Rae Woods: From Advisory Board, we are bringing you a Radio Advisory. My name is Rachel Woods. You can call me Rae. Rae Woods: A few weeks ago we released an episode about the state of the nursing workforce and how in the United States, we are facing a shortage of bedside nurses. But today I want to talk about another major part of the clinical workforce and why when it comes to the challenges of supply and demand, we've actually come to a very different conclusion. Rae Woods: To do that, I've brought two physician experts, Sarah Hostetter and Daniel Kuzmanovich. Rae Woods: Hey Sarah. Hey Daniel. Sarah Hostetter: Hi Ray. Daniel Kuzmanovich: Hi Ray. Rae Woods: It has been a while since I've had either of you, let alone both of you, on the podcast. Daniel Kuzmanovich: Glad to be back. Sarah Hostetter: I talk to you all the time, but just not on the podcast. Rae Woods: Sarah, I don't know if that's a good thing or a bad thing, but I will take it as a win and enjoy the time that the three of us have together to talk about my favorite topic: physicians. Sarah Hostetter: Our favorite too. Rae Woods: Now, I want to do something different with this episode. So I normally wait till the very end to ask my guests, what's the big take away, right? You both have done this before on Radio Advisory. But today, I actually don't want to hide the ball. So I want to start with a pretty blunt question. Do we, or will we have a physician shortage in the United States? Daniel Kuzmanovich: No. It might seem like it, it might look like it, but no. Rae Woods: Sarah? Sarah Hostetter: I agree, I just let Daniel go first because he's usually more blunt than me, but agreed, no. For the same reasons. Rae Woods: And this is probably very surprising to our listeners, or at least anybody who's been tracking all of the headlines claiming a near term, long term physician shortage. So we're going to spend some time talking about why our answer is no. Rae Woods: First, give me some context. Why are the headlines, something that maybe we should maybe not ignore, but divide by five. Sarah Hostetter: It makes me think a lot, Rae, actually about one of the times Daniel and I came on the podcast before and we talked about all the stories and headlines and anecdotes we were hearing about physician practices. That's kind of what we're seeing again. We're seeing horror stories and anecdotes and headlines about things like early retirement or physicians leaving one employer for another. It was even in the series premier of Grey's Anatomy this season, which I feel like you're like- Rae Woods: What? Sarah Hostetter: Yes, that is how you know we've hit it full scale. Rae Woods: Wait, physician shortages was a key theme in the season premier of Gray's Anatomy? Sarah Hostetter: Not only the season premier, but it's tracking through the whole season. I should be more embarrassed than I am to admit that I still watch the show, but yes. The physician shortage has been brought up on almost every episode this season. Rae Woods: So it's clearly entered the mainstream media, which is why everyday people, probably folks not even in healthcare, are thinking this is happening. Sarah Hostetter: Yeah, absolutely. I talked to a friend about it at a wedding a couple weeks ago. It is mainstream. Which, again, says more about me potentially than the position shortage, but it's everywhere. Rae Woods: I think headlines are something that we can kind of take with a grain of salt. Like you said, they're a little bit more anecdotal, but it's not just that we're hearing about this in the headlines, there are real people, real firms out there that are digging into the data and making projections that we don't have enough doctors. It can't possibly be that the math and all of these analysis are all incorrect, can it? Daniel Kuzmanovich: No. I'm not very good at math, so I personally don't have the capability to doubt the math, but at the broader level, it's not the math that I think is the challenge here. It's that the math is missing a bit of context that is really important. We are looking at the math in kind of a snapshot in time. And when these folks are doing their research, when they're giving their great answers and they're making their great projections, they're looking at the math in a snapshot in time. And the problem is, you can't project 20 years, 30 years down the road with everything that's happening right now. Rae Woods: I think COVID is a perfect example of, we can't know what's happening 20 years from now. We can't predict what's happening two years from now because we don't know what is going to change. Daniel Kuzmanovich: The projections that came out in 2019 around the physician shortage did not have a global pandemic the next year. And so even though it's great science, even though it's great math, the math was outdated within a single year because of forces we couldn't anticipate. Sarah Hostetter: Even if you look at overarching workforce projections, I was just looking at some of the BLS data on this a few weeks ago. If you look at them as a whole, they look like there's a decline in overall employment, but then if you break it down by certain sectors of the industry, you see different trends. So I think it's the same thing with physicians. If we treat physicians as a whole, we may be looking at one trend, and I hope we'll get into this later Rae, but if you break down some of the segments of the physician workforce, sure, we may see some of these trends, but we can't take that to mean it's the overarching workforce trend. Daniel Kuzmanovich: The concept of the physician shortage reminds me of the great horse manure crisis of the 19th century. Rae Woods: Okay. I did not expect that you were going to go there, but please explain to me how horse manure relates to physicians, Daniel. Daniel Kuzmanovich: You didn't think that the history nerd had a weird story to bring in here? Rae Woods: Oh, I shouldn't be surprised. Daniel Kuzmanovich: So turn of the century London is absolutely concerned, biggest city in the world, concerned that it is going to be covered in horse crap by 50 years from then, because you have all of these goods being carted around the city, you have all these people being carted around the city, and a horse produces a bunch of manure over the course of the day. It's a very real and legitimate concern. And the people who ran the math, the people who did the numbers, they did a great job. The problem was they couldn't predict certain forces, forces like the automobile, forces like the train, forces like bikes. You couldn't possibly project 50 years from now what these forces would do to the supply or demand for horse crap. Rae Woods: And that's also, by the way, a good reminder that these unpredictable forces aren't just something as terrible as a global pandemic. It can be, look at the innovation that we never expected, in this case the automobile that prevented London from being buried in six feet of horse manure. That's where I want to talk about the future of the physician shortage, or lack thereof. And to use your word Daniel, to talk about the context. So when it comes to the context of care delivery, what are some of the things that you see are missing when folks talk about this potential for a shortage? Sarah Hostetter: The one that's nearest and dearest to me is the care team. I've done a lot of work on the care team redesign broadly in advanced practice providers specifically, and the surplus of advanced practice providers in the workforce right now, surplus might be too strong, but the addition of so many more advanced practice providers is really helping protect us from feeling the shortage. Sarah Hostetter: Nurse practitioners and physicians assistants can do 85% of what physicians can do, they can bill 85% of what physicians can. They are critical in filling that gap. And more broadly, I think why we are seeing some more pain points with other parts of the workforce is that you don't have that similar role for nurses or for medical assistants, so we're feeling the gap more there. So we have team based care and we have other care team members that can supplement the physician. That's the big one for me. Daniel Kuzmanovich: And to Sarah's point about advanced practice providers, one of the big changes in the Medicare physician fee schedule rule that will go into effect starting in 2022, is that APPs, especially physician assistants and nurse practitioners, will now be able to bill on their own, not necessarily under a physician's license. That's one of those potential good changes you are talking about Rae, that allows for us to not have the shortage, for us to not have all of the challenges. Rae Woods: So there's this concept of the people who are delivering care is different. It's not just the singular physician who's doing all of the work anymore. That's one kind of important piece of context. Are there other ones that we need to keep at the front of our mind as we're assessing the future of the workforce? Daniel Kuzmanovich: How physicians spend their time, I think, is crucial. The three of us know that if we're ever going to talk about physicians, the first thing I'm going to bring up is capacity, and what the physician's capacity looks like. Right now, depending on certain specialties, physicians spend a lot of their time doing work that they might not need to be doing because it's been recently introduced into the healthcare ecosystem. Five years from now, 10 years from now, we're going to have figured out some of that. It'll be automated, or it'll be done by a different member of the care team. But how physicians spend their time today and how it's going to look five to 10 years from now is definitely not one into one. Rae Woods: And perhaps not just how they spend their time, but what tools they use when they are working with patients or when they're working with the care team, which is of course where the conversation turns to technology. Sarah Hostetter: Yeah. You hit on the other one I was going to say Rae, which Daniel picked up on, automation. We are seeing an influx of technology in healthcare. A big focus right now on AI, and specifically on AI and how it supplements what the physician is doing and makes their job easier, as opposed to replaces any members of the care team. So how do we get more time out of people and actually make their lives easier at the same time? We're not just saying, physicians, work more. We're looking for technologies that are going to make lives easier, reduce burnout, while increasing capacity. Rae Woods: That is exactly where I wanted to go next. This is happening... We're talking about context. This conversation is happening at the same time where conversations about clinician burnout, clinician trauma, the great exodus from the clinical workforce is happening. So my question is right now, still in the middle of a pandemic, is it reasonable to expect that today's physicians can spend more time on patient care? Daniel Kuzmanovich: I think so. When we first started researching physician burnout at the Advisory Board back in 2014, there were some really, frankly, raw stats that hit you in the feelings. One of them that will always blow my mind was there was a time motion study of physicians that found that primary care physicians spent 27% of their time directly on patient care, and the rest got consumed by either desktop medicine, administrative tasks, things like that. Rae Woods: Wow. That's not a lot of time spent on working with patients. Daniel Kuzmanovich: That's a quarter of your time. That is one fourth of your time when your job is to be the primary physician for that patient. But even now, five years later, we have so many different technologies that fundamentally are about putting the physician to be back able to focus on patient care, whether it's getting them out of the MR, or doing the automated care work and care planning or care gap closure, for them. So I do think there's something to what you're saying about the ability of this technology to change how physicians are going to practice. Rae Woods: And to Sarah's point, it means that we're actually taking the negative parts of physicians' time away from their plate so that they can spend more time doing what I would imagine most physicians want to do with their life, which is take care of people, work with patients, and that's something that gives us more capacity. Sarah Hostetter: Yeah, and I think what's really cool about some of the technologies I've seen providers that I work with implementing is this intersection between reducing burnout and making it easier to keep patients healthy. As we see the move to value based care, there's a huge intersection between the technologies that we're deploying to move to value based care to help providers see, where are their care gaps? When's the last time my patient's medication was filled? Are they overdue? Do they need to come see me? All of these things that actually help providers keep patients healthier, which inherently is going to both reduce time and also, in theory, should reduce burnout. Rae Woods: And this is something I think a lot of folks get. I think they expect technology to be able to unlock a lot of capacity. But I'm assuming that you don't just mean virtual visits or telehealth. What are some other examples of things that can really maybe more dramatically increase capacity and prevent us from having this kind of shortage? Daniel Kuzmanovich: There's a technology that we've profiled a few times in our research. Of course the Advisory Board is vendor neutral, but it is a smart device that sits in an exam room and does the transcription and dictation for the physician. It is called Rob- Rae Woods: The administrative work? Daniel Kuzmanovich: For the administrative work. So it's capturing all of that work and doing the things that a physician would have to do in the EMR so that the physician can actually be focused on the patient, taking that 27% and getting it closer to 50 or even higher than that. And then when they go back and enter into the EMR, suddenly rather than having to put all these things in themselves, the technology's done it for them. Sarah Hostetter: I also think there's this intersection between the technology and the care team. It's not just the technology that we're deploying to help physicians, but also, what are technologies that we can deploy to help other members the care team to actually free them up to spend more time with patients too? So some stuff around coding and care gap closure doesn't always fall to the physician. It may fall to the medical assistant. Can we automate that so the medical assistant can do rooming, can do teach back with the patient after, can help with some of the either note taking and things like that. How do we free up the rest of the care team by actually offloading tasks from everyone's plates onto a technology? Rae Woods: Sarah, this is probably one of the most important things I think you've said that I just want to make sure our listeners are hearing. Even though we are talking about the physician shortage, if we don't talk about the workload and the effort and the capacity of the rest of the care team, we're ultimately going to be missing the true outcome here. Sarah Hostetter: Absolutely. We refer to it as, the legacy way of doing things as trickle down care team redesign. Think of it of you're just passing tasks down the line. So from a physician to an advanced practice provider, from an APP to a nurse, from a nurse to a medical assistant. And as opposed to looking at the care team and trying to operate as a unit, it goes back to what we started talking about at the beginning. If you think of an ideal care team redesign, the physician is one person with ideally four or five other people around them. So how do we think about that more as a unit, and right size what everyone is doing to get everyone to top of license, because that's how you get the physician to top of license. Daniel Kuzmanovich: If we took a practice today, with the technologies that we have and the people that we have, and we said, "Don't do what you've always been taught, don't do it the way that you have been taught, and instead, use this tech, use these people and figure out the right way to take care of your patients," it would look very different than our historical approach, the trickle down care team redesign that I sometimes say, crap rolls downhill, where you have- Rae Woods: You can say shit, it's fine. We've already talked about horse manure. It's fine. It's just a theme of this episode apparently. Daniel Kuzmanovich: I seem to be on a roll when it comes to this bullshit. Horseshit, excuse me. But if the crap is going to roll downhill in the traditional care team redesign, if we instead say, okay, tech, people, physicians, put it all together in a way that actually works to accomplish the outcomes we're trying to achieve, that's something, coming back to these projections around the physician shortage, that's not what those projections are based off of, but that's where the care model of the country needs to evolve. Rae Woods: Everything both of you have said up to this point makes perfect sense to me. But if I'm honest, they're also all things that were true before the pandemic. Physicians have always been spending too much time on administrative tasks, clinicians of all stripes working below license, under utilizing technology, so on and so forth. But I have to believe that things have changed since the COVID-19 crisis began, haven't they? Sarah Hostetter: Yes, in that it's forced a lot of providers, medical groups, health systems to use the tools that they had at their disposal that have always been there. So if we took a chunk of physicians out of the day to day workforce because they were treating COVID patients, we almost operated in a state of physician shortage for our day to day to deal with the rest of the patients. Sarah Hostetter: So then we had to figure out, how do we use the care team? How do we start to put these technologies in place? I know we talk about telehealth a lot, but that's a great example. Telehealth was stood up ridiculously fast after years of resistance to telehealth. We had to use what was at our disposal because we were inherently working at a shortage relative to demand. So the question for me is then, what of these things are you going to continue to use to supplement in the future? Daniel Kuzmanovich: To Sarah's point, I was talking to a health system in a rural area a couple of weeks ago, and they lost a bunch of their frontline workers and their physicians and their APPs changed the way that they operated, and this was the emergency department. They changed the way that they operated to kind of make up some of that shortage, and they actually found that they were able to do a lot more by getting away from some of these traditional dynamics within the care team and to change their approach to delivering care. And that's just on the people side, not to mention the tech. Rae Woods: And this is kind of the classic example of, don't let a good crisis go to waste. And it sounds like, at least in this case, the pandemic forced a lot of positive momentum that the three of us certainly would've wanted to see happen anyways, and frankly, would've gotten us out of having a physician shortage in the future, regardless of the pandemic. It's just that COVID-19 actually accelerated things. Sarah Hostetter: Yeah. I feel like we were going to hit a crisis moment either way. If it wasn't a pandemic, it was going to be a workforce crisis moment. We just accelerated how quickly we got to that, and so now we are having to adapt more quickly than we thought we were going to. Rae Woods: You just mentioned crisis moment, and I think probably the... If any of our listeners are still not convinced at this point, it's because they're thinking about every other part of the workforce that is not a physician or not someone that we've talked about. I mean, we had an episode just a couple of weeks ago, talking about supply demand mismatch among bed nurses across the United States. We are seeing workforce shortages. Why is this example, why is the physician shortage different based on everything else that we're seeing? Daniel Kuzmanovich: I think a lot of it has to do with the context that we're talking about and we're kind of putting around these numbers right here, right now. And there are a lot of different options that physicians have that bedside nurses might not. Sarah Hostetter: Wait Daniel, question. So do you mean more options for nurses in terms of things they can do in their existing jobs or ways they can work their existing jobs, or more options to leave? Daniel Kuzmanovich: I meant more options in the existing job. I look at the work that a physician has to put in and I feel like we should acknowledge that when we're having this conversation about the shortage, potentially or not, of physicians. The pre-med, MCAT, med school, residency, fellowship. Physicians have to put in a lot of work, but that gives them a lot of different options for where in the healthcare industry and where in even the healthcare ecosystem they're going to work. And so that gives them options for where to move internally that nurses might not have those same options necessarily. Sarah Hostetter: Interesting. Rae Woods: Also bedside nurses don't have the same care team infrastructure around them that a physician does that can spread out some of this work and expand capacity for everyone. Daniel Kuzmanovich: And a physician can switch inpatient and outpatient, whereas the outpatient setting historically has been really bad in how it uses RNs if they wanted to leave the hospital and come into the outpatient setting. Sarah Hostetter: So that's interesting. I actually think of it in the opposite. So I think about the fact that physicians put in all this time, it takes a lot for a physician to suddenly decide I'm not going to be a physician. You may have options within being a physician that you may explore, this is why we're seeing some increased interest in private practice, for more autonomy. But it's a lot to say I put in all of the as time and then I'm just not going to be a physician. Whereas nurses still put in a lot of time, but not as much time, and they get paid a lot less, and they're the brunt of inpatient care. So if I'm a nurse, I'm low paid, I am putting in all of this time and effort and not seeing any reward from it, I may decide to go outside of healthcare altogether. And I know we're seeing that in the nursing and medical assistant realm, whereas physicians, it takes a lot more to just say, I'm giving up healthcare. Rae Woods: And I think you're actually both supporting exactly why bedside nursing is so different than physicians, because on the one hand, there's a lot less friction when nurses want to leave, whether that's leave healthcare entirely or switch to something else, and there are just fewer options to protect the workforce and meet the demand of patients if you're just looking at bedside nursing versus the holistic care team redesign that we're talking about that includes how physicians ultimately deliver care. Rae Woods: Let me also acknowledge the fact that we're talking about existing physicians, but we're trying to have a conversation about the future, the future of a potential shortage. And I feel like we can't have that conversation without talking about people who aren't yet physicians. I am talking about the people who are raising their hand and saying, I want to be a doctor, I'm enrolling in medical school. What does the influence of students mean for the potential of a shortage? Daniel Kuzmanovich: Well, we're definitely seeing more applications to medical schools right now. They call it the Fauci effect, but medical school applications are up. Granted, these folks aren't... Because of how long it takes to become a physician, these folks are not going to be joining the workforce in the near term future. But once they do, that is going to be more people, there are more interest, and the care model as we've been discussing, the care model when they join might look different. Sarah Hostetter: Yeah, I think of it... We all know that healthcare moves incredibly slowly and changes incredibly slowly. The only thing I think that changes slower than healthcare itself is medical school. Who knows what these incoming medical students are going to see by the time that they get out of all of these years of training. And I have some questions about whether our current medical school curriculum is preparing them for what they're going to see when they come out. Daniel Kuzmanovich: But there's a potential pro to these folks and the kind of changes that might need to happen by necessity, just like the care models of healthcare have had to change, the curriculums have had to change. One of the big challenges when it comes to making projections about the physician workforce is what you might call the mis-distribution, or the mal-distribution of physicians. We might have more surgeons than we need than we do compared to primary care physicians. I actually was talking to a great primary care leader and they said that, yeah, when I was in medical school, my leader, my chief resident told me I should actually try to be a surgeon rather than a primary care physician. That may have changed. We may see that these folks are making different choices about the specialties that they want to pursue based upon what's happened in the pandemic. Sarah Hostetter: I hope so because primary care is an area that does worry me. When we think about those micro trends within this broader question of the physician shortage, primary care worries me. Because yes, we can supplement with advanced practice providers, we have to do that given our current kind of staffing in primary care, our current physician staffing in primary care, but especially if we're going to shift to value based care, we have to have more primary care docs, and we aren't seeing enough right now. Rae Woods: And Sarah, that's exactly where I wanted to go next. The very first question I asked both of you is, is there a physician shortage? And you both very immediately said no, but I do want to give you a chance to maybe add a caveat or an asterisk to that answer. And maybe Sarah, you already have started to do that. But are there parts of the physician workforce, are there parts of the country, are there types of provider groups that maybe are reasonably feeling some pain today? Daniel Kuzmanovich: I'll take parts of the country for a thousand Alex. There is a very real sentiment when you look in the data from final year medical residents, that younger physicians would prefer to be in urban or suburban environments rather than rural. So at the national level, we might not see a physician shortage, but I would say that in some rural environments, they've actually been dealing with a physician shortage for a while already because of where physicians are distributed across the country. Sarah Hostetter: Although I have some questions as to whether we're going to see that shift too. Talking about things that we can't predict, we've seen a lot of change in terms of where people are living in this country coming out of COVID. Rae Woods: That's true. Sarah Hostetter: We can't forget that physicians are people, so anything that we're seeing happen to humans on planet Earth as a result of COVID is probably also happening to physicians. We are seeing people reprioritize what they care about, move to be closer to family, say, I don't want to live in a city, I want a backyard. All of these things are happening to humans and I'm starting to hear some conversation from some of the more urban providers that we work with, that they're seeing shortages where they hadn't seen them before, and I wonder if we're starting to see some of this trickle and change around, we may not go rural, but it seems like suburban medicine may actually see an influx. Daniel Kuzmanovich: Rae mentioned telehealth earlier. The rise of telehealth, the way that we flipped it on so quickly. That does allow for those physicians to work from different settings, potentially to a much more virtual and expansive panel. Rae Woods: Or serve different settings, regardless of where they work. Daniel Kuzmanovich: Absolutely. Rae Woods: Serve that rural population that's a couple of hours away from a city like Washington DC. Sarah Hostetter: I was just talking to a medical group executive who said, yeah, one of my physicians has moved to Florida and we've pivoted him to be a telehealth only physician. There are more opportunities like that, that we didn't have a few years ago. Rae Woods: We talked about geography. We talked about primary care. What about just different types of groups? I continuously hear from some organizations, hey, we are losing docs. We are seeing maybe not early retirements, but folks choosing somebody else. What do you have to say to those kinds of challenges? Sarah Hostetter: I mean, quite frankly, I would ask an organization like that, what kind of employer are you? And how are you working with your physicians? We've seen the power dynamic shift a little bit over the last 18 months where physicians are realizing they have more choices. And I hope we'll get to talk about this again later, I've been doing some work with looking at what all those choices are. But I said before that physicians are humans like everyone else, and that means that employers have to be an employer of choice. You can't just take those physicians for granted. So how are you working with your physicians? Because if they're leaving, it may not be on them. It may be on you. Rae Woods: Coming back to misleading headlines. This isn't a problem of there aren't enough docs, they're just not choosing to work with you. Sarah Hostetter: Yeah. There's way more options than there ever were, and physicians can decide what they care about in terms of an employer or in terms of, if we're talking at the physician group level, a partner. And so I'm not going to stay with someone when I have a better offer on the table. Rae Woods: Well Sarah, Daniel, I feel like we could talk about this forever, but I want to get to our final question. And as you answer the question, what is the biggest thing you want our listeners to do? Maybe remind yourself that not everybody is probably convinced by this conversation yet. So when it comes to the potential of a physician shortage, what's the biggest takeaway you have for our audience? Daniel Kuzmanovich: I'm going to steal your don't waste a good crisis. You have a chance to reframe and to work on this problem, both now, when there is a perception of shortage, and to set yourself up for the future so there isn't actually a shortage. Sarah Hostetter: Even if we aren't predicting a huge physician shortage, we do expect physician movement and physicians to have other options, and you can't just assume physician loyalty. You never could, but especially now. And so you have to work to be the employer of choice. Sarah Hostetter: We are seeing higher salaries, signing bonuses, better vacation time and benefits coming out of other employers for physicians. I go back to what the past 18 months made us all realize as humans, which is that maybe work is not the number one priority. And so if there are other... We've always asked for physicians to make work their number one priority, and I think we are seeing physicians who spent 18 months making work their number one priority and are tired. And so if you continue to push them to make that their only priority, they're going to find someone else who lets them have better balance in their lives. And so that's my message to employers is, how are you working with your physicians to make sure they stay? Daniel Kuzmanovich: And that's still not necessarily a shortage, to Sarah's point. That's not necessarily a shortage. That's a shortage for you, the employer. Rae Woods: Well, Sarah, Daniel, can't wait till you're back talking about physicians with me again in the future. Sarah Hostetter: Always happy to talk about this stuff. Daniel Kuzmanovich: Bye y'all. Rae Woods: Look, I know that it can be scary to think about a world where we don't have enough doctors. But frankly, I actually find it more depressing to imagine a world five, 10, 15 years into the future where care delivery remains completely unchanged. Rae Woods: We've seen a lot of innovation since the start of this pandemic, and that's created a lot of positive momentum, not just for patient care and patient experience, but for the deliverers of care, which includes physicians. That's ultimately what's going to prevent us from seeing a shortage. Rae Woods: And remember, as always, we are here to help.