July 17, 2025 • 37 mins
The healthcare workforce crisis is reshaping American medicine in profound ways that will impact both providers and patients for decades to come. In this eye-opening conversation, Dr. Thomas L Miller, Chief Medical Officer at the University of Utah, reveals how healthcare institutions are navigating the aftermath of what he calls "a bird's eye view of the future" following the pandemic-induced Great Resignation.
Mark as Played
Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 2 (00:21):
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:43):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthe podcast series.
Joining us today is Dr TomMiller.
Dr Miller is the chief medicalofficer of the University of
Utah.
He's held that position since2006, where he's practiced
(01:04):
internal medicine since 1993.
He's also a professor ofmedicine in the Division of
Internal Medicine of theDepartment of Medicine at the
University of Utah.
Dr Miller received his MD fromGeorge Washington University in
1988, completed his residency ininternal medicine at the
University of Utah in 1991, andhe's been a member of the
(01:26):
Division of General Medicinesince 1992.
He's board certified ininternal medicine.
His clinical expertise is inadult medicine, including
evaluation and treatment ofhypertension, lipid
abnormalities, adult onsetdiabetes and heart and vascular
disease.
And if y'all are thinking thatDr Miller's name is familiar, he
(01:48):
joined us at the AOA annualmeeting in Salt Lake on the 15th
of June in 2023 in our firstsymposium, where we discussed
the changing environment anddynamics of healthcare, which
included private equity andsupply chain, and the changes in
support staff workforce whichDr Miller spoke to, and then
(02:11):
this was subsequently publishedin the Journal of Bone and Joint
Surgery in 2024.
So Dr Miller is well-versed tothe AOA and the activities that
we're doing here.
So, dr Miller, welcome to thepodcast, sir.
Speaker 3 (02:24):
Thanks, Dr Lundy.
It's a pleasure to be here andan honor.
Thank you for having me on theshow.
Speaker 2 (02:34):
Yes, sir, my pleasure .
All right, tom.
So you, as chief medicalofficer at the University of
Utah and we discussed this whenwe were in Salt Lake, when the
AOA was there about the changesin support staff workforce you
saw this firsthand with theCOVID pandemic and then all the
great quote-unquote, greatresignation and everything that
happened after that.
So, sir, tell us from yourviewpoint, from your vantage,
where do you see the futuregoing, not just in orthopedic
(02:56):
surgery but in all the House ofMedicine, in terms of the change
in support staff workforce?
Speaker 3 (03:02):
Yeah, let's talk about nursing and all the allied
healthcare positions.
Initially, since the pandemic,we've had a leveling, so to
speak, of our ability to hirenurses.
They've come back.
We no longer have travelers, sowe've had some improvement in
that, in that I think we're atabout a 4% turnover rate now,
(03:25):
which is much better than it wasduring the great resignation.
Where we're still working hardto hire and retain would be at
the levels of the CRNAs, theregistered assistants, medical
assistants and others atentry-level positions throughout
the university and I believethis is also true throughout the
(03:46):
country.
These types of positions areheavily in demand, not
necessarily for that particularskill, but at that pay scale
throughout the economy, so theycan work at Costco or they can
work for Amazon, they could bedrivers, they could do all kinds
of different things for theentry level fee.
So we've seen an increase inour ability to hire and retain
(04:10):
medical assistants and CRNAs.
But this is the group thatwe're really focused on and is
toughest right now to retain.
And I think, Doug, I'd add that,as everybody knows, the cost of
the individuals now is risingin the sense of their wages.
We've seen nationally over thelast couple of years about a 10%
(04:31):
increase in the salaries andwages I should say wages of
these employees, and so 60% ofmost healthcare systems expenses
actually labor, so it's thelion's share of the expense, and
so this is something that isnecessary if we're going to
(04:52):
retain adequate work staff, butalso a problem for us.
Wow, Right now we're doing okay.
I mean we're we're.
We're doing a lot better thanwe were, you know, when I
presented in Salt Lake a year ormore ago.
Speaker 2 (05:06):
Okay, 60%, that's crazy.
Speaker 3 (05:10):
Yeah, that statistic comes from the AHA and their
recent publication about howhealthcare systems are doing
across the country.
I think let's see I've got here.
Labor amounted to somethinglike $839 billion of health
systems cost and that's 60% oftheir total cost.
(05:33):
You know you have 8% related todrugs as an example.
I mean, we all talk about therising cost of drugs, the
difficulty, but the realexpenses in personnel and labor.
Speaker 2 (05:45):
So that's crazy.
Well, we all we're all veryfamiliar with the fact that many
believe that the healthcaresystem is already too bloated,
that the cost of healthcare inthe United States is exceedingly
too high.
Nobody wants to put more moneyinto it.
And if that's the case, whereare we going to get these
additional funds to pay thesefolks that could get better
(06:08):
wages, better employment bydriving for Uber or loading
trucks for UPS or whatever?
Speaker 3 (06:18):
That's the million dollar question, especially when
you need these positions 24-7.
It's not like they're working.
Eight to five is nine to five,eight to five or whatever it is.
As drivers for Amazon, you needround the clock personnel to
operate a hospital and a system,and so one of the things that
I've been focused on is really,as physicians and this is kind
(06:42):
of where I think you know thispodcast is helpful is we have to
get away from the older cultureof paternalism and what I mean
by that.
We have 50% of physicians arenow women or training to be
physicians.
We need to really embrace ourcolleagues, be they nurses,
medical assistants, crnas, andkind of get out of that old mold
(07:05):
of I write the orders and youcarry out the orders, and we
need to work collaborativelybecause I think most individuals
who enter the healthcare arenain first jobs or as medical
assistants or CRNAs.
They're in those positions forabout five years and they turn
over because they're entry-levelpositions, but many times they
(07:27):
turn over as RNs or highlytrained techs.
They go to school during thattime and we want to keep them in
healthcare and to be able to dothat, we have to really embrace
them as individuals, as part ofa bigger team, and act as if
we're playing on a team, ratherthan having the kind of classic
(07:48):
separation that we've had formany, many, many years of where
we come into the hospital, wewrite the orders and everybody
else does what he says.
We need to be an integral partof the team, even if we're the
leaders of that team.
We need to have the skills toembrace these people to keep
them in place.
Team.
We need to have the skills toembrace these people to keep
them in place.
You're right, the cost isincreasing and unfortunately
(08:08):
it's getting to the breakingpoint, I think, for the common
individual out there in tryingto afford health care, and we're
all reading stories about ruralhospitals closing and obstetric
units disappearing so thatthere are delivery deserts
around the United States, andI'm sure that may be true as
well for orthopedic care incertain areas.
(08:30):
So I would say that we mustembrace a team model in order to
enliven those people who comein to healthcare at the
entry-level positions and keepthem in healthcare positions and
keep them in healthcare.
Speaker 2 (08:44):
So a lot of what you're saying a easy, simpler
solution than seeking forfunding that doesn't exist is to
improve the cultures in ourhealthcare networks and, even
though these folks potentiallycould do just as well elsewhere,
they hopefully develop a senseof meaning and belonging and
value for being there.
(09:05):
Putting words in your mouth,but that's kind of what I'm
saying.
Speaker 3 (09:08):
That's exactly what I'm saying and I think I've seen
over many years in practice andin the position I'm in, that
sort of sometimes we beat it outof them.
Speaker 2 (09:18):
Yeah.
Speaker 3 (09:19):
You know we're short.
We expect them to know morethan they do.
We have to treat them withrespect in relationship to the
skills that they have, which arenot the same as our skills, but
it's essential that they assistus.
If they don't, then we're at areal disadvantage and we will
have to pay a lot more money inorder to get the kinds of people
(09:41):
that we want, that have theskills we want.
I just don't think they'regoing to be available.
Speaker 2 (09:46):
Did y'all see this attrition prior to the pandemic?
Speaker 3 (09:50):
No, not as bad.
I mean the pandemic was afalling off point, as we're all
aware.
We continued to have turnoverand medical assistance and I
mean there's a kind of a warbetween the systems in Salt Lake
to hire these entry levelpositions through, you know,
raising wages, and so we'realways going to have that battle
(10:13):
.
But it wasn't nearly as bad asthe pandemic.
We were doing OK and I'd like tosay that we're back to where we
were without travelers.
We're able to hire, but it'sand then with nurses it's kind
of at the point where some ofthe managers are saying, look, I
can actually pick and choosenow, instead of just taking the
(10:36):
first body off the street.
And that's not quite true yetfor medical assistants or CRNAs,
but it's improving slowly.
Speaker 2 (10:47):
So this quote-unquote great resignation, this was all
as a result of the pandemic andessentially not necessarily at
the beginning but more towardthe middle and the end, correct.
Speaker 3 (10:58):
Yes.
I think the great resignation,or we should just say the
pandemic, gave us a bird's eyeview of the future.
We are stable and we don't havetravelers, but we've seen a big
(11:22):
increase in the wage inflationindex, labor inflation index.
Inflation has impacted thenecessity of increasing salaries
.
Nurses are demanding more, andit's understandable.
Salt Lake has become in ourpart of the world I'm sure it's
true in many other places muchmore expensive to live in as an
urban setting, and it's just notthe way it was 10 years ago.
Speaker 2 (11:44):
Now, in terms of supply chain y'all, I'm sure
y'all are vertically integratedwhere you have your own nursing
school, so you can try toinfluence those folks in nursing
school to work for y'all whenthey get done right.
Speaker 3 (11:56):
Yeah, that's true.
I mean again, you still havethe competition with other Sure,
and Utah pays lower than manyother states for nurses in terms
of salaries, and so we do trainour own, so to speak.
So they're homegrown.
We do have, because we have theWasatch here, we have a lot of
young nurses and techniciansthat come here because of the
(12:19):
outdoor recreation.
That's a big help, but oursalaries and wages are a bit
lower than they are on the coastfor sure, and so that's been an
issue.
So I think overall I feel likeright now we're stable.
But I put out that figure againof 60% of healthcare systems.
Costs are labor and that'sgoing to continue to increase.
(12:42):
It'll mitigate as inflationsoftens and hopefully that will
happen over the next year or twoAt least that seems to be a
little bit of the sign comingout of the feds.
But labor is a huge part ofwhat we do and I think a lot of
physicians don't realize themagnitude of that expense.
(13:02):
And again I go back to how weneed to really embrace our
colleagues in nursing and allthe other allied professions
pharmacy, social work and thenthose MAs that help us in clinic
every day.
Without them we'd be dead inthe wall, absolutely.
Or techs, I mean, I would sayI'm not in the OR as an
(13:24):
internist, but that's one of theareas where we did have trouble
.
We were hiring travelers tokeep our ORs up and running and
it was very difficult.
We were really struggling therefor a while.
So again, and when thosepositions are in scarce supply,
there's a lot of competitionfrom the non-academic centers
around the town that have moredollars to put towards salaries
(13:47):
and hire what they need.
So academic centers, they'regoing to have to come up, I
think, in the future with adifferent approach because we
can't consistently play thehigher wage or salary game in
competition with these verylarge systems.
Speaker 2 (14:02):
Right.
So you spoke at the AOA in Juneof 23, and it was fairly gloomy
then, but it's getting betternow.
When do you think that y'allmade the turn to the current
what you said 4% turnover rate?
It started about six to sevenmonths ago, I think, really
around the beginning of the year.
Speaker 3 (14:17):
One thing I'd like to say that I learned from the
current what you said 4%turnover rate.
It started about six to sevenmonths ago, I think, really
around the beginning of the year.
One thing I'd like to say that Ilearned from having to prepare
for that talk that we actuallyimplemented here is I had read a
Harvard Business Review, doug,that said that the biggest
concern of your entry-levelemployees, those who are at the
bottom of the wage scale, is notnecessarily their salary, but
(14:39):
it's their travel time, theircommute time.
The cost and effort is requiredto drive from where they live
to get to work.
And I'd never thought about it.
I mean, I maybe thought aboutit, but I didn't think about it
hard, you know, in a way thatreally got in under my skin
(14:59):
until I made that presentation.
And guess what?
After that presentation, I wentto our CEO and our counsel and
we not only have thoseindividuals driving from their
towns that are maybe 30, 40,sometimes longer minutes away
from work, but they have to payto park here.
(15:20):
Now, utah is still anautomotive transport community.
It's not like New York City orBoston.
There's subways, buses and allkinds of things there are and we
have a great track system.
But most people commute to workby automobile and the fact that
they commuted and then they hadto pay for parking was a
(15:40):
non-starter, because all of theother healthcare systems in the
valley don't charge for parking,so we started to supplement
their salaries to pay for theparking which I got out.
That was a great takeaway that Iactually was able to
operationalize from coming tothe AOA talk and again this is
something that was important toour entry-level employees and
(16:05):
what we were finding is theywere actually leaving and going
to our satellite clinics becausewe weren't charging for parking
there and when your wages are acertain leveling cost is one to
two percent of your salary.
So we it had been an issue foryears and that's because campus
you know they campus pays a lotof their costs based on their
(16:28):
parking for students, but we'reunder that umbrella.
So we said, all right, let's,let's help those who are
traveling a distance to get towork and that's made a big
difference.
We've had a lot of comments,complimentary comments, about
that.
Speaker 2 (16:44):
You know what's kind of funny about that is?
We gave a symposium this yearat the AOA meeting on resident
unions and guess what, One ofthe big issues at one of the
places was parking at one of theplaces was parking, and there
was actually one program thatsaid.
of course it was multifactorial,far more complicated than this,
(17:05):
but one of the main instigatorsthat pushed them into forming a
union was the fact that theybelieved that the system was not
accommodating their.
That was charging them way toomuch to park their cars at the
hospital, and so they it's funnythat a Kimmel.
That's also what y'all found aswell.
If anything comes out of thispodcast, I guess we should be
looking at what we charge ourstaff.
Speaker 3 (17:26):
No, I think it's true .
I mean, I really thought aboutit and and you know, being a CMO
, I mean that that that sort ofdiscussion is usually in the
pocket of the COO or the CEO,and we'd had this discussion for
a long time.
But it became very acute duringthe great resignation and when,
you know, really hit us hardbecause people were they'd say,
(17:46):
well, I'd love the job, but Idon't want to pay for parking.
And it's a little bit likesaying, well, you know, you're
working for the mine now andyou're going to shop at the
company store, so we're going tocharge you to park here, right,
right for the mine now, andyou're going to shop at the
company store.
So we're going to charge you topark here.
I mean, it might work in NewYork where everybody has to pay
for parking, but out here theyhave choices, and so that's
(18:10):
something that we did.
I credit you having me dig intothe articles and the Harvard
Business Review talking aboutentry-level employees really are
more concerned about theircommute time and the cost of the
commute than they are theirsalary, so that was quite
helpful.
I did want to switch gears alittle bit.
You were just talking aboutresidents and I wanted to talk
about that a little bit, becauseit's not only, you know, allied
health professionals that we'retalking about here in terms of
(18:33):
how we go forward to deliverhealth care in this country, but
it's also based on physiciansand house staff and APCs.
Right, I mean, this is, this isa huge thing and I we can no
longer throw residents at theincreasing patient love that we
have in our facilities.
You know the ACGME, rightly, isnot going to allow it.
Young doctors they're nottolerating right, so fast
(18:55):
disappearing.
Or residents willing to put upwith the eight hour work week
and, you know, slave and toillike they did back in the old
days.
For, you know, at the turn ofthe 20th century.
They want benefits, they don'twant to be skimped on.
And you know, part of this is,you know, half the workforce now
are women and they're havingfamilies in the prime of their
(19:17):
life, in their 20s, when theywant to raise children, and
they're just not going to put upwith it anymore.
And so one of the problems I seeis that the CMS capped
residency slots in 1997.
So I mean, we can graduate asmany medical students as we want
, but they only pay for thatmany residencies.
(19:40):
So your choke point are thenumber of residencies.
Now individual universities andhealth systems that have
residency programs have paid toincrease their residency slots,
as we have, but that stilldoesn't meet the demand.
So what I see happeningnationally is that we we have a
much greater population.
(20:00):
The population grew by what?
23% since 1997.
I think we were 273 million in1997 when they froze the
residency slots.
We're now up to 335 millionindividuals in the United States
.
And so our doctor graduationrate into into practice, into
full practice, hasn't increasedat the same pace.
(20:23):
I can't quote it, but we're notgenerating enough physicians to
to manage the care for thepopulation as it's growing and
and so income advanced practiceclinicians right Nature hits a
vacuum.
So here we've seen, just since2015, we've seen a doubling in
(20:45):
the growth of our hiring ofadvanced practice clinicians we
went from 436 to 880.
So this is also a cost to thesystem, right?
So this is also a cost to thesystem, right.
(21:14):
And we don't have thephysicians to keep up with the
growth rate.
That I mean, when you thinkabout it, there's not yet a
separate college for thetraining of nurse practitioners.
They are trained basicallywithin the College of Nursing.
But I dare say it's not going tobe too much longer before we
have we have colleges ofphysician assistant training and
(21:36):
nurse practitioner trainingthat will have their own
programs and their ownspecialties, and this is, in
fact, what's rolling out now.
We're not graduating physiciansat a rate that allows us to
take care of the population thesame way that we used to, and
care is so much more complicated.
I mean, think about when youstarted practicing orthopedics.
(21:58):
I'm sure the amount of thingsthat you could do now to assist
the patients is much differentin scope than you had when you
started.
It is for me.
I mean, the complexity of careis much greater and we need more
physicians or more health careproviders to do that, and we're
not graduating house staff fastenough.
Speaker 2 (22:19):
Wow, yeah, it's been an exponential increase in
technology and especially acrossthe field, not just with us,
but with everybody.
That in and of itself is alsoindicative of what we're seeing
on the support staff side.
So it's a total house issue,not just the sports staff as you
(22:40):
were saying.
Speaker 3 (22:42):
Yeah, it's kind of.
I mean, with the advanced carepractitioners it's the Wild West
a little bit.
Everybody's paying differentprices for salaries for their
work, they're paying nightdifferentials and currently they
can switch Like.
I wish I could just kind ofjump into orthopedics and do a
(23:05):
few hip surgeries.
Speaker 2 (23:07):
It's not that hard.
I'm sure you could.
Speaker 3 (23:10):
I think my insurer might have something to say
about that.
So would the hospital qualityboard, but they can switch right
.
So that's kind of interesting.
When you think about it is thatyou can train an APC and
orthopedics to do, let's say,sports medicine evaluations, and
then they could jump over toneurosurgery because of a night
(23:31):
differential in caring forpatients in a neurocritical care
unit.
It's just an example, right,and as medical students are
going into residency, they'realso because of debt and the
availability of higher payingspecialties.
They're sort of bypassingpediatrics.
There's a bit of a crisis inpediatrics in terms of filling
(23:51):
pediatric residency slots aroundthe country and there are fewer
of them choosing to go intofamily practice and my beloved
specialty of internal medicine.
They're going on into cardiologyand gi if they can, and with
that additional training they'lltriple their salaries in the
meantime.
So the nature again who willtake care of, who will be the
(24:12):
care managers of patients?
Primary care it's looking to memore and more like APCs, unless
we do something about the feeschedules and that sort of thing
.
That's on my end of thespectrum.
I know that's maybe not part ofthis conversation, but as we
all get older, we needphysicians to take care of us,
and when we have little kids weneed physicians to take care of
(24:33):
them and we can't take them tospecialists.
So it's a problem nationally.
So do the apcs fill this role?
Do we quick congress toincrease the funding for
residency slots so we can catchup with population growth?
Speaker 2 (24:47):
different ideas different to your point.
This is hitting while the babyboomers are maturing and
starting to approach Medicare.
Oh yeah, or well, into it.
Yeah.
Speaker 3 (24:59):
Yeah, I mean who will take care of them?
And then coordination of carealso right.
I mean who will send theorthopedist, the patient, for
the right review?
Do they send them to a sportsmedicine doc first, or are they
going to send them to anoperative orthopedist?
Do they know the difference?
All of those things areimportant.
I mean, I really like whatCharlie Saltzman did here where
(25:22):
he developed the soup to nutsorthopedic practice.
He's got all under one roofradiology, physical therapy,
non-operative physicians, apcsand operative physicians in each
of the specialty areas oforthopedic care.
Speaker 2 (25:39):
And to give Charlie credit, as Charlie was the one
that got me on to find out aboutyou, to be the speaker at our
AOA meeting.
So that's our common link isCharlie Salzman, who we all
agree is absolutely spectaculara gem of a guy.
Let me ask you this, then whatinnovative things do you see on
(26:00):
the horizon, what innovativethings that are you're
comfortable sharing with us,that y'all are doing to try to
get a hold of this incrediblechange?
It looks like, to your point,that on the top of the pyramid
if you'll let me go there theadvanced practice professionals,
whether they be PAs or nursepractitioners, are starting to
(26:23):
try to fill that vacuum a bit.
But in terms of the supportstaff as well, is there any
innovative, cool things outthere that are coming down the
pike to help stem that demand?
Speaker 3 (26:35):
Well, this may be not so innovative, but as far as
nursing goes we're movingtowards magnet recognition and
you know people have differentviews about magnet.
I think it's important.
I think what nurses are sayingis that the work that we do is
foundational and we have meaning.
(26:57):
The nurses have an ethos, theyhave professional pride around
their work and Magnet puts aribbon on that, I think.
And so I think thatorganizations should embrace
Magnet because it does value thenurses' work and purpose, value
(27:24):
the nurse's work and purpose.
We are in the middle of workingtowards our magnet designation
and I think physicians shouldembrace that.
I think, again, this is anexample where we can reach out
to our colleagues, because theADdesignation is basically
nursing, saying we're anintegral part of caring for
patients and we want you torecognize that and be our
partners in caring for patientsas well.
(27:45):
And I think any of us who haveworked with inpatients know, or
have been inpatients, as I haveknow, that the nurses are at the
bedside way way more than thephysicians are, as I have know
that the nurses are at thebedside way way more than the
physicians are.
And there are eyes and ears andwe don't always use those eyes
(28:05):
and ears in a way that benefitsthe patient to the highest
degree possible.
So I don't know that that'snecessarily terribly innovative,
but I think it is somethingthat is making its way across
the country.
That's the MAGNET program.
So I think we should try toembrace that.
The other thing that we talkabout but we have not yet done
is creating our own schoolingfor technicians and medical
(28:28):
assistants.
That's kind of a hard sell.
You know the university can onlydo so many things.
And do we want to begin a techschool training or do we leave
that to some of the localschools?
And then do we providescholarship funding for service,
tuition for service?
So those are things we havedone in the past, but clearly we
(28:50):
need to.
We need to graduate moreradiology technicians or
technicians.
I wish I had.
I wish I had a betterinnovative answer for you.
Speaker 2 (28:59):
Maybe, maybe parking everybody should focus on yeah,
my place here they I'm prettycertain I got this correct is
that tuition is free.
It's a diploma nurse program.
It's not a bsn program, butthey can get their bsn after
this.
But you can get their diplomain nursing and it's completely
it's not free.
(29:20):
I mean because they work hardto get their degree, but it
doesn't cost them anything ifthey agree to work for the
system once they're finished, sothey can come out of high
school, work or do somethingelse and then come here get
their diploma completely free ofcharge, as long as they work at
the system in some way, shapeor form, as a nurse.
(29:41):
Yeah, I don't think we havethat.
Speaker 3 (29:43):
That's great.
We don't have that At least Idon't think we have that.
I believe I would have heardabout it.
That's a great idea If thesystem can afford that.
That's a fantastic way to bringpeople in and honor their work
and their skills and then keepthem for a number of years
instead of having too muchturnover.
Speaker 2 (30:02):
Do you see a critical point in the future where all
of a sudden it becomes apparentthat throwing money at the
problem doesn't help anymore,that we just don't have enough
staff, that care is becomingincreasingly problematic, which
means that the cost of thesefolks goes up even more, because
as the supply goes down, thedemand goes way up, which so
(30:24):
goes their wages.
And then all of a sudden wehave this healthcare crisis
across the nation.
Is that looming on the horizon?
Speaker 3 (30:30):
Well, I think it's already happening with, as I
mentioned at the beginning, theclosure of rural hospitals, the
deserts of care that are beingrealized now, and I think the
thing that I worry about is thatthe large systems have the
deeper pockets and they have thecapital because of their assets
to hire at whatever prices themarket will bear.
(30:56):
And that's not only true forallied healthcare professionals,
that is absolutely true forphysicians.
So, as we were talking earlier,when you have an orthopedist or
a specialist in high need,those bigger systems can afford
much bigger deltas now than theydid in the past.
(31:17):
So I think what's troubling forsome academic centers is this
gap between what we used to saywell, you're going to join the
academic world, you're going tobe part of the proud and the
great and you're going to workin academic life and you'll make
(31:40):
less than you would make inprivate practice.
But that gap is substantiallybigger now in terms of what the
private nonprofits andfor-profits are offering for
these positions.
And they can afford it.
And you know it used to be.
Well if you were a cardiologistand maybe the academic position
(32:01):
was only $50,000 less than whatyou could make in the community,
that's now $200,000, $250,000,in some cases even more if
you're highly specialized insome aspect of cardiology like
electrophysiology.
So I don't know how it is inyour world of orthopedics
throughout the country, but Isuspect there are some
(32:22):
similarities to that, and so Ithink that that is a threat.
I think academic centers haveto figure out a way.
I actually don't know yet.
I mean, do we decrease theamount of funding that we put
into research?
We decrease the amount offunding that we put into
research in order to increasesalaries to a level that allows
us to retain and hire highlyqualified physicians, or do we
(32:47):
just?
otherwise I think we run therisk of becoming quite average.
Speaker 2 (32:52):
That's disturbing, I mean have you?
Speaker 3 (32:55):
do you see that in your field at all?
Speaker 2 (33:06):
To a degree, yeah, to a degree, but really more.
I think impacting us is thelack of support staff that we
all struggle for our medicalsystems, for the folks to help
us get through the day doing allthe things we need to do.
Speaker 3 (33:13):
The problem that I just described to you is
actually something I've beenwatching for the last couple of
years.
That is, the brain drain, ifyou will, and it's become more
acute in the last year and it'snow on everybody's mind, to the
point that we have a committeelooking at salaries position
salaries and trying to comparethat to the market salaries,
(33:38):
physician salaries, and andtrying to compare that to the
market, because I think thingsmove so quickly that the double
amc benchmarks didn't didn't cutit.
They were not representative ofwhat was actually going on out
there, and I'm talking mostabout highly paid specialists.
So, and it's it's.
It's harder too with withprimary care physicians.
I mean, there's just not enough.
So they're even commanding alittle bit higher salaries than
(34:00):
they had previously.
Speaker 2 (34:02):
Last thing, on digital media or something I saw
the other day I can't rememberwhere I saw this that it was in
one of the Asian countries.
It was, I think, either inSingapore or Japan.
If I recall, they actually hadrobotic nurses, medical
assistants, whatever that wouldhelp.
There are actually robots thatwould go in and engage with the
(34:25):
patient and give them theirmedications and measure their
vital signs and such, and it wasjust to a certain degree.
It was absolutely appallingthinking.
Granted, being taken care of bya machine, but of course, as
you can imagine, they had thisthing humanized as much as
possible, with very caring voiceand all.
Speaker 3 (34:42):
God help us, my friend, if we end up in that
place oh, my wife's alreadyordered one of those so she can
go on vacation.
She thinks it's a great idea.
Well, there's that oh my gosh,we'll see what happens.
I, the human touch, is still themost important thing and
there's so much joy in medicineand I really want to go back
(35:04):
before we conclude and say thatI think one of the best ways to
avoid burnout and yes, we allhave perhaps problems at times
to have enough staff, but towork closely and caringly for
those that are supporting us andI don't know that brings me joy
(35:24):
.
I mean, I've had the samemedical assistant for almost 20
years and she's fantastic andthe patients love her and we all
get cranky from time to time,but it's a team and it's great
and I enjoy the practice andthat's why I still have a small
practice in comparison to my CMOrole.
But it makes it all worthwhileand I think as we work together,
(35:48):
you know, communicate more witheach other about our cases,
time pending with that it's good.
It improves the joy of medicine.
That's why we got into it.
At least I did.
It helps.
Speaker 2 (36:00):
If I could summarize the three things in here one is
work on the culture in ourclinics, taking care of the
folks that take care of us.
Number two search forinnovative ways to try to
address this incoming andinevitable crisis that's coming
down the pike.
Number three make sure thatwe're not charging too much for
parking.
Speaker 3 (36:23):
Yeah, yeah, car in every garage and chicken.
And two cars in every garageand a chicken in the pot.
So there you go.
Speaker 2 (36:29):
It's been my pleasure discussing workforce issues and
the future in workforce with DrTom Miller, who's the chief
medical officer at theUniversity of Utah.
Dr Miller is obviously anexpert in these things and we
did enjoy having him at the AOAmeeting and once again on this
podcast.
So, Dr Miller, sir, thank youfor joining us there.
My pleasure.
It was great talking with you.
(36:50):
Yes, sir, and y'all lookforward to futures in orthopedic
.
On this podcast series.
Welcome to the AOA Future in Orthopedic Surgery
podcast series.
This AOA podcast series willfocus on the future in
orthopedic surgery and theimpact on leaders in our
profession.
These podcasts will focus onthe vast spectrum of change that
will occur as the futurereveals itself.
We will consider changes asthey occur in the domains of
(00:43):
culture, employment, technology,scope of practice, compensation
and other areas.
My name is Doug Lundy, host forthe podcast series.
Joining us today is Dr TomMiller.
Dr Miller is the chief medicalofficer of the University of
Utah.
He's held that position since2006, where he's practiced
(01:04):
internal medicine since 1993.
He's also a professor ofmedicine in the Division of
Internal Medicine of theDepartment of Medicine at the
University of Utah.
Dr Miller received his MD fromGeorge Washington University in
1988, completed his residency ininternal medicine at the
University of Utah in 1991, andhe's been a member of the
(01:26):
Division of General Medicinesince 1992.
He's board certified ininternal medicine.
His clinical expertise is inadult medicine, including
evaluation and treatment ofhypertension, lipid
abnormalities, adult onsetdiabetes and heart and vascular
disease.
And if y'all are thinking thatDr Miller's name is familiar, he
(01:48):
joined us at the AOA annualmeeting in Salt Lake on the 15th
of June in 2023 in our firstsymposium, where we discussed
the changing environment anddynamics of healthcare, which
included private equity andsupply chain, and the changes in
support staff workforce whichDr Miller spoke to, and then
(02:11):
this was subsequently publishedin the Journal of Bone and Joint
Surgery in 2024.
So Dr Miller is well-versed tothe AOA and the activities that
we're doing here.
So, dr Miller, welcome to thepodcast, sir.
Speaker 3 (02:24):
Thanks, Dr Lundy.
It's a pleasure to be here andan honor.
Thank you for having me on theshow.
Speaker 2 (02:34):
Yes, sir, my pleasure .
All right, tom.
So you, as chief medicalofficer at the University of
Utah and we discussed this whenwe were in Salt Lake, when the
AOA was there about the changesin support staff workforce you
saw this firsthand with theCOVID pandemic and then all the
great quote-unquote, greatresignation and everything that
happened after that.
So, sir, tell us from yourviewpoint, from your vantage,
where do you see the futuregoing, not just in orthopedic
(02:56):
surgery but in all the House ofMedicine, in terms of the change
in support staff workforce?
Speaker 3 (03:02):
Yeah, let's talk about nursing and all the allied
healthcare positions.
Initially, since the pandemic,we've had a leveling, so to
speak, of our ability to hirenurses.
They've come back.
We no longer have travelers, sowe've had some improvement in
that, in that I think we're atabout a 4% turnover rate now,
(03:25):
which is much better than it wasduring the great resignation.
Where we're still working hardto hire and retain would be at
the levels of the CRNAs, theregistered assistants, medical
assistants and others atentry-level positions throughout
the university and I believethis is also true throughout the
(03:46):
country.
These types of positions areheavily in demand, not
necessarily for that particularskill, but at that pay scale
throughout the economy, so theycan work at Costco or they can
work for Amazon, they could bedrivers, they could do all kinds
of different things for theentry level fee.
So we've seen an increase inour ability to hire and retain
(04:10):
medical assistants and CRNAs.
But this is the group thatwe're really focused on and is
toughest right now to retain.
And I think, Doug, I'd add that,as everybody knows, the cost of
the individuals now is risingin the sense of their wages.
We've seen nationally over thelast couple of years about a 10%
(04:31):
increase in the salaries andwages I should say wages of
these employees, and so 60% ofmost healthcare systems expenses
actually labor, so it's thelion's share of the expense, and
so this is something that isnecessary if we're going to
(04:52):
retain adequate work staff, butalso a problem for us.
Wow, Right now we're doing okay.
I mean we're we're.
We're doing a lot better thanwe were, you know, when I
presented in Salt Lake a year ormore ago.
Speaker 2 (05:06):
Okay, 60%, that's crazy.
Speaker 3 (05:10):
Yeah, that statistic comes from the AHA and their
recent publication about howhealthcare systems are doing
across the country.
I think let's see I've got here.
Labor amounted to somethinglike $839 billion of health
systems cost and that's 60% oftheir total cost.
(05:33):
You know you have 8% related todrugs as an example.
I mean, we all talk about therising cost of drugs, the
difficulty, but the realexpenses in personnel and labor.
Speaker 2 (05:45):
So that's crazy.
Well, we all we're all veryfamiliar with the fact that many
believe that the healthcaresystem is already too bloated,
that the cost of healthcare inthe United States is exceedingly
too high.
Nobody wants to put more moneyinto it.
And if that's the case, whereare we going to get these
additional funds to pay thesefolks that could get better
(06:08):
wages, better employment bydriving for Uber or loading
trucks for UPS or whatever?
Speaker 3 (06:18):
That's the million dollar question, especially when
you need these positions 24-7.
It's not like they're working.
Eight to five is nine to five,eight to five or whatever it is.
As drivers for Amazon, you needround the clock personnel to
operate a hospital and a system,and so one of the things that
I've been focused on is really,as physicians and this is kind
(06:42):
of where I think you know thispodcast is helpful is we have to
get away from the older cultureof paternalism and what I mean
by that.
We have 50% of physicians arenow women or training to be
physicians.
We need to really embrace ourcolleagues, be they nurses,
medical assistants, crnas, andkind of get out of that old mold
(07:05):
of I write the orders and youcarry out the orders, and we
need to work collaborativelybecause I think most individuals
who enter the healthcare arenain first jobs or as medical
assistants or CRNAs.
They're in those positions forabout five years and they turn
over because they're entry-levelpositions, but many times they
(07:27):
turn over as RNs or highlytrained techs.
They go to school during thattime and we want to keep them in
healthcare and to be able to dothat, we have to really embrace
them as individuals, as part ofa bigger team, and act as if
we're playing on a team, ratherthan having the kind of classic
(07:48):
separation that we've had formany, many, many years of where
we come into the hospital, wewrite the orders and everybody
else does what he says.
We need to be an integral partof the team, even if we're the
leaders of that team.
We need to have the skills toembrace these people to keep
them in place.
Team.
We need to have the skills toembrace these people to keep
them in place.
You're right, the cost isincreasing and unfortunately
(08:08):
it's getting to the breakingpoint, I think, for the common
individual out there in tryingto afford health care, and we're
all reading stories about ruralhospitals closing and obstetric
units disappearing so thatthere are delivery deserts
around the United States, andI'm sure that may be true as
well for orthopedic care incertain areas.
(08:30):
So I would say that we mustembrace a team model in order to
enliven those people who comein to healthcare at the
entry-level positions and keepthem in healthcare positions and
keep them in healthcare.
Speaker 2 (08:44):
So a lot of what you're saying a easy, simpler
solution than seeking forfunding that doesn't exist is to
improve the cultures in ourhealthcare networks and, even
though these folks potentiallycould do just as well elsewhere,
they hopefully develop a senseof meaning and belonging and
value for being there.
(09:05):
Putting words in your mouth,but that's kind of what I'm
saying.
Speaker 3 (09:08):
That's exactly what I'm saying and I think I've seen
over many years in practice andin the position I'm in, that
sort of sometimes we beat it outof them.
Speaker 2 (09:18):
Yeah.
Speaker 3 (09:19):
You know we're short.
We expect them to know morethan they do.
We have to treat them withrespect in relationship to the
skills that they have, which arenot the same as our skills, but
it's essential that they assistus.
If they don't, then we're at areal disadvantage and we will
have to pay a lot more money inorder to get the kinds of people
(09:41):
that we want, that have theskills we want.
I just don't think they'regoing to be available.
Speaker 2 (09:46):
Did y'all see this attrition prior to the pandemic?
Speaker 3 (09:50):
No, not as bad.
I mean the pandemic was afalling off point, as we're all
aware.
We continued to have turnoverand medical assistance and I
mean there's a kind of a warbetween the systems in Salt Lake
to hire these entry levelpositions through, you know,
raising wages, and so we'realways going to have that battle
(10:13):
.
But it wasn't nearly as bad asthe pandemic.
We were doing OK and I'd like tosay that we're back to where we
were without travelers.
We're able to hire, but it'sand then with nurses it's kind
of at the point where some ofthe managers are saying, look, I
can actually pick and choosenow, instead of just taking the
(10:36):
first body off the street.
And that's not quite true yetfor medical assistants or CRNAs,
but it's improving slowly.
Speaker 2 (10:47):
So this quote-unquote great resignation, this was all
as a result of the pandemic andessentially not necessarily at
the beginning but more towardthe middle and the end, correct.
Speaker 3 (10:58):
Yes.
I think the great resignation,or we should just say the
pandemic, gave us a bird's eyeview of the future.
We are stable and we don't havetravelers, but we've seen a big
(11:22):
increase in the wage inflationindex, labor inflation index.
Inflation has impacted thenecessity of increasing salaries
.
Nurses are demanding more, andit's understandable.
Salt Lake has become in ourpart of the world I'm sure it's
true in many other places muchmore expensive to live in as an
urban setting, and it's just notthe way it was 10 years ago.
Speaker 2 (11:44):
Now, in terms of supply chain y'all, I'm sure
y'all are vertically integratedwhere you have your own nursing
school, so you can try toinfluence those folks in nursing
school to work for y'all whenthey get done right.
Speaker 3 (11:56):
Yeah, that's true.
I mean again, you still havethe competition with other Sure,
and Utah pays lower than manyother states for nurses in terms
of salaries, and so we do trainour own, so to speak.
So they're homegrown.
We do have, because we have theWasatch here, we have a lot of
young nurses and techniciansthat come here because of the
(12:19):
outdoor recreation.
That's a big help, but oursalaries and wages are a bit
lower than they are on the coastfor sure, and so that's been an
issue.
So I think overall I feel likeright now we're stable.
But I put out that figure againof 60% of healthcare systems.
Costs are labor and that'sgoing to continue to increase.
(12:42):
It'll mitigate as inflationsoftens and hopefully that will
happen over the next year or twoAt least that seems to be a
little bit of the sign comingout of the feds.
But labor is a huge part ofwhat we do and I think a lot of
physicians don't realize themagnitude of that expense.
(13:02):
And again I go back to how weneed to really embrace our
colleagues in nursing and allthe other allied professions
pharmacy, social work and thenthose MAs that help us in clinic
every day.
Without them we'd be dead inthe wall, absolutely.
Or techs, I mean, I would sayI'm not in the OR as an
(13:24):
internist, but that's one of theareas where we did have trouble
.
We were hiring travelers tokeep our ORs up and running and
it was very difficult.
We were really struggling therefor a while.
So again, and when thosepositions are in scarce supply,
there's a lot of competitionfrom the non-academic centers
around the town that have moredollars to put towards salaries
(13:47):
and hire what they need.
So academic centers, they'regoing to have to come up, I
think, in the future with adifferent approach because we
can't consistently play thehigher wage or salary game in
competition with these verylarge systems.
Speaker 2 (14:02):
Right.
So you spoke at the AOA in Juneof 23, and it was fairly gloomy
then, but it's getting betternow.
When do you think that y'allmade the turn to the current
what you said 4% turnover rate?
It started about six to sevenmonths ago, I think, really
around the beginning of the year.
Speaker 3 (14:17):
One thing I'd like to say that I learned from the
current what you said 4%turnover rate.
It started about six to sevenmonths ago, I think, really
around the beginning of the year.
One thing I'd like to say that Ilearned from having to prepare
for that talk that we actuallyimplemented here is I had read a
Harvard Business Review, doug,that said that the biggest
concern of your entry-levelemployees, those who are at the
bottom of the wage scale, is notnecessarily their salary, but
(14:39):
it's their travel time, theircommute time.
The cost and effort is requiredto drive from where they live
to get to work.
And I'd never thought about it.
I mean, I maybe thought aboutit, but I didn't think about it
hard, you know, in a way thatreally got in under my skin
(14:59):
until I made that presentation.
And guess what?
After that presentation, I wentto our CEO and our counsel and
we not only have thoseindividuals driving from their
towns that are maybe 30, 40,sometimes longer minutes away
from work, but they have to payto park here.
(15:20):
Now, utah is still anautomotive transport community.
It's not like New York City orBoston.
There's subways, buses and allkinds of things there are and we
have a great track system.
But most people commute to workby automobile and the fact that
they commuted and then they hadto pay for parking was a
(15:40):
non-starter, because all of theother healthcare systems in the
valley don't charge for parking,so we started to supplement
their salaries to pay for theparking which I got out.
That was a great takeaway that Iactually was able to
operationalize from coming tothe AOA talk and again this is
something that was important toour entry-level employees and
(16:05):
what we were finding is theywere actually leaving and going
to our satellite clinics becausewe weren't charging for parking
there and when your wages are acertain leveling cost is one to
two percent of your salary.
So we it had been an issue foryears and that's because campus
you know they campus pays a lotof their costs based on their
(16:28):
parking for students, but we'reunder that umbrella.
So we said, all right, let's,let's help those who are
traveling a distance to get towork and that's made a big
difference.
We've had a lot of comments,complimentary comments, about
that.
Speaker 2 (16:44):
You know what's kind of funny about that is?
We gave a symposium this yearat the AOA meeting on resident
unions and guess what, One ofthe big issues at one of the
places was parking at one of theplaces was parking, and there
was actually one program thatsaid.
of course it was multifactorial,far more complicated than this,
(17:05):
but one of the main instigatorsthat pushed them into forming a
union was the fact that theybelieved that the system was not
accommodating their.
That was charging them way toomuch to park their cars at the
hospital, and so they it's funnythat a Kimmel.
That's also what y'all found aswell.
If anything comes out of thispodcast, I guess we should be
looking at what we charge ourstaff.
Speaker 3 (17:26):
No, I think it's true .
I mean, I really thought aboutit and and you know, being a CMO
, I mean that that that sort ofdiscussion is usually in the
pocket of the COO or the CEO,and we'd had this discussion for
a long time.
But it became very acute duringthe great resignation and when,
you know, really hit us hardbecause people were they'd say,
(17:46):
well, I'd love the job, but Idon't want to pay for parking.
And it's a little bit likesaying, well, you know, you're
working for the mine now andyou're going to shop at the
company store, so we're going tocharge you to park here, right,
right for the mine now, andyou're going to shop at the
company store.
So we're going to charge you topark here.
I mean, it might work in NewYork where everybody has to pay
for parking, but out here theyhave choices, and so that's
(18:10):
something that we did.
I credit you having me dig intothe articles and the Harvard
Business Review talking aboutentry-level employees really are
more concerned about theircommute time and the cost of the
commute than they are theirsalary, so that was quite
helpful.
I did want to switch gears alittle bit.
You were just talking aboutresidents and I wanted to talk
about that a little bit, becauseit's not only, you know, allied
health professionals that we'retalking about here in terms of
(18:33):
how we go forward to deliverhealth care in this country, but
it's also based on physiciansand house staff and APCs.
Right, I mean, this is, this isa huge thing and I we can no
longer throw residents at theincreasing patient love that we
have in our facilities.
You know the ACGME, rightly, isnot going to allow it.
Young doctors they're nottolerating right, so fast
(18:55):
disappearing.
Or residents willing to put upwith the eight hour work week
and, you know, slave and toillike they did back in the old
days.
For, you know, at the turn ofthe 20th century.
They want benefits, they don'twant to be skimped on.
And you know, part of this is,you know, half the workforce now
are women and they're havingfamilies in the prime of their
(19:17):
life, in their 20s, when theywant to raise children, and
they're just not going to put upwith it anymore.
And so one of the problems I seeis that the CMS capped
residency slots in 1997.
So I mean, we can graduate asmany medical students as we want
, but they only pay for thatmany residencies.
(19:40):
So your choke point are thenumber of residencies.
Now individual universities andhealth systems that have
residency programs have paid toincrease their residency slots,
as we have, but that stilldoesn't meet the demand.
So what I see happeningnationally is that we we have a
much greater population.
(20:00):
The population grew by what?
23% since 1997.
I think we were 273 million in1997 when they froze the
residency slots.
We're now up to 335 millionindividuals in the United States
.
And so our doctor graduationrate into into practice, into
full practice, hasn't increasedat the same pace.
(20:23):
I can't quote it, but we're notgenerating enough physicians to
to manage the care for thepopulation as it's growing and
and so income advanced practiceclinicians right Nature hits a
vacuum.
So here we've seen, just since2015, we've seen a doubling in
(20:45):
the growth of our hiring ofadvanced practice clinicians we
went from 436 to 880.
So this is also a cost to thesystem, right?
So this is also a cost to thesystem, right.
(21:14):
And we don't have thephysicians to keep up with the
growth rate.
That I mean, when you thinkabout it, there's not yet a
separate college for thetraining of nurse practitioners.
They are trained basicallywithin the College of Nursing.
But I dare say it's not going tobe too much longer before we
have we have colleges ofphysician assistant training and
(21:36):
nurse practitioner trainingthat will have their own
programs and their ownspecialties, and this is, in
fact, what's rolling out now.
We're not graduating physiciansat a rate that allows us to
take care of the population thesame way that we used to, and
care is so much more complicated.
I mean, think about when youstarted practicing orthopedics.
(21:58):
I'm sure the amount of thingsthat you could do now to assist
the patients is much differentin scope than you had when you
started.
It is for me.
I mean, the complexity of careis much greater and we need more
physicians or more health careproviders to do that, and we're
not graduating house staff fastenough.
Speaker 2 (22:19):
Wow, yeah, it's been an exponential increase in
technology and especially acrossthe field, not just with us,
but with everybody.
That in and of itself is alsoindicative of what we're seeing
on the support staff side.
So it's a total house issue,not just the sports staff as you
(22:40):
were saying.
Speaker 3 (22:42):
Yeah, it's kind of.
I mean, with the advanced carepractitioners it's the Wild West
a little bit.
Everybody's paying differentprices for salaries for their
work, they're paying nightdifferentials and currently they
can switch Like.
I wish I could just kind ofjump into orthopedics and do a
(23:05):
few hip surgeries.
Speaker 2 (23:07):
It's not that hard.
I'm sure you could.
Speaker 3 (23:10):
I think my insurer might have something to say
about that.
So would the hospital qualityboard, but they can switch right
.
So that's kind of interesting.
When you think about it is thatyou can train an APC and
orthopedics to do, let's say,sports medicine evaluations, and
then they could jump over toneurosurgery because of a night
(23:31):
differential in caring forpatients in a neurocritical care
unit.
It's just an example, right,and as medical students are
going into residency, they'realso because of debt and the
availability of higher payingspecialties.
They're sort of bypassingpediatrics.
There's a bit of a crisis inpediatrics in terms of filling
(23:51):
pediatric residency slots aroundthe country and there are fewer
of them choosing to go intofamily practice and my beloved
specialty of internal medicine.
They're going on into cardiologyand gi if they can, and with
that additional training they'lltriple their salaries in the
meantime.
So the nature again who willtake care of, who will be the
(24:12):
care managers of patients?
Primary care it's looking to memore and more like APCs, unless
we do something about the feeschedules and that sort of thing
.
That's on my end of thespectrum.
I know that's maybe not part ofthis conversation, but as we
all get older, we needphysicians to take care of us,
and when we have little kids weneed physicians to take care of
(24:33):
them and we can't take them tospecialists.
So it's a problem nationally.
So do the apcs fill this role?
Do we quick congress toincrease the funding for
residency slots so we can catchup with population growth?
Speaker 2 (24:47):
different ideas different to your point.
This is hitting while the babyboomers are maturing and
starting to approach Medicare.
Oh yeah, or well, into it.
Yeah.
Speaker 3 (24:59):
Yeah, I mean who will take care of them?
And then coordination of carealso right.
I mean who will send theorthopedist, the patient, for
the right review?
Do they send them to a sportsmedicine doc first, or are they
going to send them to anoperative orthopedist?
Do they know the difference?
All of those things areimportant.
I mean, I really like whatCharlie Saltzman did here where
(25:22):
he developed the soup to nutsorthopedic practice.
He's got all under one roofradiology, physical therapy,
non-operative physicians, apcsand operative physicians in each
of the specialty areas oforthopedic care.
Speaker 2 (25:39):
And to give Charlie credit, as Charlie was the one
that got me on to find out aboutyou, to be the speaker at our
AOA meeting.
So that's our common link isCharlie Salzman, who we all
agree is absolutely spectaculara gem of a guy.
Let me ask you this, then whatinnovative things do you see on
(26:00):
the horizon, what innovativethings that are you're
comfortable sharing with us,that y'all are doing to try to
get a hold of this incrediblechange?
It looks like, to your point,that on the top of the pyramid
if you'll let me go there theadvanced practice professionals,
whether they be PAs or nursepractitioners, are starting to
(26:23):
try to fill that vacuum a bit.
But in terms of the supportstaff as well, is there any
innovative, cool things outthere that are coming down the
pike to help stem that demand?
Speaker 3 (26:35):
Well, this may be not so innovative, but as far as
nursing goes we're movingtowards magnet recognition and
you know people have differentviews about magnet.
I think it's important.
I think what nurses are sayingis that the work that we do is
foundational and we have meaning.
(26:57):
The nurses have an ethos, theyhave professional pride around
their work and Magnet puts aribbon on that, I think.
And so I think thatorganizations should embrace
Magnet because it does value thenurses' work and purpose, value
(27:24):
the nurse's work and purpose.
We are in the middle of workingtowards our magnet designation
and I think physicians shouldembrace that.
I think, again, this is anexample where we can reach out
to our colleagues, because theADdesignation is basically
nursing, saying we're anintegral part of caring for
patients and we want you torecognize that and be our
partners in caring for patientsas well.
(27:45):
And I think any of us who haveworked with inpatients know, or
have been inpatients, as I haveknow, that the nurses are at the
bedside way way more than thephysicians are, as I have know
that the nurses are at thebedside way way more than the
physicians are.
And there are eyes and ears andwe don't always use those eyes
(28:05):
and ears in a way that benefitsthe patient to the highest
degree possible.
So I don't know that that'snecessarily terribly innovative,
but I think it is somethingthat is making its way across
the country.
That's the MAGNET program.
So I think we should try toembrace that.
The other thing that we talkabout but we have not yet done
is creating our own schoolingfor technicians and medical
(28:28):
assistants.
That's kind of a hard sell.
You know the university can onlydo so many things.
And do we want to begin a techschool training or do we leave
that to some of the localschools?
And then do we providescholarship funding for service,
tuition for service?
So those are things we havedone in the past, but clearly we
(28:50):
need to.
We need to graduate moreradiology technicians or
technicians.
I wish I had.
I wish I had a betterinnovative answer for you.
Speaker 2 (28:59):
Maybe, maybe parking everybody should focus on yeah,
my place here they I'm prettycertain I got this correct is
that tuition is free.
It's a diploma nurse program.
It's not a bsn program, butthey can get their bsn after
this.
But you can get their diplomain nursing and it's completely
it's not free.
(29:20):
I mean because they work hardto get their degree, but it
doesn't cost them anything ifthey agree to work for the
system once they're finished, sothey can come out of high
school, work or do somethingelse and then come here get
their diploma completely free ofcharge, as long as they work at
the system in some way, shapeor form, as a nurse.
(29:41):
Yeah, I don't think we havethat.
Speaker 3 (29:43):
That's great.
We don't have that At least Idon't think we have that.
I believe I would have heardabout it.
That's a great idea If thesystem can afford that.
That's a fantastic way to bringpeople in and honor their work
and their skills and then keepthem for a number of years
instead of having too muchturnover.
Speaker 2 (30:02):
Do you see a critical point in the future where all
of a sudden it becomes apparentthat throwing money at the
problem doesn't help anymore,that we just don't have enough
staff, that care is becomingincreasingly problematic, which
means that the cost of thesefolks goes up even more, because
as the supply goes down, thedemand goes way up, which so
(30:24):
goes their wages.
And then all of a sudden wehave this healthcare crisis
across the nation.
Is that looming on the horizon?
Speaker 3 (30:30):
Well, I think it's already happening with, as I
mentioned at the beginning, theclosure of rural hospitals, the
deserts of care that are beingrealized now, and I think the
thing that I worry about is thatthe large systems have the
deeper pockets and they have thecapital because of their assets
to hire at whatever prices themarket will bear.
(30:56):
And that's not only true forallied healthcare professionals,
that is absolutely true forphysicians.
So, as we were talking earlier,when you have an orthopedist or
a specialist in high need,those bigger systems can afford
much bigger deltas now than theydid in the past.
(31:17):
So I think what's troubling forsome academic centers is this
gap between what we used to saywell, you're going to join the
academic world, you're going tobe part of the proud and the
great and you're going to workin academic life and you'll make
(31:40):
less than you would make inprivate practice.
But that gap is substantiallybigger now in terms of what the
private nonprofits andfor-profits are offering for
these positions.
And they can afford it.
And you know it used to be.
Well if you were a cardiologistand maybe the academic position
(32:01):
was only $50,000 less than whatyou could make in the community,
that's now $200,000, $250,000,in some cases even more if
you're highly specialized insome aspect of cardiology like
electrophysiology.
So I don't know how it is inyour world of orthopedics
throughout the country, but Isuspect there are some
(32:22):
similarities to that, and so Ithink that that is a threat.
I think academic centers haveto figure out a way.
I actually don't know yet.
I mean, do we decrease theamount of funding that we put
into research?
We decrease the amount offunding that we put into
research in order to increasesalaries to a level that allows
us to retain and hire highlyqualified physicians, or do we
(32:47):
just?
otherwise I think we run therisk of becoming quite average.
Speaker 2 (32:52):
That's disturbing, I mean have you?
Speaker 3 (32:55):
do you see that in your field at all?
Speaker 2 (33:06):
To a degree, yeah, to a degree, but really more.
I think impacting us is thelack of support staff that we
all struggle for our medicalsystems, for the folks to help
us get through the day doing allthe things we need to do.
Speaker 3 (33:13):
The problem that I just described to you is
actually something I've beenwatching for the last couple of
years.
That is, the brain drain, ifyou will, and it's become more
acute in the last year and it'snow on everybody's mind, to the
point that we have a committeelooking at salaries position
salaries and trying to comparethat to the market salaries,
(33:38):
physician salaries, and andtrying to compare that to the
market, because I think thingsmove so quickly that the double
amc benchmarks didn't didn't cutit.
They were not representative ofwhat was actually going on out
there, and I'm talking mostabout highly paid specialists.
So, and it's it's.
It's harder too with withprimary care physicians.
I mean, there's just not enough.
So they're even commanding alittle bit higher salaries than
(34:00):
they had previously.
Speaker 2 (34:02):
Last thing, on digital media or something I saw
the other day I can't rememberwhere I saw this that it was in
one of the Asian countries.
It was, I think, either inSingapore or Japan.
If I recall, they actually hadrobotic nurses, medical
assistants, whatever that wouldhelp.
There are actually robots thatwould go in and engage with the
(34:25):
patient and give them theirmedications and measure their
vital signs and such, and it wasjust to a certain degree.
It was absolutely appallingthinking.
Granted, being taken care of bya machine, but of course, as
you can imagine, they had thisthing humanized as much as
possible, with very caring voiceand all.
Speaker 3 (34:42):
God help us, my friend, if we end up in that
place oh, my wife's alreadyordered one of those so she can
go on vacation.
She thinks it's a great idea.
Well, there's that oh my gosh,we'll see what happens.
I, the human touch, is still themost important thing and
there's so much joy in medicineand I really want to go back
(35:04):
before we conclude and say thatI think one of the best ways to
avoid burnout and yes, we allhave perhaps problems at times
to have enough staff, but towork closely and caringly for
those that are supporting us andI don't know that brings me joy
(35:24):
.
I mean, I've had the samemedical assistant for almost 20
years and she's fantastic andthe patients love her and we all
get cranky from time to time,but it's a team and it's great
and I enjoy the practice andthat's why I still have a small
practice in comparison to my CMOrole.
But it makes it all worthwhileand I think as we work together,
(35:48):
you know, communicate more witheach other about our cases,
time pending with that it's good.
It improves the joy of medicine.
That's why we got into it.
At least I did.
It helps.
Speaker 2 (36:00):
If I could summarize the three things in here one is
work on the culture in ourclinics, taking care of the
folks that take care of us.
Number two search forinnovative ways to try to
address this incoming andinevitable crisis that's coming
down the pike.
Number three make sure thatwe're not charging too much for
parking.
Speaker 3 (36:23):
Yeah, yeah, car in every garage and chicken.
And two cars in every garageand a chicken in the pot.
So there you go.
Speaker 2 (36:29):
It's been my pleasure discussing workforce issues and
the future in workforce with DrTom Miller, who's the chief
medical officer at theUniversity of Utah.
Dr Miller is obviously anexpert in these things and we
did enjoy having him at the AOAmeeting and once again on this
podcast.
So, Dr Miller, sir, thank youfor joining us there.
My pleasure.
It was great talking with you.
(36:50):
Yes, sir, and y'all lookforward to futures in orthopedic
.
On this podcast series.
Popular Podcasts
Crime Junkie
Does hearing about a true crime case always leave you scouring the internet for the truth behind the story? Dive into your next mystery with Crime Junkie. Every Monday, join your host Ashley Flowers as she unravels all the details of infamous and underreported true crime cases with her best friend Brit Prawat. From cold cases to missing persons and heroes in our community who seek justice, Crime Junkie is your destination for theories and stories you won’t hear anywhere else. Whether you're a seasoned true crime enthusiast or new to the genre, you'll find yourself on the edge of your seat awaiting a new episode every Monday. If you can never get enough true crime... Congratulations, you’ve found your people. Follow to join a community of Crime Junkies! Crime Junkie is presented by audiochuck Media Company.
24/7 News: The Latest
The latest news in 4 minutes updated every hour, every day.
Stuff You Should Know
If you've ever wanted to know about champagne, satanism, the Stonewall Uprising, chaos theory, LSD, El Nino, true crime and Rosa Parks, then look no further. Josh and Chuck have you covered.