When I was a child, I knew I would become a doctor. I liked science and taking care of people. We diagnose medical problems and prescribe treatment plans. Some of us perform surgeries and some focus on keeping you well. Despite this, I’m nothing special, and neither are you, my physician colleagues. Let me explain why by first taking a brief step back into the history of American health care.
Since the Flexner report ushered in the modern American medical educational system in 1910, we have created and upheld standards for obtaining a medical degree and, subsequently, certification in our areas of specialization. One effect of the Flexner report was the closure of about 50% of the medical schools in North America, resulting in a rapid slow-down in the growth of the number of trained physicians.
Change was afoot in the practice of medicine through the mid-20th century. Employers started offering health insurance as a benefit due to rising health care costs, increasing the number of insured Americans from 32 to 122 million people. Advances in medicine post-World War II also resulted in more physicians opting for specialization and moving away from general practice. The shortage in the number of general practitioners (GPs) relative to patients was only worsened by the passage of the Medicare and Medicaid amendments in 1965. A rapid expansion in the physician pool was not possible, partially due to the long duration of education and training.
Around this time, Dr. Eugene Stead, a physician in North Carolina, saw an opportunity for the rapid expansion of the number of trained clinicians by tapping into the medical experience of military corpsmen. He created a 15-month curriculum of medical training and clinical rotations, focusing on building upon their existing medical knowledge. Four Navy corpsmen graduated from Duke University as the first class of physician assistants (PAs) in 1967. Since then, we have seen an explosion in the number of PA schools. As a result, the number of PAs has grown by over 120% from 104 PAs per 1,000 physicians in 2015 to 128 PAs per 1,000 physicians in 2017.
World War II created another resource of health care professionals. Thousands of women volunteered as nurses to take care of soldiers fighting overseas, primarily learning their nursing skills on the job without formal training. After the end of the war, the government invested millions of dollars into further formalizing nursing education and developing of advanced nursing degrees. In 2010, the Institute of Medicine announced that the future of nursing would “focus on improving the preparation and utilization of nurses as a key strategy in achieving a more equitable, efficient, safe and high-functioning health system” by creating a full partnership with physicians in redesigning health care and providing pathways to higher levels of education where they can practice to the full extent of their education and training. Since then, approximately 163,000 nurse practitioners (NPs) have received their degrees, increasing the number of NPs by over 250% from 106,000 in 2010 to more than 270,000 in 2019.
Although we initially adjusted to the sudden surge in need for doctors and nurses since the 1960s, our health care system has become inefficient and expensive. In fact, the work of each American physician requires 10 administrators and 6 clinical staff to support. The work that was done by a GP and an assistant is now done by a doctor with a team of nurses, nurse practitioners, physician assistants, medical assistants, and administrative staff. Medicine has become a team sport.
In 1997, the federal government froze funding for physician residency programs. This has resulted in nearly stagnant growth in the number of doctors, rising by only 12% from 2010 to 953,695 physicians in 2016. The U.S. also loses approximately 6% of U.S. medical school graduates each year from the physician working pool because of a shortage of residency positions. As of 2019, approximately 1140 licensed physicians (i.e., those who passed the three national medical exams and graduated medical school) are shut out of practicing medicine each year in the U.S. because there was not a spot for them in a residency program.
Although physician growth has remained stagnant, health care costs ballooned to 17.8% of the American GDP in 2016. Despite this, we rank last out of the 10 highest income countries in the world for health care outcomes. Some would argue that this data is flawed, but we clearly aren’t outperforming other countries.
Although doctors account for only 8% of overall health care costs, we have been a major focus of cost-cutting efforts. Doctors are trending toward employment as hospitalist purchase private practices in order to control costs as we moved to value-based, bundled payment systems. Even so, the Kentucky Hospital Association found that 58% of its hospitals lost more than $100,000 annually per employed doctor. Despite differences in our educational pathways, nurse practitioners and physician assistants can now also independently provide the same services as physicians in many states so doctors are no longer seen as necessary and are being replaced by what is felt to be a less expensive alternative.
Our health care system is overflowing with poorly organized, large amounts of medical information. Doctors enter and review more elements of data in user-unfriendly electronic health record (EHR) systems than ever, reducing the amount of time we have to devote to decision-making while increasing the complexity of decisions we need to make. Enter artificial intelligence (AI). AI will ultimately be seamlessly integrated into our health care team. Computers have already been shown to be better than radiologists at identifying breast cancer on mammography when under a time crunch. AI can screen pathology specimens for disease. It can use “deep learning” (a type of machine learning) to perform as well as or better than physicians in cancer detection and identification of tuberculosis on chest X-rays, monitor patients remotely and analyze daily data points to screen for patients at higher risk of cardiac problems and alerting the health care team of a patient in need of closer follow up, assist in or autonomously perform parts of surgical procedures, create algorithms to choose the best chemotherapeutic regimen, predict cardiovascular risk or even make clinical diagnoses. The medicine of the future will include AI giving us cues as to how to best take care of our patients, further removing individual clinical decision making from the doctor.
What will our role look like in the medicine of the future? If we remain stagnant in number, we will have to take a more supervisory role, overseeing teams of other health care clinicians and decisions made by AI. If legislative momentum continues toward granting independent practice and we are no longer required to oversee the care of NPs and PAs, more physicians will move back toward self-employment, like direct primary care or concierge practices, as they are passed over for employment opportunities in favor of less expensive alternatives. More physicians may move toward sub-specialization in search of more stable employment opportunities.
Each patient will require less time and decision-making on the part of the physician. AI will streamline how clinical data is documented and presented to us. It will assist with order entry using a virtual assistant and perform initial radiology and pathology readings with physicians over-reading a percentage of the images and samples. AI will make recommendations on patient treatment, like what course of chemotherapy to recommend or who needs cardiac disease screening and when.
I’m sorry to break it to you fellow doctors, but it looks like we will become less special as other clinicians are hired to provide medical care without us, AI takes over tasks we used to do and tells us what needs to be done for our patients. If we are to define our future in medicine, we need to participate in creating it. What do you want your future role in medicine to look like?
Irene Tien is an emergency physician and can be reached at My Doctor Friend.
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