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Speaker 0: This is Scott beck with the becker health care podcast. And I'm thrilled today to be joined by 1 of our favorite guests. We're joined today by doctor. N Mehta. And in Doctor Meta, aside from being a physician, that runs a sort of business called physician side gigs, which is a community about physicians, they're are involved in things besides just medicine. And and it seems like every conversation I have today with physicians. Typically physicians are thriving and and happy. They're doing something in addition to their core business. And obviously, there's there's all kinds of examples systems. There's people like doctor David Fe, who a hundred years ago became a hospital, Ceo and now as Ceo of Oracle Health. Sort of the ultimate side gig operating medicines he's in the side gig. But then there's also sort of seemingly a hundreds of thousands of physicians, and doctor Meadow of a better sense of this, and involved in their core practice, but also doing something else. That could be business leadership in health care But it could also be a billion other things. And I wanted to talk about sort of what's driven that is it driven by necessities are driven by avoiding burnout, what drives this interest and physician side gigs. If you other think Doctor Met, I'd love to talk about is, we're obviously moving towards this daunting take shortage of physicians, We've got this situation with more and more physicians are moving towards part time by the time they're 40 or so, which leaves us with a, a further math problem. Not in the physician hours to deal with the population we have, But but how do we solve for some of those things as well, obviously, you can't tell a physician to do or not do something and nor do we want to, but we do have to create more physicians. Don't we. So 2 big questions. Is there a huge explosion in physician side gigs? And and and 2 is, how do we deal with this shortage that we have? How do we deal with those 2 things? Speaker 1: Absolutely. Well, Scott, thanks as always for having me on the podcast. I am excited to talk to you about some of these topics. It is really interesting. How much the growth of side gigs has taken off over the last few years. And it's funny because when we first got into this space, you know, we started with a group of less than 10 people and now we're at close to 200000 physicians on our communities. And when people had asked me at the beginning is we were growing and we hit those 45000 people were saying, why is it the doctors need a side gig? I was like, it's not that doctors need a side gig? It's really just something else that they can do another part of their brain that they can use, Maybe they get the tax benefits that they don't get with employed positions. Maybe it's that, you know, they wanna be able to scale back a little bit clinically and be able to supplement that income. Maybe it's said they have student loans hanging over their heads and so they're just trying to, you know, get those out of the way a little bit earlier. And so it was it was not so much a need as much as it was a want for most people. And I think the interesting trend over the last few years has been more and more, like, people feel that they need a side gig, which is which is both interesting and kind of depressing, because obviously, we we go to med school for a long time, and I don't think any of us goes to med both thinking, hey, we're gonna practice part time where we're gonna need to supplement our income. But I think that so many of these changes in the health care landscape, it's really nec this need for physicians to kinda think outside of the box about their careers. And I think 1 of the things that Side gigs to is give physicians leverage. Right? Because it gives them another revenue stream to be able to say, hey, this is really burning me out, I wanna be able to cut back clinically. Or as healthcare consolidation kind of drives things to... More of a business mindset of the employers, a lot of the employers have started to play hard ball with contract negotiations, and the physicians are starting to say, hey, we need leverage at the negotiating table, We need the power to walk away if somebody offers us a really bad contractor asks us to do something that we're not comfortable doing or that we feel is not in line with the standards that we wanna practice medicine at. And so there's starting to see side gigs as not just this extra bonus thing that they do on the side to kinda have something fun and, you know, make a little bit of extra cash or use a different part of their brain or just be involved in health care on a greater level. All of those things I think still apply to why doctors want to do side gates. But really now they're also starting to say, I need a plan b because plan a is starting to look more and more grim, which is a little bit scary. Speaker 0: And and let me ask your a question about the compensation side of all this, not on the side of side, but on the core traditional physician side. It seems like there's such a shortage of physicians that physician should be able to do economically. Why is the supply and demand rules don't work in healthcare like this. Should. What why is that? Speaker 1: Yeah. So that's really interesting. And we've been diving deep lately because we do do our own compensation databases within the communities, not... Dissimilar to what an Mgm a and, you know, some of these other databases too. But we go into a lot more detail about them in terms of, you know, what benefits are being offered, What what do people's jobs look like? How hard are they working for that money. And it's not the physician compensation hasn't gone up. It actually actually has been going up a little bit over the last few years if you look at our data. The problem is is number 1 is it keeping up with inflation, but number 2, also, how hard are you work king for each dollar that you are making. And I think that's the big difference. So it's not that the salaries haven't gone up, a lot of it is that that that marginal amount of work that you have to do to earn that extra dollar is just so taxing in the way that these compensation structures have been set up. The people are saying, you know what? I don't wanna see 15 extra patients in a day so that I can come home with 5 percent more money. And so you're starting to see people saying thanks but no thanks. To a lot of those compensation structures. And and I think that that eventually, as these shortages amplify, I do think that applying and demand curves are going to start to shift in the favor of physician compensation going even higher because everybody knows you need doctors, and there's just less and left of them. So already, we're starting to see signing bonuses going up. We're starting to see some of those recruitment incentives in terms of just staying, retention incentives rather. Starting to be a bigger part of these contracts and and giving a little bit of extra bonus money, but I think the problem is is that in the business world, you kinda think everything can be solved with money. And in the physician world, you know, once you achieved a certain level of baseline happiness. It's not necessarily about how much money you earn. And it's about how much fulfillment and how much happiness you have and your day job. And has the forces that are eroding away from that satisfaction with the doctor patient relationship are just getting worse and worse. You're seeing more and more physicians saying I don't need extra money, but I really do need to be happy. Speaker 0: And and let me ask you the question about on the compensation side and physicians just see the supply demand curve. We certainly see more and more communities that it's very hard to get a primary care physician for example, in Florida, if you want a primary care physician under an intern, trying to get 1 outside the concierge system has become increasingly challenging. It... And as a physician. You understand this, you're getting whatever amount of money up front each year, you're you're almost handling your your your core, economic, not through concierge practice and fees, and then you're billing for services, and in God bless. But debt relief, if you talk about a a health equity problem. Speaker 1: Yeah. It's a huge 1. Speaker 0: But there... But there's no way around it because if you're a physician you're ultimately your own business, and, you know, if... And and there's not enough of you, does, you you could be in the concierge business and it's become really expensive and it really means that you're not. If you can't afford the concierge fees in certain parts of the country, you just don't have a primary... Very hard to a primary care decision would. Speaker 1: Right. And I think that we're moving towards the system where we really are increasing in equity within the system because of you know, who is being... Who is taking what kinds of insurance who is walking away from an insurance based model, and just how many physicians are leaving, and therefore, having a lot more people being seen by non physician practitioners within healthcare care. I think it's it is really, really scary. And it's, like, you know, we've been yelling about this for years it, and I just, you know, the number of physician residency spots has not increased significantly. There's all these these things that, you know, we've been pushing for for years now that I think everybody just kinda thinks these problems are gonna solve themselves, or maybe maybe they just feel like they'll be out of healthcare once it becomes not profitable, But for from a public health standpoint, it's really terrifying what our shortages are showing. And then you see these these policies, you know, I'll tell you, Scott 1 of the policies that I'm looking at right now is a lot of insurance companies trying to change the way that they do the modify 25 code reimbursement, the when it comes to, for example, So if you go and you see your doctor for a screening examination, and they're able to biopsy something at that time, it's always been that if you added a modi or 25, you would get paid both for the screening visit and, you know, the diagnosis that you... And the diagnostic exam, that you performed or the procedure that you performed to take care of that problem. And now you're seeing in short insurance companies trying to, you know, squeeze on an extra ounce of profit and really take advantage of the alt of physicians and saying, well, they're not gonna make those those patients come back for another appointment. So why don't we just pay them half for the screening exam if they do, anything else. And so what you're seeing is practice is saying we're not sustainable. I mean you you guys are cutting us in every different angle. And pretty soon. We're gonna have to start telling patients like, sorry, even if we are willing to reach, you know, re refinance angle our schedule so that we can actually do this biopsy. So you don't have to come back a second time. Now your insurance company is telling us we're not gonna pay for this. You know, for this original visit that you had in full because now we've added something else on, and so, unfortunately, now you're gonna have to go back into the line for an appointment, you're gonna have to pay another c, and you're gonna have to come back. To have this procedure done. Right? And then you think about an equity and who comes back and who can afford to pay the other c and who maybe, you know, falls off the screening list because other things in their lives take over. And again, you just start seeing the system that just continues to perpetuate in equity, but but everybody's profits over patients, which is just frustrating. Speaker 0: And so Doctor Meadow. Where do we end up in this? Is this because ultimately Congress, they don't have the same access problems at the rest of us habit, but they're they're extended families must. I mean, because it's... So clear we need more residents to us work. Doctors where everything. I also solve itself. Because not gonna solve itself, how do we solve this? Speaker 1: You know, I... The cynical part of me says that everything crashes and then people fix it, and people don't have the incentive to fix it until it's already dire, And and I think those us that are in health would argue it's already at that point, but maybe you know, those outside of healthcare care, I haven't seen it spelled out for them. I mean, if you think about the things that insurance companies and payers are able to get away with right now, know I mean, can you imagine a system, for example, with that modi or 25 code. Can you imagine going to a restaurant and ordering... You something, and then asking to pay half for for the second thing that you order because you've already paid the fees for being there and and for taking up a table. So now you're like, well, I already ordered a salad and paid full price for that. So now I should be able to order the stake and pay half price for that, and you're kind of, like, I I mean, this this these kinds of things don't exist in other business models. And yet, I everyone wants to squeeze every ounce of profit that they can out of health care systems and out of physician practices. And at some point the system just breaks, and you know, right now, if you look at who's got power and who's got the year of congressional leaders, a lot of times it's businesses. And so, the insurance companies obviously, have a stronger lobby than a lot of physician, you know, individual physician practices certainly and even collective. Physicians. There's less than a million practicing positions in the Us So how are you... You know, how can you compete with those those sorts of forces, and I think until we have patients that are really standing up and saying this is not okay. I... So part of what I feel like we need to do is just better educate patients on what's happening and get them to advocate because, I do think congressional leaders are going to pay a lot more attention to what patient need say and what their experiences are and their delayed diagnoses and their, you know, bad outcomes that happen. That... Those are gonna be, unfortunately, the stories that need to be told and those of us in healthcare are watching that wrecking ball happening and can't and just feel a lot of times powerless to stop it. Speaker 0: And so we've talked about sort of Speaker 2: the this the situation in healthcare where access feels like it's at a breaking point. The insurance companies seem to be cram down physicians so hardcore core that they've almost left physicians at a breaking point. Like, in any business, there's always sort of easier and harder ways to make money. And if every single dollar makes has to be a brutal tower. It just makes it a very career. And 1 thing things about health care is every single 1 of us our consumers as well as, you know, somehow or another touching the system. But even for consumers that are doctors in the old days it used to be very easy for a doctor to get preference into other doctors to get access to get all access and needed. In But even that we're seeing getting harder. And so think about that, If it's harder and harder for a physician to get special access with their family, their relationships with their people. Think about how challenge it must be for the average American. And and and and there's there's no way to really fix this without us creating more doctors, quickly is there. I mean, just I I don't see a way around. This my obviously there's left Nba They'll help. But at the end the day, we need more doctors don't way. Speaker 1: Yeah. I think at the end of the day. I mean, even out, a lot of how... You know, we've got these 2 groups physician side gigs and then we have physician community, which is just an online... Virtual doctor's lounge. And and our doctors all the time are using that community to to help, you know, get appointments for friends and family and for themselves, to get people in because these wait times are just getting so ridiculous. And I think that to your point, I mean, if doctors are having to do that in order order to get seen with those kinds of connections, then everybody else is just, you know, kind of at mercy to the system, and And that's really terrifying because you just think about how many things are getting dropped and how much preventative care is not happening, and and, you know, every time you set up barriers. To people being able to see people health outcomes get worse. And I think that, you know, we're already at a place where we spend so much on health care in this country and yet our health out comes are are really sub par compared to where we should be as a nation and and compared to what we spend and and where, you know, the Us and some interest industrialized country. And so, you know, if you can never... You're you're not increasing doctors in any capacity right now, what you're seeing is a net loss of every every physician that's retiring right now is replaced by a physician who statistically is going to work less hours in their career. So it's not even a 1 for 1 switch out even if everybody stays in met in. Right? And then you compound that with the number of physicians that are leaving. Like, in recent years, we've had anywhere, you know, we've had 10 percent of physicians leaving the workforce single year. And and if you pull physicians, 25 percent of physicians are thinking about leaving medicine within the next few years. So the the numbers problem is just amplifying more and more. And I think until you can find tangible solutions to physician burnout until you can compensate physicians appropriately until you stop trying to squeeze every ounce of productivity out of them, to the point where they burn out and just say, hey, this isn't worth it anymore. I think that is actually, like, something that a lot of business people who come into Meta and don't realize. Right? Because they're used to working with these so called Cogs in in these other business models where where they rely on the fact that those people need jobs and and the financial trajectory of a physician is very unique in which that first decade of practice, yes. The physicians desperately need to repay all of their student debt. But then within that second decade of practice, they hit a point where if they could live with less, they really can retire. And so any year that they spend after that is spent because they actually really enjoy the job. And if we can't... To a point where we're letting people enjoy the job, we're gonna see more and more people leaving early. And if we don't do something to number 1, address, get the causes that they're leaving and then number 2 rep repeat the pipeline and actually expand the pipeline to having more physicians. This number problem is gonna get worse and worse and worse. Speaker 2: Yes. No. I think there's so many pieces there. I I start with the big piece that you mentioned. We have we have a... Hours and numbers problem, meaning you've got more and more physicians going part time, because they can, because they want to or for a million different reasons and god bless them, but that leaves the amount of hours available from physicians pure our population, which is growing at just a really frightening number and pricing number. I you a couple of these things differently. I I don't believe business people in every sector, at least ones that are good at it, understand that their people aren't cogs and their commodities You wanna keep around a good team for a long time, you've gotta make sure you're working life and working with them in a way that works for their lives and so forth. If I I think it's it's a it's a much deeper problem than business people running these things being shorts sighted ed. I think many of them realize that you hear more and more business people saying, I got 30 different nurses, every single 1 of them working a different schedule or 20 years ago I wanna would have wanted all of them to work at least 30 hours a week. Now you've got people working a tons of a job a quarter of a job, and and many people just realized there's no choice around that, but to give them that kind of flexibility if they wanna staff, they wanna stay out. I'd I I think it's it's much more a Washington problem and residency problem and a 80 in a a guilt system problem. We've got so many issues with this. The medical education was developed before the Internet. We've got 50000 people trying to get a that medical school a year, about 18000... Start medical school year to 20000 start a year. We granted about 25000 a year, some but we lose about 25000 a year, and and and you're absolutely right. The 25000 that we gain, the stat, half of them will be working part time by 40. And I don't think you're gonna change that with a better work environment, a worse work environment. I think there's a lot of people that want that balance life. And I don't think Doctor might the thing Would disagree with you honest. I think that's different in other aspects of of the world either. Like, when when companies now say to people, you have to come back to work full time and work in your office. What happens is companies can't do that as hard as they like to because people won't do it because people have lives outside their outside their work. I mean, certainly, if you went back, 40 years ago and physicians all work 80 hours a week, you know, and they were building on entrepreneurial practices in small towns. It's just a completely different world today. Where half the people coming out our raising families as well and they're the principal person take care of the family as well as taking care of the the practice. It's just a very different world, and I don't know that the the biggest issue to me is just a numbers issue. I mean, obviously, you you you get being down by insurance companies a lots. Other the otherwise, there's no question about it. Right, we don't have nearly the amount of doctors. We have our doctor hours we need. And our our medical education system was built for your project for the Internet. And, annoying to me or irritated to me, is there are plenty of countries that produce fantastic doctors in a quicker period time than we do. Speaker 0: Mh. But I mean, that to Speaker 2: me is, like, it's just eye opening, we've got some sort of guild system, the the the, you know, if you look at certain countries, they could bind the residency and medical going 5 to 6 years versus 8 years that we have, you know, and they produce very good doctors. And I don't think Washington should spends time on this issue. It's not... It's not a sexy issue. How do we produce word actors, and it's not a fun issue and it's sounded politically, it's not even a politically controversial. We all know when you more doctors. Speaker 1: Right? Yeah. No. I mean, I I think you and I... Are probably on the same page about a lot of these things in terms of some of this is just a generational shift and and a demographic shift in who the... The average physician is these days. Right? 50 percent of meticulous into medical school, a little bit over 50 percent of mat into medical school or females. Who statistically are very different, and demographic are very different than their male counterparts. But we're also seeing our male counterparts also saying the same things, in terms of, hey, Like, you talk about wanting to make your kids soccer game. I wanna make my kids soccer game too. And part of that is as the culture shifts it's becoming okay for everybody to say, yes, I'd like to have a little bit more of a life. I do think that on the communities, I see a lot of... Straw that broke the camel back moments where people make that shift to saying, hey, I can't work these hours anymore, and those tend to be related to frustrations within the system. You know, doctors have always worked really hard. But... And and that was kind of something you signed up for. You knew you wanted to do that. You knew that you kinda came in with a calling. And, yes, some hours have been reduced because it's become culturally okay to say, hey. I don't wanna work that much But I do think that there's a lot more people that are having this sort of is it worth it conversation, and money, you know, before you didn't have anybody asking, is this worth it. And so if they were cutting back, it was really because they had a significant... Competing interest. Whereas now, a lot of times people are saying, there are so many other things I could be doing with my life. But the only reason I'm thinking about those things in my life is because I'm not as swift failed in as happy doing my primary thing anymore. You know? And I always go back to, you know, the stories of my dad, practicing cardiologist for over 40 years And, you know, to this day, I can walk into the mall there, and people will recognize me in the small town and be like, oh, your debts... Saved my life. Your dad saved my mom's life, whatever. And it was just a very different feel practicing medicine, and I think there was a high associated with the sort of feeling of of fulfillment that you had done so much good. And and I think that that was something that drove people to really want to spend as much time as they could making a difference? And now there's there's this question of, like, am I making a difference? Am I just doing with the insurance? Speaker 2: That that I can do and and talk about that. Because I think your point there is social important, and and it does transcend other professions as well But your point is so well. It's so important because you have a physician that at 1 point had a regular patient phase or at least had longer episode people, wasn't treated as a commodity that sort of fill the spot, sort of, you know, you know, just a piece it fill the spot, but was deeply involved in their patient's lives. And obviously, I don't know if obviously, but that's just a much more satisfying way to practice and with than it is where you're just doing, you know, you're you're getting... You're you're just sort of in and out and you're a cog. Way, we talked to so many people that They go see to the doctor, at 1 point they would have a regular doctor. Now they go see whoever's there at that office that day, whether it's Pa at doctor whoever it is, And that's just not nearly as satisfying. It might be the only way to make the economics work, other things work, but it does lead to lower satisfaction, I would assume. Speaker 1: It leads to both lower satisfaction on both sides. Right? The patients don't like it. And the the clinicians feel like they don't have that same draw. I mean, you know, like I said, like, to this day, every blanket, every throw blanket in my parents house has been knitted by a patient of my dad's. You know? I mean, he thinks about his patients. All the time because there's so many reminders of them. And I think you talk to physicians now, and they're like, well, somebody told me, I'm not allowed to spend more than 10 to 15 minutes in a room with a patient. And, you know, I don't have the time to get to know their back stories. I have all this chart that I need to do, I have all these things that I need to ask so that I can get paid and that, you know, have to be documented. And so the focus turns from that, or it turns into that from this very deep meaningful relationship that made you go home every day and just think, wow, I'm so fortunate. To do what I do. You know? And I think there's these little windows of that present, when people go into things like direct primary care or these practices that you're talking about where you can spend that time with that patient. Right? Or you can enjoy the science of what practices what you do. You know, I'm fortunate to be in an environment where when I go to work, I I can spend the time that I want, really just enjoying this science, and sometimes I'll kinda look at these images and be like, well, the bones are so beautiful. You know, I have the time to do that, and I love that. And I come home feeling really, really good about what I did every day. And I don't think that that is the case for all physicians now because of this erosion of things. And I think that's why they're starting to look to other things. You know, I mean, we we all made it through med school residency working 80 hours a week and this or more, and we didn't complain about it because it was so mission driven, but now you have this feeling that your alt and your your mission is kind of being taken advantage of to extract profit for other people, and then you don't feel as good about being a part of that system, And and then people start thinking about their exit plan. Right? People don't start thinking about their exit plan until they're not happy with what's in front of them. Speaker 2: But, and and this is true. That the the thing that I find is true. And I know that sometimes physicians say to hear that. I I know that's nice position seem to hear this, but this is true of every work environment that we're around. People leave not, you know, often because they're not satisfied. They're not comfortable don't enjoy themselves. They don't love the coworkers, They don't have other treated by their people that don't have the culture, a million different reasons that are true in medicine in true and every other place. Maybe at some point we took it for granted with physicians that they would just work out we wanted them to work, but at the end of the day, Mean, the the studies show, people don't really leave their work environment, you know, because they're getting a pay underpaid unless they're getting paid so badly that they come to work every morning irritated about it. But but they leave because of the that work as our satisfaction works, all these reasons. And very similar with physicians, and the thing that we're faced with with physicians is to so challenge is is the numbers are so clear it's the amount of physician hours we have to utilize versus the entire population, and you're absolutely right. We could address some of that at the in park by trying to make it more satisfying from them us it's just trying to be more sensitive to it, But that's often a person by person issue versus an institutional issue if I need to work there Speaker 1: like, practical technicalities. Like you said about the number of patients that need to get seen. So balancing that out when you have... Less doctors and more baby boom generation that are retiring and living longer with chronic disease. Right? Your patient needs are going up, your physician workforce is going down. All of these are are problems that I think are... They've been numbers of problems that we've projected for decades gates. Right? There's there's great studies back from, you know, 2001, 2003, 2005 showing what these numbers were going to be even before this era of burnout, showing that we had a numbers problem back then, And I think ultimately, until somebody is willing to really take a good hard look at that and say, hey, we need to increase the number of medical... You know, we need to increase the pipeline and and increase the number of doctors that are out there and really commit to, you know, whatever it takes to make that happen, we're gonna continue to have a numbers problem. Speaker 2: No. He gets really right. And a lot of this is driven unfortunately through Washington because the funding of additional residences probably has comes to Washington. We you mean, they talk about 4001 of these bills. We probably need so many more of them, but it really is daunting because... I mean, I don't think I... You might. I don't sit here with confidence thinking either a president Biden or a president Trump. Who will be able to meaningfully impact the situation or, you know, or force it to be an issue because it seems... You know, it's not a simple fix and it's it's a 10 year fix to even create the 15000 more residences. Speaker 1: Yes. The pipeline is really long. And this is why... You know, whenever I talk to anybody who's like, oh, we'll just get another physician. There will be another physician. I'm like, you can't take it for granted any anymore. That if you fire a physician or you decide this physician's not a good fit that there's gonna be that ideal Bar that you want of a physician that's gonna be standing there. Waiting to take their place because the numbers are just so so the the difference in the like, the delta and what you need versus what you have is so great that this is going to be a decades, long problem that America is gonna be dealing with. Even if you start putting have an action plan into place right now. It's gonna be, you know, it's gonna be a long time before you can undo the damage that's been done to the workforce over the past 2 decades. Speaker 2: Well, the thing I will tell you is Doctor. Mat. 1, it's always great to visit with you 2. I think I agree with you on 90 and 9.9 percent of everything used. Say and it's such a pleasure in every way to visit with you. Thank you for joining us again on the Becker Healthcare podcast. Take 1 moment tell the audience about physician side gigs, if you don't mind. Speaker 1: Yeah. Absolutely. Well, you know that the feeling is mutual. Thanks again for having me. Physician side gigs is the largest online physician community in the country. We're closing in on about... 200000 members or about 15 percent to 20 percent of the physician workforce. So it's been really a a great way for 2 me to be able to kind have my pulse on on what the grassroots physician is thinking, and and hopefully use that as a positive force for change If anybody would like to learn more about us, you could go to our website at WWW dot physicians side gigs dot com. Speaker 2: Doctor Mehta, thank you as always for joining us. Thank you very much. Speaker 1: Absolutely. Thanks, Scott.