With a doctor shortage looming, those practicing now say the profession is in decline and the doctor-patient relationship will continue to suffer. If someone told you not to go into their field of work, you’d be wise to listen. If that advice came from your doctor, you might be foolish not to take it. While it’s the dream of countless parents that their child become a doctor, the reality is that the majority of physicians wouldn’t recommend medicine as a career to their own children or other young people. Dr. Ernest Brown is a family physician who does only house calls in Washington, D.C. He would recommend practicing medicine to his son only if he did so in a country besides the United States. “There’s no heart and soul in it,” he told Healthline. “It’s all commodities and profit.” Dr. Kristen Miranda-Gaines works in obstetrics and gynecology at Kaiser Permanente in Oakland, Calif. She has reservations about a recommendation for her profession. “I don’t know. I lean toward saying no, but at the same time it’s hard because I see people in many jobs who are frustrated and disillusioned,” she told Healthline. “I wouldn’t persuade or dissuade them, but I’d tell them about the realities.” One reality is half of practicing physicians in the United States report cutting back on the number of patients they plan to see, switching to part-time or concierge medicine, or taking other steps to treat fewer people. Another is that the American Association of Medical Colleges (AAMC) predicts the U.S. will be short between 46,000 and 90,000 physicians by the year 2025. About a third of the shortfall will consist of primary care physicians. Kyle Mattice, president of health services for the Execu|Search Group, a staffing and recruitment company on the East Coast, said he’s the busiest he’s been in 13 years as hiring for physicians and nurses are “through the roof.” “In the healthcare industry, we’ve seen this coming for a while,” he told Healthline. “The clinical need is real right now. It’s fast and furious.” The need for these physicians is driven by many factors, mainly as 10,000 baby boomers reach the age of 65 every day and millions of new patients now insured under the Affordable Care Act (ACA) start going to see the doctor. Research shows Americans continue to have longer, but not necessarily healthier, lives. As we get older, we are likely to have one or more chronic conditions such as obesity, diabetes, heart disease, hypertension, arthritis, depression, addiction, or dementia. And we’re counting on someone to make us better. Read More: This Is What Your Doctor’s Office Will Look Like in Five Years »

The Doctor Is In (Distress) How could it suck to be a doctor of medicine in the United States, a place where healthcare spending exceeds $2.5 trillion each year? For many doctors practicing today, it’s being forced to do more with less, a scenario that, to them, erodes the core values of the profession. Those in the medical profession say the key to a healthy society is trust between doctor and patient, one cultivated over time through meaningful interaction, discussion, and understanding. The looming problem over modern healthcare, they say, is that the model is structured to increase output, not better long-term health. That, in turn, creates high levels of stress when productivity is matched against altruism. And no one disagrees that there aren’t enough hands around when the heavy lifting needs to be done. “The landscape of healthcare has changed from when we grew up,” Mattice said. “The new healthcare model is very patient-driven and about cost savings.” A survey of 13,575 American physicians found that 80 percent say relationships with their patients are the most satisfying part of their jobs, but they’re suffering because of healthcare bureaucracy, creating a high level of pessimism for the future of medicine. More than 84 percent of those physicians surveyed say the medical profession is in decline, a third said they wouldn’t choose medicine as a career if they had a do-over, and 60 percent said they’d retire immediately if they could. But becoming a doctor in the U.S. is a form of modern-day indentured servitude. After undergraduate schooling, medical school, and residency, new doctors are facing an average debt of $169,000. Considering the average salary for physicians doesn’t break $60,000 a year until after their fifth year of practice, getting into medicine for the money makes no financial sense, especially considering the hours involved. “I still have to remain in the field for the next decade to pay off my student loans,” Miranda-Gaines said, noting she has $150,000 left of her original $200,000 debt. Read More: Do Doctors Get Paid Too Little? »

Quality Suffers with Too Few Hands on Deck Prior to Kaiser, Miranda-Gaines worked as a family physician for La Clínica, the community clinics that brings needed health services and education to the underserved people of Oakland. With her social justice mindset, Miranda-Gaines thought she would be at a place like La Clínica for the rest of her career. But because it serves those who need it most, reimbursement for services are difficult to come by, which means the facility had to maximize the number of people it served to keep the doors open. “What suffers is your quality of care,” Miranda-Gaines said. “I felt these systems had a lot of turnover and was extremely short-staffed. It made me feel unsafe.” So she switched to Kaiser, the largest managed care organization in the country. Despite its size, Kaiser’s 17,791 physicians report higher satisfaction scores compared with other medical groups. Still, Miranda-Gaines is expected to see 24 patients a day. And those planned 15-minute visits often go long, which means she’s always running late to the other waiting rooms. “The volume of work is more than there are people to do, but I can’t envision a system where this doesn’t exist,” she said. “If I saw fewer patients, I believe I could provide better quality.” While autonomy is often the first sacrifice of working in managed care facilities, Miranda-Gaines said that’s one thing that isn’t an issue at Kaiser. “Their guidelines are based in evidenced-based medicine,” she said. “I haven’t experienced any push back if I use my best judgment and go against them.” Read More: Why More Non-White Doctors Are Needed »

The Changing Landscape for the Family Physician Just as Miranda-Gains had to switch from family practice to OB/GYN inside the Kaiser system, doctors are often pressured to sharpen their focus on a specialty inside the healthcare system. The family physician — the one who’s been the cornerstone of white coats and stethoscopes — is quickly losing its foothold in American healthcare. “I’m a family physician and we’re dinosaurs,” Brown, the house-call doctor from D.C. said. “In modern healthcare, medicine is factory work.” That’s why Brown decided to “tune in, turn on, and drop out.” He does two kinds of home (or hotel) visits: concierge medicine for visiting dignitaries and charity care for the impoverished and homebound in our nation’s capital. Brown’s donated car and rented 740-square-foot apartment serve as his office, allowing home care to provide “a level of involvement unlike anything else out there.” “I don’t charge patients when I first see them,” Brown said. “I charge them when they get better so they see the value in it.” In 2012, he was called to a hotel room in D.C.’s Dupont Circle. There, a patient had been vomiting but needed to be ready for an upcoming meeting. Brown gave the man an IV and some injections and in 45 minutes, the patient was feeling better. Brown even helped the man get dressed. The man was Dimitris Avramopoulos, then-minister of defense for Greece, and his meeting was with President Barack Obama. As a form of thank you, Avramopoulos flew Brown out to the island of Kos, where Hippocrates taught medicine. “He told me to go out there and recite the Hippocratic oath and I did,” Brown said. “He showed me how much my care meant to him. It’s the one thing you want to see: comfort in care.” Brown says to improve healthcare and bring back the heart and soul of medicine, the nation needs to move away from institutionalized medicine. Inside these HMOs the focus is on disease and treatment, so physicians can’t fully care for their patients by focusing on their health and wellness. To change that, he said, would take a revolution. “You can’t stop the machine. It’s like Big Tobacco or Big Oil. It’s become a behemoth, like a cancer,” he said. “You can’t approach health to monetize it. It’s life.” Read More: Do Doctors Really Loathe Obamacare? »

The Rise of the Nurse Practitioners and Physicians Assistants General medicine, or the focus on treating the whole patient and not just a single organ, is in decline, many say. Doctors are encouraged to enter specialized work because that’s where they can find value in top-down healthcare. Hospital systems across the nation are relying more on nurse practitioners for routine visits with patients, reducing the need for and filling in the gaps for the lack of physicians. As the U.S. faces a shortage of between 46,000 and 90,000 physicians by 2025, there’s an estimated additional 47,600 nurse practitioners needed by 2022, according to projections by the Bureau of Labor Statistics (BLS). While available duties vary from state to state, nurse practitioners — those with master’s degrees and board certification — can perform many of the same key duties as a doctor, such as prescribe medicine and order tests. Since advanced practice registered nurses (APRN) on average are paid less than half than the average family physician, hospital systems are leveraging them as the person patients will see more often. (The average family physician makes $227,541 a year, according to data from more than 18,000 physicians. APRNs average $96,460.) “What that translates to is the biggest bang for the buck,” Brown said. When it comes to available career options that allow people to work directly with patients, it’s hard to compete with the physician assistant (PA) field, which has been rated one of the top professions of 2015. Projected to grow by 38 percent — much faster than the average for all occupations —the BLS projects an additional 33,300 PAs will be needed by 2022. Working in collaboration with a physician or surgeon, PAs examine patients, diagnose illnesses and injuries, and provide treatment to the average tune of $90,930 a year. Jeffrey Katz, president of the American Academy of Physician Assistants, said PAs are key to helping patients navigate the healthcare system and are at the forefront of keeping empathy, passion, and patient advocacy. “That’s what’s missing in medicine today,” he told Healthline. “We’re really trying to be cost-effective and remain passionate about helping patients.” PAs earn a master’s degree through one of the 196 accredited programs in the United States, where Katz says there are often 10 times more applicants than open seats. To help keep up with demand, an additional 66 PA programs are expected to start up within the next five years. Read More: The Future of Healthcare Could Be in Concierge Medicine »

Private Has Its Own Challenges As of 2012, 53 percent of physicians were self-employed, according to the American Medical Association, but more private practices are being bought by larger scale entities. Besides being adept and up-to-date on medicine, doctors in private practice must also possess good small business management skills. While that involves just as much, if not more, time spent on paperwork, it often pays dividends when it comes to how a doctor chooses to practice. Dr. Allen Kamrava is a colorectal surgeon who has been in private practice in Los Angeles for the past year and a half. After spending time in other physicians groups, he opted to go out on his own. He spends four days of his week seeing patients, while Wednesdays are reserved for paperwork and payroll. “I basically molded my practice to what I want to treat and who I want to work with,” he told Healthline one Wednesday in September. While Kamrava says he makes less in private practice than he did as an employed surgeon, he says there’s potential to make more down the road. His goal, he says, is to be able to buy a house and send his children to private school. But just because he’s his own boss, that doesn’t mean he’s sitting on stacks of cash. Kamrava partners with local hospitals to perform surgeries on his patients. Recently, one of his friends needed a new rectum built. Of the $297,000 the patient was billed, Kamrava said he only collected $1,540, which included all of the consultations before and after the surgery. “What’s happening in medicine is that all the money is going to hospitals,” he said. Getting reimbursed, whether through private insurance companies or the federal government for Medicaid or Medicare, is a major hurdle for doctors in private practice. These compounding frustrations create the inherent pessimism toward the structure of modern medicine, not the practice of it. Kamrava calls this the “background noise.” “When people say they don’t like medicine, it’s the background noise,” he said. “I like medicine, but the background noise drives me nuts.” Read More: ‘Cowboy Surgeons’: Why Hospitals Are Cracking Down on Them »