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Join guest Richard E. Anderson, chairman and CEO of The Doctors Company and TDC Group. We’ll delve into pressing issues shaping the future of U.S. health care, from the impact of AI-powered clinical decision support tools to strategies for addressing physician shortages and managing health care costs amid consolidation. With insights from a seasoned industry leader, we’ll explore the evolving landscape of patient care, liability risks, and the pivotal role of technology in shaping health care delivery.

Richard E. Anderson is chairman and chief executive officer, The Doctors Company and TDC Group.

He discusses the KevinMD article, “Harnessing U.S. health care’s resources to navigate the next decade.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Richard Anderson. He is chairman and chief executive officer of The Doctors Company and TDC Group. Today’s KevinMD article is “Harnessing U.S. health care’s resources to navigate the next decade.” Richard, welcome back to the show.

Richard Anderson: Thank you, it’s very nice to be here. Nice to see you again.

Kevin Pho: So Richard’s been on in the past. Go to KevinMD.com/podcast to search his name to see his story and prior episode. But today let’s jump right into your most recent article, “Harnessing U.S. health care’s resources to navigate the next decade.” For those who didn’t get a chance to read your article, tell us what it’s about.

Richard Anderson: Well, each year we at The Doctors Company take a broad overview of American health care and try and pick the trends that we think will be most significant over the coming year and the coming decade. And this recent article takes a look ahead over the coming decade at what we see as the most important trends in American health care.

Kevin Pho: All right. So take us into this report. What are some of those important trends that you’re talking about?

Richard Anderson: OK. Well, I think it’s very interesting, because as we look back over these reports, and just look back at American health care directly over the last few years, everything is moving in the same direction but faster and further. We’ve long since passed the tipping point on most of these trends.

For example, consolidation in health care. Burnout being a tremendous issue, exacerbated by the pandemic, the effect of the pandemic itself, but now the second generation effects of the pandemic, both on staff burnout, on long COVID, and, very worrisome, an erosion of America’s belief in science and discouragement with medicine.

Doctors and nurses and staff were true American heroes during the pandemic, and were truly operating under battlefield conditions, risking actually their own lives and families in order to serve. And there was a well-deserved halo effect.

But now fast forward a few years to where we are today, and that halo effect is gone, and it’s been replaced by two things. Number one, a real assault on science. I mean, there are some people who deny we even had a pandemic. So it’s pretty shocking.

But in addition, the exigencies of the pandemic response. Patients dying alone, that is, alone without family, in the hospital. The horrible early images of the pandemic, when we couldn’t actually even accommodate the bodies in respectful conditions. Those have lingered, and it’s a tremendous issue for us going forward.

So those are continuations of major trends. The digitalization of medicine, of course, now it’s well into its second decade, and it has moved along dramatically. We went from essentially virtually no electronic health care records to everybody has an electronic health care record. The problem with that being that great electronic health records are great, but most practicing physicians don’t like their electronic health care record.

Number one, they don’t like it as a record. But more to the point, they have become the clerical staff for the entire electronic health care record. And it’s one of the fundamental forces, not the only one certainly, but one of the fundamental forces that’s driving burnout. Most doctors end up, after a long day of patient care, spending after dinner hours completing their electronic health care records. Yes, it’s nice that you have access 24/7, but it’s not nice that you’re having to input data 24/7.

So I think those are all trends that have been here. I think the newest one that everyone’s talking about, and it’s not just in medicine, it’s really the most dramatic technology wave that I can recall, of course, is artificial intelligence, ChatGPT and the like.

And the promise is unlimited, the risks are obvious enough. And our legal system is uniquely incapable of dealing with this kind of disruptive technology.

But as Dr. Bob Wachter and his colleague have written dramatically about medicine in general, but about what they see might be different about AI in medicine, and they make several I think really important points.

That number one, this is the fastest moving technology that most of us has ever really experienced, at least moving on the ground. Number two, it’s amazingly easy to use. It’s basically plain language, it doesn’t require any coding skills on the user side. Inputs are plain language, the results are unbelievably fast, I mean shockingly fast. It doesn’t require any esoteric hardware. So the barriers to adoption or implementation are exceptionally low. They could hardly be lower than they are.

The question, of course, is, how good will it be? And we know that in some areas in medicine, particularly medical research, complicated genomic studies, things like that, the organic chemistry of biology, it’s unbelievably sophisticated and powerful, and we certainly would be optimistic about its ability to drive better therapies in that regard.

And it will also be helpful, I think, in terms of medical records. There are now two major commercial versions of this, there are many, as always, with anything in medicine, but there are two major ones that have been widely used, and with really high levels of satisfaction, where basically patient encounters are recorded in the background, the AI summarizes those and puts it in a format compatible with a traditional electronic health care record, saving physicians, nurses, and all clinical staff a tremendous amount of time. So those are certainly positive.

When I say I’m discouraged about the ability of our legal system to adapt, I mean, this AI is a truly disruptive technology. And you have physicians now in a world where more and more decisions will incorporate what an AI system is suggesting is appropriate care, a therapeutic pathway or diagnostic pathway suggested by AI.

And so of course we have the classic issue. If the physician follows the AI and it’s correct, great, no problem, everyone’s happy. If the physician’s judgment says the AI is wrong, and he or she chooses to follow their own judgment, and the physician’s judgment is correct, great, no problem. But where AI and the physician make different decisions or pathways and the outcome is negative, who takes responsibility for that? And of course, in our legal system we don’t know how to do anything except sue everyone.

And of course, having a huge faceless defendant, the large mega technology companies that are really driving AI today, is very attractive for the plaintiffs’ bar. On the other hand, it’s been pointed out that because the AI algorithms are generally quite opaque, it actually may make it harder to win a court case saying that the AI algorithm was the problem, because nobody will know exactly what the algorithm said or how it got to the conclusion that it did. So we will have a modern version of he said, she said, between algorithms and people, in litigating adverse outcomes.

So it’s an incredible technology, I mean truly. And certainly in my life, but I think in most of our lifetimes, it’s the most impactful short-term technology that I could ever see, and the potential expansion into the future is really unlimited, with enormous challenges but also great opportunities. But that to me is the biggest impact going forward. And I’m optimistic that the net effect will be positive. I am optimistic, but it’s going to be a long and winding road.

Kevin Pho: So I do agree with you in terms of the disruptive and transformative impact AI is going to have on our health care system and on medical practice. You are, of course, the chairman and CEO of The Doctors Company, which is the nation’s largest physician-owned medical malpractice insurer. So I’m interested in hearing from that perspective. Are you already seeing malpractice risk from doctors getting in trouble from AI generated decisions, or from these AI scribes, or any AI related cases that you’re seeing? Or has it been too soon?

Richard Anderson: Yeah, that’s a billion-dollar question. And actually, to my surprise, we’ve seen very few, if any, cases that are specifically where AI was central to the case. In part because in most situations today it’s operating in the background, really, and it’s been widely adapted for things like transcription, or creation of electronic health care records, for scheduling, for laboratory kinds of things and so on and so forth.

Whereas where it plays a role in clinical decision making, it’s a little less obvious. It’s not dramatically different in that regard. The technology is different, but the interface with clinicians is not dramatically different than the computer-based clinical decision support tools we had, let’s say, a decade ago and have been using since. Those have had some impact, but not much, and they haven’t become the subject of sort of separate medical legal litigation.

So no, at this point we aren’t seeing it as much as I thought we would, but it’s hard for me to believe that there won’t be a reckoning down the road.

Kevin Pho: Now, how are you advising your physician clients in terms of how to approach AI and reduce any potential risk going forward when they do interact and use AI?

Richard Anderson: Well, that’s, again, that’s a billion dollar question. And the answers are to some degree unsatisfying. The most obvious, but important, is to document everything. It’s document, document, document.

If you’re following the AI, explain your judgment. Whether you’re following an AI algorithm or you’re not following an AI algorithm, note your judgment in the chart. Make the chart reflect why you made the decision that you made. Broadly speaking, good charting requires that anyway. But here there’s sort of a second level of it. It’s not just your thinking, it’s, how did you incorporate this boldface recommendation from an algorithm, which may well end up being part of the electronic health care record itself? So documentation is very important.

The other issue for physicians, it’s tough, and that is a very challenging one, which is vigilance and deskilling. I put those two together.

If you’re in a situation where the AI is operating sort of side by side with you, and, let’s take radiology, radiology is a good example. So you have radiology imaging studies being interpreted by AI almost instantaneously. So when the radiologist is using them, he has a result from the AI right next to him or her as they’re interpreting the result.

It’s very difficult to stay vigilant when the system is pretty good. Even if the system is very good, it’s very difficult to make sure that you’re doing a thorough read of the X-ray itself. When it makes a call that you don’t expect, you have to really be sure, you look again to be sure. But if you don’t see it, or you don’t agree with it, you really have to document that, and you have to explain what the difference is. Or, as we often do with difficult clinical situations, ask a colleague for an opinion, get a consultation.

So I think the vigilance that’s required to work side by side with AI is one. And the better AI gets, the potential deskilling of physicians is also worrisome. And again, we’ve seen this with pilots. I mean, it’s quite true that an airliner can take off in New York and land in Los Angeles actually without the pilots doing much of anything. On the other hand, you need the pilot when something’s not working. But the pilots need to have their skills ready to take over in those situations. And again, that’s a similar challenge that American medicine will face.

Kevin Pho: So another part of your article that you talk about when discussing future trends is the physician shortage, specifically the primary care shortage, and the role of advanced practice practitioners in terms of filling that. So talk more about that point.

Richard Anderson: Yeah, thanks for that, it’s a great question. Physician shortages are a real challenge, and those are now hardwired into our system. In other words, we can debate whether by 2030 we’ll be 50,000 physicians short or 150,000 physicians short, but anybody who’s tried to get an appointment with a primary care physician in the last couple of years knows that there’s already a significant shortage.

And we also know what the choke points are. American medical schools have increased the number of medical school slots by 10 or 15 percent over the last decade. It’s not huge, but 10 or 15 percent is 10 or 15 percent. But the number of American residencies has increased almost none.

The net effect of that is that the residency slots that previously were taken by foreign medical graduates have been taken now by American medical graduates. OK, but it doesn’t increase the net number of practicing physicians in the system.

So projections now, pretty solid projections, say that over the decade between 2020 and 2030 the physician workforce will grow by less than 1 percent a year, which is far less than the increase in demand, with an aging population and with more procedures and more medications and so on and so forth. That’s the bad news, and I think that’s hardwired, and I don’t see any of that really changing.

The good news is that APCs, advanced practice clinicians, are present. They have been present for a long time. But nurse practitioners and physician assistants are growing at between four and six times the rate of the physician population.

And we will get to a better medical system if everyone is working at the highest level of their license. I mean, that’s kind of why you go to medical school. You don’t just want to do the stuff that’s really routine, you want to be challenged, you want to be of service, you want to be able to help your patients in a profound way. So it’s not a bad thing for physicians, it’s probably a good thing for physicians.

On the other hand, the economics of it is challenging. From an economic point of view, primary care practices are difficult to sustain economically even today. But if we strip away the low hanging fruit to APCs, and particularly to retail care, then what’s the economic basis of survival for primary care practices?

So again, from a system point of view, APCs will fill some of these gaps, but it will require a transition from the way medicine is organized now, and a very wrenching transition for those physicians whose practices are directly affected by these trends.

Kevin Pho: So what do you see as the path forward for these primary care practices? You mentioned that they have to undergo some wrenching decisions. So what are some potential possibilities for them?

Richard Anderson: Yeah. Well, I think for one thing, primary care physicians in the United States as a group are graying somewhat. If you look at the roughly million practicing physicians in the United States, we can argue about the number, but at The Doctors Company, for example, about 40 to 45 percent are in independent practices, either solo practices or small groups. Nationally that figure is probably only about 30 percent.

Primary care physicians who are practicing within a large group have potentially an easier road, although they’re constrained by whatever the requirements of the group are. They also have the resources of the group. They don’t have to worry so much about trying to figure out their own electronic health care system, and a lot of the paperwork, clerical stuff, to some degree gets done by ancillary personnel. In a solo or small practice it’s much harder to do that.

On the other hand, as the cohort of American physicians who are approaching retirement, and about one-third of practicing physicians in the United States are 55 or older, many of them who are going to move into groups have made that move. And so we’re seeing actually a declining slope of doctors making that transition, meaning that many of the doctors who are still in small practices have more or less decided that they’ll remain in those small practices until they themselves choose retirement.

So it isn’t going to be easy either way. Transitional generations are difficult. And my generation of American physicians, and the generation immediately behind mine, it’s a very difficult transition from the way we used to practice to the way we must practice today. It’s a very difficult transition.

The hope would be that doctors training in these new systems, with team medicine, with high technology medicine, with integrating retail medicine, and an economic system that is not based solely on throughput, will result in doctors who are comfortable within the system, have a better work-life balance, have to worry a little bit less about day-to-day economics of meeting a payroll and paying their staff and hiring and firing, and can devote themselves to the reason that everybody went to medical school in the first place, which is to deliver really good care.

Kevin Pho: We’re talking to Richard Anderson. He is chairman and chief executive officer of The Doctors Company and TDC Group. Today’s KevinMD article is “Harnessing U.S. health care’s resources to navigate the next decade.” Richard, during this conversation we talked about the impact of AI as well as the primary care physician shortage. With those topics in mind, let’s just leave our audience with some take-home messages that you want to leave with.

Richard Anderson: Well, my number one message, and hopefully I’m preaching to the choir with this message, medicine is still a wonderful profession. It’s a serving profession. I think for most of us, no matter what we did in the course of our lives, it’s the apex of our achievement, the apex of our satisfaction. And it’s actually, the practice of medicine is quite remarkable.

I mean, we sort of fear for humanity on a global level. On the other hand, human beings are the only species in the world that actually practice medicine. We codify medicine and study medicine and have true healing arts. So it’s a wonderful profession. That’s number one.

Number two, what makes it difficult are the practice environments in which good care is taking place in the United States, and elsewhere as well. These problems aren’t limited to the United States. Technology does have the potential for making it much better, which is good, because technology to some degree has actually made it worse. And it’s a little bit ironic that we’d be looking forward to something like AI to solve the problems that were created by electronic health care records. I mean, there is an irony there that I think we’re all aware of. But it doesn’t mean that it may not be the case.

So as I look forward, I believe in medicine, I believe in American medicine. I think we all believe in medicine. There’s nobody who’s saying, well, we need to just eliminate medicine, because we’ll all go back to roots and herbs and whatnot.

As we get through this transition, I think the promise of the technology, the promise of more reliable health care financing, which is really the core of the problem with American medicine, is health care financing. When we get to a system that does that more readily, that’s more equitable both to practitioners and to patients, we could re-enter a golden age of medicine. And I would be optimistic that that’s the direction we’re heading. But we still have some road ahead of us.

Kevin Pho: Richard, thank you so much for sharing your perspective and insight, and thanks for coming back on the show.

Richard Anderson: Thank you for having me. It’s a pleasure to see you.