AI transcript
0:00:05 Hey there, it’s Stephen Dubner.
0:00:10 Quick announcement, I will be doing a live event on Sunday, November 2nd in Washington,
0:00:13 D.C. at 6th and I, which is a great room if you’ve never been.
0:00:19 I will be in conversation with Jeff Bennett of PBS NewsHour, celebrating 20 years of Freakonomics
0:00:20 and talking about what’s next.
0:00:21 Hope you can make it.
0:00:25 For tickets, go to Freakonomics.com slash live shows.
0:00:27 And now here is today’s episode.
0:00:38 Have you ever tried to make an appointment with your doctor and been told it would be
0:00:40 weeks or even months before you could get in?
0:00:46 Or maybe you were referred to a specialist and it turned out that the nearest specialist
0:00:47 isn’t at all nearby?
0:00:52 One obvious cause of this problem is good old supply and demand.
0:00:58 We have around a million working physicians in the U.S., or one for every 340 people.
0:01:02 That is a much lower ratio than other high-income countries.
0:01:05 I’m telling you, we’re 180,000 doctors behind.
0:01:07 It’s not going to get us to where we need to be.
0:01:11 There are also mismatches in where physicians work.
0:01:15 Some cities have a surplus, while some rural areas have a shortage.
0:01:18 There are also mismatches when it comes to specialties.
0:01:23 Some places have plenty of cardiologists and oncologists and psychiatrists,
0:01:25 while others have very few.
0:01:28 And how about the physicians themselves?
0:01:29 How are they doing?
0:01:32 We decided to ask our listeners.
0:01:33 My name is Sanjoy Dutta.
0:01:36 I graduated Harvard Medical School in 1993,
0:01:41 and I’ve been a practicing general and bariatric surgeon since 2003.
0:01:45 My job today is vastly different from when I started 20-plus years ago.
0:01:48 Operating room productivity and efficiency is much higher.
0:01:53 I used to do two bariatric operations a day, and now I do a minimum of five.
0:01:59 With the electronic medical record replacing paper charts, dictation software, and now AI scribes,
0:02:02 I see twice the number of patients in a day that I used to.
0:02:05 And on top of that, I am answering patient emails throughout the day.
0:02:12 Today, my staff and I spent countless hours appealing denials for essential imaging or medication,
0:02:16 trying to prove a patient meets criteria that often don’t make sense.
0:02:19 The health care system has become increasingly complex,
0:02:23 and we are often stuck in a maze of phone systems and transfers,
0:02:25 arguing our case to no avail.
0:02:33 This is Dr. Jeff Wood, and I live in a rural area in southern Kansas.
0:02:36 From my perspective as a doctor in private practice,
0:02:39 it seems like we’re facing a perfect storm of challenges.
0:02:43 Insurance companies are a huge part of the problem, in my opinion.
0:02:47 They’re starting to dictate what treatments we can provide,
0:02:50 sometimes even suggesting AI-based alternatives,
0:02:53 before we can even use our own clinical judgment.
0:02:58 What was the point of becoming a doctor if you’re just going to be told what you’re supposed to do?
0:03:06 Today on Freakonomics Radio, the docs are not all right, and therefore, neither are the rest of us.
0:03:11 We will look into the factors that limit the supply of physicians.
0:03:15 Can you imagine telling a 14-year-old high school freshman that to be a doctor will take 15 years
0:03:20 and maybe $100,000 in college debt plus $200,000 or more in medical school debt?
0:03:23 And we’ll look at the factors driving the demand.
0:03:28 17.5 million people will be over the age of 85 in 2050.
0:03:33 We’ll also hear about a moment in medical history that is still having a ripple effect.
0:03:36 Low-quality doctors were actually harming people.
0:03:40 This episode will attempt to do no harm, and it starts now.
0:03:57 This is Freakonomics Radio, the podcast that explores the hidden side of everything,
0:03:59 with your host, Stephen Dubner.
0:04:12 I knew I wanted to be a physician, like, when I was 10 or something.
0:04:12 Did you really?
0:04:14 Yes, I really did.
0:04:18 I had this wonderful pediatrician named Dr. Judith Osha.
0:04:23 I had no idea at the time that she was a giant in her field.
0:04:27 She was what made it possible for me to see that women in medicine could be.
0:04:28 She was revered.
0:04:29 I just didn’t know it.
0:04:32 That is Rochelle Walensky.
0:04:35 Today, she, too, is revered in the field of medicine.
0:04:40 She was director of the CDC, the Centers for Disease Control and Prevention,
0:04:41 during the Biden administration.
0:04:46 Before that, she ran the Infectious Diseases Division at Massachusetts General Hospital
0:04:48 and taught at Harvard Medical School.
0:04:52 She’s back at Harvard now and does some consulting, too.
0:04:57 Walensky is perhaps best known for her research contributions to HIV screening,
0:04:59 testing, and treatment.
0:05:06 When I became an HIV infectious disease clinician because I was an intern in inner-city Baltimore
0:05:13 in 1995, that was the year that the FDA approved the third drug of what would become the HIV
0:05:14 cocktail.
0:05:21 If you’re at the bedside for the first six months of 1995, you understand that having AIDS and HIV
0:05:23 is, for certain, a death sentence.
0:05:30 And in that moment, when the FDA approved that third drug, we could tell patients that if you took
0:05:33 dozens of pills three times a day, you might live.
0:05:37 It was just an incredibly motivating time.
0:05:43 The science was moving so very fast that we could actually tell patients that you had a chance.
0:05:44 It was incredible.
0:05:49 And then all rolled up into that conversation was, can you afford it?
0:05:51 Will it be available to you?
0:05:53 What are the stigmas associated with that?
0:05:55 Do you have a place to go?
0:05:56 Do you have a place to store your meds?
0:05:58 Do you have a place where they won’t be stolen?
0:06:03 Even when the science was available, we had to take care of the patient who had all sorts of
0:06:07 challenges in making that science available to them personally.
0:06:13 So you’ve had a pretty eventful career when it comes to infectious disease, I would say.
0:06:14 Who would have thought?
0:06:21 As you mentioned, HIV-AIDS, toward the beginning of your career, you became head of the CDC while
0:06:24 COVID was still raging.
0:06:25 I think raging is an appropriate word.
0:06:27 I think most raging.
0:06:29 Yeah, 4,000 deaths a day when I was sworn in.
0:06:33 I read that when I was reading about you, 4,000 deaths a day.
0:06:35 I can’t believe how quickly I forgot how many it was.
0:06:37 That’s such a massive number.
0:06:41 Can you just take us inside that for a moment?
0:06:43 I mean, you were appointed by President Biden.
0:06:46 You took over right at the start of the administration, correct?
0:06:49 Yes, I was sworn in several hours after the president was sworn in.
0:06:56 Just describe the state of the CDC at that moment, but especially the state of COVID at
0:06:58 that moment, and walk us through those first couple of weeks or months.
0:07:01 I was working really hard at Mass General.
0:07:06 We were still in really difficult times in these COVID waves.
0:07:12 I remember early on in the pandemic, walking to the hospital and seeing a morgue sitting outside
0:07:15 because we needed to increase morgue capacity at the hospital.
0:07:18 That period was so very dark.
0:07:24 My faculty, some had family members who were immunocompromised, but they were at the bedside.
0:07:28 It was really a stressful, scary time for all of us.
0:07:29 This was, of course, pre-vaccine.
0:07:35 I remember where I was when I got the CNN news alert that the vaccine actually worked.
0:07:36 Where were you?
0:07:37 It was a rainy day.
0:07:41 It was at around 7 in the morning, and I was walking into Mass General.
0:07:46 It literally stopped me before the door of the hospital because there was hope.
0:07:47 There was finally hope.
0:07:50 I was cold-called by the administration.
0:07:52 I did not apply for the job.
0:07:54 Do you know how you got on their radar?
0:07:56 I had done a lot of work in HIV policy.
0:08:00 I was a pretty well-respected infectious disease clinician.
0:08:02 I had done some media.
0:08:06 I had done some work in the policy realm in HIV.
0:08:09 I had known a lot of people in many of these policy circles.
0:08:15 And was your HIV-AIDS background considered a leg up because COVID was still raging?
0:08:17 I don’t know, to be honest.
0:08:19 I had sat on guidelines committees.
0:08:27 I had done a lot of work in cost and cost-effectiveness, which means I had never taken a penny from industry.
0:08:28 I had absolutely no conflicts.
0:08:34 And they needed somebody who knew infectious diseases in this moment at CDC.
0:08:42 Having started your career with HIV-AIDS, having gone through COVID at CDC, what are you worried about now?
0:08:43 Workforce.
0:08:49 If you’re an infectious disease doc in 2018 and somebody says to you, what do you do?
0:08:50 And you say, I’m an infectious disease doc.
0:08:51 They say, what does that mean?
0:08:57 But in 2020, while at Mass General, as we were knee-deep in some early days,
0:09:01 there were so many companies reaching out and saying,
0:09:05 can you come talk to our organization about what we should do?
0:09:09 Airlines and cruise ships, all sorts of folks were reaching out.
0:09:13 And I thought to myself, where are all the infectious disease docs?
0:09:22 So we created a map of the United States and realized that 80% of counties in the country did not have a single infectious disease doc.
0:09:33 In the middle of COVID, in some of our darkest days, I am in my office as the director of the CDC and I’m hearing hospital beds are closed because they don’t have staff and personnel.
0:09:39 And so I said, I really need to understand what’s going on with the health care workforce.
0:09:43 And that’s what led me down this research endeavor.
0:09:52 This research endeavor that Walensky is talking about culminated in an article for the New England Journal of Medicine, which she co-authored with Nicole McCann.
0:09:56 And that’s the article that made us want to speak with Walensky.
0:09:57 Here’s what they wrote.
0:10:01 An urgent health care workforce crisis is looming.
0:10:09 Many potential reforms require congressional action and accountability, which have been all too slow to enact meaningful change.
0:10:17 So when you began to put together this data, how surprised were you by the magnitude of the physician shortage?
0:10:19 I had seen it in pieces.
0:10:21 So I wasn’t surprised by any singular piece.
0:10:28 But putting it all together sort of recognized that at every step of a consecutive path, there were challenges.
0:10:37 We were weeding people out along the way and we were getting to a workforce that is burnt out, retiring, smaller.
0:10:44 We have an anticipated one hundred and eighty seven thousand deficit by 2037.
0:10:46 That’s a huge number.
0:10:51 As I mentioned earlier, the physician shortage is not uniform over the next decade or so.
0:10:57 Rural areas are expected to have a 60 percent shortage compared to a 10 percent shortage in metro areas.
0:11:05 The specialties with the biggest expected shortages are family medicine, vascular surgery, ophthalmology and respiratory medicine.
0:11:09 So what exactly is going on here?
0:11:13 Let’s start by looking at the demand for physicians.
0:11:15 There is one issue here that’s bigger than the rest.
0:11:22 We will increase the population that is over the age of 85 in 2050 by threefold.
0:11:25 One question is who will take care of them?
0:11:32 Our life expectancy has increased so much over the past hundred years, especially.
0:11:36 But in recent years as well, if you’re healthy, you tend to live really long.
0:11:43 I think the most common age of death in the U.S. today is 87, which shocked me when I read it.
0:11:45 But I’m pretty sure that’s actually true.
0:11:46 Yeah, it sounds about right.
0:11:54 Do you expect that there will be a fall off in lifespan if we don’t increase the supply of physicians and especially gerontologists?
0:11:59 Well, first, I want to say that there are a whole host of physicians that can treat the elderly.
0:12:03 It is very helpful to have gerontologists, but we have primary care doctors.
0:12:10 We have others who don’t necessarily have to have a geriatric specialty in order to treat the geriatric patient.
0:12:20 And it is also the case that while many people are living that long, we have a challenge in getting all populations to live that long.
0:12:30 If our goal is to improve health by increasing life expectancy in this country, we actually have to focus on those folks who have the most life expectancy lost.
0:12:49 We recently published a three-part series called Cradle to Grave, which looked at various angles of this big lifespan change.
0:12:53 And when we asked listeners for input for this episode, we heard a lot about that.
0:12:57 Here is Paul Goodwin, an orthopedic trauma surgeon in Texas.
0:13:02 There’s a huge silver tsunami coming of patients needing joint replacements.
0:13:13 The estimate is that every orthopedic surgeon will have to double their caseload in order to meet the demand if the supply of surgeons stays constant.
0:13:21 Also, interestingly, the incidence of hip fractures in the coming decades is supposed to approximately double.
0:13:24 That is a lot of patients to take care of.
0:13:29 If you think about medicine as a business, which, of course, it is, at least to some degree.
0:13:37 And if the demand for this business is growing, why is the supply of physicians having such a hard time keeping up?
0:13:45 In her New England Journal paper, Rochelle Walensky identifies one big factor, the scarcity of slots in American medical schools.
0:13:51 Over the past decade, there’s been a 10 percent increase, but given the need, that’s not enough.
0:13:54 We have some extraordinary young people.
0:14:00 And in fact, if I had one bright light about the future, it would be the incredible talent that’s applying to medical school right now.
0:14:07 We are systematically turning them away by some of the difficulties in getting into medical school.
0:14:19 I wrote a paper with my husband, who is also a physician scientist, and we talk about how to watch a child, our own child, apply to medical school and what that process looked like.
0:14:24 Kids are being suggested to apply, I think, on average, to 18 schools.
0:14:26 Many kids are applying to 25 and 30.
0:14:28 It’s an expensive process.
0:14:31 MCATs are over $350 or so.
0:14:34 Each application is $150 or so.
0:14:39 The secondary applications are somewhere between four and eight essays.
0:14:48 So if you do all that math, you see these incredible, talented kids who are writing somewhere between 50 and 100 essays and may or may not get in.
0:14:55 You’re also starting to explain the fact that lower income people are much less likely to become physicians, yes?
0:14:55 Absolutely.
0:15:03 When we think about the medical school standards in the U.S., they are famously high, for which I think everyone is really grateful.
0:15:17 On the other hand, it’s been argued that there are plenty of people who are smart enough to meet those standards, but that the number of slots in medical schools and residencies has just not kept up with the demand.
0:15:26 Are the kids who are not getting into medical school not getting in because they are not smart or capable enough or simply because there aren’t enough slots?
0:15:28 More the latter than the former.
0:15:39 We gave an example in the piece of an extraordinarily talented young woman who applied to 33 medical schools at the cost of almost $5,000.
0:15:41 She had gone to an elite Ivy League school.
0:15:44 She got 96th percentile in her MCATs.
0:15:54 She applied to 33 schools, got interviewed at two, and was rejected from all of her safeties, as they assumed she’d never come, and was waitlisted and never got in.
0:16:01 Now, you take somebody like that, and many people would simply say, I’m done, I’m going to pursue another incredible career.
0:16:08 She, to her great credit, said, I’m going to take another year off and apply again, and she got a full ride at a top medical school.
0:16:13 But if it weren’t for her grit, she would have become an investment banker or something.
0:16:14 Right, exactly.
0:16:20 So there are not as many slots as one might want, but who is constraining the number of slots?
0:16:23 First of all, we have only a finite number of medical schools.
0:16:26 Right, but that’s not a permanent situation, correct?
0:16:27 That is eminently fixable.
0:16:30 We certainly could open more medical schools.
0:16:33 Just to be clear, it’s extraordinarily expensive to open these, right?
0:16:38 Teaching at a medical school is not the compensation of seeing patients.
0:16:44 So you have to pay these faculty, and then those schools have to be affiliated with hospitals that can train the students.
0:16:47 Because it is not just about the didactics in the classroom.
0:16:50 It is about going to the bedside and training those students.
0:16:58 So there has to be this partnership with a hospital that allows students to come in and to be trained, and where there are faculty and doctors who can train these students.
0:17:09 There are fewer than 200 medical schools in the U.S. today, with many of them concentrated in the most populous states like New York, California, and Texas.
0:17:13 So other than the expense, why aren’t there more medical schools?
0:17:16 One reason goes back over 100 years.
0:17:18 We were surprised.
0:17:19 This paper took a while.
0:17:25 And part of the reason it took a while was because we were surprised.
0:17:26 That’s coming up.
0:17:28 After the break, I’m Stephen Dubner.
0:17:29 This is Freakonomics Radio.
0:17:30 We’ll be right back.
0:17:44 Before the break, we heard about some of the factors that put a strain on our physician workforce.
0:17:48 There is the big rise in the share of the elderly population.
0:17:52 There is the urban-rural divide when it comes to physician supply.
0:17:55 And there is the relative scarcity of medical schools.
0:17:58 Let’s stay with that last one for a bit.
0:18:03 If you want to understand the current medical school landscape, there is a bit of history you should know.
0:18:08 The Flexner Report is so important and has such a huge legacy.
0:18:16 Everybody in medicine knows about the Flexner Report, and yet we really don’t know that much about it.
0:18:17 That’s Karen Clay.
0:18:21 She’s an economic historian at Carnegie Mellon University,
0:18:24 and she is one of four authors of a new working paper called
0:18:30 Medical School Closures, Market Adjustment and Mortality in the Flexner Report Era.
0:18:33 Okay, there’s a lot to unpack here.
0:18:35 Let’s start with the Flexner Report itself.
0:18:39 I had heard about it a little bit.
0:18:43 I knew that there was this report and a bunch of medical schools shut down.
0:18:49 So, Karen Clay and her co-authors set out to measure the effects of this Flexner Report.
0:18:57 One of her co-authors, Grant Miller at Stanford, had been doing research on the low quality of physicians in developing countries.
0:19:03 It’s not that all doctors in developing countries are of low quality, just that there are significant numbers of them.
0:19:16 So there had been some floating of ideas of whether they should try and address these low quality medical schools that are turning out these low quality doctors in order to bring the standard up.
0:19:23 I guess that gets you to the question central to your paper, which is, is a low quality doctor better than no doctor at all?
0:19:27 It’s really what is the impact of having these low quality doctors?
0:19:31 Some people would then not go to any doctor.
0:19:35 Some just weren’t aware that there was a higher quality doctor nearby.
0:19:43 But it looks like the answer, at least based on what we have in the paper, is that low quality doctors were actually harming people.
0:19:47 OK, so they found that low quality doctors were actually harming people.
0:19:50 That’s a big deal and we will get into it soon.
0:19:53 But let’s set the stage a little bit more.
0:19:56 The Flexner Report was published in 1910.
0:19:59 This is a period in which the U.S. is growing rapidly.
0:20:01 The standard of living is rising.
0:20:05 And one of the things people want to consume is medical services.
0:20:07 So there’s demand.
0:20:13 People often would go to a medical school in their town and then set a practice in their town.
0:20:16 What kind of people were starting these schools?
0:20:17 Were they entrepreneurs?
0:20:18 Were they do-gooders?
0:20:20 They’re entrepreneurial physicians.
0:20:22 It’s a way to make some extra money.
0:20:25 It had some prestige attached to it.
0:20:27 That is, I was a founder of a medical school.
0:20:33 And it signals to people that I am a very good physician and therefore you should come to me.
0:20:38 So there were medical schools around that did not require even a high school education, correct?
0:20:39 That is correct.
0:20:47 As you can imagine, with all these medical schools starting up, the quality of training was uneven.
0:20:51 The American Medical Association began to take notice.
0:20:54 But the AMA back then was different than it is today.
0:21:02 The AMA in the late 19th century is primarily an organization by and for elite physicians.
0:21:12 In the early 20th century, these physicians realized that if they want to have political power, they need to be much more inclusive.
0:21:17 They need to harness the fact that there are many, many, many doctors out there.
0:21:21 And many of those doctors are also concerned about quality.
0:21:24 They’re also concerned about the fact that they’re not making a ton of money.
0:21:34 They then reorganize so that if you become a member of your state medical society, you automatically become a member of the American Medical Association.
0:21:41 And so the membership goes up very quickly and they establish a council on medical education.
0:21:50 They publish educational standards beginning in 1905 and then start to visit medical schools and start publishing quality ratings.
0:22:02 So the AMA, alongside the Carnegie Foundation, commissioned a well-regarded educator and reformer named Abraham Flexner to examine the state of medical education in the U.S. and Canada.
0:22:05 Abraham Flexner is an interesting guy.
0:22:10 He had already done some work studying the American college system.
0:22:19 This was partly in light of the fact that Europe had what was widely considered to be, on average, better education at the university level.
0:22:24 But he actually had no experience with medical schools.
0:22:42 It turns out that he was hired through some connections, basically, by the Carnegie Foundation and was sent to collaborate with the AMA, although the collaboration was kind of hidden, to look at the status of medical schools in the U.S.
0:22:48 Was the AMA’s connection to the Flexner report downplayed?
0:22:51 I think that everyone understood that they had commissioned it.
0:22:59 The thing that they did not maybe fully disclose was that, first of all, Flexner wrote this report very rapidly.
0:23:09 And so he received significant assistance from the AMA, in part because they had already done evaluations of all the medical schools.
0:23:20 But because it was politically complicated to criticize medical schools, they decided that it was better for this objective third party to do it.
0:23:31 What he did is he evaluated each medical school to say, this is too poor to salvage, or this is something we can work with, or this is the gold standard.
0:23:36 That, again, is Rochelle Walensky, the physician and former CDC director.
0:23:40 And he compared, at the time, gold standard, interestingly enough, to Johns Hopkins.
0:23:46 Interestingly enough, Walensky says, because Johns Hopkins is where she went to medical school.
0:23:49 One of my professors in medical school was a descendant, was a Flexner.
0:23:55 Abraham Flexner, while preparing his report, visited nearly 150 medical schools in the U.S.
0:24:02 He was accompanied by Nathan Colwell, who was a physician and an official at the American Medical Association.
0:24:04 So what were they looking for?
0:24:09 One of the things that they were really focused on was the biomedical sciences.
0:24:16 They wanted to have a really robust scientific basis and laboratory sciences in their curriculum.
0:24:22 Another was whether they were collaborating with hospitals and whether training in those hospitals was up to par.
0:24:30 The strength of the physician-scientist faculty, relationships to those hospitals, how close were they, how committed were they to the medical schools?
0:24:38 In his report, Flexner argued that the vast majority of medical schools did not meet these standards, and he suggested closing many of them.
0:24:42 Not surprisingly, his report got some buzz.
0:24:44 Here are a couple of headlines from back then.
0:24:46 Poor medical colleges, a danger.
0:24:49 And country flooded with quacks.
0:24:53 And here again is the economic historian, Karen Clay.
0:24:57 The Flexner report didn’t just shock people at the time.
0:25:09 I found the fact that the Flexner report recommends keeping only 31 medical schools, which it deemed would be enough to train enough doctors for the entire U.S., to be really radical.
0:25:13 That’s not what happened, but it was still really, really surprising.
0:25:19 So during the period after the Flexner report, what share of medical schools in the U.S. closed?
0:25:26 By 1915, the number of medical schools has fallen to between 90 and 95.
0:25:27 Wow.
0:25:28 So big decline.
0:25:34 It eventually does continue to fall a little bit and stabilizes at around 70.
0:25:40 In the paper, you explain that the schools that ended up shutting down, they weren’t forced to shut down.
0:25:43 They were pushed out by market forces, essentially.
0:25:50 The Flexner ratings came out, and if you were running a school that was poorly rated, students just stopped applying.
0:25:51 That is correct.
0:25:56 Describe the primary characteristics or demographics of the schools that did close.
0:26:00 Were they mostly in smaller cities or rural areas?
0:26:02 They’re mostly not in rural areas.
0:26:05 They tend to be in medium and larger cities.
0:26:08 Some cities just had a lot of medical schools.
0:26:14 Cook County, for example, which is where Chicago is, had many medical schools.
0:26:22 I read here that before the report, there were more than a dozen black medical schools in the U.S., several of them at HBCUs.
0:26:25 But that within a decade, there were only two.
0:26:29 Howard University College of Medicine in D.C. and Meharry Medical College in Nashville.
0:26:31 So tell me about that.
0:26:40 Since a lot of medical care at the time was segregated, how did those closures affect black patients and would-be black physicians?
0:26:48 A lot of these black medical schools, a lot of medical schools in the South, full stop, are taking people who don’t even have a high school education.
0:27:01 That’s just because the pool of people at the time who have a high school degree is relatively small, and the pool of people who have some colleges even smaller in the black community.
0:27:06 The other thing about the black medical schools is they tend to be a bit smaller.
0:27:09 There is surely a decline, though, in slots.
0:27:17 It is a fascinating and tragic part of the Flexner Report in terms of impacts of why are there not more black physicians.
0:27:30 By virtue of closing five out of seven HBCU medical colleges, we now have about 30,000 less black physicians than we might have had.
0:27:32 That’s Rochelle Walensky again.
0:27:36 She says the Flexner Report had a number of long-lasting effects.
0:27:44 It also created a divide, and this divide is relatively unique to America, between medical schools and schools of public health.
0:27:52 That is really a challenge for our country, that we have the silos of public health departments and medicine.
0:27:55 I never thought about the fact that the U.S. is unique.
0:27:58 In Europe and elsewhere, you’re saying they’re bonded together?
0:28:00 They’re more fluid relationships, for sure.
0:28:05 From a COVID standpoint, I vividly remember people saying to me,
0:28:10 how come you’re relying on data from the U.K. and Israel for our vaccine effectiveness?
0:28:16 One of the beauties of being an infectious disease doc is I have infectious disease friends across the country.
0:28:20 I called a handful of different hospitals while I was CDC director, and I said,
0:28:23 can you tell me who in your hospital has COVID and is vaccinated?
0:28:24 And they said, no.
0:28:28 We can tell you who’s hospitalized, and we can tell you who’s hospitalized with COVID,
0:28:34 but the vaccination data are in the departments of public health, and they don’t actually connect.
0:28:43 Okay, so those are some of the long-term effects of the Flexner Report.
0:28:45 But what about the one that we really care about?
0:28:49 At least the one that I first wondered about when I read this new paper.
0:28:52 What were the health effects of all those medical schools closing?
0:28:56 You might think that fewer medical schools means fewer physicians,
0:29:02 which means less access to physicians, which means trouble.
0:29:04 But that’s not what the data said.
0:29:09 The data that Karen Clay and her colleagues analyzed showed that medical school closures
0:29:17 after the Flexner Report led to an 8% drop in infant mortality and a 4% drop in non-infant mortality.
0:29:21 And keep in mind that mortality rates back then were much higher.
0:29:23 So how many people does this translate into?
0:29:30 It’s an estimated 16,000 infant lives saved per year in the U.S.
0:29:32 and 38,000 non-infant lives.
0:29:37 If you find this result surprising, and Karen Clay says that she did,
0:29:41 you need to remember that the whole purpose of the Flexner Report
0:29:44 was to get rid of low-quality medical schools.
0:29:53 So it would appear that, A, it worked, and B, that having a bad doctor can be worse than having no doctor at all.
0:29:59 I asked Clay how this Flexner effect compares to other life-saving medical interventions.
0:30:05 Putting in water and sewerage in the Boston area reduced infant mortality by 23%.
0:30:11 Municipal water filtration reduced infant mortality by 11% to 12%.
0:30:18 In cities between 1900 and 1940, prohibition caused infant mortality to decrease,
0:30:23 and the lifting of prohibition actually increases infant mortality by 4% to 5%.
0:30:27 Today, if you did something that reduced infant mortality by 8%,
0:30:30 you would be winning the Nobel Prize in medicine.
0:30:34 Karen Clay told us that it took a long time for her and her colleagues
0:30:38 to convince themselves that these research findings were robust.
0:30:42 We really had to spend a lot of time thinking about,
0:30:44 are we doing this estimation correctly?
0:30:47 Is there something we haven’t looked at?
0:30:50 We sort of thought that any result would be interesting.
0:30:56 My personal skepticism about the fact that doctors were harming people
0:31:00 was allayed somewhat when we went back to the developing country literature,
0:31:05 where they have done extensive work on doctor quality.
0:31:12 Many parts of the doctor quality distribution are more likely to harm patients
0:31:14 than they are to help them, even today.
0:31:20 Today, of course, a not very good doctor in a developing country can still give you IV fluids.
0:31:23 They can still give you antibiotics.
0:31:27 But these are doctors who don’t have that.
0:31:32 This is also a period in which, although germ theory has been well known,
0:31:35 the practicing of hygiene is not uniform.
0:31:42 If you are a low-quality doctor, you may not be paying that much attention to those sorts of things.
0:31:46 You could easily, quote, help someone by stitching them up,
0:31:50 but give them some terrible infection in the process.
0:31:55 And I went back to Rochelle Walensky to get her thoughts on the Flexner Report paper.
0:31:59 I think it’s a super interesting story, and it is not necessarily the one that I would have anticipated.
0:32:04 The methods seem really sound, and I applaud the authors for what they’ve done.
0:32:08 Many of those deaths that were probably averted were infectious.
0:32:09 They were related to hygiene.
0:32:17 So Walensky doesn’t doubt the research findings, but she does wonder if the solution at the time was the right solution.
0:32:22 What happens if we fast-forward the clock, and instead of closing those medical schools down,
0:32:25 we improve what they learn about hygiene?
0:32:30 We do all the things that we should be doing to improve the training,
0:32:34 even if it wasn’t at the level of Dr. Flexner’s Johns Hopkins.
0:32:39 Where would we be now 100-plus years later in terms of that training?
0:32:43 Would we still see the decreases in infant mortality,
0:32:46 or would we actually be in a better place than we are now?
0:32:51 On balance, though, do you think that the Flexner Report was a success
0:32:54 in that it closed down schools that were substandard?
0:32:57 I’m agnostic there. I’m not sure.
0:33:00 We see that it’s so hard to open medical schools
0:33:04 that it is not obvious to me that that might have done harm
0:33:08 rather than not having the capacity to bring people in
0:33:10 to continue to train and improve that training.
0:33:16 In other words, the Flexner Report and the American Medical Association,
0:33:21 by being so strict, may have contributed to the current dilemma.
0:33:27 Too few medical school slots and too few physicians for too many patients.
0:33:31 Still, this is just one of many factors behind the current situation.
0:33:33 If you’re looking for another cause,
0:33:36 you might want to think about doctor frustration and burnout.
0:33:39 We heard a lot about that from our listeners.
0:33:42 And you might especially want to consider the private equity revolution,
0:33:47 where smaller medical practices are often rolled up into large corporate practices.
0:33:52 That, too, can make the life of a practicing physician much less attractive.
0:33:56 So this is all sounding pretty grim.
0:33:58 Coming up after the break,
0:34:02 we hear about a few solutions to the physician shortage.
0:34:04 A few maybe solutions, anyway.
0:34:05 I’m Stephen Dubner.
0:34:06 This is Freakonomics Radio.
0:34:07 We’ll be right back.
0:34:20 The number of physicians being trained in the U.S.
0:34:25 is constrained not only by the number and location of medical schools
0:34:27 and the number of slots at each school,
0:34:29 but by another layer of oversight.
0:34:33 Our country’s GME, or Graduate Medical Education System,
0:34:36 here again is Rochelle Walensky.
0:34:39 Once you leave medical school, you can’t go and practice.
0:34:43 You need to train, as we call it, internship, residency, fellowship.
0:34:48 Those slots for training are capped federally.
0:34:50 It’s run out of CMS and Medicare.
0:34:54 They were capped since back in the 1980s, 1990s,
0:34:57 when there was an anticipation that we would have too many physicians.
0:35:00 We are not there.
0:35:02 I read that in your paper, and I have to say I chuckled
0:35:06 because I’ve never thought about a world where we were worried about having too many physicians.
0:35:08 So can you briefly take us back to there?
0:35:12 What created the environment where we thought there would be a glut of physicians?
0:35:15 Physicianhood was revered.
0:35:17 People were going into medical school.
0:35:18 We had fee-for-service.
0:35:22 People were being financed and compensated really well,
0:35:24 and this was a really great field to be in.
0:35:29 There was this concern that we were in a place where, uh-oh, we might have too many.
0:35:34 And so Congress came in and constrained the numbers by constraining the training numbers.
0:35:38 You’re given federal slots in these hospitals for your entire training programs,
0:35:44 and that’s everything from pediatrics and neurology and internal medicine and cardiology to surgery.
0:35:46 States can supplement those.
0:35:49 Hospitals can supplement those, but they’re expensive to do.
0:35:55 Over the last 20 years, we’ve really only increased our GME training slots by around 15,000.
0:35:59 So I’m telling you we’re 187,000 doctors behind.
0:36:02 It’s not going to get us to where we need to be.
0:36:08 If you look at survey data from the public and from physicians themselves,
0:36:14 it’s clear that respect for the profession has fallen, as has trust in the profession.
0:36:16 A lot of our listeners commented on this.
0:36:17 Here’s one.
0:36:20 My name is Evelyn Kim, and I’m an emergency physician.
0:36:28 I started probably at the beginning of the wave after the show ER brought a lot of people
0:36:34 into our specialty, but I originally went to medical school following the path of my father,
0:36:37 like so many of my colleagues whose parents were physicians.
0:36:44 And I have definitely seen the work itself change, the attitudes of physicians change,
0:36:48 and society’s attitude towards physicians change.
0:36:53 I come from an era where I was happy to identify as being a physician.
0:36:55 It is who I am.
0:37:01 It is a part of me, and I’m not afraid to admit that oftentimes I have no work-life balance.
0:37:04 That wasn’t even a concept for my father or for me throughout my career.
0:37:12 I’m nowhere near feeling like I want to retire because I still feel like I have a lot to contribute,
0:37:18 but I don’t think that that is the prevalent attitude amongst physicians these days.
0:37:21 And here’s another listener.
0:37:25 My name is Colin Larkin, and I’m part of the problem.
0:37:31 Larkin studied chemical engineering in undergrad at the University of Rochester with a plan to become a physician.
0:37:36 Society does a really good job of convincing our young people that it’s a really good idea.
0:37:38 You get to save lives.
0:37:40 You are revered by society.
0:37:42 You’re very well-educated.
0:37:43 You get to make a good living.
0:37:48 You see House and Grey’s Anatomy and all these things that glorify physicians in the media.
0:37:53 Larkin got a master’s at Oxford and then enrolled in medical school at Northwestern University.
0:38:00 His plan was to become a neurosurgeon, but once he got into an actual hospital setting, his plan changed.
0:38:02 I just realized that I didn’t like it.
0:38:05 A lot of what you end up doing is clerical work.
0:38:11 It’s very algorithmic in a lot of ways and hyper-repetitive and all these different things that I didn’t really realize until I got there.
0:38:14 So I ended up taking some time off.
0:38:21 I worked in management consulting at Boston Consulting Group through actually a program that they have specifically for med students to try to recruit them into consulting.
0:38:27 Went back, finished up my degree, did a couple different things during the fourth year, including starting a medical device company,
0:38:32 applying to residency, and then applying into venture capital roles, which is ultimately where I ended up.
0:38:41 I graduated in the spring of 2024, and now I am a Silicon Valley life sciences and health tech investor at SoftBank.
0:38:51 So if you are someone who is concerned about the physician workforce, losing someone like Colin Larkin to venture capital has to hurt.
0:38:53 If you’re someone like Rochelle Walensky, for instance.
0:38:58 Physicianhood used to be a somewhat revered field.
0:39:02 Over the last several years, that has certainly no longer been the case.
0:39:03 You see physicians under attack.
0:39:05 You see science under attack.
0:39:09 You see compensation not close to what people are hoping,
0:39:15 certainly not close to what would make up for the extraordinary loans that these students have to take out.
0:39:28 They’re thinking, why would I take another deferred year of compensation for a, on average, $200,000 loan when there are other great ways to pursue a career?
0:39:29 Ah, yes.
0:39:31 The cost of medical school.
0:39:37 Here is another Freakonomics Radio listener, John Clark, who is an urgent care doctor in Colorado.
0:39:43 I’ve been hearing dire predictions about physician shortages since I was in medical school in the mid-1990s.
0:39:55 By way of demographic context, I’ve had experience in rural and suburban emergency departments, an academic teaching environment, traditional office-based primary care, and for the last several years in an urgent care setting.
0:39:58 I think you’ve covered the cost of higher education very well in the past.
0:40:05 Can you imagine telling a 14-year-old high school freshman that to be a doctor, it’ll take 15 years of formal education and training,
0:40:09 maybe $100,000 in college debt plus $200,000 or more in medical school debt?
0:40:12 Don’t think a lot of kids would eagerly sign up for that path.
0:40:20 I went back to Rochelle Walensky to talk about med school tuition, debt, and what looks to be one encouraging sign.
0:40:30 There is a movement lately from private philanthropists to make some top-tier medical schools free, tuition free.
0:40:34 I would think you are in favor of that idea or no?
0:40:35 Yes, and?
0:40:37 Yes, and? What’s the and?
0:40:42 We are making it free, but we are not changing the cost of producing a doctor.
0:40:44 It does matter who’s paying.
0:40:48 Certainly, it’s helpful to have it be free.
0:40:55 Some of the motivation around doing that is to bring in people from less affluent communities,
0:41:01 to bring in people into primary care, and that people do not leave in debt,
0:41:04 and therefore that they go into the lower-paying specialties.
0:41:07 The jury’s still out on that.
0:41:11 Some of the earliest data from the free medical schools are not panning out that way.
0:41:15 I don’t think that alone is going to fix the issue.
0:41:24 One of the things that I’m very worried about is a policy in the Big Beautiful Bill that speaks to how much loans one is allowed to take.
0:41:30 The average loan of a graduating medical student is in the $200,000 range.
0:41:34 70% to 90% of students have debt.
0:41:42 So if it is the case that, on average, more than half of students have debt, and that debt is over $200,000,
0:41:47 you’re going to lose half of your medical students if you don’t allow them to borrow money.
0:41:49 What are the borrowing constraints?
0:41:51 I believe a maximum of $200,000.
0:41:56 We recently published a series on air traffic control in the U.S.
0:42:00 A lot of the problems you’re describing sound similar to those problems.
0:42:06 A kind of outdated training infrastructure, not enough slots to train new entrants.
0:42:09 There’s some congressional sludge in both cases.
0:42:15 There’s also just complications in making this market, if you want to call it a market, work well.
0:42:25 Do you have any thoughts on that or perhaps other parallel systems you look to to increase the supply and the status of physicians?
0:42:28 Yeah, I think the one that you highlight is actually a really sound one.
0:42:30 I think that that very much resonates.
0:42:34 I also think that there is a geography problem.
0:42:41 What is it that we are going to do to address the paucity of physicians in rural areas?
0:42:45 Now, some of those issues relate to medical school closures back in 1910.
0:42:53 Some of those relate to many physicians, once they’ve trained, want to stay at the places that they’ve trained.
0:42:57 And to be fair, more people want to live in urban areas than ever before.
0:42:58 That’s just the way it is.
0:42:59 It’s not just here.
0:43:00 It’s around the world.
0:43:04 So that leaves rural areas wanting for physician care.
0:43:08 Have you seen anything useful, practical that started to reverse that?
0:43:12 I think we need to incentivize folks to go into rural areas.
0:43:14 I mean, we do that to some degree already, don’t we?
0:43:15 We do.
0:43:19 We increase Medicaid payments, I think, by 10 percent.
0:43:24 The things that have been done over 50 years have not necessarily demonstrated that they’re working.
0:43:31 We have a partnership here in Massachusetts with a tribal nation out in the Dakotas.
0:43:34 And our residents love going out there.
0:43:35 They love learning.
0:43:37 They love caring for that patient population.
0:43:41 Many of them would be willing to go there for months.
0:43:45 The challenge is financing it after they’re done training.
0:43:47 Who’s going to pay for that?
0:43:52 There are models to explore, but you need the finances and you need the political will.
0:43:57 I do also want to just comment on unintended consequences of policies.
0:44:15 Whatever one wants to think about the Dobbs decision, there have been surveys about physicians, not just obstetricians or training obstetricians, but about physicians who are interested in going to states where there will not be abortion access.
0:44:23 Now, if you look at a standard resident, they are generally between the ages of, let’s call it, 26 and 35.
0:44:25 And what share are female these days?
0:44:27 It’s probably a little bit more than half and half.
0:44:30 But that doesn’t matter because many of the men are partnered with women.
0:44:37 And they move to an area that doesn’t have abortion access just at the time that they might want to have children.
0:44:38 That is a driver.
0:44:49 However it is one feels about the policy, it may have unintended consequences of not having people wanting to go to those areas of the country at the time that they’re of childbearing age.
0:44:54 Another driver, you write, of the physician shortage is physician exodus.
0:44:57 You know, COVID-19 was hard on a lot of physicians.
0:44:59 Burnout, as we know, and suicide rates.
0:45:05 And there are all sorts of negative indicators for physicians and others in the medical field.
0:45:14 Do you have any thoughts, whether it’s drawn from your practice, your teaching, your CDC service, on how to make the daily life of a physician better?
0:45:19 There’s so much that we get and can do as physicians.
0:45:25 That said, physician hours are extended and much of that is not satisfying hours.
0:45:34 There was one 2017 study that demonstrated that in an 11-and-a-half-hour workday, almost six hours of it was spent in front of the computer.
0:45:37 Or what they call pajama time.
0:45:42 This is the time after 7 p.m. when you’ve seen your last patient and you’re going home after a long 12-hour day.
0:45:45 You’ve finished dinner, but you have 10 notes to write.
0:45:49 So you’re spending all of your evening time just catching up on the paperwork from the day.
0:45:53 Those things really are exacerbating the challenge.
0:45:59 One of the other big challenges is the churn of patients in the hospital.
0:46:07 I took care of a patient who had an inflammatory disease that needed a monoclonal antibody infusion as an outpatient.
0:46:10 She could not afford this infusion.
0:46:12 It was several thousand dollars.
0:46:13 Her disease flared.
0:46:15 She ended up with a three-day hospitalization.
0:46:20 We tried to give her an infusion as an inpatient and insurance declined.
0:46:27 So the burnout is not just the long hours because actually doctors knew they were going to get in for long hours.
0:46:34 It was that the things that we’re doing for our patients are actually not working to help make them better because the system is failing them.
0:46:40 You’ve written that solving this shortage requires not just increasing the supply, but also decreasing the demand.
0:46:43 Tell me how you see the demand part changing.
0:46:45 This is going to take time.
0:46:48 We’re not going to see decreases in demand immediately.
0:46:51 But the best way to decrease demand is to work on prevention.
0:46:54 We talk about health care as if we pay for health.
0:46:55 We actually pay for disease.
0:46:57 We pay to treat diseases.
0:47:02 We do very little to invest as a country in prevention interventions.
0:47:07 There’s a lot that we could do by just maintaining prevention interventions.
0:47:11 How is our breast cancer screening rates in rural America?
0:47:12 How are our colonoscopy rates?
0:47:19 While I was at CDC, I had the great pleasure of visiting Alaska, which has one of the highest rates of colon cancer in the world.
0:47:22 It’s very hard to screen for colonoscopy in Alaska.
0:47:23 It’s two flights.
0:47:28 There’s stuff that we could do on the prevention side that we simply can’t access and do.
0:47:33 So are you still seeing patients?
0:47:33 Yeah.
0:47:34 Funny that you ask.
0:47:45 Back in July, I put on my white coat for the first time after a very long time, and it was just wonderful to be back and to remember my passion for taking care of the patient.
0:47:47 Do you have a next move?
0:47:55 I realize you have all kinds of affiliations and opportunities and so on, but is there something big that you’d like to get toward next?
0:47:58 I am keeping my options open at the moment.
0:48:03 I suspect that there’s another big job ahead of me, I hope.
0:48:07 I like going to places that are hard so that I learn something.
0:48:14 I’m working on more papers like the challenges to the workforce, areas that are really important to me that I think should be highlighted.
0:48:16 I’ve never shied away from a hard job.
0:48:17 Yeah.
0:48:22 You know, people started in the last, whatever, bunch of years to use the phrase wicked problems.
0:48:23 Yeah.
0:48:25 Well, I’m from Boston, so everything’s wicked here.
0:48:25 There you go.
0:48:32 But I always wonder about that because, you know, the definition of the wicked problem is pretty much an unsolvable problem.
0:48:40 And I’m just curious how you think about that, because if you think something’s unsolvable, you’re going to be maybe going for a second best solution or something.
0:48:49 But have you been able to remain optimistic or optimistic-ish, at least, in the face of all the turmoil of the last decade or two?
0:48:49 You know what?
0:48:52 Perhaps to my detriment, I’m a chronic optimist.
0:48:56 I like calling it the, I live in the land of yes, not the land of no.
0:49:00 I once had a research mentor say that if it was easy, somebody else would have done it.
0:49:02 Well, you’re either optimistic or delusional.
0:49:05 Or a little bit of both.
0:49:09 That, again, was Rochelle Walensky.
0:49:15 Thanks to her, as well as to Karen Clay and all of you physician listeners who wrote in.
0:49:19 To everyone else, I would love to hear your thoughts on this topic.
0:49:22 Our email is radio at Freakonomics.com.
0:49:30 Coming up next time on the show, we begin a series on one technology, if you want to call it that, that helped create the modern world.
0:49:36 Everything in this country was either produced by or moved by horsepower.
0:49:40 That technology has by now been rendered mostly obsolete.
0:49:45 But there are still around 7 million horses in America.
0:49:47 So, who’s riding them?
0:49:48 Who’s buying them?
0:49:49 Selling them?
0:49:52 And what do those horses do all day?
0:49:55 They can eat grass, get sunshine, roll around.
0:49:58 That’s what they do between breedings.
0:50:00 It’s their version of smoking a cigarette.
0:50:06 Everything you’ve always wanted to know about the economics of horses, but were afraid to ask.
0:50:09 How do I say this without a hit being put out on me?
0:50:11 That’s next time on the show.
0:50:13 Until then, take care of yourself.
0:50:15 And if you can, someone else too.
0:50:19 Freakonomics Radio is produced by Stitcher and Renbud Radio.
0:50:22 You can find our entire archive on any podcast app.
0:50:26 Also at Freakonomics.com, where we publish transcripts and show notes.
0:50:30 This episode was produced by Dalvin Abouaji and edited by Ellen Frankman.
0:50:34 It was mixed by Eleanor Osborne with help from Jeremy Johnston.
0:50:39 Special thanks to Bapu Jenna, Rebecca Allensworth, and Ezekiel Emanuel for research guidance.
0:50:44 The Freakonomics Radio Network staff includes Augusta Chapman, Alina Cullman, Elsa Hernandez,
0:50:51 Jasmine Klinger, Gabriel Roth, Greg Rippin, Morgan Levy, Sarah Lilly, Tao Jacobs, and Zach Lipinski.
0:50:56 Our theme song is Mr. Fortune by The Hitchhikers, and our composer is Luis Guerra.
0:50:58 As always, thanks for listening.
0:51:05 What I can say to that patient is, let’s make a deal.
0:51:10 You’re going to smoke 15 cigarettes a day, and instead of that other five, you’re going to have a pretzel.
0:51:11 Okay.
0:51:13 Let’s see if we can do that.
0:51:14 Can I smoke the pretzel?
0:51:16 You can smoke the pretzel if you’d like.
0:51:22 The Freakonomics Radio Network.
0:51:24 The hidden side of everything.
0:51:29 Stitcher.
0:00:10 Quick announcement, I will be doing a live event on Sunday, November 2nd in Washington,
0:00:13 D.C. at 6th and I, which is a great room if you’ve never been.
0:00:19 I will be in conversation with Jeff Bennett of PBS NewsHour, celebrating 20 years of Freakonomics
0:00:20 and talking about what’s next.
0:00:21 Hope you can make it.
0:00:25 For tickets, go to Freakonomics.com slash live shows.
0:00:27 And now here is today’s episode.
0:00:38 Have you ever tried to make an appointment with your doctor and been told it would be
0:00:40 weeks or even months before you could get in?
0:00:46 Or maybe you were referred to a specialist and it turned out that the nearest specialist
0:00:47 isn’t at all nearby?
0:00:52 One obvious cause of this problem is good old supply and demand.
0:00:58 We have around a million working physicians in the U.S., or one for every 340 people.
0:01:02 That is a much lower ratio than other high-income countries.
0:01:05 I’m telling you, we’re 180,000 doctors behind.
0:01:07 It’s not going to get us to where we need to be.
0:01:11 There are also mismatches in where physicians work.
0:01:15 Some cities have a surplus, while some rural areas have a shortage.
0:01:18 There are also mismatches when it comes to specialties.
0:01:23 Some places have plenty of cardiologists and oncologists and psychiatrists,
0:01:25 while others have very few.
0:01:28 And how about the physicians themselves?
0:01:29 How are they doing?
0:01:32 We decided to ask our listeners.
0:01:33 My name is Sanjoy Dutta.
0:01:36 I graduated Harvard Medical School in 1993,
0:01:41 and I’ve been a practicing general and bariatric surgeon since 2003.
0:01:45 My job today is vastly different from when I started 20-plus years ago.
0:01:48 Operating room productivity and efficiency is much higher.
0:01:53 I used to do two bariatric operations a day, and now I do a minimum of five.
0:01:59 With the electronic medical record replacing paper charts, dictation software, and now AI scribes,
0:02:02 I see twice the number of patients in a day that I used to.
0:02:05 And on top of that, I am answering patient emails throughout the day.
0:02:12 Today, my staff and I spent countless hours appealing denials for essential imaging or medication,
0:02:16 trying to prove a patient meets criteria that often don’t make sense.
0:02:19 The health care system has become increasingly complex,
0:02:23 and we are often stuck in a maze of phone systems and transfers,
0:02:25 arguing our case to no avail.
0:02:33 This is Dr. Jeff Wood, and I live in a rural area in southern Kansas.
0:02:36 From my perspective as a doctor in private practice,
0:02:39 it seems like we’re facing a perfect storm of challenges.
0:02:43 Insurance companies are a huge part of the problem, in my opinion.
0:02:47 They’re starting to dictate what treatments we can provide,
0:02:50 sometimes even suggesting AI-based alternatives,
0:02:53 before we can even use our own clinical judgment.
0:02:58 What was the point of becoming a doctor if you’re just going to be told what you’re supposed to do?
0:03:06 Today on Freakonomics Radio, the docs are not all right, and therefore, neither are the rest of us.
0:03:11 We will look into the factors that limit the supply of physicians.
0:03:15 Can you imagine telling a 14-year-old high school freshman that to be a doctor will take 15 years
0:03:20 and maybe $100,000 in college debt plus $200,000 or more in medical school debt?
0:03:23 And we’ll look at the factors driving the demand.
0:03:28 17.5 million people will be over the age of 85 in 2050.
0:03:33 We’ll also hear about a moment in medical history that is still having a ripple effect.
0:03:36 Low-quality doctors were actually harming people.
0:03:40 This episode will attempt to do no harm, and it starts now.
0:03:57 This is Freakonomics Radio, the podcast that explores the hidden side of everything,
0:03:59 with your host, Stephen Dubner.
0:04:12 I knew I wanted to be a physician, like, when I was 10 or something.
0:04:12 Did you really?
0:04:14 Yes, I really did.
0:04:18 I had this wonderful pediatrician named Dr. Judith Osha.
0:04:23 I had no idea at the time that she was a giant in her field.
0:04:27 She was what made it possible for me to see that women in medicine could be.
0:04:28 She was revered.
0:04:29 I just didn’t know it.
0:04:32 That is Rochelle Walensky.
0:04:35 Today, she, too, is revered in the field of medicine.
0:04:40 She was director of the CDC, the Centers for Disease Control and Prevention,
0:04:41 during the Biden administration.
0:04:46 Before that, she ran the Infectious Diseases Division at Massachusetts General Hospital
0:04:48 and taught at Harvard Medical School.
0:04:52 She’s back at Harvard now and does some consulting, too.
0:04:57 Walensky is perhaps best known for her research contributions to HIV screening,
0:04:59 testing, and treatment.
0:05:06 When I became an HIV infectious disease clinician because I was an intern in inner-city Baltimore
0:05:13 in 1995, that was the year that the FDA approved the third drug of what would become the HIV
0:05:14 cocktail.
0:05:21 If you’re at the bedside for the first six months of 1995, you understand that having AIDS and HIV
0:05:23 is, for certain, a death sentence.
0:05:30 And in that moment, when the FDA approved that third drug, we could tell patients that if you took
0:05:33 dozens of pills three times a day, you might live.
0:05:37 It was just an incredibly motivating time.
0:05:43 The science was moving so very fast that we could actually tell patients that you had a chance.
0:05:44 It was incredible.
0:05:49 And then all rolled up into that conversation was, can you afford it?
0:05:51 Will it be available to you?
0:05:53 What are the stigmas associated with that?
0:05:55 Do you have a place to go?
0:05:56 Do you have a place to store your meds?
0:05:58 Do you have a place where they won’t be stolen?
0:06:03 Even when the science was available, we had to take care of the patient who had all sorts of
0:06:07 challenges in making that science available to them personally.
0:06:13 So you’ve had a pretty eventful career when it comes to infectious disease, I would say.
0:06:14 Who would have thought?
0:06:21 As you mentioned, HIV-AIDS, toward the beginning of your career, you became head of the CDC while
0:06:24 COVID was still raging.
0:06:25 I think raging is an appropriate word.
0:06:27 I think most raging.
0:06:29 Yeah, 4,000 deaths a day when I was sworn in.
0:06:33 I read that when I was reading about you, 4,000 deaths a day.
0:06:35 I can’t believe how quickly I forgot how many it was.
0:06:37 That’s such a massive number.
0:06:41 Can you just take us inside that for a moment?
0:06:43 I mean, you were appointed by President Biden.
0:06:46 You took over right at the start of the administration, correct?
0:06:49 Yes, I was sworn in several hours after the president was sworn in.
0:06:56 Just describe the state of the CDC at that moment, but especially the state of COVID at
0:06:58 that moment, and walk us through those first couple of weeks or months.
0:07:01 I was working really hard at Mass General.
0:07:06 We were still in really difficult times in these COVID waves.
0:07:12 I remember early on in the pandemic, walking to the hospital and seeing a morgue sitting outside
0:07:15 because we needed to increase morgue capacity at the hospital.
0:07:18 That period was so very dark.
0:07:24 My faculty, some had family members who were immunocompromised, but they were at the bedside.
0:07:28 It was really a stressful, scary time for all of us.
0:07:29 This was, of course, pre-vaccine.
0:07:35 I remember where I was when I got the CNN news alert that the vaccine actually worked.
0:07:36 Where were you?
0:07:37 It was a rainy day.
0:07:41 It was at around 7 in the morning, and I was walking into Mass General.
0:07:46 It literally stopped me before the door of the hospital because there was hope.
0:07:47 There was finally hope.
0:07:50 I was cold-called by the administration.
0:07:52 I did not apply for the job.
0:07:54 Do you know how you got on their radar?
0:07:56 I had done a lot of work in HIV policy.
0:08:00 I was a pretty well-respected infectious disease clinician.
0:08:02 I had done some media.
0:08:06 I had done some work in the policy realm in HIV.
0:08:09 I had known a lot of people in many of these policy circles.
0:08:15 And was your HIV-AIDS background considered a leg up because COVID was still raging?
0:08:17 I don’t know, to be honest.
0:08:19 I had sat on guidelines committees.
0:08:27 I had done a lot of work in cost and cost-effectiveness, which means I had never taken a penny from industry.
0:08:28 I had absolutely no conflicts.
0:08:34 And they needed somebody who knew infectious diseases in this moment at CDC.
0:08:42 Having started your career with HIV-AIDS, having gone through COVID at CDC, what are you worried about now?
0:08:43 Workforce.
0:08:49 If you’re an infectious disease doc in 2018 and somebody says to you, what do you do?
0:08:50 And you say, I’m an infectious disease doc.
0:08:51 They say, what does that mean?
0:08:57 But in 2020, while at Mass General, as we were knee-deep in some early days,
0:09:01 there were so many companies reaching out and saying,
0:09:05 can you come talk to our organization about what we should do?
0:09:09 Airlines and cruise ships, all sorts of folks were reaching out.
0:09:13 And I thought to myself, where are all the infectious disease docs?
0:09:22 So we created a map of the United States and realized that 80% of counties in the country did not have a single infectious disease doc.
0:09:33 In the middle of COVID, in some of our darkest days, I am in my office as the director of the CDC and I’m hearing hospital beds are closed because they don’t have staff and personnel.
0:09:39 And so I said, I really need to understand what’s going on with the health care workforce.
0:09:43 And that’s what led me down this research endeavor.
0:09:52 This research endeavor that Walensky is talking about culminated in an article for the New England Journal of Medicine, which she co-authored with Nicole McCann.
0:09:56 And that’s the article that made us want to speak with Walensky.
0:09:57 Here’s what they wrote.
0:10:01 An urgent health care workforce crisis is looming.
0:10:09 Many potential reforms require congressional action and accountability, which have been all too slow to enact meaningful change.
0:10:17 So when you began to put together this data, how surprised were you by the magnitude of the physician shortage?
0:10:19 I had seen it in pieces.
0:10:21 So I wasn’t surprised by any singular piece.
0:10:28 But putting it all together sort of recognized that at every step of a consecutive path, there were challenges.
0:10:37 We were weeding people out along the way and we were getting to a workforce that is burnt out, retiring, smaller.
0:10:44 We have an anticipated one hundred and eighty seven thousand deficit by 2037.
0:10:46 That’s a huge number.
0:10:51 As I mentioned earlier, the physician shortage is not uniform over the next decade or so.
0:10:57 Rural areas are expected to have a 60 percent shortage compared to a 10 percent shortage in metro areas.
0:11:05 The specialties with the biggest expected shortages are family medicine, vascular surgery, ophthalmology and respiratory medicine.
0:11:09 So what exactly is going on here?
0:11:13 Let’s start by looking at the demand for physicians.
0:11:15 There is one issue here that’s bigger than the rest.
0:11:22 We will increase the population that is over the age of 85 in 2050 by threefold.
0:11:25 One question is who will take care of them?
0:11:32 Our life expectancy has increased so much over the past hundred years, especially.
0:11:36 But in recent years as well, if you’re healthy, you tend to live really long.
0:11:43 I think the most common age of death in the U.S. today is 87, which shocked me when I read it.
0:11:45 But I’m pretty sure that’s actually true.
0:11:46 Yeah, it sounds about right.
0:11:54 Do you expect that there will be a fall off in lifespan if we don’t increase the supply of physicians and especially gerontologists?
0:11:59 Well, first, I want to say that there are a whole host of physicians that can treat the elderly.
0:12:03 It is very helpful to have gerontologists, but we have primary care doctors.
0:12:10 We have others who don’t necessarily have to have a geriatric specialty in order to treat the geriatric patient.
0:12:20 And it is also the case that while many people are living that long, we have a challenge in getting all populations to live that long.
0:12:30 If our goal is to improve health by increasing life expectancy in this country, we actually have to focus on those folks who have the most life expectancy lost.
0:12:49 We recently published a three-part series called Cradle to Grave, which looked at various angles of this big lifespan change.
0:12:53 And when we asked listeners for input for this episode, we heard a lot about that.
0:12:57 Here is Paul Goodwin, an orthopedic trauma surgeon in Texas.
0:13:02 There’s a huge silver tsunami coming of patients needing joint replacements.
0:13:13 The estimate is that every orthopedic surgeon will have to double their caseload in order to meet the demand if the supply of surgeons stays constant.
0:13:21 Also, interestingly, the incidence of hip fractures in the coming decades is supposed to approximately double.
0:13:24 That is a lot of patients to take care of.
0:13:29 If you think about medicine as a business, which, of course, it is, at least to some degree.
0:13:37 And if the demand for this business is growing, why is the supply of physicians having such a hard time keeping up?
0:13:45 In her New England Journal paper, Rochelle Walensky identifies one big factor, the scarcity of slots in American medical schools.
0:13:51 Over the past decade, there’s been a 10 percent increase, but given the need, that’s not enough.
0:13:54 We have some extraordinary young people.
0:14:00 And in fact, if I had one bright light about the future, it would be the incredible talent that’s applying to medical school right now.
0:14:07 We are systematically turning them away by some of the difficulties in getting into medical school.
0:14:19 I wrote a paper with my husband, who is also a physician scientist, and we talk about how to watch a child, our own child, apply to medical school and what that process looked like.
0:14:24 Kids are being suggested to apply, I think, on average, to 18 schools.
0:14:26 Many kids are applying to 25 and 30.
0:14:28 It’s an expensive process.
0:14:31 MCATs are over $350 or so.
0:14:34 Each application is $150 or so.
0:14:39 The secondary applications are somewhere between four and eight essays.
0:14:48 So if you do all that math, you see these incredible, talented kids who are writing somewhere between 50 and 100 essays and may or may not get in.
0:14:55 You’re also starting to explain the fact that lower income people are much less likely to become physicians, yes?
0:14:55 Absolutely.
0:15:03 When we think about the medical school standards in the U.S., they are famously high, for which I think everyone is really grateful.
0:15:17 On the other hand, it’s been argued that there are plenty of people who are smart enough to meet those standards, but that the number of slots in medical schools and residencies has just not kept up with the demand.
0:15:26 Are the kids who are not getting into medical school not getting in because they are not smart or capable enough or simply because there aren’t enough slots?
0:15:28 More the latter than the former.
0:15:39 We gave an example in the piece of an extraordinarily talented young woman who applied to 33 medical schools at the cost of almost $5,000.
0:15:41 She had gone to an elite Ivy League school.
0:15:44 She got 96th percentile in her MCATs.
0:15:54 She applied to 33 schools, got interviewed at two, and was rejected from all of her safeties, as they assumed she’d never come, and was waitlisted and never got in.
0:16:01 Now, you take somebody like that, and many people would simply say, I’m done, I’m going to pursue another incredible career.
0:16:08 She, to her great credit, said, I’m going to take another year off and apply again, and she got a full ride at a top medical school.
0:16:13 But if it weren’t for her grit, she would have become an investment banker or something.
0:16:14 Right, exactly.
0:16:20 So there are not as many slots as one might want, but who is constraining the number of slots?
0:16:23 First of all, we have only a finite number of medical schools.
0:16:26 Right, but that’s not a permanent situation, correct?
0:16:27 That is eminently fixable.
0:16:30 We certainly could open more medical schools.
0:16:33 Just to be clear, it’s extraordinarily expensive to open these, right?
0:16:38 Teaching at a medical school is not the compensation of seeing patients.
0:16:44 So you have to pay these faculty, and then those schools have to be affiliated with hospitals that can train the students.
0:16:47 Because it is not just about the didactics in the classroom.
0:16:50 It is about going to the bedside and training those students.
0:16:58 So there has to be this partnership with a hospital that allows students to come in and to be trained, and where there are faculty and doctors who can train these students.
0:17:09 There are fewer than 200 medical schools in the U.S. today, with many of them concentrated in the most populous states like New York, California, and Texas.
0:17:13 So other than the expense, why aren’t there more medical schools?
0:17:16 One reason goes back over 100 years.
0:17:18 We were surprised.
0:17:19 This paper took a while.
0:17:25 And part of the reason it took a while was because we were surprised.
0:17:26 That’s coming up.
0:17:28 After the break, I’m Stephen Dubner.
0:17:29 This is Freakonomics Radio.
0:17:30 We’ll be right back.
0:17:44 Before the break, we heard about some of the factors that put a strain on our physician workforce.
0:17:48 There is the big rise in the share of the elderly population.
0:17:52 There is the urban-rural divide when it comes to physician supply.
0:17:55 And there is the relative scarcity of medical schools.
0:17:58 Let’s stay with that last one for a bit.
0:18:03 If you want to understand the current medical school landscape, there is a bit of history you should know.
0:18:08 The Flexner Report is so important and has such a huge legacy.
0:18:16 Everybody in medicine knows about the Flexner Report, and yet we really don’t know that much about it.
0:18:17 That’s Karen Clay.
0:18:21 She’s an economic historian at Carnegie Mellon University,
0:18:24 and she is one of four authors of a new working paper called
0:18:30 Medical School Closures, Market Adjustment and Mortality in the Flexner Report Era.
0:18:33 Okay, there’s a lot to unpack here.
0:18:35 Let’s start with the Flexner Report itself.
0:18:39 I had heard about it a little bit.
0:18:43 I knew that there was this report and a bunch of medical schools shut down.
0:18:49 So, Karen Clay and her co-authors set out to measure the effects of this Flexner Report.
0:18:57 One of her co-authors, Grant Miller at Stanford, had been doing research on the low quality of physicians in developing countries.
0:19:03 It’s not that all doctors in developing countries are of low quality, just that there are significant numbers of them.
0:19:16 So there had been some floating of ideas of whether they should try and address these low quality medical schools that are turning out these low quality doctors in order to bring the standard up.
0:19:23 I guess that gets you to the question central to your paper, which is, is a low quality doctor better than no doctor at all?
0:19:27 It’s really what is the impact of having these low quality doctors?
0:19:31 Some people would then not go to any doctor.
0:19:35 Some just weren’t aware that there was a higher quality doctor nearby.
0:19:43 But it looks like the answer, at least based on what we have in the paper, is that low quality doctors were actually harming people.
0:19:47 OK, so they found that low quality doctors were actually harming people.
0:19:50 That’s a big deal and we will get into it soon.
0:19:53 But let’s set the stage a little bit more.
0:19:56 The Flexner Report was published in 1910.
0:19:59 This is a period in which the U.S. is growing rapidly.
0:20:01 The standard of living is rising.
0:20:05 And one of the things people want to consume is medical services.
0:20:07 So there’s demand.
0:20:13 People often would go to a medical school in their town and then set a practice in their town.
0:20:16 What kind of people were starting these schools?
0:20:17 Were they entrepreneurs?
0:20:18 Were they do-gooders?
0:20:20 They’re entrepreneurial physicians.
0:20:22 It’s a way to make some extra money.
0:20:25 It had some prestige attached to it.
0:20:27 That is, I was a founder of a medical school.
0:20:33 And it signals to people that I am a very good physician and therefore you should come to me.
0:20:38 So there were medical schools around that did not require even a high school education, correct?
0:20:39 That is correct.
0:20:47 As you can imagine, with all these medical schools starting up, the quality of training was uneven.
0:20:51 The American Medical Association began to take notice.
0:20:54 But the AMA back then was different than it is today.
0:21:02 The AMA in the late 19th century is primarily an organization by and for elite physicians.
0:21:12 In the early 20th century, these physicians realized that if they want to have political power, they need to be much more inclusive.
0:21:17 They need to harness the fact that there are many, many, many doctors out there.
0:21:21 And many of those doctors are also concerned about quality.
0:21:24 They’re also concerned about the fact that they’re not making a ton of money.
0:21:34 They then reorganize so that if you become a member of your state medical society, you automatically become a member of the American Medical Association.
0:21:41 And so the membership goes up very quickly and they establish a council on medical education.
0:21:50 They publish educational standards beginning in 1905 and then start to visit medical schools and start publishing quality ratings.
0:22:02 So the AMA, alongside the Carnegie Foundation, commissioned a well-regarded educator and reformer named Abraham Flexner to examine the state of medical education in the U.S. and Canada.
0:22:05 Abraham Flexner is an interesting guy.
0:22:10 He had already done some work studying the American college system.
0:22:19 This was partly in light of the fact that Europe had what was widely considered to be, on average, better education at the university level.
0:22:24 But he actually had no experience with medical schools.
0:22:42 It turns out that he was hired through some connections, basically, by the Carnegie Foundation and was sent to collaborate with the AMA, although the collaboration was kind of hidden, to look at the status of medical schools in the U.S.
0:22:48 Was the AMA’s connection to the Flexner report downplayed?
0:22:51 I think that everyone understood that they had commissioned it.
0:22:59 The thing that they did not maybe fully disclose was that, first of all, Flexner wrote this report very rapidly.
0:23:09 And so he received significant assistance from the AMA, in part because they had already done evaluations of all the medical schools.
0:23:20 But because it was politically complicated to criticize medical schools, they decided that it was better for this objective third party to do it.
0:23:31 What he did is he evaluated each medical school to say, this is too poor to salvage, or this is something we can work with, or this is the gold standard.
0:23:36 That, again, is Rochelle Walensky, the physician and former CDC director.
0:23:40 And he compared, at the time, gold standard, interestingly enough, to Johns Hopkins.
0:23:46 Interestingly enough, Walensky says, because Johns Hopkins is where she went to medical school.
0:23:49 One of my professors in medical school was a descendant, was a Flexner.
0:23:55 Abraham Flexner, while preparing his report, visited nearly 150 medical schools in the U.S.
0:24:02 He was accompanied by Nathan Colwell, who was a physician and an official at the American Medical Association.
0:24:04 So what were they looking for?
0:24:09 One of the things that they were really focused on was the biomedical sciences.
0:24:16 They wanted to have a really robust scientific basis and laboratory sciences in their curriculum.
0:24:22 Another was whether they were collaborating with hospitals and whether training in those hospitals was up to par.
0:24:30 The strength of the physician-scientist faculty, relationships to those hospitals, how close were they, how committed were they to the medical schools?
0:24:38 In his report, Flexner argued that the vast majority of medical schools did not meet these standards, and he suggested closing many of them.
0:24:42 Not surprisingly, his report got some buzz.
0:24:44 Here are a couple of headlines from back then.
0:24:46 Poor medical colleges, a danger.
0:24:49 And country flooded with quacks.
0:24:53 And here again is the economic historian, Karen Clay.
0:24:57 The Flexner report didn’t just shock people at the time.
0:25:09 I found the fact that the Flexner report recommends keeping only 31 medical schools, which it deemed would be enough to train enough doctors for the entire U.S., to be really radical.
0:25:13 That’s not what happened, but it was still really, really surprising.
0:25:19 So during the period after the Flexner report, what share of medical schools in the U.S. closed?
0:25:26 By 1915, the number of medical schools has fallen to between 90 and 95.
0:25:27 Wow.
0:25:28 So big decline.
0:25:34 It eventually does continue to fall a little bit and stabilizes at around 70.
0:25:40 In the paper, you explain that the schools that ended up shutting down, they weren’t forced to shut down.
0:25:43 They were pushed out by market forces, essentially.
0:25:50 The Flexner ratings came out, and if you were running a school that was poorly rated, students just stopped applying.
0:25:51 That is correct.
0:25:56 Describe the primary characteristics or demographics of the schools that did close.
0:26:00 Were they mostly in smaller cities or rural areas?
0:26:02 They’re mostly not in rural areas.
0:26:05 They tend to be in medium and larger cities.
0:26:08 Some cities just had a lot of medical schools.
0:26:14 Cook County, for example, which is where Chicago is, had many medical schools.
0:26:22 I read here that before the report, there were more than a dozen black medical schools in the U.S., several of them at HBCUs.
0:26:25 But that within a decade, there were only two.
0:26:29 Howard University College of Medicine in D.C. and Meharry Medical College in Nashville.
0:26:31 So tell me about that.
0:26:40 Since a lot of medical care at the time was segregated, how did those closures affect black patients and would-be black physicians?
0:26:48 A lot of these black medical schools, a lot of medical schools in the South, full stop, are taking people who don’t even have a high school education.
0:27:01 That’s just because the pool of people at the time who have a high school degree is relatively small, and the pool of people who have some colleges even smaller in the black community.
0:27:06 The other thing about the black medical schools is they tend to be a bit smaller.
0:27:09 There is surely a decline, though, in slots.
0:27:17 It is a fascinating and tragic part of the Flexner Report in terms of impacts of why are there not more black physicians.
0:27:30 By virtue of closing five out of seven HBCU medical colleges, we now have about 30,000 less black physicians than we might have had.
0:27:32 That’s Rochelle Walensky again.
0:27:36 She says the Flexner Report had a number of long-lasting effects.
0:27:44 It also created a divide, and this divide is relatively unique to America, between medical schools and schools of public health.
0:27:52 That is really a challenge for our country, that we have the silos of public health departments and medicine.
0:27:55 I never thought about the fact that the U.S. is unique.
0:27:58 In Europe and elsewhere, you’re saying they’re bonded together?
0:28:00 They’re more fluid relationships, for sure.
0:28:05 From a COVID standpoint, I vividly remember people saying to me,
0:28:10 how come you’re relying on data from the U.K. and Israel for our vaccine effectiveness?
0:28:16 One of the beauties of being an infectious disease doc is I have infectious disease friends across the country.
0:28:20 I called a handful of different hospitals while I was CDC director, and I said,
0:28:23 can you tell me who in your hospital has COVID and is vaccinated?
0:28:24 And they said, no.
0:28:28 We can tell you who’s hospitalized, and we can tell you who’s hospitalized with COVID,
0:28:34 but the vaccination data are in the departments of public health, and they don’t actually connect.
0:28:43 Okay, so those are some of the long-term effects of the Flexner Report.
0:28:45 But what about the one that we really care about?
0:28:49 At least the one that I first wondered about when I read this new paper.
0:28:52 What were the health effects of all those medical schools closing?
0:28:56 You might think that fewer medical schools means fewer physicians,
0:29:02 which means less access to physicians, which means trouble.
0:29:04 But that’s not what the data said.
0:29:09 The data that Karen Clay and her colleagues analyzed showed that medical school closures
0:29:17 after the Flexner Report led to an 8% drop in infant mortality and a 4% drop in non-infant mortality.
0:29:21 And keep in mind that mortality rates back then were much higher.
0:29:23 So how many people does this translate into?
0:29:30 It’s an estimated 16,000 infant lives saved per year in the U.S.
0:29:32 and 38,000 non-infant lives.
0:29:37 If you find this result surprising, and Karen Clay says that she did,
0:29:41 you need to remember that the whole purpose of the Flexner Report
0:29:44 was to get rid of low-quality medical schools.
0:29:53 So it would appear that, A, it worked, and B, that having a bad doctor can be worse than having no doctor at all.
0:29:59 I asked Clay how this Flexner effect compares to other life-saving medical interventions.
0:30:05 Putting in water and sewerage in the Boston area reduced infant mortality by 23%.
0:30:11 Municipal water filtration reduced infant mortality by 11% to 12%.
0:30:18 In cities between 1900 and 1940, prohibition caused infant mortality to decrease,
0:30:23 and the lifting of prohibition actually increases infant mortality by 4% to 5%.
0:30:27 Today, if you did something that reduced infant mortality by 8%,
0:30:30 you would be winning the Nobel Prize in medicine.
0:30:34 Karen Clay told us that it took a long time for her and her colleagues
0:30:38 to convince themselves that these research findings were robust.
0:30:42 We really had to spend a lot of time thinking about,
0:30:44 are we doing this estimation correctly?
0:30:47 Is there something we haven’t looked at?
0:30:50 We sort of thought that any result would be interesting.
0:30:56 My personal skepticism about the fact that doctors were harming people
0:31:00 was allayed somewhat when we went back to the developing country literature,
0:31:05 where they have done extensive work on doctor quality.
0:31:12 Many parts of the doctor quality distribution are more likely to harm patients
0:31:14 than they are to help them, even today.
0:31:20 Today, of course, a not very good doctor in a developing country can still give you IV fluids.
0:31:23 They can still give you antibiotics.
0:31:27 But these are doctors who don’t have that.
0:31:32 This is also a period in which, although germ theory has been well known,
0:31:35 the practicing of hygiene is not uniform.
0:31:42 If you are a low-quality doctor, you may not be paying that much attention to those sorts of things.
0:31:46 You could easily, quote, help someone by stitching them up,
0:31:50 but give them some terrible infection in the process.
0:31:55 And I went back to Rochelle Walensky to get her thoughts on the Flexner Report paper.
0:31:59 I think it’s a super interesting story, and it is not necessarily the one that I would have anticipated.
0:32:04 The methods seem really sound, and I applaud the authors for what they’ve done.
0:32:08 Many of those deaths that were probably averted were infectious.
0:32:09 They were related to hygiene.
0:32:17 So Walensky doesn’t doubt the research findings, but she does wonder if the solution at the time was the right solution.
0:32:22 What happens if we fast-forward the clock, and instead of closing those medical schools down,
0:32:25 we improve what they learn about hygiene?
0:32:30 We do all the things that we should be doing to improve the training,
0:32:34 even if it wasn’t at the level of Dr. Flexner’s Johns Hopkins.
0:32:39 Where would we be now 100-plus years later in terms of that training?
0:32:43 Would we still see the decreases in infant mortality,
0:32:46 or would we actually be in a better place than we are now?
0:32:51 On balance, though, do you think that the Flexner Report was a success
0:32:54 in that it closed down schools that were substandard?
0:32:57 I’m agnostic there. I’m not sure.
0:33:00 We see that it’s so hard to open medical schools
0:33:04 that it is not obvious to me that that might have done harm
0:33:08 rather than not having the capacity to bring people in
0:33:10 to continue to train and improve that training.
0:33:16 In other words, the Flexner Report and the American Medical Association,
0:33:21 by being so strict, may have contributed to the current dilemma.
0:33:27 Too few medical school slots and too few physicians for too many patients.
0:33:31 Still, this is just one of many factors behind the current situation.
0:33:33 If you’re looking for another cause,
0:33:36 you might want to think about doctor frustration and burnout.
0:33:39 We heard a lot about that from our listeners.
0:33:42 And you might especially want to consider the private equity revolution,
0:33:47 where smaller medical practices are often rolled up into large corporate practices.
0:33:52 That, too, can make the life of a practicing physician much less attractive.
0:33:56 So this is all sounding pretty grim.
0:33:58 Coming up after the break,
0:34:02 we hear about a few solutions to the physician shortage.
0:34:04 A few maybe solutions, anyway.
0:34:05 I’m Stephen Dubner.
0:34:06 This is Freakonomics Radio.
0:34:07 We’ll be right back.
0:34:20 The number of physicians being trained in the U.S.
0:34:25 is constrained not only by the number and location of medical schools
0:34:27 and the number of slots at each school,
0:34:29 but by another layer of oversight.
0:34:33 Our country’s GME, or Graduate Medical Education System,
0:34:36 here again is Rochelle Walensky.
0:34:39 Once you leave medical school, you can’t go and practice.
0:34:43 You need to train, as we call it, internship, residency, fellowship.
0:34:48 Those slots for training are capped federally.
0:34:50 It’s run out of CMS and Medicare.
0:34:54 They were capped since back in the 1980s, 1990s,
0:34:57 when there was an anticipation that we would have too many physicians.
0:35:00 We are not there.
0:35:02 I read that in your paper, and I have to say I chuckled
0:35:06 because I’ve never thought about a world where we were worried about having too many physicians.
0:35:08 So can you briefly take us back to there?
0:35:12 What created the environment where we thought there would be a glut of physicians?
0:35:15 Physicianhood was revered.
0:35:17 People were going into medical school.
0:35:18 We had fee-for-service.
0:35:22 People were being financed and compensated really well,
0:35:24 and this was a really great field to be in.
0:35:29 There was this concern that we were in a place where, uh-oh, we might have too many.
0:35:34 And so Congress came in and constrained the numbers by constraining the training numbers.
0:35:38 You’re given federal slots in these hospitals for your entire training programs,
0:35:44 and that’s everything from pediatrics and neurology and internal medicine and cardiology to surgery.
0:35:46 States can supplement those.
0:35:49 Hospitals can supplement those, but they’re expensive to do.
0:35:55 Over the last 20 years, we’ve really only increased our GME training slots by around 15,000.
0:35:59 So I’m telling you we’re 187,000 doctors behind.
0:36:02 It’s not going to get us to where we need to be.
0:36:08 If you look at survey data from the public and from physicians themselves,
0:36:14 it’s clear that respect for the profession has fallen, as has trust in the profession.
0:36:16 A lot of our listeners commented on this.
0:36:17 Here’s one.
0:36:20 My name is Evelyn Kim, and I’m an emergency physician.
0:36:28 I started probably at the beginning of the wave after the show ER brought a lot of people
0:36:34 into our specialty, but I originally went to medical school following the path of my father,
0:36:37 like so many of my colleagues whose parents were physicians.
0:36:44 And I have definitely seen the work itself change, the attitudes of physicians change,
0:36:48 and society’s attitude towards physicians change.
0:36:53 I come from an era where I was happy to identify as being a physician.
0:36:55 It is who I am.
0:37:01 It is a part of me, and I’m not afraid to admit that oftentimes I have no work-life balance.
0:37:04 That wasn’t even a concept for my father or for me throughout my career.
0:37:12 I’m nowhere near feeling like I want to retire because I still feel like I have a lot to contribute,
0:37:18 but I don’t think that that is the prevalent attitude amongst physicians these days.
0:37:21 And here’s another listener.
0:37:25 My name is Colin Larkin, and I’m part of the problem.
0:37:31 Larkin studied chemical engineering in undergrad at the University of Rochester with a plan to become a physician.
0:37:36 Society does a really good job of convincing our young people that it’s a really good idea.
0:37:38 You get to save lives.
0:37:40 You are revered by society.
0:37:42 You’re very well-educated.
0:37:43 You get to make a good living.
0:37:48 You see House and Grey’s Anatomy and all these things that glorify physicians in the media.
0:37:53 Larkin got a master’s at Oxford and then enrolled in medical school at Northwestern University.
0:38:00 His plan was to become a neurosurgeon, but once he got into an actual hospital setting, his plan changed.
0:38:02 I just realized that I didn’t like it.
0:38:05 A lot of what you end up doing is clerical work.
0:38:11 It’s very algorithmic in a lot of ways and hyper-repetitive and all these different things that I didn’t really realize until I got there.
0:38:14 So I ended up taking some time off.
0:38:21 I worked in management consulting at Boston Consulting Group through actually a program that they have specifically for med students to try to recruit them into consulting.
0:38:27 Went back, finished up my degree, did a couple different things during the fourth year, including starting a medical device company,
0:38:32 applying to residency, and then applying into venture capital roles, which is ultimately where I ended up.
0:38:41 I graduated in the spring of 2024, and now I am a Silicon Valley life sciences and health tech investor at SoftBank.
0:38:51 So if you are someone who is concerned about the physician workforce, losing someone like Colin Larkin to venture capital has to hurt.
0:38:53 If you’re someone like Rochelle Walensky, for instance.
0:38:58 Physicianhood used to be a somewhat revered field.
0:39:02 Over the last several years, that has certainly no longer been the case.
0:39:03 You see physicians under attack.
0:39:05 You see science under attack.
0:39:09 You see compensation not close to what people are hoping,
0:39:15 certainly not close to what would make up for the extraordinary loans that these students have to take out.
0:39:28 They’re thinking, why would I take another deferred year of compensation for a, on average, $200,000 loan when there are other great ways to pursue a career?
0:39:29 Ah, yes.
0:39:31 The cost of medical school.
0:39:37 Here is another Freakonomics Radio listener, John Clark, who is an urgent care doctor in Colorado.
0:39:43 I’ve been hearing dire predictions about physician shortages since I was in medical school in the mid-1990s.
0:39:55 By way of demographic context, I’ve had experience in rural and suburban emergency departments, an academic teaching environment, traditional office-based primary care, and for the last several years in an urgent care setting.
0:39:58 I think you’ve covered the cost of higher education very well in the past.
0:40:05 Can you imagine telling a 14-year-old high school freshman that to be a doctor, it’ll take 15 years of formal education and training,
0:40:09 maybe $100,000 in college debt plus $200,000 or more in medical school debt?
0:40:12 Don’t think a lot of kids would eagerly sign up for that path.
0:40:20 I went back to Rochelle Walensky to talk about med school tuition, debt, and what looks to be one encouraging sign.
0:40:30 There is a movement lately from private philanthropists to make some top-tier medical schools free, tuition free.
0:40:34 I would think you are in favor of that idea or no?
0:40:35 Yes, and?
0:40:37 Yes, and? What’s the and?
0:40:42 We are making it free, but we are not changing the cost of producing a doctor.
0:40:44 It does matter who’s paying.
0:40:48 Certainly, it’s helpful to have it be free.
0:40:55 Some of the motivation around doing that is to bring in people from less affluent communities,
0:41:01 to bring in people into primary care, and that people do not leave in debt,
0:41:04 and therefore that they go into the lower-paying specialties.
0:41:07 The jury’s still out on that.
0:41:11 Some of the earliest data from the free medical schools are not panning out that way.
0:41:15 I don’t think that alone is going to fix the issue.
0:41:24 One of the things that I’m very worried about is a policy in the Big Beautiful Bill that speaks to how much loans one is allowed to take.
0:41:30 The average loan of a graduating medical student is in the $200,000 range.
0:41:34 70% to 90% of students have debt.
0:41:42 So if it is the case that, on average, more than half of students have debt, and that debt is over $200,000,
0:41:47 you’re going to lose half of your medical students if you don’t allow them to borrow money.
0:41:49 What are the borrowing constraints?
0:41:51 I believe a maximum of $200,000.
0:41:56 We recently published a series on air traffic control in the U.S.
0:42:00 A lot of the problems you’re describing sound similar to those problems.
0:42:06 A kind of outdated training infrastructure, not enough slots to train new entrants.
0:42:09 There’s some congressional sludge in both cases.
0:42:15 There’s also just complications in making this market, if you want to call it a market, work well.
0:42:25 Do you have any thoughts on that or perhaps other parallel systems you look to to increase the supply and the status of physicians?
0:42:28 Yeah, I think the one that you highlight is actually a really sound one.
0:42:30 I think that that very much resonates.
0:42:34 I also think that there is a geography problem.
0:42:41 What is it that we are going to do to address the paucity of physicians in rural areas?
0:42:45 Now, some of those issues relate to medical school closures back in 1910.
0:42:53 Some of those relate to many physicians, once they’ve trained, want to stay at the places that they’ve trained.
0:42:57 And to be fair, more people want to live in urban areas than ever before.
0:42:58 That’s just the way it is.
0:42:59 It’s not just here.
0:43:00 It’s around the world.
0:43:04 So that leaves rural areas wanting for physician care.
0:43:08 Have you seen anything useful, practical that started to reverse that?
0:43:12 I think we need to incentivize folks to go into rural areas.
0:43:14 I mean, we do that to some degree already, don’t we?
0:43:15 We do.
0:43:19 We increase Medicaid payments, I think, by 10 percent.
0:43:24 The things that have been done over 50 years have not necessarily demonstrated that they’re working.
0:43:31 We have a partnership here in Massachusetts with a tribal nation out in the Dakotas.
0:43:34 And our residents love going out there.
0:43:35 They love learning.
0:43:37 They love caring for that patient population.
0:43:41 Many of them would be willing to go there for months.
0:43:45 The challenge is financing it after they’re done training.
0:43:47 Who’s going to pay for that?
0:43:52 There are models to explore, but you need the finances and you need the political will.
0:43:57 I do also want to just comment on unintended consequences of policies.
0:44:15 Whatever one wants to think about the Dobbs decision, there have been surveys about physicians, not just obstetricians or training obstetricians, but about physicians who are interested in going to states where there will not be abortion access.
0:44:23 Now, if you look at a standard resident, they are generally between the ages of, let’s call it, 26 and 35.
0:44:25 And what share are female these days?
0:44:27 It’s probably a little bit more than half and half.
0:44:30 But that doesn’t matter because many of the men are partnered with women.
0:44:37 And they move to an area that doesn’t have abortion access just at the time that they might want to have children.
0:44:38 That is a driver.
0:44:49 However it is one feels about the policy, it may have unintended consequences of not having people wanting to go to those areas of the country at the time that they’re of childbearing age.
0:44:54 Another driver, you write, of the physician shortage is physician exodus.
0:44:57 You know, COVID-19 was hard on a lot of physicians.
0:44:59 Burnout, as we know, and suicide rates.
0:45:05 And there are all sorts of negative indicators for physicians and others in the medical field.
0:45:14 Do you have any thoughts, whether it’s drawn from your practice, your teaching, your CDC service, on how to make the daily life of a physician better?
0:45:19 There’s so much that we get and can do as physicians.
0:45:25 That said, physician hours are extended and much of that is not satisfying hours.
0:45:34 There was one 2017 study that demonstrated that in an 11-and-a-half-hour workday, almost six hours of it was spent in front of the computer.
0:45:37 Or what they call pajama time.
0:45:42 This is the time after 7 p.m. when you’ve seen your last patient and you’re going home after a long 12-hour day.
0:45:45 You’ve finished dinner, but you have 10 notes to write.
0:45:49 So you’re spending all of your evening time just catching up on the paperwork from the day.
0:45:53 Those things really are exacerbating the challenge.
0:45:59 One of the other big challenges is the churn of patients in the hospital.
0:46:07 I took care of a patient who had an inflammatory disease that needed a monoclonal antibody infusion as an outpatient.
0:46:10 She could not afford this infusion.
0:46:12 It was several thousand dollars.
0:46:13 Her disease flared.
0:46:15 She ended up with a three-day hospitalization.
0:46:20 We tried to give her an infusion as an inpatient and insurance declined.
0:46:27 So the burnout is not just the long hours because actually doctors knew they were going to get in for long hours.
0:46:34 It was that the things that we’re doing for our patients are actually not working to help make them better because the system is failing them.
0:46:40 You’ve written that solving this shortage requires not just increasing the supply, but also decreasing the demand.
0:46:43 Tell me how you see the demand part changing.
0:46:45 This is going to take time.
0:46:48 We’re not going to see decreases in demand immediately.
0:46:51 But the best way to decrease demand is to work on prevention.
0:46:54 We talk about health care as if we pay for health.
0:46:55 We actually pay for disease.
0:46:57 We pay to treat diseases.
0:47:02 We do very little to invest as a country in prevention interventions.
0:47:07 There’s a lot that we could do by just maintaining prevention interventions.
0:47:11 How is our breast cancer screening rates in rural America?
0:47:12 How are our colonoscopy rates?
0:47:19 While I was at CDC, I had the great pleasure of visiting Alaska, which has one of the highest rates of colon cancer in the world.
0:47:22 It’s very hard to screen for colonoscopy in Alaska.
0:47:23 It’s two flights.
0:47:28 There’s stuff that we could do on the prevention side that we simply can’t access and do.
0:47:33 So are you still seeing patients?
0:47:33 Yeah.
0:47:34 Funny that you ask.
0:47:45 Back in July, I put on my white coat for the first time after a very long time, and it was just wonderful to be back and to remember my passion for taking care of the patient.
0:47:47 Do you have a next move?
0:47:55 I realize you have all kinds of affiliations and opportunities and so on, but is there something big that you’d like to get toward next?
0:47:58 I am keeping my options open at the moment.
0:48:03 I suspect that there’s another big job ahead of me, I hope.
0:48:07 I like going to places that are hard so that I learn something.
0:48:14 I’m working on more papers like the challenges to the workforce, areas that are really important to me that I think should be highlighted.
0:48:16 I’ve never shied away from a hard job.
0:48:17 Yeah.
0:48:22 You know, people started in the last, whatever, bunch of years to use the phrase wicked problems.
0:48:23 Yeah.
0:48:25 Well, I’m from Boston, so everything’s wicked here.
0:48:25 There you go.
0:48:32 But I always wonder about that because, you know, the definition of the wicked problem is pretty much an unsolvable problem.
0:48:40 And I’m just curious how you think about that, because if you think something’s unsolvable, you’re going to be maybe going for a second best solution or something.
0:48:49 But have you been able to remain optimistic or optimistic-ish, at least, in the face of all the turmoil of the last decade or two?
0:48:49 You know what?
0:48:52 Perhaps to my detriment, I’m a chronic optimist.
0:48:56 I like calling it the, I live in the land of yes, not the land of no.
0:49:00 I once had a research mentor say that if it was easy, somebody else would have done it.
0:49:02 Well, you’re either optimistic or delusional.
0:49:05 Or a little bit of both.
0:49:09 That, again, was Rochelle Walensky.
0:49:15 Thanks to her, as well as to Karen Clay and all of you physician listeners who wrote in.
0:49:19 To everyone else, I would love to hear your thoughts on this topic.
0:49:22 Our email is radio at Freakonomics.com.
0:49:30 Coming up next time on the show, we begin a series on one technology, if you want to call it that, that helped create the modern world.
0:49:36 Everything in this country was either produced by or moved by horsepower.
0:49:40 That technology has by now been rendered mostly obsolete.
0:49:45 But there are still around 7 million horses in America.
0:49:47 So, who’s riding them?
0:49:48 Who’s buying them?
0:49:49 Selling them?
0:49:52 And what do those horses do all day?
0:49:55 They can eat grass, get sunshine, roll around.
0:49:58 That’s what they do between breedings.
0:50:00 It’s their version of smoking a cigarette.
0:50:06 Everything you’ve always wanted to know about the economics of horses, but were afraid to ask.
0:50:09 How do I say this without a hit being put out on me?
0:50:11 That’s next time on the show.
0:50:13 Until then, take care of yourself.
0:50:15 And if you can, someone else too.
0:50:19 Freakonomics Radio is produced by Stitcher and Renbud Radio.
0:50:22 You can find our entire archive on any podcast app.
0:50:26 Also at Freakonomics.com, where we publish transcripts and show notes.
0:50:30 This episode was produced by Dalvin Abouaji and edited by Ellen Frankman.
0:50:34 It was mixed by Eleanor Osborne with help from Jeremy Johnston.
0:50:39 Special thanks to Bapu Jenna, Rebecca Allensworth, and Ezekiel Emanuel for research guidance.
0:50:44 The Freakonomics Radio Network staff includes Augusta Chapman, Alina Cullman, Elsa Hernandez,
0:50:51 Jasmine Klinger, Gabriel Roth, Greg Rippin, Morgan Levy, Sarah Lilly, Tao Jacobs, and Zach Lipinski.
0:50:56 Our theme song is Mr. Fortune by The Hitchhikers, and our composer is Luis Guerra.
0:50:58 As always, thanks for listening.
0:51:05 What I can say to that patient is, let’s make a deal.
0:51:10 You’re going to smoke 15 cigarettes a day, and instead of that other five, you’re going to have a pretzel.
0:51:11 Okay.
0:51:13 Let’s see if we can do that.
0:51:14 Can I smoke the pretzel?
0:51:16 You can smoke the pretzel if you’d like.
0:51:22 The Freakonomics Radio Network.
0:51:24 The hidden side of everything.
0:51:29 Stitcher.
The U.S. has a physician shortage, created in part by a century-old reform that shut down bad medical schools. But why haven’t we filled the gap? Why are some physicians so unhappy? And which is worse: a bad doctor or no doctor at all?
- SOURCES:
- Karen Clay, professor of economics and public policy at Carnegie Mellon University.
- Rochelle Walensky, physician-scientist and former director of the CDC.
- RESOURCES:
- “Medical School Closures, Market Adjustment, and Mortality in the Flexner Report Era,” by Karen Clay, Grant Miller, Margarita Portnykh, and Ethan Schmick (National Bureau of Economic Research, 2025).
- “Application Overload — A Call to Reduce the Burden of Applying to Medical School,” by Rochelle Walensky and Loren Walensky (New England Journal of Medicine, 2025).
- “Challenges to the Future of a Robust Physician Workforce in the United States,” by Rochelle Walensky and Nicole McCann (New England Journal of Medicine, 2025).
- “The first step to addressing the physician shortage,” by Rochelle Walensky and Nicole McCann (STAT, 2025).
- “Physician Workforce: Projections, 2022-2037,” (National Center for Health Workforce Analysis, 2024).
- “Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools,” by Kendall Campbell, Irma Corral, Jhojana Infante Linares, and Dmitry Tumin (JAMA Network, 2020).
- “Medical Education in the United States and Canada,” by Abraham Flexner (The Carnegie Foundation for the Advancement of Teaching, 1910).
- EXTRAS:
- “Is the Air Traffic Control System Broken?” series by Freakonomics Radio (2025).
- “Are You Ready for the Elder Swell?” by Freakonomics Radio (2025).
- “Are Private Equity Firms Plundering the U.S. Economy?” by Freakonomics Radio (2023).
Hosted by Simplecast, an AdsWizz company. See pcm.adswizz.com for information about our collection and use of personal data for advertising.
Leave a Reply
You must be logged in to post a comment.