Who Is John Galt?

Where Are Our Doctors Disappearing To?

Reminder to readers and newly enrolled Substack followers- colored/highlighted text is linked to supporting or referenced information. Those of us who read Ayn Rand’s Atlas Shrugged, will appreciate that our nation’s doctors are disappearing. Just like the business leaders in her fictional work, doctors are checking out. In the novel, we learned that when people asked why the productive individuals in society left, the reply was “Who Is John Galt”? This came to mean basically a shrug emoji like “damned if I know and damned if I care”. It was the end result of recognizing the futility of trying to improve matters when government and collective coercion was mastering over the individual. Does this sound/look familiar? And it isn’t just in the profession of medicine, this attitude is pervading all areas of our economy.

Who Is John Galt?

So far, I find no evidence that the doctors have found a hidden Galt’s Gulch oasis to regroup- so far…. In the novel Atlas Shrugged, Galt Gulch turned out to be a hidden valley in Colorado where all those leaving society went. The intent was to start all over, without the burden of the government and collective master.

Galt’s Gulch Reset

Is it just me or does it seem like doctors are disappearing? Here in Lee County most noticeably, the past 1-2 years, many colleagues have retired. A more concerning trend is more are selling their practices. Locally, the Millennium group is now owned by private equity and was sold off after 10’s of private primary care doctors sold to the group. The Millennium story and our local Lee Health experience illustrates exactly what is being documented in physician practice trends. From a fairly recent AMA report on physician employment trends the following is noted:

In addition, private practices and hospital-owned practices differ in terms of their inclusion of primary care. A practice is considered to include primary care if the surveyed physician is in a primary care specialty or if their practice includes primary care physicians.11 Sixty-one percent of physicians in hospital-owned practices work in practices that include primary care compared to 44.9 percent of physicians in private practice. In the hospital-owned setting, a large majority of primary care occurs in multi-specialty groups. In fact, 39.0 percent of physicians who work in hospital-owned practices do so in multi-specialty groups that include primary care. In contrast, primary care in private practice is typically provided in the solo or single specialty setting, with 30.9 percent of private practice physicians working in a solo or single specialty primary care practice and only 13.7 percent working in a multi-specialty practice that includes primary care.

And physician physical retirement is only going to accelerate in the coming years. From white paper published by Jackson Physician Search this is noted:

Among physicians under age 60, primarily Gen X, many hope to retire sooner rather than later. According to a 2022 Rural Physician Recruitment Whitepaper, Gen X physicians are more likely than Baby Boomers to report feeling dissatisfied with their levels of professional fulfillment (43% vs. 31%) and personal fulfillment (47% vs. 36%). So, perhaps it is not surprising that nearly 60% say they plan to retire before they turn 60 years old. If their intentions hold true, this generational shift in retirement age will have a significant effect on physician supply.

The prior Jackson Physician report stated:

According to a 2022 report published by the Association of American Medical Colleges (AAMC), nearly half (46.7%) of practicing physicians were already over the age of 55 in 2021. This means more than two of every five active physicians will reach age 65 within the next ten years

The AMA has additional reports on physician practice trends which go on to document additional trends that certainly appear to be happening here locally. Included are the following findings.

• Between 2012 and 2022 the share of physicians who work in practices wholly owned by physicians – private practices – dropped by 13 percentage points from 60.1 percent to 46.7 percent. I wrote in a prior post statistics much worse than this (closer to 30%).

• Hospital employed or ownership of practice is rising.

• The percentage of physicians under the age of 45 who were owners decreased from 44.3% in 2012 to 31.7% in 2022. This shift explains why in the last few years, private equity is acquiring former private practice businesses especially specialty practices.

• Women physicians were less likely to be owners than men, with only 35.7% compared to 48.6% being owners in 2022. In 2019 an historic shift in demographics confirms the majority of medical students now are women.

• Additionally, solo or single specialty practices are predominantly private (80.8%), while multi-specialty practices are more common in hospital-owned settings (43.5%). Getting bigger lends to eliminating private physician owned practice.

• Higher payment, access to costly resources and regulatory and administrative requirements are the top reasons for doctors to leave private practice and seek hospital employment.

Even when our doctors don’t actually retire, they continue to disappear. They disappear into administrative jobs and now they are busy supervising non-physician extenders. It is a given that if you take a hospital job, you will be required to supervise a non-physician extender as part of the job contract. Instead of a doctor, new patients are now routinely assigned to a nurse practitioner or physician assistant when joining a medical practice be it primary care or specialty care. If a patient questions this, the statement from Atlas Shrugged applies “Who is John Galt”?

So Is There a Galt’s Gulch For The Profession of Medicine?

For me the answer lies in the Free Market Medical Association. The pillars of the association are the mutually beneficial agreements for optimal economics. These principles can allow for the individual participants to mutually benefit from a proper and open market exchange for health care.