How the silent exodus will worsen the doctor shortage

American Medical News has an important article - Will a “silent exodus” from medicine worsen doctor shortage?

Frustrated by mounting regulation, declining pay, loss of autonomy and uncertainty about the effect of health system reform, doctors are cutting back the number of hours they work and how many patients they see.

Between 2008 and 2012, the average number of hours physicians worked fell by 5.9%, from 57 hours a week to 53, and doctors saw 16.6% fewer patients, according to a survey of nearly 14,000 doctors released in September. If the trend continues through 2016, it would equate to the loss of 44,250 full-time physicians, said the report, conducted by the doctor-recruiting firm Merritt Hawkins & Associates for the Physicians Foundation. The foundation was started in 2003 with more than $30 million from class-action settlements that 22 state and county  medical societies made with health plans.

“This is a silent exodus,” said Mark Smith, president of Merritt Hawkins. “Physicians are feeling extremely overtaxed, overrun and overburdened.”

As I round these day in a community teaching hospital, I have many colleagues in private practice.  These physicians are warriors.  Our hospital has, in my opinion, too few physicians in several specialties.  Thus, those physicians work very long hours.

When one first starts out, fresh out of residency or fellowship, long hours seem reasonable.  Medicine is exciting, and the excitement and the intellectual and emotional challenge spur one to work very hard.

But as we get older, this lifestyle starts to get old also.  Common wisdom says that critical care docs become sleep docs around age 50.  That example tells the beginning of the story.

With the new work hour restrictions, the newly minted specialists and subspecialists will less likely accept very long hours.  Women (now around 50% of graduates) are less likely to work very long hours.

Oh, and we are producing no more specialists and subspecialists while the population increases and we need more physicians per patient because we have improved the care of chronic disease, so we have patients living longer and thus needing more care.

Many physicians have made enough money, and handled that money well enough that retiring will have no impact on their quality of life.  Many physicians are willing to make less money as a trade off for improved lifestyle.

And then we must mention electronic health records.  Many physicians hate learning EHRs.  As much as I like the idea of EHRs, and understand the advantages that they can bring to health care, any object observer will tell you that current programs are counter intuitive and time  consuming.  Meaningful use has made the physicians’ job more difficult and added time per patient for record keeping.  So some physicians just retire rather than dealing with computers.

We have a disconnect between those who make the rules (usually Congress or CMS or insurance companies) and an understanding of the moving parts required for successful health care.  We need more physicians and particularly well trained, fairly compensated primary care physicians.  Too many of our laws and regulations act to hamper health care.

This is a smoldering crisis, and our policy wonks, CMS regulators and Congress are all asleep at the wheel.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Ed Sodaro

    If anything this article understates the problem. God only knows, for example, what is in the tens of thousands of pages of insane regulations hemorrhaging out of hyper corrupt Washington. But you can be certain it will negatively impact on patient care.

    • sphenoid

      “But you can be certain it will negatively impact on patient care.” More likely, some policies will make things more difficult and improve other parts.

      • azmd

        I would not be so sure of that. When you have non-physician bureaucrats dictating how care is delivered, it seems intuitively obvious that the quality of care will not be improved, and that adding regulatory and clerical tasks to the healthcare provider’s workload will only distract them from doing what they are supposed to be doing, which is taking care of patients.

        As an example, the studies so far on EHR are not encouraging; there is no evidence that they have improved patient health:

        There is, however, an overwhelming amount of anecdotal evidence that physicians feel that EMR systems adversely impact their ability to deliver care.

        • ninguem

          I wanted simple tools with my EHR. Refill six medicines on a diabetic? Simple click. The routine, repetitive stuff is what humans do badly and computers do well. Like writing out six prescriptions and making sure I don’t make a decimal error. And it’s printed 100% clear.

          As soon as they added that stupid “meaningless use”, my nice simple and relatively cheap EHR went buggy, crashes every day, and the price shot up through the roof.

          No, I agree with azmd completely. But hey, what do I know, I’ve only practiced for decades and had a EHR the last fifteen years. I’m a regular computerphobic Luddite.

          • azmd

            Don’t even get me started about EPIC.

  • Virginia Scanlan

    Dr. Center: I believe the idea was to reduce cost by reducing access. That is why specialists’ Medicare reimbursements have been cut to the point that they can no longer afford their overhead. Not all hospitals in all communities can afford to hire them. So the patients will wait for appointments, even if it means a deterioration in health. Like the barefoot doctors in Cuba, PAs and nurse practioners, viewed as cheaper alternatives, will provide most of the care. I cannot figure out why the specialty colleges and AMA abandoned their own members, did not stick up for the rigorous training their members receive, nor constant efforts to define standards of care. Many of their leadership acted as if private practice doctors were corrupt. Now, as it turns out, private practice is the low cost provider compared to hospital based care with notorious facilities fees. They allowed the insurance companies and government to pretend that hospitals do not have quality review committees for the entire hospital and for specialty groups. There has been no strong and effective voice for medicine. They have been outspent and gunned down by insurance company and hospital system lobbyists, or by EHR companies with their huge political donations.Our citizens have become so intimidated by our own government, that no one, including doctors will say, “no, I won’t do that.”

    • sphenoid

      Never has there been an “idea” to reduce the cost of healthcare by reducing access to physicians. Instead, the “idea” is to improve access, to prevent disease and stall progression, instead of people showing up to the ER for prescription refills. Medicaid reimbursements are now federally mandated to be 100% of the Medicare fee schedule to encourage private offices and healthcare systems to accept Medicaid patients and again…. improve access.

      • Michael Chen, MD

        I believe Virginia’s point is from the perspective of a private practice physician. We can all agree and say that the “idea” was never to reduce access to physicians (who would?), however, there have been consequences of neglecting the needs and concerns of private practice physicians over the years (ie poorly written legislation like the HITECH act, poor and disproportionate reimbursement of services) that do actually cause reduced access to physicians even though the “intent” was never to do so. The problem that Virginia points out is that those that supposedly represent us (AMA, AAFP, etc) have chosen to not bring forth the interests that concern private practice physicians who do provide critical services to our communities and now we are left with a silent (and some not so silent, like me) exodus of physicians who are upset with the way the health care system (ie corporatized medicine) has perverted the interests of physicians and patients to the detriment of both.

        • David Gelber MD

          An example of what is happening between rpivate practice and hospital employed physicians: Two years ago one the junior partners in out six member general surgery group left to take an employed position with one of the hospitals. He has a guaranteed salary, at least at the moment. If he is called to see a patient in consultation now, he will often refuse. he only operates 2 days a week and the hospital is losing money on him. Those of us in private practice pick up the slack, but for how long?

        • ninguem

          In decades of practice, I’ve encountered about half a dozen docs who had to be nudged out of practice because of old age. They were really too frail to continue to practice safely.

          Sometimes the physicians themselves were the ones endangered, they were getting angina in the operating room and clinic.

          They just wanted to keep on working. They’d work the free clinic, anything. The decision was usually a sad affair for all.

          Retired docs who would show up at the doctor’s dining room every day just to be around it. They did a lot of medical school teaching, they were thrilled to have students. I was one of them in the day. The docs would teach medicine, and they had the institutional memory of the place. Great stories about WW-2 medic days as flight surgeon in China behind the Japanese lines…….

          Not anymore. The docs retire as soon as they can, and turn their back on any free clinic work. And try to find a doc’s dining room anymore.

          That “silent exodus”, will be no doc willing to cover free clinics or other volunteer settings, and private practice docs going to employed positions with lower productivity and HIGHER COSTS (facility fees).

          • Guest

            I think you’re absolutely right, and it’s damned depressing. None of my colleagues (we are in our mid 40s) have much interest in practicing even now.

      • azmd

        You may not be aware that there have been significant cuts to the Medicare fee schedule to the point where most primary care providers as well as psychiatrists actually have to spend money to see a Medicare patient.

        Pegging Medicaid reimbursements to this fee schedule would thus only improve access in the minds of non-physicians who inexplicably would expect physicians to commit financial suicide by continuing to see large volumes of Medicare and Medicaid patients. Expecting healthcare institutions such as hospitals to continue to absorb losses on these patients is similarly unrealistic.

        It’s really difficult to understand how exactly our lawmakers thought that giving out pay cuts to the people who provide health care would improve health care access…

  • Rayn

    Younger doctors (often female like myself) now would simply like to a reasonable number of hours, like 40 a week, and for some reason that is considered “part time”. When I am done with residency I will be looking for a “part time position” so that I can work 40 hours and still have a family. The problem is that often times to actually only work 40 hours means actually seeing patients for much less like 30 hours (rough approximation) to have enough time to do all the other things we are expected to do (charting, phone calls, etc.). I know I will get paid much less for this “part time” job, and still have to pay my student loans, but I will hopefully have a more balanced life then if I was working the 57 hours a week described in the article as the expected full time in 2008.

  • Jason Simpson

    This article ignores the fact that there are over 50 new medical schools either opened or in development since the last 5-7 years. There is a huge doctor surplus coming.

    • Dave

      And there are no new residency slots being added, so we’re heading for a bottleneck, not a surplus.

  • Brian Stephens MD

    DB, always enjoy your post.

    The politicians are not stupid… they know exactly what they are doing. They cont to give everyone “everything” while at the same time slapping ANY hands that actually try to get paid for providing the service. Eventually no one will be willing to do it.

    in a few years when the public is crying foul that they can not get adequate care, the politicians will shrug their shoulders and say, “of course we give you all these benefits, we can not help that those greedy doctors wont provide the care for you.”

    at which point, they will declare “free market” healthcare a failure and immediately “take over” everything.

    im not commenting on whether this is good or bad… but it certainly will be different.

    I suspect people are not going to be any happier once they “get what they want.”

    • sphenoid

      This may be your prediction of what might be happen, but couldn’t you talk about it in more neutral terms? If this is what you believe, how do your assertions align with various factors in sociology, politics, history, economics, and business? This is a complicated topic; discussing these stories with thinly veiled cynicism makes it difficult to ascertain any truth in your comments.

    • ninguem

      Agree with Brian Stephens. In fact, since doctors get blamed for all the failures in medicine caused by the politicians, I’ve decided to change my name to Emmanuel Goldstein.

  • WarmSocks

    Silent exodus: my daughter’s pediatric rheumatolgist cut patient hours to half-a day once a week. When the doctor only sees patients four hours a week, it’s pretty difficult to get an appointment.

    • Suzi Q 38

      She must be independently wealthy or work in academia.

      • WarmSocks

        All pediatric rheumatologists in my state are affiliated with the medical school.

  • Eyes

    I agree with the author 100%. As one of those preparing for my silent exodus the day the SGR cuts go into play or the EMR penalties become too strict or the ICD-10 codes become mandatory. Notice, none of the reasons for my walking have anything to do with taking care of patients, but when the government says “jump”, I will tell them where to stick by letting them see my back as I recede away.


    Well said. Between meaningless use, EHR, ICD-10, and documentation by “checkbox”……the profession once known as medicine is dying.

  • waffleweave

    As more or less an outsider looking in, this is what I observe in my role as staff of a county medical society…doctors are in a field full of change, most will adapt, evolve and grow, and many will choose to drag their feet and not get on board, but rather bemoan how it used to be. The medical field is one of the last to have to adapt to modern changes. Electronics, affordability, right or privilege…all facets to a complex profession. What we do know for certain is that not enough doctors are taking charge of the situation through the means that they have. Our medical society offers regular meetings with our local, state and federal legislators and the percentage of those who actually show up to an event is at best 10%. Physicians can blame others all they want, but when push comes to shove and they have the opportunity to step up and speak out…how many really do?

    • Fred Ickenham

      As an insider looking out, you are spot on. Most physicians don’t see it as their role to advocate. They only give lip service to those who do, so fewer participate. Tragedy of the commons applies.

  • sarah93

    Is there some reason we can’t simply train more doctors if we need them?

    • John Henry

      Training requires hospitals with the requisite volume and variety of patients and medical problems to provide an adequate training experience. They require a faculty of teaching physicians to oversee the training process. They require money to support resident salaries, since Medicare and the federal government prohibit billing for resident work. The problem is not a shortage of medical graduates; we have always had enough from U.S. schools, offshore schools and J1 visa applicants. The problem is the number of training programs which, because of federal law, require federal funds to support, and the number of hospitals that have the size and quality to support adequate training.

  • sarah93

    PS: I do not mean to imply the training is simple, just that when you have a shortage the obvious (simple) solution is to get more of whatever it is that’s lacking. In this case, train more doctors.

  • Rahul

    Doctors have always worked beyond their duty hours. Earlier it was considered the need of the hour and no one bothered. Now things have changed. The IT industry and networking has come up in a big way and doctors see their colleagues in other professions working for a limited time period. Things do move on after a time

  • doc99

    Dr. Centor, the policy wonks, regulators and legislators know exactly what they are doing. To them, this silent exodus isn’t a bug; it’s a feature.


    “Progressive” government has long sought a single payor federal health delivery system in this country, in which they, the feds, control health delivery throughout this country. These many federal mandates cited, are effectively designed to achieve exactly that. Drive out nonparticipants. Make them ‘economically nonviable.’ Doctors, whether they agree or not, must recognize this and make their own decisions.

  • T H

    Four thoughts:
    1. Everyone else lobbies/negotiates for reasonable hours. Why not physicians? If 40 hour work week is the gold standard (and doctors love gold standards), why not shoot for that?

    2. Seeing more patients in a day often leads to poor care. For IM and FM, 15-20 in a day? Fine. 30 is pushing it. 40: clearly ridiculous. There is a local pediatrician in my area who sees 65+ kids a day 5days a week. Counseling? What’s that? If we REALLY want to give better care, modulate the number of patients to something reasonable.

    3. EHR: that genie has escaped from the bottle and smashed said bottle into pieces. They are here to stay. BUT. And it’s a big BUT.

    Administrators, legal-eagles, politicos, and insurance companies need to understand that there are very real limitations to EHRs: they are slow, GIGO still applies, and even if the doctors use them properly, we are more dependent that ever on a properly trained (and still underpaid, undereducated) support staff to triage, do vitals, transcribe/scan a quick screening questionnaire, etc.

    As long as those groups don’t pretend they’re as fast and accurate as paper charting, I’ll swallow my bitter pill of an EHR (which still tastes like powdered Pen VK).

    4. Payors (mainly gov’t) either need to commit to truly covering the cost of indigent care or quit shamming and stop it all together… AND provide EMTALA relief for rural and inner city hospitals that take it on the chin for indigent care. It’s pretty bad now and it’s going to get worse.

  • civisisus

    Why don’t all of you whiny primary care MDs sack up and attack the RUC? You could even set it to a dance beat….

    You’re pointing fingers at all sorts of ‘enemies’ except the right ones…your fellow physicians, who happen to be specialists. You’ve been sold down the river by your own. Get mad about THAT. At least you’d be whiny and RIGHT.

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