To Define Our Future in Medicine, We All Need to Participate

When I was a child, I knew I would become a doctor. I liked science. I liked taking care of people. It has been a natural fit. Most everyone knows what a doctor does. We diagnose medical problems. We prescribe treatment plans. Some of us perform surgeries. Some of us focus on keeping you well.

Despite making my parents proud, however, 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. Medicine has historically been a highly respected profession in America. We have wielded power over life and death. In exchange for the professional privileges bestowed upon us by the public, we have worked very hard to continue to assure that those privileges are taken very seriously. Since the Flexner report ushered in the modern American medical educational system in 1910, we have created and upheld rigorous 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 percent 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, Eugene Stead, MD, a physician in North Carolina, saw an opportunity for 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 percent — 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 percent 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 an inefficient and expensive behemoth. In fact, the work of each American physician requires 10 administrators and 6 clinical staff to support. The work that used to be done by a GP with an assistant is now done by a doctor with a team of nurses, nurse practitioners, physician assistants, medical assistants, and administrative staff.

Medicine has indeed 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 percent from 2010 to 953,695 physicians in 2016. This country also loses approximately 6 percent of US medical school graduates each year from the physician working pool because of a shortage of residency positions. As of 2019, approximately 1140 licensed physicians (ie. those who passed the 3 national medical exams and graduated medical school) are shut out of practicing medicine each year in the US because there was not a spot for them in a residency program. 

At the same time that physician growth has remained stagnant, the number of professionals needed for one doctor to provide medical care ballooned the cost of health care to 17.8 percent of the American GDP in 2016. Despite this, we rank an abysmal tenth 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 percent of overall health care costs, we have been a major focus of cost-cutting efforts. Doctors have seen a trend toward employment over self-employment in an effort for hospitals to better control costs as they moved to value-based, bundled payment systems. Even so, the Kentucky Hospital Association found that 58 percent 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. As a result, 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 also overflowing with poorly organized but 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 inevitably be seamlessly integrated into our health care team. Computers have already been shown to beat 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. 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, over-seeing 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 Primary Care physicians will move back toward self-employment, likely opening 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 stream-line how clinical data is documented and presented to us. It will assist with order entry using a virtual assistant. AI will perform initial radiological and pathological readings with physicians over-reading a percentage of the images and samples. Surgeons may delegate more routine parts of surgery to an autonomous robot, taking direct control only during the more complex portions of the procedure. AI will also make recommendations on patient treatment, like what course of chemotherapy to recommend or who needs cardiac disease screening and when.

So, I’m sorry to break it to you, fellow doctors, but looks like we will become less special in the future 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 all need to participate in creating it. What do you want your role in medicine to look like in the future?

Irene Tien, MD, MSc is a board-certified Emergency Medicine and Pediatric Emergency Medicine physician who has been striving for 22 years to cultivate her empathy and provide the best medical care she can for her patients. She runs the blog My Doctor Friend.

Tien is a 2018–2019 Doximity Author.

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