the future of medicine and doctors

Hi all,

I have been reading some on the future of the health care system, medicine, and physicians.

How some doctors are nervous about what changes will come even in the next 6 years. However, there is really no real information on WHAT and HOW (of course) those changes will be and how they will occur.

I have seen some findings about the elimination of primary care, eventual elimination peditricians in urban areas, and even no doctors…where doctors will become more known as consultants. On the other side, there is the information about the doctor shortage, growth in genetics, and the necessity for technology knowledge for doctors to thrive, and the new now, but formerly common mainstay, of the growth of fee for service practices, house calls, etc.

I would love to hear some feedback from OPM on this, and any other findings you may have come across…all sides and ideas

Really I am just trying to find out more information surrounding this topic…


-soda AKA RB

I don’t pretend to know that much about medicine in specific since I’m not a doctor yet myself, but from talking to numerous people in various capacitities in health care and even one hospital administrator, I don’t think doctors will ever be phased out or be in such a position where job security is concern. The costs of health care, and their out-of-control spiral, will indeed have to be addressed but that will not change the makeup of the health care industry in my opinion…only how it does business.

Besides, the medical community has something akin to the power that the teacher’s union has over their field, so I don’t think they would ever allow themselves to become extinct to begin with.

Plus due to the predatory nature of ambulance-chasing lawyers, they’re always going to want someone competent to point the finger at so they can cash in on doctors as much as possible. So in essence, even the enemies of the health care industry will help keep doctors in business and free from the normal concerns that most people have about job security.

thanks Tim…I wonder what others would think…if what I read is just fauder (sp?)?

I wonder what people are hearing about the shortage too…since like you I am not a doc yet and just starting my pre-reqs.



While there is definitely a shortage of primary care physicians serving rural/urban areas, I hope that more incentives will be offered to persuade physicians to specialize in primary care. While PAs and NPs are a big help, they were created as mid-level alternatives only to physicians and not to replace physicians. I’m not trying to come down on PAs and NPs - this is just the nature of their niche. They help out tremendously in routine primary care, but physicians are absolutely necessary to take care of the complicated AND uncomplicated issues related to health care.

Before anyone argues that PAs/NPs with x number of years experience are better than newly-minuted MDs/DOs in residency, I day “duh!”. But eventually the newly minted MDs/DOs gain experience with their scope of practice and surpass the knowledge and expertise of PAs and NPs, which makes sense. That doesn’t mean that there is no place for NPs or PAs, but that physicians should always have a place in primary care too.

I think many states and the fed are on to something with loan forgiveness for those primary care physicians that serve in areas of most need. I think it would also help tremendously to have rural/urban-type scholarships/stipends at the ready for med students who sign an agreement to go into primary care in these areas (this is already happening in some areas) and not even have to worry about loan repayment at that point.

Another biggie is malpractice reform. No doctor wants to work in an area where they LOSE money based on other physicians’ foul-ups. Sometimes it IS the physician’s fault, and sometimes it’s just the way things happen, whether it be a risky pregnancy, surgery, or illness. Unfortunately our society has people with money signs in their eyes any time something goes wrong, even if it’s really no one’s fault. Or worse, the patient’s fault!

It’s going to be a heckuva long time before rural/urban areas find most needs met regarding physicians, but that doesn’t mean that rural/urban areas should give up on trying to get the best possible care for their residents, including luring physicians back to underserved areas.

Another 2c from a non-doc working in health care:

I semi-joke that I want to get into medicine because I figure by the time I’m through the whole process, I’ll be the only doctor left. My understanding is that the social/political/economic climate add further concerns to practicing medicine, but they certainly don’t preclude it.

Possibly my favorite prof I’ve had was an Ob/Gyn; she dropped the obstetrics aspect of it due to ridiculous malpractice insurance rates (in FL). I’m fortunate that this is what gave her the time to teach anatomy, but I wouldn’t be surprised to see us moving towards midwives in the near future.

Politcally, there are some fun power plays between government, HMOs, pharma companies, etc. Of course, it’s difficult to say that any of them place the patients first.

I mistrust pharma reps, but I can have some interesting discussions with them about it. I’m unenthused with HMOs telling me that my patient needs to try and fail on Thorazine before they’ll trust the doctor’s discretion on Risperdal, or that “treat and street” is a great paradigm of care for an actively psychotic individual. I suppose by its very nature, though, we put a distinct price on every aspect of health care; how much money is it worth to prevent tardive diskinesia? … diabetes? What is the price on somebody’s quality of life? I don’t believe that a fully socialized system of health care would truly be better; I suppose I’m just leery of overtly capitalist motivation in fields like this.

We’ll just have to deal with a climiate where the new American dream is to get hurt and sue, and liability is more important than responsibility. I dunno - is it overly cynical to think that a doctor’s most important letters aren’t “MD” or “DO,” but “CYA?”

All very good points. It’s interesting because this was briefly brought up today in my first class for sociology. One of the topics the teacher mentioned was the trouble that our health care system is in and how the motto for health care in this country is “Don’t Get Sick.” Now, while I don’t think it’s correct to advocate not seeking care if injured or ill, I can see where that conclusion can come from.

The problem is that people who live in the U.S. only know privatized health care. They talk about how everyone should have health care, it should be dirt cheap, who cares what letters are after the clinicians’ name, blah blah blah yet if they went to a socialized system like Canada they would probably never speak ill of the system we have again…despite all of the misgivings that have proliferated inside of it.

My main hope is not that we’ll still have the ability to be doctors in five, ten, etc. years but that we won’t completely be at the mercy of insurance and pharmaceutical companies. Because if you ask me, it’s already looking quite precarious as far as that goes.

I can’t say too much about the medical system in the US, since I’m not living there and have not worked in it myself. I’m in Canada, and both my DH and I have worked in healthcare here for many years, and I just feel compelled to respond to the comment that somewhat maligns Canada’s system. Our system here is definitely not perfect. There are waitlists for surgeries, no question, and our ERs are full. However, this is mostly due to extreme shortages of healthcare personnel: docs, nurses, auxilliary workers. Yet, no one in Canada is refused treatment on the basis of insurance coverage, and they receive the same quality of care as anyone else. HMOs do not exist here, and physicians are not as limited in their ability to treat patients based on what their insurance dictates. Waitlists for elective surgery such as joint replacements can be lengthy, particularly in smaller centres, however, surgeries and diagnostics (MRIs, etc) for urgent cases have little, or no, waitlists. The rate of malpractice suits here is very small compared to the US, the costs of medical school are far less, and the government has all sorts of loan-forgiveness programs and other financial incentives to lure physicians to under-served areas. We do use midwives and NPs quite extensively in underserved areas, not because they are replacing physicians, but because there are simply not enough physicians to go around. In other words, the health care system is not nearly as dire here as the media would suggest.

I could go on and on, but I think I should stop!

Any system rations care. The question is how the care is rationed. In Canada the rationing process is centralized and more or less rational. In the United States rationing is diffuse, rationing decisions are made by many people (HMOs who limit care; employers who do not provide healthcare; healthcare providers who limit the number of Medicaid/Medicare patients that they see, etc), rationing is not coordinated, and much of the time it is not at all rational. The most egregious form of rationing is the most pervasive, and one which requires no single decision–by linking healthcare options to ability to pay, we have rationed care on the basis of wealth.

In terms of the future of primary care… I see myself as someone who will be a primary care doc with a focus on HIV and populations at risk for HIV–a hybrid of specialist and non-specialist, with part of my specialty being the health needs of the community I serve, and part of my expertise being especially knowledgeable about one particular area, like HIV care. Geriatricians are a different version of this model. I think that variations on this theme will become more and more common. Primary care doctors will create distinct niches for themselves in order to distinguish themselves from their MD, NP and PA colleagues, while specialists will be compelled to operate more as a hybrid of specialist and primary care doctor–as do many ID specialists doing HIV care, many oncologists, and many rheumatologists, just to name a few.

The reason for this is not only because people need primary care doctors, but also economics: there can only be so many people that the system is going to pay to see the same patient. At some point, someone sees a patient more than any other provider does; might be a specialist or might not be, but they’re going to have to do the job of being the primary doctor instead of the consulting doctor. I think that we as patients will demand that someone be primarily responsible for our care and actually know us at least a little bit, and while there are many ways that we as patients are stepped on, there are some ways that we can exert our political and economic power, and I think this is one of them.

Although mid-level practitioners are likely to be more common in primary care’s future, I am not sad about that at all. What that future means to me is that as someone who will likely be supervising mid-level folks as part of what I do, I’ll get to do the interesting work of providing them with academic support–in terms of being the one in the office who helps explain why some studies are better than others, or helps explain the basic science underlying our clinical choices, and so on. (After all, there must be some reason we get all this extra training, right?) And I’ll get to do the interesting work of helping them continue to become better and better clinicians. To the extent that PAs and NPs function like more experienced but less academically-oriented medical residents, I’m looking forward to having them in the mix of people I am teaching, working with, and learning from, along with medical students, residents, and medical colleagues. The end result is a more interesting and diverse set of colleagues.

I’ll also have the great luxury of knowing that they will take much of the drudgery out of my job by seeing many of the ordinary sore throat and runny nose visits while referring more difficult-to-figure-out cases to an MD like me. That’s a bonus, for which I will gladly sign many approval forms for my mid-level colleagues’ prescriptions and treatment plans.

And finally, I know that if I can’t talk the most talented nurses I meet into going to medical school, I might be able to help recruit them to become nurse practitioners, which is a great way for our society to take advantage of the often-untapped talents of our brightest nurses, only some of whom are intrepid or foolhardy enough (take your pick) to become OldPreMeds.

In terms of the death of primary care–primary care has been about to die for at least the last thirty years if not longer. It has been the underdog side of the medical profession for a very long time. There are lots of terrible forces that make it tough to be a primary care doctor, and will continue to do so.

The most significant forces are those that ration care for our patients on the basis of irrational and often horrifying criteria (like wealth, for instance) and make it difficult for us to care for them in the way that we would like. I personally think there will always be a need for primary care doctors in some version, even if we will probably also continue to be beleaguered and underappreciated sometimes. But hey, what you lose in income, you gain in muscle strength from all that patting yourself on the back you get to do for all your good work!


Universal Health care may happen in some form now that Hillary Clinton is running for President and like her or not she may win!

I guess it stems from whether or not you believe health care is a right or priviledge. I say priviledge.

I understand but I think it is an obligation of to take care of each other. So may not be a right but it is a duty. Duty to God and fellow man.

I think one of the richest countries of the world should take car of it’s population. Why should my tax dollars go to tobacco farmers and other such fluff when I think taking care of the sick is much more productive then making them sick?

I feel no such obligation. How much obligation does my fellow man have to take care of themselves? How far does this obligation extend? How much of the responsibility falls on the individual?

While I do agree US dollars can be better spent health care is not a priority, neither are kids nor the elderly. If the US government and we, the people, truly cared we would get the government to subsidize the education of those who want to go into FP or IM. Have more money for USPHS scholarships and create more programs such as this.

Problem is the money every politician wants to recoup for healthcare is from those providing the service. Many still believe doctors make too much yet fail to see the years of mediocre at best wages, education debt, insurance, and the human cost required to provide care.

I believe doctors do enough without having to resort to probono work. Those that do, my heart goes out to you. I’ve worked at a free health clinic and my idealism came to an end real quick.

For me, my obligation comes from several sources:

  1. Religion

  2. A natural feeling that helping someone else who needs it is it’s own reward

  3. 9 years as a Boy Scout Leader

  4. Being poor myself for many years and wishing some one else cared, some did.

  5. If I do not care then who will? If all did then it would be easy.

  6. Possesion and money is not something that matters after we are Dead, why make it number 1,2,3,4 or 5 on your list for motivation? Living a good and Happy life should always be number one and I’m happiest when I have done for others. Always have been.

    Now I do want to make a good living but not for the reasons you would think, I want to provide for myself and Wife, I want to provide for my family and be able to take care of them if need be. I want to enjoy my time here, but I do not need extreme wealth to do that. But you can help others and make money at the same time.

    These are my thoughts and beliefs I do not fault any one for theirs.
  • whuds Said:
But you can help others and make money at the same time.

Sure, they're called social workers.

Seriously, I get your drift. We have more in common than I'm willing to admit however I still believe healthcare is a priviledge. If it were presented as such I believe there would be a bigger effort. I don't think there's a nation who isn't experiencing problems with healthcare. Even Canada is having major problems. That bit comes from a report conducted by their own government.

SO true! The problems are deep and many, brought about by so many advances now, it used to be that there were not that many treatments and there were so many limitations, it will just continue to grow as to the possible treatments for different conditions and it all costs money in some form or another, knowledge is not enough, you need the materials too. It all costs.

Question is what and how do we pay for it? Should some of these procedures and treatments be done?

Should people be treated who knowingly harmed themselves as a choice? ( I believe so but it’s still a question) Smoking Alcohol abuse, is every addiction an illness? Is everything that causes disease such as over eating an illness? Where do we draw the line for paying for these things? I do not have the answers since on one hand I see a sick person I want to help, on the other I do not like helping them to return back to the unhealthy lifestyle I just treated them for, but they have a right to live the way they want, and no one should suffer needlessly so its a dilemma of massive proportions, (how did I get on to this? LOL)

I agree with both Crooz and Whuds, each to a certain extent, as far as health care goes. Yes, we should have some sort of obligation to help someone else who needs care, but like Crooz my idealism died real fast after seeing how unappreciative a lot of patients who go to the hospital are and how poorly they treat the people working or volunteering there. Even if the patient is the nicest person in the world, if you’re helping them for free then your family is starving as a result so in essence, you didn’t help one person but hurt at least two (yourself and your wife) and 3 or more people if you have kids. So I strongly disagree with any sort of probono, free, etc. health care. It’s just not feasible. As long as medical education costs so much, doctors should be given a competitive salary.

Now as far as people being unable to afford health care, part of this problem was created /by/ patients because when they get treated, some sort of complication develops and then they want to sue that doctor for malpractice (even if he did the best he could and made no mistake) I’m sure you can guess what happens to the health care field as a result of the lawyers who are more than happy to take the case. Defensive medicine appears to be a very strong reason of why health care is so expensive these days and I don’t see that changing until the lawyers are reigned in. Hell, I don’t even think I’m going to practice in this state once I get my MD because I’m sure most of you know that California has the highest amount of frivolous lawsuits in the entire country. So there’s another problem right there. If someone doesn’t want to practice in a state because of fear of getting sued, that reduces how many clinicians are in the state, and usually when the demand stays the same but the supply diminishes, the price of each unit of supply goes up. So there’s a compounding effect here.

I’m not going to villify the lawyers too much though, it’s not like they’re breaking down the doors at doctor offices and hospitals and yelling “I’m going to sue you because I hate your guts!” It’s the people’s damn fault who sue in the first place. Now granted some doctors do commit malpractice and should be held accountable but I’m sure the percentage of doctors who actually /should/ have been sued is extremely small.

If Bush really gave a damn about health care, he would place more restrictions on who can sue doctors just for the hell of it or do something that would help alleviate the problem of defensive medicine. What if defensive medicine is here to stay? Well, the government could stop pissing away money on a pointless war for people who would rather see us dead than help them and they could subsidize some of the costs of defensive medicine. Heaven forbid our government actually helps it’s own people though; it’s too busy abandoning us and helping people in other countries who don’t even appreciate it. But that’s another topic, I digress.

The main problem with health care is that a lot of the problems could have been avoided if certain people such as lawyers and insurance companies weren’t allowed to metaphorically run through hospitals with a loaded gun causing as much damage as they could. That’s another reason health care is so expensive. Insurance companies keep raising their premiums, reducing their reimbursements, and completely denying more claims. How would I know that they’re denying them just to make money and not because the claim should have been denied? Well, I did use to work at Blue Shield. Granted some claims that are denied should have been but the vast majority of claims that get denied should have been paid. And I sincerely doubt that’s an innocent mistake.

Anyway, hopefully Bush’s plan to revise health care will be shot down since all it’s going to do by making health benefits taxable is reduce the number of employers who are willing to offer health care coverage. So it’s going to raise the number of uninsured people in this country. Regardless of who does become the next president (I won’t mention what Bush can do since he’s an idiot and I have no faith in him), I hope that health care is on their agenda because as I said, legislation needs to be introduced to restrict how much damage the legal and insurance fields do to the health care field.

  • Tim Said:
I agree with both Crooz and Whuds, each to a certain extent, as far as health care goes. Yes, we should have some sort of obligation to help someone else who needs care, but like Crooz my idealism died real fast after seeing how unappreciative a lot of patients who go to the hospital are and how poorly they treat the people working or volunteering there. Even if the patient is the nicest person in the world, if you're helping them for free then your family is starving as a result so in essence, you didn't help one person but hurt at least two (yourself and your wife) and 3 or more people if you have kids. So I strongly disagree with any sort of probono, free, etc. health care. It's just not feasible. As long as medical education costs so much, doctors should be given a competitive salary..................

Ok I hear ya on this one but you have to remember people are sick and scared. Adrenalin and altered states of mind are at play. Even a saint may act up when like this. I took care of a priest I knew once and he had end stage lung cancer, oh the things he said and did! He was a kind and friendly man before but when this sick...... We see people vulnerable and at their worse. SO they act a little selfish and nuts at times.

What I have a major peeve is how we excuse other animals like our dogs and cats for bad behavior and still treat them but humans cannot have bad behavior when sick. I do understand and have corrected many a patient to act better as an RN, there is acceptable ways to act and then unacceptable and many have crossed the line, but for the many I have never thought of not treating them for pay or for free makes no difference to me all deserve the care in my book when they ask for it.

Don't be so quick to condemn these people that might be why they are the way they are.

If anything this is a good discussion and even ethics involved…

Really no right or wrong answers just opinions I enjoy reading the responses, really!

  • Quote:
Possibly my favorite prof I've had was an Ob/Gyn; she dropped the obstetrics aspect of it due to ridiculous malpractice insurance rates (in FL). I'm fortunate that this is what gave her the time to teach anatomy, but I wouldn't be surprised to see us moving towards midwives in the near future.

I think it would be more like "back to the future" with regard to midwives since they were all but phased out during the early part of the 20th century with birth moving toward hospital and becoming a business that would catch the whole family's health care concerns. Anyway, I think a lot of OBs (not on the ACOG board or lobby of course!) would agree their services and time are better spent with high risk and surgical care, along with GYN surg, leaving low risk normal to midwives.

I have lived under the so called “socialized healthcare” and let me tell ya…they (the government) actually “picks” and dictates who will get treatment. Please, do not go and think that if the government is running your heathcare needs that it will give a shit about you. I can go on and on but do not have time. My stepfather a young 60 yo was NOT given the option for chemo/radiation/surgery for a cancer and died on a weekend that there were NO oncologists on call! he could have lived a month more but alas! in socialized healthcare the patient is NOT the priority…be careful what you wish for.