May 22, 2026

Dear Interested Readers,

 

If We Hope To Move Ahead Someday, We Need To Know How We Got Here.

 

Last week’s letter was a bit of a downer. I reported that the Wellesley Offices of Atrius Health had told my wife that she needed to go elsewhere to find a PCP. Her beloved PCP of almost forty years was retiring. She had been encouraged to see an NP who had worked with her PCP, which would have been fine, but now that NP was leaving the practice. No other practitioners at the site were accepting new patients.

 

That communication was not very personal. It was delivered via a MyChart posting. I wonder how many other long-term patients of Atrius, formerly Harvard Vanguard, formerly Harvard Pilgrim Health Care, formerly  Harvard Community Health Plan, got the same message. My wife had continuously gotten her care at HCHP and its legacy organizations since the early 70s. It felt to her a little like being disowned.

 

For me, it was evidence that no matter who you are or how excellent your healthcare coverage is, the physician shortage can affect your access to care. From a revenue standpoint, my wife should have been considered desirable, since we don’t use Medicare Part B but rather Federal Retirees’ Blue Cross. My wife worked for many years at the West Roxbury VA as an NP managing the care of veterans with CHF and other related cardiac concerns. 

 

It is one thing to write about our critical shortage of doctors, mid-level clinicians, nurses, and other essential healthcare professionals; it is a totally different issue to have the health of someone close to you be impacted by the problem. It’s a bit like conversations about global warming before your house is flattened by a tornado, washed away in a flood, or consumed by a forest fire. From the moment she opened that My Chart message, the problems we had cared about as distant concerns of others became our personal concern. I am reminded of the confessional poem written by the German pastor, Martin Niemöller, who wrote:

 

First they came for the Communists
And I did not speak out
Because I was not a Communist

Then they came for the Socialists
And I did not speak out
Because I was not a Socialist

Then they came for the trade unionists
And I did not speak out
Because I was not a trade unionist

Then they came for the Jews
And I did not speak out
Because I was not a Jew

Then they came for me
And there was no one left
To speak out for me

 

The last paragraph of the main section of last week’s letter announced that, over the next few weeks, I would like to explore how our workforce problems developed over time. Next, I will explore my own experience with training, practice, and leadership that spans from the golden era of the 60s, when our government recognized its responsibility to ensure adequate medical resources, to what changed that commitment, and how I experienced and observed the transition.

 

I have always felt that understanding what happened yesterday enables better decisions for tomorrow. Finally, I hope to explore in more depth our rapidly evolving experience with AI in healthcare. There is no certainty, but there is a possibility that thoughtfully used AI resources could make us much more hopeful about our collective healthcare future. There is great certainty that we will be using AI, and there have been a number of failures as well as celebrated successes that we need to understand if we are going to use AI in the future without harm. Those were the thoughts I had when I wrote the last paragraph of the first section of my letter last week.

 

Perhaps, and with some hope, AI may be what rescues us. Over the next few weeks, I plan to use these notes to further explore how we got to this moment, concerns that I have had since at least the mid-80s, and then review potential solutions. I welcome any ideas that you might send me directly by email at drgenelindsey@gmail.com or through the comment window of this website. 

 

As you may have noticed from previous posts over the past few years, I have increasingly embraced AI as an aid in researching and organizing complex topics. As I have said, the likelihood of AI “hallucinations” is reduced by asking good questions and paying attention to the resources the “bot” cites. On several occasions, this process has led me to realize that I had only a partial understanding of the subject, or that there were nuances or time relationships that I had distorted. Sometimes, my questions are not posed adequately to reveal all that I previously had known to be true from personal experience. And so it was that I asked Google’s Gemini, “Can you trace the origins of our current doctor shortage?”

 

From my perspective, looking back, I expected an answer about policies that could be traced to the late 70s or early 80s. That was not the answer I received. What Gemni said was:

 

The current doctor shortage is primarily a human-made bottleneck caused by an outdated 1997 federal cap on Medicare-funded residency training. This structural limit collided head-on with skyrocketing demand driven by the aging Baby Boomer population and mass physician retirements, resulting in severe geographic and specialty shortages. [1, 2, 3, 4, 5]

Tracing the crisis reveals a few specific, historical and systemic causes:

 

1. The 1997 Medicare Cap (The Supply Bottleneck)

 

• The Decision: In 1997, Congress passed the Balanced Budget Act, placing hospital-specific caps on the number of medical residents Medicare would fund.

• The Rationale: Lawmakers were swayed by an erroneous 1980 federal forecast (the GMENAC report) that predicted a massive physician surplus. To save money and prevent “too many doctors,” funding was frozen at 1996 levels.

• The Aftermath: Because a medical residency is mandatory to become a licensed physician, this cap created a bottleneck. Even as medical schools graduate more students today, thousands remain stranded without a residency slot. [1, 3]

 

2. The Aging Demographic (The Demand Spike)

 

• The Patients: The American population is living longer and experiencing more chronic illnesses. By 2030, nearly all Baby Boomers will be 65 or older, and the demographic aged 75 and older is projected to grow substantially. These populations require significantly more healthcare per capita.

• The Doctors: The physician workforce is aging right alongside the population. Approximately 40% to 45% of active clinical physicians are over the age of 55, meaning a large retirement wave has hit. [1, 2, 3, 4, 5]

 

3. The Generational Burnout Wave

 

• Administrative & Financial Pressures: Decades of escalating administrative work (“charting”), corporate consolidation, and falling or stagnant Medicare reimbursement rates (when adjusted for inflation) have drastically lowered physician autonomy and job satisfaction.
• Pandemic Exodus: The immense strain of the COVID-19 pandemic accelerated these issues, causing a massive spike in early retirements, reduced working hours, and doctors abandoning clinical medicine altogether. [1, 2, 3]

 

4. Severe Maldistribution

 

• Specialties vs. Primary Care: Because of the way the residency system is financed, hospitals historically funnel slots toward lucrative, specialized procedures (like orthopedics or cardiology) rather than general practice, causing a dire primary care and behavioral health deficit.

• Medical Deserts: Urban centers attract the vast majority of trained specialists, while rural and historically underserved urban areas are transformed into “medical deserts”. According to the U.S. Health Resources and Services Administration (HRSA), non-metropolitan areas face the brunt of these structural imbalances. [1, 2, 3, 4, 5]

 

What is Being Done?

 

Congress ended the nearly 25-year freeze on residency slots by authorizing a modest increase of 1,000 Medicare-supported GME positions in 2020. Professional organizations like the American Medical Association (AMA) and the Association of American Medical Colleges (AAMC) continue to lobby for larger legislative fixes, such as the Resident Physician Shortage Reduction Act, to expand Medicare-funded training slots. [1, 2, 3, 4]]

 

Gemini produced 16 references to back up its position, drawn from reliable sources such as Health Affairs, AMA publications, the NIH, and respected political commentators. I could have produced much of the commentary myself in reasons 2-4, but honestly, the Balanced Budget Act of 1997 and its impact on residency training were news to me. According to Wikipedia:

 

The Balanced Budget Act of 1997 (Pub. L. 105–33 (text) (PDF), 111 Stat. 251, enacted August 5, 1997) was an omnibus legislative package enacted by the United States Congress, using the budget reconciliation process, and designed to balance the federal budget by 2002. This act was enacted during Bill Clinton‘s second term as president.

According to the Congressional Budget Office (CBO), the act was to result in $160 billion in spending reductions between 1998 and 2002. After taking into account an increase in spending on welfare and children’s healthcare, the savings totaled $127 billion. Medicare cuts were responsible for $112 billion, and hospital inpatient and outpatient payments covered $44 billion. In order to reduce Medicare spending, the act reduced payments to health service providers. However, some of those changes to payments were reversed by subsequent legislation in 1999 and 2000.

 

We have selective memories. I do remember the creation of CHIP. I do remember that Clinton balanced the budget, but I didn’t remember how he reduced Medicare by about 120 billion over a short time to do it, and I had no idea of the changes in medical staffing, residency programs, and the work life of academic physicians in hospitals created by these cuts. At the time, our practice had only a small senior population, since most of the individuals and families we cared for came to us through employer contracts rather than Medicaid or Medicare.

 

I was still convinced that my memory and bias that the origin of our current staffing crisis went back to the late 70s or early 80s. I did notice under section one of Gemini’s answer a veiled reference to that possibility when it said:

 

• Lawmakers were swayed by an erroneous 1980 federal forecast (the GMENAC report) that predicted a massive physician surplus. To save money and prevent “too many doctors,” funding was frozen at 1996 levels.

 

Could there be more? So I asked, “Can you trace support for medical education to before the mid-90s concerns about a doctor glut?”

 

Gemini then presented me with information that confirmed my memory and bias and added even more history as a bonus.

 

Before concerns about a “doctor glut” triggered a massive policy reversal in the 1980s and 1990s, the federal government spent decades aggressively expanding medical education. Driven by mid-century fears of catastrophic physician shortages and growing populations, the era from the 1940s to the 1970s was a golden age of medical training expansion.

The evolution of federal support during this period followed a clear trajectory: [1]

 

1. The Post-WWII Research Boom (1940s–1950s)

 

Following World War II, the federal government dramatically reshaped medical school financing. Inspired by wartime scientific successes, lawmakers heavily funneled money into biomedical research through the National Institutes of Health (NIH). [1, 2]

• The Impact: NIH research funding grew from $8.3 million in 1947 to $1.7 billion by 1974.

• The Structural Shift: By 1965, direct federal research grants accounted for roughly 40% of total medical school revenue. This effectively institutionalized and stabilized the academic medical centers we rely on today. [1, 2]

2. Direct Subsidy & Infrastructure Expansion (1960s)

 

By the 1960s, a growing population and inaccurate demographic projections stoked major panic about an impending doctor shortage. Congress pivoted from funding research to funding the actual production of doctors via the Health Professions Educational Assistance Act of 1963. [1, 2, 3]

• Brick-and-Mortar Grants: The federal government provided construction grants to physically build and expand medical school facilities.

• The School Boom: This targeted financial injection successfully grew the number of accredited U.S. medical schools from 89 in 1965 to 127 by 1982.

• Student Aid: The 1963 Act and its 1965 amendments created the first massive waves of federal student loans, scholarships for low-income students, and loan-forgiveness programs for practicing in underserved areas. [1, 2, 3, 4]

 

3. The “Capitation” Era and Accelerated Programs (1970s)

 

The push to manufacture physicians peaked with the Comprehensive Health Manpower Act of 1971. The government introduced “capitation grants”—direct formula grants that paid medical schools a flat fee per student enrolled ($2,000 to $4,000 per student). [1, 2]

• The Catch: To get the money, medical schools were legally required to increase their first-year class sizes or establish compressed, accelerated three-year MD paths to churn out doctors faster.

• The Result: Driven by these government financial incentives, over 25% of all medical schools operated accelerated three-year graduation programs by 1973. [1, 2]

 

4. The Original Medicare Entitlement (1965)

 

When Medicare was established in 1965, the program automatically agreed to reimburse teaching hospitals for the “reasonable costs” of treating patients. Because teaching hospitals inherently run higher expenses due to training residents, Medicare began paying them a premium. This established the open-ended, uncapped Graduate Medical Education (GME) funding model that hospitals freely utilized to expand residency slots at will—until the 1997 cap permanently froze it. [1]

 

One interesting aspect of the story about the increase in medical schools, encouraged by federal support from 89 in 1965 to 127 in 1982, is what happened in South Carolina during that era. When I graduated from the University of South Carolina in 1967, most of the premed students in my class went to the only medical school in the state, The Medical College of South Carolina. It was founded in Charleston in 1824 and is the oldest public medical school in the South. It has been renamed as the Medical University of South Carolina. Now there are two more allopathic medical schools: one in Columbia at the university, opened in 1977, and one in Greenville as an extension, opened in 2012.  In 2010, an osteopathic school opened in Spartanburg as a response to the state’s shortage of PCPs. 

 

I will interrupt Gemni’s very instructive overview of the history up until the mid-seventies, to say that I was delighted to be a beneficiary of the government’s support to individual medical students in such a progressive environment. I have reported in the past that shortly after winning a full-ride scholarship to Vanderbilt Medical School, which included living expenses, I got a telegram during my oldest son’s two-year-old birthday party welcoming me to the Class of 1971 at Harvard Medical School.

 

I did not know what to do with this very positive dilemma. It was late on a Friday afternoon, so I decided to call the Dean’s office at Harvard first thing on Monday. There was no problem connecting with the office, and I don’t know if the woman I spoke to had any authority to make promises, but when I presented my problem, the voice on the other end of the line said, “I can’t remember any time we have ever had a student leave because of financial problems.” I thanked her for the information, hung up, and called Vanderbilt to tell them I appreciated their offer of support, but they should give the scholarship to someone else. 

 

To finish the story which I have told before, sometime after I graduated in June 1971, having had the bulk of my tuition forgiven through federal support to the school, I got a communication saying that for my part, I owed $10,000 in federal loans which would be collected over a ten-year period beginning five years after I had completed all of my post-graduate training. Interest would not begin to accumulate until then and would be 5.25% a year. In 1981, ten years after graduation, I got a coupon book from Harvard Medical School with 120 coupons, each for $100.99, for monthly payments.

 

I like to say that by 1981, I was spending multiples of that amount every month on babysitters, dinner, and a movie on weekends. In 1981, when I began to pay. I had just bought a house with a 16% mortgage, which was pretty good since data show that the average mortgage rate in the country in 1981 for a thirty-year mortgage was 16.67%. My medical loan was essentially “free money.” There is probably not a better example of what has been lost when you realize that so many graduates from medical school this year will carry loans of up to or perhaps more than $450,000. The median debt load for this year’s graduates is reported to be $223,000. Is there any wonder that no one wants to go into primary care when they might earn three or four times more as a specialist of some sort?

 

Gemini continues its tale of woe:

 

The Abrupt U-Turn

 

This aggressive talent pipeline came to a screeching halt when the federal government’s Graduate Medical Education National Advisory Committee (GMENAC) issued a 1980 report predicting a massive surplus of 70,000 doctors by 1990. Believing the shortage was solved, the federal government terminated all direct capitation support for medical schools at the start of the 1980s, ending a 25-year era of medical school creation. [1, 2, 3]

 

It is interesting to track what happened in the Reagan era following this report. To place the report and the status of our economy and politics in time, we had just spent a ton of national treasure on a fruitless and tragic war in Vietnam that had collapsed many of the social programs of Lyndon Johnson’s “Great Society” legislation. We had just experienced a huge jump in energy costs with the first Arab oil embargo, and the new Iranian theocracy had humiliated us by holding captives for more than 400 days.

 

Economically, we were in the midst of stagflation with both high unemployment and high interest rates. Our president would eventually say that the nine scariest words in the English language were “I’m from the government, and I’m here to help.” “Welfare Queens” was becoming acceptable political language.  By 1984, Reagan was promising a new “Morning in America” by cutting taxes and eliminating much of our “wasteful” government spending, and was reelected by a resounding plurality.  Some of that “wasteful spending” supported our medical schools and residency programs.  

 

Both Gemini and ChatGPT often offer a “deeper dive,” so I was not surprised when Gemini offered to provide me more information about the impact of the 1980 “Graduate Medical Education National Advisory Committee (GMENAC) report.” It said: 

 

If you want, I can dive deeper into how medical schools adapted financially once that federal funding disappeared, or map out the specific criteria the government used in the 1980 GMENAC report to predict that oversupply. [1]

 

I said, “Please do.”

 

When federal capitation grants abruptly vanished at the beginning of the 1980s, U.S. medical schools were thrown into a sudden financial crisis. Federal per-student funding collapsed by roughly half within a few short years, forcing institutions to aggressively seek new ways to replace what had been their most flexible pool of operating cash. [1, 2, 3]

The structural pivot of medical school financing in the 1980s was highly innovative, yet it was completely undermined by a highly flawed mathematical model that convinced the government a massive oversupply of doctors was imminent. [1]

 

How Medical Schools Financially Adapted

 

To survive the post-capitation era, medical schools transitioned from heavily government-subsidized academic centers into competitive, revenue-generating healthcare corporations. They survived through three main mechanics: [1]

• The Rise of Faculty Practice Plans: This was the single most transformative shift. Medical schools required their clinical faculty (the doctors who taught the students) to treat paying patients under school-owned corporate entities. A massive percentage of the billable clinical revenue generated by these faculty practices was funneled directly back to fund the educational and research operations of the medical school.

• Aggressive Tuition Hikes: Stripped of federal subsidies, schools immediately passed the financial burden on to students. Tuition rates skyrocketed throughout the 1980s, marking the birth of the massive student-debt model that defines medical education today.

• State Government Reliance: Public medical schools leaned intensely into state appropriations. While states stepped in with per-student subsidies, it created a massive funding disparity. Public schools averaged ten times more state aid per student than private medical institutions, which forced private medical schools to rely almost entirely on clinical practice revenues and private endowments. [1, 2, 3, 4, 5]

 

The 1980 GMENAC Report’s Flawed Criteria

 

While medical schools scrambled to restructure their finances, a massive 1980 study by the Graduate Medical Education National Advisory Committee (GMENAC) single-handedly locked down the supply of future doctors. Charged by the Department of Health, Education, and Welfare to evaluate the workforce, GMENAC deployed three highly complex mathematical models. [1, 2, 3]

The specific criteria they used to predict a 70,000 doctor surplus by 1990 (and 145,000 by 2000) included: [1, 2, 3, 4, 5]

 

1. The Supply Model Criteria

GMENAC projected that by 1990, active practicing physicians would grow by 58% to nearly 600,000. They built this calculation on: [1]

• The Momentum Baseline: Extrapolating the peak class sizes built during the 1970s capitation boom.

• Osteopathic Addition: Incorporating the rapid expansion of DO-granting schools, which were not as tightly controlled by early federal limits.

• Immigrant Doctor Inflow: Factoring in a fixed estimate of foreign medical graduates entering the U.S. workforce annually. [1, 2, 3]

 

2. The Flawed “Need-Based” Requirements Model

Instead of measuring “economic demand” (what patients and insurance companies actually spend money on), GMENAC invented an adjusted “need-based” model. They brought together panels of clinical experts who used the following criteria to map out exactly how many doctors America should need: [1, 2, 3, 4, 5]

• Epidemiological Prevalence: They charted the occurrence rates of specific diseases and medical conditions across the U.S. population.

• Standard Time-per-Condition: The panels calculated how many minutes or hours of a doctor’s time it realistically took to treat each specific condition.

• Delegation Assumptions: They assumed a strict percentage of care would successfully be delegated to nurse practitioners and physician assistants. [1]

 

3. Why the Criteria Failed (The Blind Spots)

The criteria used in the need-based model were heavily criticized for operating in an ideological vacuum:

• The “Universal Access” Fallacy: The model assumed perfect, friction-free geographic distribution and universal healthcare access for all Americans. It failed to anticipate that insurance constraints, poverty, and local shortages would leave millions unable to access the theoretical supply.

• The “Physician-Induced Demand” Myth: Policymakers firmly believed that a surplus of doctors would drive up healthcare spending because doctors would invent unnecessary procedures to make money. They prioritized cutting numbers to lower federal expenditures rather than protecting patient access.

• Underestimating Boomer Longevity: The model dramatically undercalculated the sheer complexity, multi-morbidities, and massive healthcare utilization spike of the aging Baby Boomer generation. [1, 2, 3, 4, 5]

As a direct result of these flawed assumptions, the government cut medical scholarships, slashed training program supports, and schools enacted a devastating 25-year voluntary moratorium on creating new medical institutions. [1, 2]

 

It is a complicated and sad story. We should use the flawed analysis of an impending doctor glut and the public policy changes it engendered, which have resulted in the professional shortages that we now have as a warning of what happens when bad policy dismantles programs that are working well. Will it be that in forty years, we will be looking back on this era of MAGA/MAHA-induced dismantling of public support to medical research, medical care access, and withdrawal from collaboration in programs of international public health as a tragic mistake from which quick recovery was impossible? Gemini seemed as concerned as I was and made another offer:

 

If you’d like to look closer at the aftermath, I can map out how specific specialties (like psychiatry vs. surgery) were uniquely impacted by these 1980 recommendations, or break down when and why the medical community finally realized the GMENAC report was dangerously wrong. [1, 2]

 

Gemini advised me that the continuing story would be informed by reports from 20 sites, including government reports, think tanks, and peer-reviewed journals. I looked at the references and let my AI teacher forge ahead. I have bolded what I believe to be the most tragic miscalculation. Remember what I call the “law of garbage” in statistical analysis, “Garbage in, Garbage out.”

 

To understand how this crisis fully solidified, we have to look at how specific medical fields were intentionally dismantled after the 1980 report, and the exact moment the medical establishment realized they had made a catastrophic mathematical error.

 

1. How Specific Specialties Were Targeted

 

The 1980 GMENAC panel did not just call for a general freeze; they issued highly specific, targeted report cards for individual medical specialties.

The committee explicitly ranked specialties into three categories:

The “Oversupply” Scapegoats

The report predicted massive, dangerous surpluses in high-paying surgical fields and specialized medicine.

• The Targets: Surgery (especially general, thoracic, and orthopedic surgery), Obstetrics/Gynecology, Cardiology, and Endocrinology were hit hardest.

• The Action: Residency directors in these fields purposefully restricted growth and cut back on available first-year slots throughout the 1980s. This created structural deficits in surgical pipelines that took decades to reverse.

The “Balanced” Illusion

• The Fields: Pediatrics, Family Medicine, and General Internal Medicine were deemed to be in a state of near-perfect equilibrium.

• The Action: Because policymakers assumed primary care was “solved,” federal and state incentives to push students into general practice were quietly dismantled, setting the stage for the massive primary care shortages felt today.

The Few “Shortage” Fields

• The Fields: Only Psychiatry, Emergency Medicine, and Preventive Medicine were flagged as lacking doctors.

• The Failure: Because the overarching narrative was “we have too many doctors overall,” the solutions proposed for these shortage fields were poorly funded and largely ignored, leaving psychiatry chronically understaffed for the next forty years.

 

2. The Turning Point: Realizing the Mistake

 

For over fifteen years, the GMENAC prediction was treated as absolute gospel. The turning point arrived in March 2002, when a landmark paper titled “The Imminent Physician Shortage” was published in Health Affairs by researchers Richard Cooper, Thomas Getzen, and colleagues.

Cooper’s team threw out the old “need-based” disease checklists and looked at a much more reliable metric: Gross Domestic Product (GDP) and economic growth.

They proved that as a nation gets wealthier, its citizens naturally spend more money on healthcare, regardless of what an expert panel thinks they “need.” Cooper accurately calculated that the U.S. was actually facing a massive deficit of over 100,000 doctors by 2020.

Shortly after, the Association of American Medical Colleges (AAMC) officially reversed its position in 2006, sounding the alarm and begging schools to increase enrollment by 30%.

 

3. The Modern Trap

 

The tragedy of the 2002 realization is that it came five years too late. By the time the medical community realized the 1980 report was wrong, Congress had already passed the 1997 Balanced Budget Act, legally locking the Medicare residency funding cap into stone.

Medical schools responded heroically to the AAMC’s 2006 plea by opening dozens of new institutions and expanding class sizes. However, because the 1997 federal residency cap remained completely unchanged, the system developed a severe mismatch:

 

This abrupt recognition may explain why a new medical school and a new school of osteopathy opened in South Carolina around 2010 as attempts to address a huge access-to-care problem in the state. Was the problem solved or at least on the way to improvement? No, as Gemini continues, we realize that the persistent cuts to Medicare funding for residency programs for teaching, which will worsen as we cruise into the full impact of the One Big Beautiful Bill next year, will continue to deny us the medical talent we so desperately need. Gemini delivers a disappointing analysis and forecast.

 

We now produce more than enough medical school graduates, but thousands of qualified applicants are artificially blocked from entering the workforce every single year because Congress capped the final, mandatory step of their training.

If you would like to explore further, let me know if you want to look at:

• How the birth of managed care (HMOs) in the 1990s temporarily masked the shortage.

• The current bipartisan legislative efforts to permanently repeal the 1997 cap.

• How the shortage is specifically impacting rural vs. urban communities today.

 

I don’t know for sure whether we now produce enough medical school graduates, or whether the true impact of federal cutbacks on residency programs is the final blockage in our attempt to improve access to care, especially primary and psychiatric care. What I do know is that those problems are real and that our current administration has neither the skill nor the intent to improve the situation. As Paul Krugman has noted and as I have reviewed, a “market-based” system of healthcare finance has no chance of providing the access we need. We had a working and improving system between the end of World War II and 1980, made possible by significant federal support that was later lost. Blame whom you like, but the reality is that in pursuit of lower taxes and based on a very flawed view of the future, we withdrew the resources from a program that was working, and now we are living with the consequences. We are told that history doesn’t repeat itself, but it does rhyme. I guess we are into the second or third verse of a very sad song.

 

I have always harbored a bias against the AMA regarding its role in the origin of our shortage of medical professionals. I was surprised that Gemini didn’t finger them to any extent in its report to me. This letter is already quite long, but I decided to ask directly about the role the AMA played in creating the problem that now brings grief to so many of its members. So I asked, “What was the role of the AMA in generating our current shortage of physicians?”

 

The prompt answer was:

 

The American Medical Association (AMA) bears significant historical responsibility for the current U.S. physician shortage due to aggressive lobbying in the 1990s to restrict the supply of new doctors based on flawed economic projections. Believing a major “physician oversupply” was imminent, the AMA partnered with other medical organizations in March 1997 to explicitly recommend cutting residency positions by 25% and capping federal funding. Congress enacted these caps later that year through the Balanced Budget Act of 1997, creating a structural bottleneck in medical training that persists decades later.

 

In fairness, in recent years, the AMA has tried to use its political influence to rectify the problem concerning physician training, but it has continued to resist allowing mid-level clinicians, NPs, and PAs greater practice autonomy. Gemini continues:

 

While the AMA has aggressively reversed its stance on residency slots and now lobbies Congress to lift the 1997 caps, critics point out that it continues to exacerbate the shortage through its defensive posture on “scope of practice” laws. [1]

 

• The AMA spends millions of dollars lobbying against state and federal legislation that would allow Nurse Practitioners (NPs), Physician Assistants (PAs), and psychologists to practice independently or prescribe medication.

• The AMA defends this by arguing that patients are put at risk by clinicians with less rigorous training than traditional medical school graduates. However, economists and policy analysts note that this restriction actively blocks a critical safety valve that could alleviate the immediate primary care and mental health shortages in rural and underserved areas. [1, 2, 4]

 

Another takeaway for me is the reality that while things were deteriorating, we, myself and others who cared deeply about the future of medical practice and the plight of patients, pressed on in the pursuit of partial solutions that seemed plausible and were laudable in their intent like the efforts to improve quality, equity, and the cost of healthcare, without fully realizing that those goals remain strategically impossible if patients can’t get the care they need from a damaged delivery systems suffering from extremely indebted, overworked, and morally damaged providers who can’t see much hope for an improvement in their personal professional experience within their lifetimes.

 

 Many of us knew that things weren’t right, but the problem was so vast that we could only see a small portion of the landscape. We hoped that if we worked hard to address the problems near us, things might get better. The IHI was famous for advocating thinking globally and acting locally. Perhaps that was good advice in the past, but it feels like what has been happening globally since 1980 has overshadowed and negated many of our local accomplishments. 

 

Our problems are complex, and the solutions will require more than simply passing legislation. I learned early in practice and later in management that today’s problems are very often the brilliant solutions to yesterday’s problems. Examining where our good intentions failed us is a good starting point. Obama began crafting the ACA by examining how previous efforts to expand care had failed. That exercise also pointed out that accepting less-than-perfect solutions can still represent beneficial progress. 

 

Having used more than 5,000 words to review how we got to this moment without even discussing RVUs, I know that there is much that I have left unsaid, and the discussion will continue next week. The goal is still to eventually explore solutions once we come to grips with how we got here. Your patience and time are appreciated. 

 

Goodbye to Stephen, and Out on the Water at Sunset

 

What can I say? It was the end of something important. It was a concrete example of the shadow of illiberalism and political corruption, festering like a disease that will erupt in time. Think tuberculosis, herpes, or perhaps better, some genetic defect manifested as a predilection to a cancer that will erupt in midlife; that robs us of the future with a loved one.

 

My wife and I are usually up till after his monologue, and “Meanwhile” every Monday to Thursday evening when a new Colbert show airs. We often watch what follows sometime the next day. It has been one of the perks of retirement. For over six months, we have dreaded the arrival of May 21. Now it has come and gone.

 

I don’t think that I have yet fully realized how important Colbert’s humor has been to my emotional well-being and ability to tolerate the daily abuses coming from an increasingly dangerous and unhinged president. I am sure that Mr. Colbert will be fine. He is creative, extremely talented, and brave enough to say what must be said without obvious personal fear of the consequences. It is how his absence will impact those of us he has sustained with humor and political satire that concerns me most. What has happened to free speech? They came for Stephen, and now he is gone. Who will they come for next?

 

After boring you for weeks about how winter weather kept returning for encores, I must admit that we got to the mid-80s a couple of times this week. Unfortunately, the trend didn’t hold, and we are looking at a Memorial Day weekend with a prediction of 48 with rain on Sunday and the low sixties with an overcast sky and some rain for the remainder of the “first weekend” of summer. A major reason for my concern is that the lake’s water temperature has been in the fifties. The air has to be warm consistently for many days before the water temperature even gets close to something I can tolerate, even in my wetsuit. 

 

On Tuesday evening, despite the cold lake temperature, I ventured out in my kayak for the first time this year. We had been hearing the loons talking back and forth on the warmer evenings when we could open windows. I wanted to check out whether anything was happening on the float for nesting that the Loon Preservation Committee has maintained for several years. I had heard that someone had seen a Canada goose trespassing there. I was pleased to see no goose, and I saw no loon, but on my way back across the lake, I did see my first great sunset of the summer, which you can see in the header of this letter.

 

I hope that you have plans for a great holiday weekend. Summer will eventually come and stay. I am sure of it.  

Be well,

Gene