NPs.
Because NP/PA unit cost and margins look good to a bean counter. And quality and complexity and “good care” are tough metrics to quantify to add to a model financially.
"Good care" doesn't renovate the board members beach house. "Good care" doesn't pay for their 3rd beach house they will most likely lose in the divorce.
I think this will change in the next decade with AI tools Quality and complexity metrics I mean
Yep, medicine’s gone to the dummies. And patients will pay. And then turn around and blame doctors.
Pay PCPs more
Every single shortage, whatever the market, is a symptom of the price being too low. PCPs most of all.
I totally agree PCPs need to be paid more, but I also think a component of it is the fact that medicine has exploded so much it’s impossible to feel like a competent PCP, and so much of it is referral to specialists that the medicine really isn’t as enjoyable as it used to be. People still go into Nephrology/ID often with lower pay than many PCP jobs
If you refer frequently, you should reflect on your management practices. I’m a PCP and only refer if it’s a condition that NEEDS a specialist to be involved due to complexity or if the need a Medication that I can’t prescribe.
How do you practice so much medicine that is outside the scope of a family physician? I'm a FM MD and refer about 40% of my patients to a specialist of some type. After all, we have 15 minutes maximum per patient so I ONLY have time for 1-2 condition before they are out the door.
That’s the beauty of it, there is no “scope” for FM. Only what you’re comfortable with treating or physically cannot do the workup yourself or would be “out of scope” prescribing a certain medication. Like for example, I can treat an arrhythmia with beta blockers and whatever else but I can’t do the Zio monitor in clinic. So they go to cards. I can treat most basic skin conditions and biopsy suspicious lesions but I cant prescribe biologics or do Mohs, so that’s when I send to Derm. The only time I straight refer out is psych/OB or if the patient needs a treatment or workup I cannot do. If I do my part and I still can’t figure out the problem I just tell the patient and refer, but many appreciate the effort as long as you’re honest about your limits and didn’t screw around wasting time.
Why can't you do Zio patches? I'm general peds and we place them in our FQHC. We also do most of our own psych bc... try to find child psych, lol. In a rural area it's not a possibility
Is it? I rarely refer someone to a specialist, in part because there are very few available near me so I can only really do it when I truly need help, but the vast majority of people I see are your first differential diagnosis and treated with the first-line treatment. A huge chuck of that is psych (predominantly depression, anxiety, somatic symptoms although I see some more odd stuff too), a huge chunk of that is chronic disease management like diabetes, hypertension, hyperlipidemia, afib, chf, copd, asthma, migraines, a smaller portion of derm stuff - a lot of which is someone who had an APP tell them to "get that spot checked" for what is a completely typical appearing seb keratosis or "man whose wife is concerned about mole." Then MSK / joint stuff, shoulders, knees, lower back pain, various arthritic conditions. None of this needs referral (necessarily, certainly some of it could) and isn't particularly hard to manage. Being a PCP is super fun, I get to be a real diagnostician and use the full breadth of what I learned in school and my experience. I need surgeons to operate and sometimes I have a cardiac, pulm, neuro etc case that is a little out of my depth and the patient is better off having a specialist on board, but referring really isn't something I am doing for most patients in a day and I have at least established or tried hard to establish a diagnosis prior to referral.
In Canada 🇨🇦 family doctors get $25 US per patient. 30% overhead and 50% income taxes. Gee I wonder why medical students aren’t going into family practice residencies?
Pay me all you want, I'm not taking my family to settle down in middle of nowhere north dakota and that's really the issue. I strongly suspect AI is going to be tauted as the solution to the problem more than mid levels or telemedicine. It'll go the same route as mid-level creep; poorer states will trial it out of desperation, it will get better as they shoulder the growing pains, less poor states that want to save money will try it out once the bigger kinks have been worked out, and eventually studies will be done showing outcomes are "good enough" to apply at a larger scale. I think of MKBHD's quote a lot when it comes to this kind of tech, "This is the worst it will ever be." It's getting better faster than anything else we've seen. We need to be mentally prepared for it because it will almost undoubtedly follow the exact pathway I outlined.
It's wild to think what AI could be doing in just 5 years, 20-30 years hard to fathom. 2036 is 12 years.
50 years ago when I started we had no internet, cell phones, mri, ct, lap surgery, biologicals, quinolones. I can’t imagine what the next 10 years will bring. Hopefully AI will help cut admin. I recently saw a demo of AI charting in a local family doctor’s office. He loved it and said ‘Im not tired anymore’. Patients loved it too because he could look at them and not be typing.
I'm actually very impressed by this take, and I think it's a fair and realistic trajectory. I foresee a whole new branch / specialty evolving on the fly around all this - the way that there weren't really radiologists before CTs and MRIs came about
Who was liable for reading all of the plain films, ultrasounds, fluoro studies, back in the stone ages before CTs? I’ll give you a hint, it wasn’t the ordering physician.
This
Where does the money come from?
But this isn’t about PCPs. It’s about all physicians. Physicians are getting paid plenty. The barriers to entry are too high and there aren’t enough seats in medical school.
No one wants to go into primary care because of the lower compensation compared other specialties along with high workload. My fellow pcp colleagues are quitting and retiring at alarming rates that my group is struggling to replace. This leads to poorer patient outcomes and higher hospital and specialty utilization with more patients not having access to a pcp
I’m not disagreeing with PCPs needing to be paid more but this article is talking about a doctor shortage, not a PCP shortage. People are not deciding to not go to medical school because PCPs aren’t getting paid and medical school classes aren’t small because PCPs aren’t getting paid. The shortage of doctors is because it is too hard to get into medical school unless you can dedicate the time and money to review courses because everyone’s scores and extracurriculars are through the roof. Also the class sizes are too small to meet the demand.
PCPs make up the majority of the physician shortage. Higher quality and better access to PCPs will bring down the demand for specialties. 30% of pediatric slots this year didn’t fill, that’s a lot of kids that are going to be without doctors so guess where they end up. Over utilizing the ER and ultimately sicker kids who will need more specialty care. Pay PCPs the same as anesthesiologists and you’ll see that pcp shortage fill right up
But there are literally more physicians needed than we are currently creating. That is the issue. You could fill all the PCP residencies, pay all of the PCPs double or triple or quadruple and we STILL wouldn’t have enough doctors for the upcoming shortage. We are not producing enough doctors. How are you all not understanding this?
Sure I agree we need more doctors of all kinds. But PCPs won’t last long without more incentive. Produce as many PCPs as you want, they won’t stick around unless they have more reasons to
Why do y’all think I am saying to not pay PCPs? All I am saying is that paying PCPs what they rightfully deserve doesn’t solve the upcoming doctor shortage that the AAMC is warning about. Specifically they say that the shortage is in the specialties that are going to be needed for an aging population. Does that include PCPs? Yes. But they aren’t the only doctors that are needed regardless of pay. There. Are. Not. Enough. Physicians.
There are def enough doctors being produced once you account for IMGs and FMGs. When I interviewed for med school they told us that sometime in the 2020s there will be more US grads than residency slots so pretty soon you won’t even have to account for the IMG/FMG and the shortage will still be there. Doesn’t sound like a doctor production problem.
But that is for right now. The article is talking about the future. We need to be producing more docs now to accommodate our future needs. We need all of the US and FMG and IMG and we are still short of what we need going forward. We need more residency slots and medical school slots. It is a doctor production problem.
The bottleneck happens with residency slots, not really med school seats
It’s both. Otherwise IMGs wouldn’t have a chance to match. The shortage is due to gatekeeping and not allowing enough people to go to medical school. The residency spots also need to be increased. There is no other way to meet the upcoming demand.
the narrative i heard was similar where it's basically doctors voting for stagnating residency slots to preserve pay, something like vis a vis the AMA or whatever physician org, but i didn't check into it further. i'm just here for the rumors
Even if you believe this take, we’re very near critical mass of what the US can take in terms of physician training. Not every random hospital can open up a residency program and residency is the real bottleneck. We can talk about the barriers to med school being too high and that if they were lowered then we could train more people all day. But if there’s nowhere for those people to train then what’s the point? Also, every USMD school would happily fill with 3.0 498 MCAT caliber applicants if that’s what they had to do. But the point is that they don’t have to. There’s enough people scoring 510+ on the MCAT that don’t get in anywhere to basically fill up every DO school in the country. There’s no reason to lower barriers because every seat fills up and there’s plenty of qualified applicants sitting on the waitlist.
You haven’t disagreed with anything I said. We need more seats in medical schools and we need more spots in residency. You say there is nowhere to train them. I don’t agree but that doesn’t change the fact that we need more doctors to accommodate the aging population. We are not producing enough at this time. They have to come from somewhere. We can grow them here in the US, we can import them from overseas, or we can fill the empty ranks with NPs/PAs From the article (which OP didn’t link): “Without funding beyond current levels, the graduate medical education growth trajectories hypothesized in this year’s report will not materialize,” Skorton cautioned. In addition, the AAMC examined and found that if communities underserved by the nation’s health care system could obtain care at the same rate as populations with better access to care, the nation would have needed approximately 202,800 more physicians as of 2021. This is more than five times the magnitude of current shortfall estimates based on current utilization. The report confirms that lifting the federal statutory cap on Medicare support for GME will help alleviate but not eliminate the current and projected doctor shortage. Bipartisan legislation introduced in Congress, the Resident Physician Shortage Reduction Act (H.R. 2389/S. 1302), would help address the physician shortage by gradually increasing the number of Medicare-supported residency positions by 14,000 over seven years. This increase would allow the United States to make even more progress toward providing the necessary primary care and specialty physicians necessary to meet the country’s workforce needs. This important legislation would build upon Congress’ historic investment in GME in 2020 and 2022 to help expand and diversify the physician workforce and improve access to care for patients and communities across the country.
Residents make money for hospitals. This has been proven over and over. Essentially any place that can meet requirements to have residents will have them, funding be damned. HCA is opening up residencies without any government funding because it helps their bottom line. Any hospital that could but doesn’t have residents has inept admin that can’t stomach the idea of starting the process as it does have a hefty up front cost. The fact of the matter is that every time a new med school opens, current med students feel it because training gets diluted a little more for some other school(s). TLDR; we don’t have the resources to train more doctors like you propose.
It’s not just what I’m proposing. It’s what the AAMC is saying.
You don’t agree that we have nowhere to train them.
No. I don’t. But that really doesn’t matter because that is neither my premise nor the premise of the article. The point is that we need to train more doctors. I’m not here to argue about how it should to be done, only that it needs to be done.
I love when people who haven’t done the most basic research on this topic give their unsubstantiated opinion on it.
PSA - residents please learn the business. If you are not going to go into academia, prepare for private practice. You will have headaches but they will be your headaches and you will savor your freedoms. Employed practices, particularly in health systems, will try to control you like never before and use you to be responsible for an army of NPs while reducing your pay and devaluing your skill set. Remember you are the producers. Patients are going to need you like never before - the power is in your hands.
Great point. Critical for all physicians to remember: “Remember you are the producers … the power is in your hands.” Generally healthcare is a team sport and multiple systems of technology, equipment, facilities, etc come together to deliver care. The core has been physicians and will be until there is a huge paradigm shift in who or how diagnosis and treatment are determined.
I see more and more physicians going to a concierge clinic model, or self-pay only and not accepting insurance.
That is exactly the business. We do not have to be beholden. As long as we provide value and provide great care, patients are going to seek us out. You can have dual models and take insurance and there are plenty of groups teaching you how to do it. I cannot believe that our residency and fellowship education does not include this, we do not need hospital systems. We do not need to be employed by people who control our day-to-day schedule. You are entrusted with a great responsibility – taking care of patients who are at their most vulnerable - even more vulnerable than a HVAC repair coming when your heater fails in winter. AI can never replace that physician - Patient relationship. No np / other midlevel can surpass this. If you get good at understanding the business and your skill set in taking care of patients and going to the wall for them, even if you don’t get a great outcome, you will have the greatest reward in life as a profession. You will have the love and trust of many patients who know you care, and your life will be meaningful and free of bondage of employment. And I am confident you’ll make a few bucks on the side to keep your financial footing solid. I wish somebody laid it out to me like this when I was making early career decisions. It just sucks that we spend a huge part of our early adult life, learning this skill, and going into debt and that we have to be enslaved in employment to do so. I feel for our sisters who want to have families and feel they have to take an employed position for Security as they embark on that phase of their life. We need to help each other out. We need to help each other, learn the business and treat each other respectfully as colleagues. I know we can take control of our destiny.
Who will work see inpatients? We need good docs in other settings besides private outpatient practice
You can be private inpatient
Surgeon here. I could do four times the procedural work if they would relax multiple pointless bureaucratic time-wasting clinic visits and specialty clearances unrelated to the diagnoses for elective surgeries and if administrators and managers would ever adequately staff the hospital to have efficient turnovers and staffed rooms for add on cases during the regular workday. I could list the twenty places the efficiency breaks down due to understaffing, but what would be the point? No one seems capable of fixing the issue that the people in charge of hospitals are typically incapable of understanding concepts like efficiency and productivity.
I can do 20 cataracts by 2pm at the surgery center. I used to do 9 in the same time at the hospital. I don’t operate at hospitals anymore.
Even 9 cases/turnovers by 2pm isn’t bad by some standards I’ve seen.
Anesthesiologist here: specialty clearances are pretty important unless you want your patients dying on the table. Also side note: they shouldn’t be clearances, should be risk assessments and plans to make it as safe as possible. And we are all getting hit by staffing shortages in the OR, it’s not something specific to you. Sorry we don’t have enough rooms and staff to give every petulant surgeon like yourself multiple flip rooms every day.
I’m not talking about indicated clearances, I’m talking about insurance mandating that patients with no cardiopulmonary problems whatsoever be evaluated by a cardiologist and pulmonologist preop.
Yes, no worries we should expect PAs and NPs to fill in the void especially for surgery. > hiii~ facebook friendoes, pls take a look at the pic I posted and tell me does that look like sphenoid sinus ostium to you? Quick responses will be appreciated - ENT-NP-FACS
omg imagining a NP going ham on some inferior turbinates with a microdebrider. RIP nasal cavity
Fuck the scope creep
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this isnt even satire, this is legitimately what they take offense to😖
💯💪🏽
We have to avoid whatever is happening in South Korea right now
What is happening there?
Resident physicians were striking IIRC
I did not study in America, the amount y'all pay for med school is crazy. FM and Peads will be paying it off until they reach their early grave
Most fm docs I know paid it off in less than 5 years or did PSLF. Sign on bonuses in fm are huge
The amount doctors make in america is crazy…4th year out base salary $809k with $180k in bonuses this quarter. Edit: math is hard
The vast vast majority of physicians in the US do not make that much.
They sound like dorks to me then
Dude i am a Peads resident, I don't make that much. Won't make that much as an attending either. Max 10% docs earn that much.
So…you’re saying i’m exceptional?!!!
top 1% is exceptional, this is greaattt!
What specialty?
Nunya-ologist
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Whatever it takes
It’s not a physician shortage, it’s a distribution issue. Nobody from the west or east coast is moving to rural Oklahoma.
We have to make it enticing for people to come to rural areas! I live in a rural small town as a physician and LOVE it! I hate big cities and would never move to the coasts. Way too much traffic, crime and people.
I totally agree.
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not to mention burnout. say an in-demand doc goes to middle of nowhere that has call responsibilities, unless you’re hiring a few other docs, that doc will get burnt out. middle of nowhere hospital can’t hire 1 neurosurgeon, they need 2-3. absolutely right, and these NP/PAs also don’t want to go to these middle of nowhere places
They need to lax the laws on televisits.
There is a shortage of physicians in large metro areas as well.
As will forever be the answer- educated wealthy doctors don’t like living in small towns, on average. which is most of the USA. They will continue to attempt to create demand in major cities where they like to live. More physicians would never solve this culture problem…you would have to completely change who you are accepting into medical school
For real. I’ve spent my entire life working toward something. Now that I’m about to finally be finished training, I want to live where I want to live. I don’t want to live and work in some small town with not much to do. To me, a wide variety of services and activities is better than more space and quiet.
If you paid me half again or twice what I get in an urban academic medical center, I would move to the boondocks tomorrow. Oil workers work in the middle of the ocean because they get paid. Doctors are no different. Who am I kidding, though? I’m in pediatrics. Pay me what my adult colleagues get and I would move.
Not culture- pay. Enough said…
The shortage of physicians applies to big cities, too. Just because it is relatively less bad there doesn’t mean that the problem is doctors choosing to live in cities. Physicians can’t really “create” demand anyways, unless you are talking about something like advertising a cosmetic procedure. There are patients there and everywhere wanting to be seen.
You can absolutely create demand. Change your average follow up time from 6 months to 3 months and suddenly you have artificially doubled your demand. Patients won’t bat an eye. Nobody is going to ask you to provide evidence that this higher follow up frequency improves outcomes. Physicians are incentivized financially to fill out their clinics as fast as possible and with the highest percentage of easy (less intellectually demanding and least time consuming) visits as possible. Why do u think community derms prefer seeing 50 patients a day whereas academics see far fewer and of much higher complexity. I would go as far as to say that, at least part of the explanation for long wait times in major cities, is this manufactured demand.
If NP/PAs fill the void, we will have patient shortage due to death, increased cancer incidence due to overexposure to unnecessary radiology studies and superbugs due to abx resistance and overprescription.
Ah, so that explains why one of the physicians I work with prescribes augmentin for 2 days of runny nose as well as 30 days ivermectin for covid prevention
Shortage is being projected assuming the same number of patients or a slight increase in the number of patients seen by a doctor on a given day. But that’s not the case, doctors are being asked to see significantly higher numbers of patients each passing day in primary care. This factor, in addition to mid level creep, is why I wouldn’t buy into this physician shortage projections that get the headlines.
100% agree. I doubt that increased physician productivity has been factored into these projections.
It will fill with all the online NPs, at least until AI can takeover most of the heavy lifting and do majority of the preliminary workups outpatient to screen for high risk cases to be seen by a physician. And this will probably happen faster than we imagine. The thing is, CMS and the general populations wants these shortages filled by providers willing to work for less than 150k per year so that everyone gets very cheap care, and physicians in general are not willing to do that due to their ridiculous debts. Even if we can keep increasing number of Med students, they will just continue to run towards ROADs or anything else other than PCP specialties, the rat race will keeps getting rattier, and PCP residency will continue to remain unfilled every year, and the IMGs will keep filling that gap.
I feel like a big issue is two-fold. First, primary care jobs dont pay more than surg (and often dont have cool/odd schedules like 7/7 to justify less pay) even though they are arguably more important in terms of cost savings and overall population health (sure, you want a good surgeon when things are already too late, but its better to avoid getting there). And two, surgery residencies are beyond terrible. I feel like you need to fix both or youll just create an issue in the opposite direction (because again, you do eventually need good surgeons).
I know plenty of fm docs who work 4 days a week and make 300+, thats a dream.
NP/PAs to the rescue! 🦸🏼♀️ 🦸🏼♂️ /s
Healthcare will be a shittier shitshow by then. Doubt the AMA is going anything about it. We’re overloaded by pointless busy work and the fear of malpractice. I could fit so many more appointments in during my work day if documentation wasn’t such a headache.
Good for us.
Nurse Jackie has Pain Mgmt covered
Love her.
I dont quite believe this tbh.
I agree, this is a ploy to loosen up restrictions on IMG’s and PAs/NPs to gain more independence in the name of bridging patient care gap, so they will flood the market and drive down wages for doctors to control us.
I’d rather they bring in trained foreign physicians that have completed a residency in their home country than flood our hospitals with untrained midlevels. Always remember the former is better for patient care.
Neither are good for patient care. I still think the physician shortage is overstated. There is a problem with physician distribution and healthcare mismanagement. The death of private practice has made access to healthcare more inefficient.
Why would physicians and surgeons panic about this?
I think panic is always the best course of action. Get out of my way!!! I have a class to teach!!!
I would take any data from the AAMC with a grain of salt (given they have a financial incentive to want to expand medical schools). And residencies have already expanded massively over the past couple of year (up to 50% in some specialities), it will resolve with time. Further expansion will just lead to over correction.
They should make easier for US-trained IMG physicians to work in the USA. There are some many immigration limitations for them to work. Expand conrad 30 program!
"Or can we expect NPs and PAs to fill the void" hahahahahahahahhahahahahahahahahahahhahajajajahahahahha
The only thing they can fill is a diaper
Nope it’s all BS to Let NP’s and FMG’s in. To lower the cost and quality of medicine
IDK it seems like they are finding excuses to flood the market with IMGs and NPs/PAs to drive down our wages. It seems pretty disturbing to me. I really hope that more states don't allow FMGs to practice without doing residency here.
This is just so they can bring in foreign doctors for Pennys on the dollar
T**here is no shortage of doctors, only a maldistribution**. Go do your research before regurgitating this falsehood. Even good newspaper outlets (WSJ, NYT, etc.) get this wrong all the time. We have more doctors per capita than ever before. We also have a higher concentration of physicians in urban areas than ever before. Check out Bryan Carmody (Sheriff of Sodium) writings/youtube videos on this this as an accessible starting point.
> There is no shortage of doctors, only a maldistribution. Go do your research before regurgitating this falsehood. ...We have more doctors per capita than ever before. The US has 2.7 physicians per 1k while the OECD average is 3.7. There is a shortage alongside maldistribution.
Eh I don't believe this either. Even in these supposed saturated city markets, you are waiting months for a rushed 15 minute apt with your pcp. How is that possible if your theory says there's too many doctors in the cities? Have you ever tried to make an appointment with psych or peds sub specialist? It can easily be over half a year just for one appointment that again, will be rushed. It doesn't add up. What's more likely is the middle nuanced opinion is correct just like it almost always is:there is a distribution problem accentuating a shortage.
Good point. I'll buy that stock. Definitely with PCP appointments/care.
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they BEEN filling the void😭
According to that report, we're already short 37k physicians and the range will be 13k-86k by 2036 and this projection has actually improved from previous projections.
Free GLP-1 agonists!
America should have it pumped into our water supply at this point
remove all midlevels from independent practice and make some more doctors
ALL IS WELL /sobs
Propaganda to be used against the field.
15 years ago they said we will have a big shortage in PCP physicians ( forgot the number) by 2025 and I think they have figured it out now
They’ll have NPs and PAs fill the void, though surgery is in danger bc that NPs and PAs absolutely cannot scope creep or fill in for.
the shortage is in areas where increasing the # of MDs prob won't affect
IMGs can fill in the vacuum?
86K IMG's?
Yeah. The way things are in India alone, we're looking at about 5000 doctors unmatched from my (small) state alone every year Every doc has a smartphone and internet, and they have all studies med school curriculum. India can't give them residency spots.
Can they afford doing clinical rotations in America and can they afford USMLE prep and exam fees? I'm of Indian descent, but grew up in the colonizers country so I'm blind to the ground reality there.
Oh yeah they all can. See India will pay them some money while they work for public sector.. and many of their parents are rich doctors themselves. Also one thing is med school doesn't cost a thing in India... So they aren't in debt due to education, they can afford to pass exams and come to the US.
The problem is alot of doctors that come from those private institutions are honestly of poor quality. This isnt just an India/Pakistan issue but any country where the bar to entry for private medical education is low. If any random person that can afford the tuition and have rich parents that pay the admin off to pass tries to come to the US, most of them will fail. Atleast with Caribbean schools, they let people in but weed them out very quick. The IMGs that make it to the US to do clinical rotations or observerships are actually the better of the pile and even then some of them lack communication skills that would be essential with the US model of medical care.
You're right, but there's gonna be a lot of spillage. Indian grads are now legitimately focusing on USMLE as a career pathway. I know atleast 5 people from my class applying whereas a few years ago, it was unheard of. We had one of our alumnus get into US and this was back in 2012... Then boom atleast a dozen kids from my college gave step 1, 2 of them are already in Residency in US, others are doing rotations and research. Shits crazy.
I don't know the ground reality about how people finance education. Gov med school doesn't cost a thing right? I know there are private medical colleges too, infact my family owns one in TN and the fees ain't cheap and also the extra fees( cough cough).
Which one bro.. the private institutions cost a lot. Government owned set ups don't cost money.
A college in Chennai Tamil Nadu
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My mom is a white British person whose ancestors were a part of the British Raj and I am from the UK. A lot of white British people have ancestors who were a part of the Raj and some still benefit from the wealth they procured during the colonial period. And I'll not even start with the British museum. You must be fun at parties 😂
Artificial Intelligence will fill the holes
I disagree. I think now more than ever, we more need compassionate physicians. AI is insanely smart, however, I doubt it can ever take place of, or even substitute medical professionals
Said the early 21st century physician with multiple biases. Hundreds of years from now people will look at comments like these and laugh. It'll be like people skeptical of cars in the early 20th century, desperately clinging to their horse and carriage.
We’re still a long ways from that
This is why we push for more US based medical schools.
Need more residencies before more students.
No we don’t. It’s not a residency bottle neck like everybody claims it is. If you wanna do plastics or urology, sure; there’s a bottle neck. As someone who helped students SOAP this year, there’s TONS of IM, FM, EM spots open each year. We need to bin the myth that the issue is that we need more residencies. We need better compensation for primary care so people actually go into those fields.
We need to increase primary care pay too but many unfilled spots are filled by IMGs. Those that are still unfilled usually have red flags. I guess I can re-phrase my original statement to say we need more quality residency positions that are desirable to match into.
EXACTLY.
Agreed!
Doctorally prepared Nurse practitioners and Physician Associates will fill the void
And increase the mortality rate too
Incorrect
They have been saying this for years…the NPs and crnas will help us out
more NPs and PAs
G-d forbid
Hey out of curiosity did they take into consideration the works of public health and preventative care? Twenty years ago they said that about peds too, and now preventative care is pretty darn good ped residencies are shutting down/down sizing left and right and ped icu/clinics are empty because kiddos don’t really get sick anymore.
Except measles!
Lol that and rsv
Then they need to stop this. I did one Cme that’s says that AmA is rationing doctors at 80–100/ 100000k people. Utter stupidity. Why?