As VP with the nation’s largest physician recruiting firm, Phillip Miller deals with the daily realities of physicians seeking employment. Mr Miller has authored several books on current conditions in American medicine, initiated the "Country Doctor of the Year Award," and cited in dozens of publications and media outlets latest of which is Physicians In Their Own Words: 12,000 Physicians Reveal Their Thoughts on Medical Practice in America (2010). Mr Miller discusses the reasons behind the projected shortage of physicians in the United States in this interview with ModernMedicine’s Richard Reece, MD.

What’s going on in American health care? Give us a sense of physician morale and mindsets.

Well, we just did a book on this subject, Physicians In Their Own Words: 12,000 Physicians Reveal Their Thoughts on Medical Practice in America (2010), based on a survey conducted for The Physicians Foundation. The book is based on written comments submitted by practicing physicians. It provides a compelling snapshot on the state of the union of the medical profession.

What does that snapshot tell us?

There’s a lot of angst and demoralization. The main reasons are the eroding autonomy over how doctors practice and the economies of what they are paid. There’s a disconnect between the type of people who go into medicine—basically the upper 5% of college classes who are self-motivated , diligent, and work very hard—and the realities once they get into the workforce, where they find others telling them how to practice and what they can earn. This has undermined professional status and satisfaction.

Has this angst and feeling of helplessness contributed to the doctor shortage?

It has, but not in ways you might expect. There are still people applying to medical school. But numbers are down over peak years. Students still go into medicine for the right reasons—to take care of people and to create the bond of the physician-patient relationship. The most important thing about being a doctor is the positive impact you can have on your patients’ lives.

The difficulty arises once they have gone through all those years of training and begin practice. They find the medical practice environment interrupts their dreams and disrupts patient relationships. At that point, physicians become disaffected with the profession, more so than they were in the past. In the past, you worked hard, 24/7; the idea that you ought to have set hours and a controlled life style didn’t exist.

What is the main problem with medicine today?

It’s a question of overall man hours. We have the same number of doctors we had in the mid-80s. The supply has been maintained, but the number of man hours is eroding. Doctors are less committed to working long hours. Instead of being independent business owners and controllers of their own fate, they tend to think like employees, and many of them are literarily employees of hospitals or medical groups. This state of affairs reduces the commitment and number of man hours available.

You speak of man hours. But half of medical school graduates are now women, who, on average, work about 20% fewer hours and retire earlier than men. Younger doctors are more protective of their time as well.

That’s a significant contributor to fewer doctor hours. In addition to that, you have an evolving mindset among doctors about what medicine is or ought to be. The first questions we hear now are “What are my hours?” “What’s the call schedule?” “How many vacation days do I have?”

They are now more committed to life style issues. This has its pluses and minuses. There ought to be a balance between work hours and private hours. The current balance is shortening physician availability.

This also impacts on the choice of specialties, does it not? Medical students are aware specialists make more money and work shorter hours.

We have a saying: Younger doctors are taking the ROAD to success—Radiology, Ophthalmology, Anesthesiology, and Dermatology—all high paying specialties with set hours. It contributes to the fact that over 50% of primary care residents are now internationally trained graduates.

Of all practicing physicians today, 25% are foreign-born or -trained. US grads are not going into primary care. In some specialties, the number of foreign graduates is even higher—anesthesiology, 28%; cardiology, 31%; gastroenterology, 27%; hospitalists, 40%; nephrology, 40%; and urology, 31%.

What can doctors do in the face of politicians and policy wonks who seem to be saying “Medicine is too important to be left to doctors?”

In the last go-around, when Hillary Clinton had her task force of over 500 folks to decide what to do about health care, there was not a single practicing doctor participating. That psychology is still in place. It’s odd—we have this resource of highly trained physicians. It’s puzzling that you would systematically go about removing their autonomy, ability to use their judgment, and undermining their morale. It would seem we would want a dynamic profession, but we seem to be working diligently in the opposite direction.

Do you have any specific observations on this matter?

One, doctors are now voting with their feet and getting out of private independent practice and becoming employees, mostly of hospitals, and turning over their autonomy to their employers.

Two, others are turning their backs on third-party payers and opening up concierge practices. We are going to see a lot more of this when the economy stabilizes. That will further erode access at the same time we are talking about opening the system to millions of more people.

Three, a lot more doctors will be practicing locum tenens. They are becoming more mobile and getting out of private practice.

Four, when the economy rebounds, you are going to see a lot more doctors retiring or getting into nonclinical roles, particularly in management.

I smell a political crisis brewing out there as 78 million baby boomers start entering the Medicare rolls and as many as 30 million more people become insured. Who is going to care for these folks?

It’s going to be a whole new world, the implications of which haven’t sunk in yet. People are aware we have this doctor shortage, but nothing serious is being done about it. We will have longer wait times. We will push down the care chain to mid-level providers. We will just have to find a way to shift the work away from physicians.

Richard L. Reece, MD, is the former Editor in Chief of Minnesota Medicine and Physician Practice Options and the author of 9 books on the health care system and managed care, including Innovation-Driven Health Care: 36 Key Innovations, and his most recent book, Obama, Doctors, and Health Reform (iUniverse), in which he explores what physician mindsets, patient concerns, the US culture, and our system’s complexities portend for reform. This book is available at iUniverse.com, amazon.com, and barnesandnoble.com.