I’ve carried many pagers in my life (literally, not figuratively).
As an intern in October 2018 working a month of overnight shifts at Cook County Hospital, I carried four or more pagers at once, one per surgical service. General surgery on my left hip. Vascular surgery on my right. Those were my two busiest, so feeling a buzz and hearing a beep from one side of my body helped me differentiate between the two. (For those curious, pediatric surgery and plastic surgery rounded out my Batman-esque utility belt.)
At County, pagers only showed a phone number to call back. Doing so felt like a choose your own adventure novel. Would it be a nurse telling me something simple like a stone-cold normal set of vital signs (“74 125/75 98 15 36.5”)? Or an emergent, life-or-limb threatening issue (“806’s left foot has no pulse”) that’d send me running down the hall? (Or perhaps everyone’s favorite? A consult from the ER about yet another patient who went abroad for cheap plastic surgery, only to fly home and Uber straight from the airport to the hospital.)
The page pictured above fits somewhere between those two. Many problems in health care are urgent, needing fixing sooner rather than later, but the house isn’t currently engulfed in flames.
Some health care problems require novel solutions. Hepatitis C (HCV) treatment prior to the approval of Sovaldi (an once daily pill, discovered by Pharmasset and acquired by Gilead prior to going to market) required 6-12 months of interferon injections with side effects so awful, few patients completed treatment. With a more tolerable side effect profile and no injections (NB: Never underestimate how much people will do to avoid a shot), Sovaldi and its subsequent combination therapies revolutionized HCV treatment, preventing countless cases of cirrhosis and the need for a liver transplantation.
That’s a problem of novelty. We needed a new drug to do that.
But other health care problems don’t require something novel. Your six-year-old wheezes too often and has poorly controlled asthma. But there’s a four month wait to see a pediatric pulmonologist two hours away. We already know how to treat asthma well with the therapies currently available. The system just needs more providers in the right locations and the correct generic inhalers at your local CVS or Walgreens to do so.
That’s a problem of abundance.
Both problems are rarely life-or-death at any given moment:
60-70% of people infected with HCV will progress to a chronic infection without treatment.
Of those, 15-30% will develop cirrhosis within 20 year.
There is an acute form of the disease, but its worst effects are chronic, to the point hepatologists and infectious disease specialists held off treating asymptomatic patients with interferon in hopes of a more tolerable and more efficacious therapy.
Most people with asthma (myself included) will never be admitted to the hospital for it.
Each year, 6% of kids age 4 or younger and 3% of age 5 or older require hospital admission for asthma. (The prevalence of asthma and the quality of outpatient treatment varies greatly based on socioeconomic factors and racial identity.)
Clearly, both end stage liver disease and a severe asthma exacerbations are life threatening, emergent conditions. But when considering all patients with either HCV or asthma, I’d call them “urgent not emergent.”
Likewise, many problems of abundance are similarly urgent.
Overall, two public intellectuals have influenced my thinking about the concept of “abundance”.
Ezra Klein is a columnist and podcast host for The New York Times. But I’ve read his work since his days at The Washington Post’s Wonkblog and listened to him on podcasts since he hosted Vox’s “The Weeds”. (All the OG and even the second generation hosts are now elsewhere. And the same podcast feed has transformed into a show named “Explain It to Me.” No idea what that is. Please see these links to two great episodes about rising health care costs and rising health insurance costs. Super nerdy.)
Derek Thompson was a longtime writer for The Atlantic who moved to writing his own newsletter last year. He once hosted the podcast “Crazy/Genius” but now hosts “Plain English”. Since I shared two episodes above, here are two of my favorite episodes of his: “Why Did Stanley Water Bottles Suddenly Become a Cultural Phenomenon?” (As someone who uses really only one shaker bottle, this blew my mind.) And “Is Old Music Killing New Music?” with Ted Gioia. (In the four years since this episode, I have made a purposeful effort to list to new songs but know I am bad at listening to new artists.)
Together, Klein and Thompson wrote the book “Abundance” in March 2025, but the themes and ideas in their book permeated their writing and podcasting years before, covering building more in many domains: housing, clean energy, infrastructure. When discussing health care, they focus mainly on topics such as “How is NIH funding biased against scientists taking risky bets that could generate amazing new drugs?” or on how the speed of new discovery depends on many policy choices. (Operation Warp Speed to create mRNA vaccines for COVID-19 proceeded much faster than any prior drug development process.)
Those are extremely valid questions, ones I hope people fix. But I am going on focus on three other areas drawn from my personal experiences in clinical medicine (over two or three articles, in an effort to keep each a semi-readable length):
Producing more providers (including, but not limited to primary care)
Placing those providers in the necessary places (geography lesson)
Providing them with enough supplies to do their jobs (even if the supplies are old, boring, and off patent)
Clinician shortages exist in (almost) all health care professions, especially post-pandemic when a larger-than-otherwise-expected percentage of the workforce left health care jobs.
Unrelated to the pandemic, Baby Boomers made up a large percentage of the health care workforce. They are now retiring from the workforce AND are utilizing more health care. Even if a similar proportion of subsequent generations enters health care, that influx is a lower absolute number of workers due to smaller generational cohorts at a time with rising demand due to the larger size of the Boomer generational cohort. (Shortages in the pediatric workforce have some overlapping and some different origins.)
For physicians (the training pathway I am personally familiar with), we graduate from medical school (Undergraduate Medical Education - UME) and then first specialize in residency (e.g. anesthesiology or internal medicine). After completing residency, some physicians enter practice (e.g. a general pediatrician or a general psychiatrist) while others pursue further training in a subspecialty fellowship (e.g. pediatric anesthesiology, gastroenterology, spine surgery). Both residency and fellowship training fall under the umbrella of Graduate Medical Education (GME). The overall number of Graduate Medical Education (GME) spots depends primarily on federal government funding from Medicare via two sources: Direct and Indirect..
Direct GME funding is a subsidy for trainee salaries and benefits, affiliated faculty costs, and program administration and depends on the number of trainee FTEs (full time equivalents) a hospital has (among other factors). Indirect GME funding is a increased percentage for each Medicare payment to a teaching hospital when paying for clinical care (relative to what a non-teaching, community hospital receives).
A Medicare bill in 1997 capped the number of FTEs eligible for direct funding. Residency positions are most frequently funded directly as 1.0 FTE positions, but fellowship spots are often 0.5 FTEs per trainee (meaning a hospital must pay for the other 0.5 FTE). Hospitals can add additional residency or fellowship positions beyond their allotted, directly-funded number if they desired, but they must bear the full cost of the position. Some chose to do so because it was at times cheaper than employing an additional advanced practice provider (APP) such as a nurse practitioner (NP) or physician assistant (PA)1.
Hospitals must consider the training of these residents and fellows when deciding whether or not to self-fund additional spots. They must have sufficient case volumes for each trainee to ensure they receive appropriate clinical training. (For example, a pediatric anesthesiology fellow must provide at least ten anesthetics to kids undergoing major neurosurgical procedures.) Paying for another trainee may have a positive NPV in isolation, but the training component also matters greatly.
Medicare rarely dictates how a certain hospital distributes its GME positions. For example, the hospital where I completed my residency increased the number of residents in my anesthesiology class relative to prior years. To make that possible, our hospital cut the number of general surgery preliminary intern positions. Thus, my class had three or four surgery rotations during our intern year, compared to only one rotation in prior classes. We needed to make up the clinical work of a couple surgery interns. (It’s how me and my Batman-belt of pagers ended up spending a month on surgery “night-float” over at County.) Medicare told the hospital how many funded positions it got, not how to use them.
The percentage of patients on Medicare at the specific teaching hospital serves as a multiplier for direct GME funding (separate from the increased payment via indirect funding). Reasonable for an adult academic center, but not great for a children’s hospital with almost no Medicare patients. (Never say never. Being on dialysis due to permanent kidney failure can get you Medicare coverage regardless of your age. A small number of kids meet that qualification.) Children’s hospital instead receive much of their funding via the Children’s Hospital Graduate Medical Education (CHGME) program.
Unlike Medicare-financed direct GME, CHGME depends on annual Congressional appropriations for its funding (and we all know how smooth of a process that is). CHGME payments are neither mandatory nor required to grow with inflation, as Medicare direct GME payments are. Ultimately, children’s hospitals receive ~38% of the per trainee payment as do adult medical centers, even though employing the trainees and their supervising attending physicians costs no less.
As children’s hospitals receive a disproportionate amount of their revenue from Medicaid, they often have lower margins than adult medical centers and greater difficulty offering advanced training opportunities. Further, such reliance on Medicaid funding results in overall lower salaries for pediatricians and pediatric specialists.
None of us went into pediatrics because of the money, but reimbursement and salary make a difference on the margins. A medical student interested in cardiology may choose internal medicine and adult cardiology over pediatric cardiology. Likewise, a pediatrics resident may pursue general pediatrics over pediatric infectious disease because the pay as an attending is comparable, but an ID fellowship would mean three more years at a trainee’s salary. (Time value of money and compound interest, people!) Ask any children’s hospital CEO or president: one of their greatest worries is adequate staffing (at all levels, not just physicians, because pediatric NPs, RN, respiratory therapists, etc. all require extra training and on-boarding). Finding pediatric specialists can be an even greater challenge than finding general pediatricians!
Some medical schools have increased their enrollments because of these shortages, but doing so will not affect the overall number of practicing physicians without also increasing subsidized residency positions further. (Many well qualified international medical graduates (IMGs) apply for and receive US residency positions due requirements for completing GME in the US to obtain a license. Medical licensure is a state-by-state process, so exact requirements differ slightly. Increasing US medical school graduates often decreases the number of IMGs accepted into residency programs.) Government funding has gradually added subsidized residency positions over the past five years, some specifically to needed areas like primary care or psychiatry, but hospitals that have self-funded more positions often use that money to offset those costs, resulting in fewer net positions than expected.
To fix physician shortages, we need to start by taking several steps:
More (federally) subsidized residency positions; with or without restrictions on what specialties a hospital can use them towards
Improved (state-by-state) pathways for foreign trained physicians to qualify for medical licenses. It is reasonable to require testing or observation for assessment of clinical skill, but requiring all to fully repeating a residency isn’t.
Equal funding for pediatric training programs relative to adult training programs that is mandatory and benchmarked to inflation
We’re not only short on physicians… we’re short on everyone.
According to the American Association of Colleges of Nursing, applications to RN programs increased by 7.6% in 2025, but US nursing colleges turned away nearly 100,000 applications because of an insufficient number of nursing college faculty to teach and precept students.
So interest in the profession remains… but so do exits. Nearly a quarter of nurses plan to leave the profession within the next five years. The American Nursing Association reports the main causes are: burnout from long shifts, high patient-to-nurse ratios, a feeling of being undervalued, and bullying.
Shortages exist on the Advanced Practice Provider (APPs) level as well: NPs, PAs, Certified Registered Nurse Anesthetists (CRNAs), Anesthesiologist Assistants (AAs; most people have never heard of them, so think PA style training but for anesthesia). In this day and age, health care is a team sport; physicians are not the only players in the game. We need more members on the team to adequately take care of patients with each working up to the highest level of their training.
Like with physicians, RNs and APPs who work with kids need extra training. They often have a longer onboard process when starting a new job and require additional in-service education. One reason (of many)? Kids come in many shapes and sizes. A newborn is very different from a 16 year old teenager: physically, physiologically, emotionally. Staying prepared for that isn’t easy.
We’re even short on phlebotomists, the “vampires” (as some patients call them) who come around and draw your blood. Why we’re short makes more sense when you think through it.
Phlebotomy training courses last 5-6 weeks. Some graduates will get jobs in clinics or lab centers (e.g. Quest Diagnostics). But many will work in hospitals. And do you know one of the most popular times to need labs drawn? 4:00 AM. (If you’ve been a patient, you may, unfortunately, know that.) But do you know why we often order those early, early morning labs? Once drawn, the technicolored vials take a ride via the tube system to “the lab,” where diagnostic techs run each lab: CMP, CBC, CRP, etc. Ideally, those lab results arrive before morning rounds so the medical team can make decisions for the day, ordering appropriate follow up studies or consults early enough in the day, lest you wait around another day for those. Thus, we need more phlebotomists working between 3:00 AM and 6:00 AM to draw all the those labs! Not most people’s ideal time to be at work. But given the clinical need, do you pull second shift phlebotomists and schedule them for the early AM shift?
One recently approved solution is a robot to draw your labs with multiple robots supervised by one phlebotomist2. Company sponsored surveys suggest patients are open to trying this, but can robots (even AI powered ones) replace health care workers? Maybe. A robot may be a perfectly capable of assisting or augmenting RNs at the bedside (e.g. used as a tool to assist in lifting patients, allowing for 1-2 RNs to do so rather than 3-4), but people frequently want another person to be the one caring for them or their loved one, especially when it involves intimate or highly emotion moments.
Health care is not only physical touch, but also emotion and empathy for what are some of the most challenging times we face. You can only outsource so much of those crucial elements to a robot or a computer.
The reasons I listed above for why nurses leave health care apply to nearly all domains and specialties. Caring for critically ill or dying patients is stressful, but those patients will always exist. I don’t have a great solution for that. But if the problem is burnout due to patient volume overloads and long hours, then the solution is to assign each provider fewer patients, to schedule them for shorter shifts, or to require fewer total hours. Doing so would require a health system to hire more providers, who we’ve established are already in both short supply and high demand. Not an easy task. Making individual providers less productive increases the costs of an already expensive health care system.
Except, our system already pays a price for these shortages. Turnover of physicians costs an estimated $4.6B per year as health care systems spend more and more to recruit, interview, relocate, and onboard new physicians and while also losing revenue when short physicians (i.e. “business school speak” for patients facing delays for elective but necessary procedures because of staffing shortages). Now add in similar costs for nursing shortages, estimated to be between $3.6M and $6.5M per hospital per year (for a national total in the billions).
The “newsvendor model” from all introductory operations classes frames these problems: what is the ideal ratio of overage and underage costs? Is your greater risk spending too much for excess capacity you are not using fully or is it spending too little, resulting in net loses and forced throughput reduction?
In all areas of business (not just health care), it is easy to calculate what a 15% increase in salary expenses costs. More difficult? Calculating what it’ll cost the organization if you maintain your current benefits but lose just the exact wrong people as a result.
Several different managerial considerations come into play at this point:
Shifting those longer term loses to upfront costs in the form of increased salary expenses or less demanding staffing schedules is challenging for hospital executives. In a 1% margin hospital, suddenly increasing your upfront, recurring staff expenses by 15% because doing so will save you 25% long-term may not be possible. Perhaps, what is instead possible is first focusing on your bottleneck providers, the ones who if they drop below an minimum number, you’ll face a disproportionate drop in throughput. (Drops elsewhere may not change throughput unless the bottleneck changes.)
For example, I care for many kids undergoing open heart surgery. A necessary provider is the perfusionist, the person actively managing the cardio-pulmonary bypass machine during surgery. Cardiac surgery (for both adults and for kids) is a high margin service line in busy centers operating above a certain annual volume (due to high fixed costs to support the program). For as talented as cardiac surgeons are, they cannot do their job (and generate the margin that supports other clinically vital but less profitable service lines) without a perfusionist. If a hospital has a borderline number of perfusionists and losing a net of one would result in a severe drop in cases performed, then the best managerial decision would be to increase the pay and benefits specifically of the perfusionists3 rather than risk being understaffed.
Photo Credit: https://www.akronchildrens.org/inside/2014/09/12/a-day-in-the-life-of-hospital-perfusionists/ A hospital may apply a similar approach to specifically ICU nurses if a lack of night nurses, not a lack of patient beds, is the main cause of ICU patients waiting in the ER or the OR recovery room.
Someone currently working a 1.0 FTE job who requests a change to 0.75 FTE should accept a corresponding decrease in pay. (NB: Hospitals may fully benefit any employee above a specified FTE percentage, for example 0.7 or 0.8. Dropping from 1.0 to 0.75 FTE may not change the cost of those benefits to the employer.)
Managers may be hesitant to grant such a reduction in FTE, even with the corresponding decrease in compensation. They need a certain number of employees each day to maintain throughput. But if the employee making such a request is truly willing to leave absent the change in FTE and would be difficult to replace due to overall provider shortages, then the manger must recognize the choice is between 0.75 FTE and 0 FTE, not 0.75 FTE and 1.0 FTE. A slight reduction now hurts a little, but as stated before, a larger reduction via attrition hurts more later.
Hospitals can apply a similar focus to increasing trainees. Just as focusing on perfusionist or ICU nurse compensation and scheduling can have an outsized stabilizing effect, so can increasing trainee positions in specific specialties.
For example, a children’s hospital short on oncologists could elect to self-fund an additional pediatric hematology-oncology fellowship position. Ranking in-house or local applicants highly and then filling that spot with someone likely to remain after fellowship decreases the risk of being understaffed. The payoff is years later, slower than retaining current staff.
This theme of “increased upfront costs resulting in longer term system stability and/or savings (or improved outcomes)” will appear again and again over the next two categories where we need health care abundance: the geographic locations where providers practice and our ability to supply them with the right type and amount of equipment.
Ideally, small upfront increases in targeted expenses can stabilize revenue and decrease long term expenses. However, stabilized but flat revenue cannot support increased expenses for long if the long term expenses associated with turnover do not subsequently drop. In those cases, we need to rewrite the rules of the game to stabilize the system. It is out of the hands of the hospital managers.
I’ll explore all of that more in Part 2 of this post.
Residents received their title in the early 1900s at Johns Hopkins because they actually lived in the hospital. Now, they face some “duty hour” maximums which equate to 80 hours and one day off per week averaged over four weeks. I highly recommend the book Let Me Heal: The Opportunity to Preserve Excellence in American Medicine by the medical historian Kenneth Ludmerer for anyone who wants a real deep dive on the structure of and changes to medical education in America.
Thank you, Dr. Michael Evans, for bringing this to my attention. You’re welcome to try and cite this mention of you in your C.V.
Hospitals often note compensation as a percentile relative to the specialty or job. (e.g. Salary is at the 60th percentile.) Going above a higher percentile is possible and certainly justifiable, but doing so may require very high level approval as it opens up the institution to additional IRS scrutiny. Accounting choices are not black and white, and the IRS could disagree with a reasonable choice. Thus, hospitals may have some hesitancy going above a specified percentile relative to expected workload. More on that later.
Really enjoyed reading this dive into an area quite foreign to me, Mike (and see OR lingo used effectively!). I am curious - where (if anywhere) have you seen efforts to implement solutions similar to those that you have suggested? I can imagine 1.0 —> 0.75 FTE transition being, perhaps, the easiest one to implement from the standpoint of organizational mechanics. Is that the case?