“Where have all the doctors gone?” is the headline on the cover article of the January/February 2025 edition of the AARP Bulletin. Perhaps it should include, “or are going?” The article, which is quite extensive, explores why patients have a difficult time finding a physician, let alone seeing a specialist. The article is quite sympathetic to physicians. Admitting that primary care doctors make $250,000 per year, and specialists twice that, it explores the harsh financial realities of becoming a physician: that students graduate with educational debt of over $250,000—added to the number of years of study needed to achieve mastery of their specialty—make success quite an achievement. One-in-four students drop out before graduation, finding the demands, pressures and lifestyle just too onerous. These negative impediments result in an America burdened with a physician shortage. Our aging population will keenly appreciate this loss of expertise since their avuncular family physician will exist only in faded yellow copies of the Saturday Evening Post.
We will explore the significance of this article later, but it is notable that the AARP Bulletin chose to publish the piece as its cover article.
Challenges of pursuing a medical career
One would think that a generous salary and comfortable lifestyle would attract more young people to pursue medicine, but the exact opposite has happened. Those bright young students discovered that they could make more money at a younger age without the painful years of medical school, on-call nights in residency, and emotional burdens of patient care (not all cases go well). The need to postpone customary milestones, such as getting married, buying a home, and raising a family, disincentivizes many students who might otherwise be attracted to the profession.
My youngest son experienced the challenge. As a third-year college student at a major Florida university, he had all the attributes necessary to be a great physician: intelligence, drive, motivation and compassion. I arranged for him to spend the day with the dean of a medical school to discover if he would find the profession appealing. The dean was both hospitable and gracious. My son had a very enjoyable day. At about 4:30 p.m., as I was finishing a difficult case, my phone rang. It was him. I asked how it went. His voice was polite but non-committal. He thoroughly enjoyed the day, raved about how nicely the dean treated him, and found the visit interesting.
Well, I asked, did you find your experience stimulating enough to pursue medicine? His response was blunt. “It would take me another year of college, four years of medical school and at least another four years of residency. That’s nine years.”
“Dad,” he went on, “I’ve seen how hard you’ve worked, sacrificing time with us, Saturdays, Sundays, leaving at night, and I appreciate your dedication. I’ve seen you upset when you’ve lost a patient, or someone didn’t take good care of your patient. And, after working all those years, you could have a patient go bad, get sued and, even if it’s not your fault, lose everything that you’ve worked for all these years. Why would I want to do that?”
Why indeed? Perhaps it’s a calling from which we enjoy tremendous gratification. For the sake of completion, my son is a very successful attorney who is married with children and thoroughly enjoys his life (and his profession). His story exemplifies life choices that are available to young people without the rigors and sacrifice that we accept as part of our profession.
For those who have become doctors, the most attractive alternative after completing residency is to become employed. This guarantees a steady income and more predicable hours. Student debt weighs heavily on their choices. Close to 80% of recent doctors are now employed. But employment comes at a price. They have never enjoyed physician autonomy. In terms of this article, physician autonomy is doing what you believe is best for the patient, without a corporate entity telling you how to practice. But that is changing.
Intense patient dissatisfaction
The December assassination of the UnitedHealth Group executive exposed a deep undercurrent of dissatisfaction among patients. There was no outpouring of sympathy for the deceased but rather public ennui, reflecting little concern for the loss of a rich executive who only made life worse for millions of people. I am sure Austria felt the same way when Archduke Franz Ferdinand was assassinated. Andrew Witty, the president of UnitedHealth, admitted that the system needs to function better, as reported in his remarks Jan. 12, 2025, in Fortune magazine. He went on to add: “Ultimately, improving healthcare means addressing the root cause of healthcare costs,” which he blames on over-usage and high pharmacy prices.
Going further, he offered, “Seniors recognize value, which is why the majority of them choose Medicare Advantage.” He ignored the fact that seniors cannot afford co-insurance and the deductibles that come with it, and have no alternative. He also ignored the fact that the Federal Trade Commission (FTC) revealed that UnitedHealth severely overcharged cancer patients for life-saving drugs. And UnitedHealth owns its own pharmacy benefit managers, which allows the company to make a huge profit from pharmaceuticals.
He theorizes that too many people want too much care, and we can’t afford to provide that level of care for everyone. Absent from his assertion is the financial reality that America spends twice as much as any developed country, yet our outcomes are worse than many other countries, having the highest infant mortality rate and the lowest life expectancy among 11 high-income countries, according to a Lancet report from Dec. 7, 2024. Our government is reluctant to spend more. Physician Medicare reimbursement has not risen in 25 years, while physician payments have been drastically reduced. Since hospitals are not likely to lower their fees, and GLP-1 agonists are not going to be discounted, physicians should not expect increased compensation. We who actually deliver care—doctors—have been poorly compensated. What this means for the employed physician is that employers place more demands on them.
Corporate medicine increase demands on employed physicians
Relative value units (RVUs) will be taken seriously, and the 95th percentile will be the new standard. Fifteen minutes a visit computes to four patients an hour, placing a premium on speed rather than meeting patients’ needs. New patients require significantly more time to provide good care. Past records and computed tomography (CT) images have to be checked. While an orthopedic surgeon can do a cast check in 15 minutes, delivering proper care requires time, conversation and compassion—attributes not found in artificial intelligence (AI). Those essentials will not be possible in the enhanced corporate medical world.
How many bypasses or aneurysms can a vascular surgeon perform in a day without jeopardizing care of the patient? Our specialty has already debated who should police unnecessary venous ablations. The pressure to maintain income (and profit margins) will lead to marginally indicated procedures. Administrative types and corporate leaders have little knowledge of—or regard for—how medicine is practiced. Their concern is for efficiency, RVUs and number of cases. As long as outcomes are acceptable and their bottom line is robust, they have accomplished their goal.
In an effort to increase efficiency (and profitability), mid-level providers have been substituted with negligible success. Nurse practitioners (NPs) and physician assistants (PAs) are utterly unqualified to diagnose and treat patients without supervision. They actually increase healthcare costs, as demonstrated in a 2022 study by Mississippi’s Hattiesburg Clinic. Replacing physicians with PAs and NPs resulted in higher costs of more than $28 million annually. Increased costs came from tests, specialist referrals and patients sent to emergency departments. Beyond that, are we fulfilling our responsibility to a patient when a PA or NP performs the initial consultation and then is signed off with a cursory physician review?
Currently, hospitals are able to sustain high physician salaries since a portion of their compensation is derived from hospital reimbursement. As healthcare dollars become scarce, the net result is that physician incomes are expected to decrease. And those doctors employed by private equity firms had better expect demands to work “harder,” see more patients, do more procedures, and maximize their billing. High-level executives in boardrooms care little about patient outcomes. As insurers, hospitals and pharmaceuticals try to protect their shares, these entities refuse to yield. Doctors and patients are caught in the middle.
The December assassination in New York pulled the scab off the purulent healthcare wound and exposed intense patient dissatisfaction.
The medical profession’s grand challenge
The challenge to doctors looms large. Having lost leadership in healthcare, what remedies can physicians avail our patients and ourselves to correct this monstrously distorted delivery system? While the American Medical Association (AMA) has proposed a strong legislative initiative, it is unlikely to be successful since the bipartisan AMA bill has no Senate sponsor. Some medical leaders opine that the AMA should become more “muscular.” What those muscular approaches include are yet to be defined.
Unionization has been discussed at the highest levels. Consideration is being given to class action lawsuits against health insurance companies, specifically targeting the prior authorization process, low compensation and downcoding, to name a few. Again, using the powerful legal arm of the AMA, initialing a class action lawsuit against pharmacy benefit managers is also on the table. Advocacy against hospitals that have engaged in oppressive practices is necessary. Their abhorrent facility fees create hardship for patients and obstacles to physicians trying to provide care.
To be successful, physicians have to be cognizant that our success depends solely on advocacy for our patients. Patients lack the organizational structure to challenge these trillion-dollar adversaries, and are utterly without resources when sick and confronted with enormous expense.
Which is why it was refreshing to see the article in the AARP Bulletin sympathetic to physicians. Perhaps the story was a journalistic nudge for physicians to cross healthcare’s Rubicon and strongly advocate for the needs of their patients and themselves.
Arthur E. Palamara, MD, is a vascular surgeon practicing in Hollywood, Florida, for 44 years. He is active in county, state and national medical organizations.
