Do Not Go Into Medicine

The practice of medicine has been experiencing major deteriorations with no signs of improvement for decades. The financial design indicates clearly that more abuses are on the way. These abuses will be made worse by fewer, larger, and more powerful health care employers and private equity buy outs. Osteopathic, nurse practitioner, and physician assistant graduates are increasing rapidly at rates far above population growth, demand growth, or dollars for these health professionals. The health care design is adding more new technology and micromanagement costs which minimize what can be spent on physicians and other delivery team members. Bad situations regarding health care delivery for most Americans stuck at half enough generalists and general specialists will get even worse.

The Killer for Physicians - Massive Overexpansions

If you are a leader in your type of workforce (NP PA DO MD RN) you want to avoid overproduction at all costs. Overproduction results in too many in the workforce with too few jobs. Employers can game you and force lower salaries, benefits, health insurance as well as worse employment conditions (low staffing ratios, scope of work beyond comfort zone).

The Hydra of Overexpansion Has Four Heads - NP PA DO and MD

Nurse practitioner and physician assistant graduates are being expanded at rates faster than physicians (5 to 6%) or annual population growth (0.6%) or dollars going to health professionals.

The NP and PA combined addition to the workforce will soon reach 50,000 more added each year. In just a few class years, they will be adding 60,000 with just 30,000 for US MD and DO.

Why Go into Medicine When There Is Massive Overexpansion of MD DO NP and PA Workforce that Goes Unchecked?

US MD or allopathic medical schools have added new schools and more graduates resulting in 3 to 4% more each year. Osteopathic graduates double each 14 years at a steady 5% growth rate and none of these 3 doublings since the 1960s have added more primary care as their retention in primary care has been halved each time (65%, 35%, 18%) with even faster decline in the recent combined match giving DO grads more options outside of primary care (DO often forced FM due to discrimination in GME funding).

International graduates from Caribbean sources and from other nations (half from Asia) still are about 20 - 25% of entering US physicians. It is bad enough to have massive expansions of NP PA DO US MD and Caribbean, but international continues.

Those claiming that they need more graduates and more graduate medical education positions are not being reined in. They have a powerful lobby. They benefit most from tuition dollars and have financial partners that benefit from financing tuition and cost of living.

Competition for Health Care Jobs Will Worsen. No Job and High Debt Is a Really Bad Combination. Profit and financial designs drive NP and PA workforce and employment

NP and PA are lower in employer cost and are being used more to replace higher cost physicians as much as possible. The physicians will be used for some of the highest cost services. Employers will support fewer physicians with NP and PA doing the office, hospital rounds, and additional sites of care to maximize market share and minimize personnel costs - essential for best performance and best gains for stockholders or private equity firms.

For these reasons, NP and PA are adding more new specialties with more added to each specialty - all following the financial design that supports procedural, technical, subspecialized, hospital, most concentrated services. What they cannot do is boost primary care or care where most needed.

• Primary care spending has long been flat and so has what primary care can support in terms of workforce. More graduates cannot go into primary care because the financial design prevents more.
• This is why NP and PA cannot solve primary care deficits as their retention in primary care has tanked below 25% (lower for PA). More graduates with limits on primary care spending minus additional costs for micromanagement shapes less primary care workforce - not more.
• The last doubling of PA graduates results in no gain in primary care as entry and retention fall by half with a doubling of graduates. PA with greater acceptance and fewer limitations has tanked from 54% family practice in 1985 to 15% or less. Why primary care with lower salaries, fewer and lesser delivery team members, and complex care - all made worse by the financial design for primary care.

The Cover Graphic Brings Home the Physician Financial Equation

Physician pay has increased about 0.4% a year

The cost of running a medical practice increases by about 1.7% a year

Added costs of micromanagement contribute even more to practice costs by adding new types of costs and the costs of updating each type. Other studies demonstrate higher increases in the costs of delivering care year after year.

Physician payment has declined over 20% in two decades when adjusted for practice costs

Some Very Important Questions that Shape "Avoid Medicine"

• How are physicians going to be paid if there are increasing limitations in revenue for physicians at the same time of massive expansions of physicians
• How will health professionals be paid more with the higher inflationary costs of running practices plus the added costs of micromanagement all reducing what can be paid to physicians and other delivery team members
• How will we help the 30 states and 2621 counties with the worst workforce deficits as their NP PA DO and MD services are worst paid and most abused by health insurance?
• And all of the above contribute together for worse in the smaller and medium size practices that also have higher turnover costs and the most challenges addressing micromanagement and fewer and lesser delivery team members and the greatest challenges dealing with the usual disruptions (loss of key personnel, changes in billing, EHR, ownership, location)
• Now add in the massive overproductions of physician assistants at 5% more a year
• Now add in the most massive overproductions of nurse practitioners increasing annual graduates at 6% a year from 10,000 to 40,000 since the 1990s with no signs of letting up

Reasons to Go into Medicine and Why Not

Going into Medicine To Help People Who Need Help

Most of your patients do not need medical care, but they come anyway. Health literacy in the United States is poor and getting worse. You will be frustrated by those who come to you who are too early or too late. Many will request treatments that are not indicated.

In my experiences in primary care and urgent care over 95% of the xrays you will be forced to order will be negative. Most of the antibiotics prescribed will not be indicated but patients demand them.

As someone focused on caring, you may be hurt most by design changes. Higher empathy levels have been connected to higher levels of burnout. Frustrations abound if you truly gain awareness of the US people and how poorly most are valued in health care and other designs. Generalist and general specialty careers are valued least along with most Americans that have half enough of these most important basic health access contributors.

If you are indeed empathetic and truly care and explore what people really need - you will be frustrated with your patients being abused by landlords, legal entangles, workers compensation, family disputes and related legal actions, and especially health care insurance plans.

Inequities abound for those who care and who choose front line caring careers.

• You will ask yourself why you are paid less than specialized physicians because the design favors procedural, technical, subspecialized, hospital, and most concentrated services.
• If you are office, basic, cognitive, primary care, mental health, women's health, basic surgical, and most needed - you will be upset continually by the discrimination, the lack of being valued.
• You will face more complex populations with fewer and lesser delivery team members that turn over more frequently and are less productivity because of the financial design, the turnover, and the micromanagement added duties.
• You will be held responsible for outcomes that you cannot change.

This graphic from Mayo Clinical Proceedings was before COVID and used intent to leave practice or reduce hours as markers of burnout. The generalists and general specialists on the front lines were hit hardest. Declines are seen across these specialties. More also take additional fellowships or pursue better financial designs. For example, family medicine had few options outside of primary care until the massive growth in hospitalist, emergency room, and urgent care employment. Retention in primary care has been cut in half. My read is that the financial design is bad and getting worse, the team members are shaped fewer and lesser, there is more to do that is meaningless, and blame factors are increasing.

The best distributed workforce is most abused and this shows up in declines in the workforce, departures from these areas, turnover, burnout, and worse.

Medicine is a poor choice to change outcomes because real improvements in outcomes are about changing people. Micromanagement Rules and says outcomes are about changing physicians and practices and hospitals. Micromanagement is misguided, costly, distracting, and abusive.

Micromanagement is the dominant health care designer influence and has been since the 1980s beginning with cost cutting and metastasizing to quality improvement. This micromanagement bandwagon has been powerful and clearly focuses the blame upon practices and hospitals - the ones least likely to be about to change populations or outcomes.

How can you change people in the minutes of contact with people in primary care per year after 60 plus years of life influences that often shape adverse outcomes?

Quality as Deming indicated is best seen as a multifactorial matrix of relationships all shaping outcomes lesser for populations least valued and better for those enjoying the best concentrations of health care, education, health plans, social determinants, parents, grandparents, living environments, working environments, behaviors, and more. What is required by micromanagement is far beyond the ability of clinical intervention to address. It is actually beyond the ability of the nation to address other than generation to generation improvements in the populations most behind - and this is already at 40 - 50% of the population and increasing.

And the micromanagers continue to double down on their claims and efforts when their failures are exposed. Micromanagement costs work together in budget outlays with declines in revenue to shape lesser support of delivery team members where they are needed most. They are of course the heart of health care and caring - the ones that do the work and must relate best with patients, caregivers, and community.

You will discover that the health care designers are destroying health care by shaping fewer and lesser delivery team members and burdening them unnecessarily with meaningless tasks.

• Flat line revenue
• Revenue not keeping pace with costs of delivery increasing due to inflation
• Revenue not keeping pace with more costs of micromanagement and increases in these costs
• Lower productivity due to fewer and lesser delivery team members and more meaningless tasks that act to decrease productivity and revenue - worsening the financial design even more.

People and non-clinical factors drive outcomes. Practices that have the correct approaches and have more and better delivery team members to work on multiple factors that shape outcomes - are rare.

You Cannot Avoid the Abuses Being Shaped By Too Many Graduates, Increasing Costs of Medical School, Increasing Costs of Living During Training, and Future Abuses After Graduation

Medicine may work out for those focused on the highest rewarded procedural, technical, subspecialized, and hospital areas. But beware that your colleagues will be fewer. A 5 physician cardiothoracic group will become just 3 with NP and PA associates to cover the office, hospital rounds, and other areas.

To understand this you should know that some systems are shrinking numbers of physicians as they move to highest concentrations of nurse practitioners. NP is the least experienced workforce due to massive expansion turning more and more with little or no experience plus only 60% active plus shortest careers plus high churn between specialties plus high departure from lowest financed areas such as primary care (driving off those with primary care experience).

The Overall Health Care Workforce Situation

You should understand that the nation has tolerated massive overproductions of MD DO NP and PA at multiple times the level of population growth or dollars for these health professionals. There is no sign of slowing of the 4 to 6% annual increases in graduate growth for each source. NP and PA will soon reach 50,000 graduates a year and a few years later will reach 60,000 or twice the level of US allopathic and osteopathic schools with 4 to 5% annual growth levels. The nation will continue about 20% of physicians via international and Caribbean medical schools.

The workforce glut will be bad, particularly for the physicians. But there is worse

Mergers and acquisitions by huge systems, hospitals, health insurers, and health care conglomerates is resulting in fewer, larger, and more powerful health care employers. Opportunities for independent practice and autonomy are going away.