Get Your Weekly Digest

Receive the best podcast summaries and insights delivered to your inbox every week.

We respect your privacy. Unsubscribe anytime.

Freakonomics Radio

650. The Doctor Won't See You Now

with Rochelle Walensky, Karen Clay, Sanjoy Dutta, Jeff Wood, Paul Goodwin, Evelyn Kim, Colin Larkin, John Clark

Published October 24, 2025
View Show Notes

About This Episode

Stephen Dubner examines the growing shortage of physicians in the United States, exploring both demand-side pressures like an aging population and supply-side constraints in medical education and training. Former CDC director and infectious disease physician Rochelle Walensky outlines workforce data, training bottlenecks, burnout, debt, and rural access problems, while economic historian Karen Clay explains how the early 20th-century Flexner Report raised medical standards but also sharply reduced the number of medical schools and doctors, with complex long-term consequences. Throughout, practicing and former physicians describe how bureaucracy, insurance rules, changing public attitudes, and alternative career options are reshaping the medical profession.

Topics Covered

Healthcare system Labor and workforce issues Aging Education system Burnout AIDS and HIV research controversy COVID-19 response and public health policy Insurance Private equity Rural and urban disparities

Disclaimer: We provide independent summaries of podcasts and are not affiliated with or endorsed in any way by any podcast or creator. All podcast names and content are the property of their respective owners. The views and opinions expressed within the podcasts belong solely to the original hosts and guests and do not reflect the views or positions of Summapod.

Quick Takeaways

  • The U.S. is facing a projected deficit of around 187,000 physicians by 2037, with particularly severe shortages expected in rural areas and in specialties like family medicine and respiratory medicine.
  • Medical school and residency (GME) capacity are tightly constrained by high costs, limited school numbers, and federally capped training slots, turning away many highly qualified applicants.
  • The early 20th-century Flexner Report shut down many low-quality medical schools and led to fewer but better-trained doctors, which research suggests reduced mortality-but also sharply reduced capacity, especially for Black physicians.
  • Physician burnout is driven not just by long hours but by administrative burdens, insurance denials, and electronic documentation that often consume more time than direct patient care.
  • High educational debt, declining professional status, and attractive alternative careers in consulting, industry, and venture capital are drawing some highly trained people away from clinical medicine.
  • Demand for physician services is rising due to the "silver tsunami" of older patients, including a tripling of the 85+ population by 2050 and large projected increases in joint replacements and fractures.
  • Efforts like tuition-free medical schools may help but have not yet clearly shifted graduates toward lower-paying primary care or underserved specialties.
  • Walensky argues that long-term solutions must focus not only on increasing physician supply but also on reducing demand through better prevention and public health measures.

Podcast Notes

Introduction: Access problems and U.S. physician shortages

Difficulty getting timely appointments and specialist referrals

Long waits for primary and specialty care[1:41]
• Dubner describes people being told it can take weeks or months to see a doctor or reach a specialist.
Simple supply-and-demand imbalance in U.S. physician workforce[2:05]
• There are around 1 million working physicians in the U.S., roughly one for every 340 people.
• This physician-to-population ratio is described as much lower than in other high-income countries.
Maldistribution of physicians by geography and specialty[2:25]
• Some cities have a surplus of physicians, while many rural areas have a shortage.
• Certain locations have plenty of cardiologists, oncologists, and psychiatrists, while others have very few.

Physician workload and administrative burdens: listener perspectives

Surgeon Sanjoy Dutta on rising productivity and complexity[2:47]
• Sanjoy Dutta graduated from Harvard Medical School in 1993 and has practiced as a general and bariatric surgeon since 2003.
• He says operating room productivity and efficiency are much higher now; he used to do two bariatric operations a day and now does a minimum of five.
• With electronic medical records, dictation software, and AI scribes, he now sees twice as many patients per day as he used to.
• He also answers patient emails throughout the day, adding to workload.
• He and his staff spend "countless hours" appealing insurance denials for imaging or medications, often based on criteria that do not make sense to them.
• He describes the healthcare system as increasingly complex, with doctors trapped in phone trees and transfers without success.
Rural doctor Jeff Wood on insurance and clinical autonomy[3:41]
• Jeff Wood practices in a rural area in southern Kansas in private practice.
• He describes a "perfect storm" of challenges and sees insurance companies as a huge part of the problem.
• He says insurers are starting to dictate treatments and even suggest AI-based alternatives before doctors can use their own judgment.
• He questions the point of becoming a doctor if others will dictate what he is "supposed" to do.

Framing the episode: physicians and patients both under strain

Dubner announces focus on physician well-being and patient impacts[4:25]
• He says "the docs are not all right," and therefore "neither are the rest of us."
Preview of main themes: supply, demand, and history[4:25]
• He promises to look at factors limiting physician supply, including long training times and debt.
• He notes that people over age 85 will reach 17.5 million by 2050, raising demand.
• He previews a historical episode in medical education where low-quality doctors were harming people.

Guest background: Rochelle Walensky and infectious disease career

Childhood inspiration and early interest in medicine

Role model pediatrician Judith Osha[5:32]
• Rochelle Walensky says she knew she wanted to be a physician by about age 10.
• Her pediatrician was Dr. Judith Osha, whom she later learned was a giant in her field.
• Osha made it possible for Walensky to see that women could be in medicine and be revered.

Walensky's leadership roles and HIV work

Major positions held[5:42]
• Walensky served as director of the CDC during the Biden administration.
• Before that she led the Infectious Diseases Division at Massachusetts General Hospital and taught at Harvard Medical School.
• She is now back at Harvard and also does consulting.
Becoming an HIV infectious disease clinician[6:16]
• She was an intern in inner-city Baltimore in 1995, the year the FDA approved a third HIV drug.
• In early 1995, having AIDS or HIV was "for certain a death sentence" for patients she saw at the bedside.
• After the third drug was approved, doctors could tell patients that taking dozens of pills three times a day might allow them to live.
• She calls it an incredibly motivating time with very fast-moving science that suddenly offered patients a chance.
• Even with available science, many patients faced barriers: affordability, availability, stigma, safe storage, and risk of theft of their meds.
• Her early HIV experience highlighted that delivering scientific advances required addressing patients' real-life circumstances.

COVID-19, CDC leadership, and concern about infectious disease workforce

Taking over CDC during peak COVID mortality

State of the pandemic when Walensky became CDC director[7:35]
• She became CDC director while COVID was still "raging," with about 4,000 deaths per day when she was sworn in.
Hospital experience in early pandemic[8:22]
• At Mass General Hospital she recalls walking in and seeing a mobile morgue outside to increase morgue capacity.
• Faculty with immunocompromised family members still worked at the bedside, creating a stressful, scary, pre-vaccine environment.
Emotional impact of the first vaccine efficacy news[8:12]
• She remembers getting a CNN alert that the vaccine worked while walking into Mass General on a rainy morning around 7 a.m.
• The news "literally" stopped her at the hospital door because it finally represented hope.

How she was selected to lead CDC

Recruitment and qualifications[8:26]
• Walensky says she was cold-called by the administration; she did not apply for the job.
• She had done substantial work in HIV policy, was a well-respected infectious disease clinician, and had media and policy experience.
• She had served on guidelines committees and done cost and cost-effectiveness work, never taking money from industry and having no conflicts of interest.

Current worry: infectious disease workforce and broader healthcare workforce

Lack of infectious disease specialists[10:00]
• Before COVID, many people did not understand what infectious disease doctors did.
• During early COVID, she received many requests from companies like airlines and cruise ships to advise them on what to do.
• She and colleagues mapped infectious disease doctors and found that 80% of U.S. counties lacked a single infectious disease physician.
Hospital staffing crisis during COVID[10:46]
• While at CDC, she heard that some hospital beds were closed simply because there were no staff and personnel available.
• This triggered her desire to understand the healthcare workforce more broadly, leading to a research endeavor.

New England Journal of Medicine article on looming workforce crisis

Key message of Walensky and McCann's paper[11:07]
• The article states that an "urgent healthcare workforce crisis is looming."
• They argue that many necessary reforms require congressional action and accountability, which have been too slow to produce meaningful change.
Magnitude of projected physician shortage[12:03]
• Walensky references an anticipated deficit of 187,000 physicians by 2037.
• She says she had seen pieces of the problem before, but assembling all the data showed that at every step along the training path there are challenges that weed people out.
• She notes that the existing workforce is burnt out, retiring, and smaller than needed.
Uneven distribution of shortages[12:15]
• Over the next decade, rural areas are expected to have about a 60% physician shortage, versus about a 10% shortage in metro areas.
• Specialties with the largest expected shortages include family medicine, vascular surgery, ophthalmology, and respiratory medicine.

Demand-side pressures: aging, life expectancy, and disease burden

Demographic change and the "silver tsunami"

Growth of the very elderly population[12:32]
• Walensky notes that by 2050, the population over age 85 will increase threefold.
• She poses the question of who will care for this large group.
Life expectancy patterns and disparities[12:41]
• Dubner says he has read that the most common age of death in the U.S. today is 87, and Walensky says that sounds about right.
• Walensky emphasizes that many people are living very long if they are healthy, but there are significant gaps across populations.
• She argues that to improve overall life expectancy, the U.S. must focus on people with the most life expectancy lost, such as those dying early from cardiovascular disease, hypertension, stroke, and diabetes.
• These conditions and premature deaths occur differentially across populations.

Orthopedic surgeon listener on aging-related surgical demand

Joint replacement and fracture projections[14:17]
• Orthopedic trauma surgeon Paul Goodwin from Texas describes a "huge silver tsunami" of patients needing joint replacements.
• He says estimates suggest every orthopedic surgeon would have to double their caseload to meet projected demand if the number of surgeons stays constant.
• He notes that the incidence of hip fractures is expected to approximately double in coming decades.

Medical school capacity and barriers to entry

Limited growth in medical school slots

Slow expansion relative to need[15:05]
• Walensky says that over the past decade there has been about a 10% increase in medical school slots, which is not enough given the need.
• She describes current medical school standards as famously high, which people appreciate, but notes that there are many people capable of meeting those standards.

Competitive and expensive application process

Typical application load and costs[14:24]
• She and her husband wrote about watching their own child apply to medical school and the challenges involved.
• On average, applicants are being advised to apply to about 18 schools, with many applying to 25 or 30.
• The MCAT exam costs over about $350.
• Each primary application is about $150, and secondary applications often require four to eight essays each.
• She says talented applicants may end up writing 50 to 100 essays and still may not get in.
Impact on lower-income and diverse applicants[16:07]
• Dubner notes that the process helps explain why lower-income people are much less likely to become physicians, and Walensky agrees.

Example of an exceptionally strong applicant initially rejected

Case study of one applicant's experience[16:36]
• Walensky describes an applicant who applied to 33 medical schools at a cost of almost $5,000.
• This candidate attended a private "league" (elite) university and scored in the 96th percentile on the MCAT.
• She was interviewed at only two schools, rejected from all her "safety" schools (which assumed she would not attend), and was waitlisted and never admitted that cycle.
• Instead of giving up for another career, she took a year off, reapplied, and ultimately received a full-ride scholarship at a top medical school.
• Walensky notes that without this applicant's grit, she likely would have gone into another lucrative field such as investment banking.

Constraints on opening more medical schools

High costs and need for hospital partnerships[17:58]
• Walensky says the number of medical schools is finite but could be increased; however, opening a school is extraordinarily expensive.
• Faculty must be paid to teach rather than see patients, and schools must affiliate with hospitals where students can receive bedside training.
• Hospital partnerships are needed to provide clinical training and supervising doctors for students.
Current distribution of medical schools[17:45]
• There are fewer than 200 medical schools in the U.S., concentrated in populous states like New York, California, and Texas.

Historical context: the Flexner Report and medical school closures

Introduction to the Flexner Report and research question

Basic description of the Flexner Report[21:28]
• Economic historian Karen Clay says the Flexner Report is hugely important and widely known in medicine, but surprisingly little is deeply understood about it.
Motivation for studying Flexner's impact[21:36]
• Clay co-authored a working paper titled "Medical School Closures, Market Adjustment and Mortality in the Flexner Report Era."
• Her co-author Grant Miller had studied low-quality physicians in developing countries and the idea of addressing low-quality medical schools to raise standards.
• They focused on the question of whether low-quality doctors are better than no doctor at all and found evidence that low-quality doctors were actually harming people.

Medical education landscape before Flexner

Rapid growth and uneven quality[22:19]
• The Flexner Report was published in 1910, during a time of U.S. economic growth and rising demand for medical services.
• Many physicians would attend medical school in their town and then practice there; entrepreneurial physicians started schools as a way to earn extra money and enhance prestige.
• Some medical schools did not require even a high school education for admission.
• Quality of training varied widely due to proliferation of schools.
AMA's evolving role and concern about quality[24:10]
• In the late 19th century, the American Medical Association was an organization primarily for elite physicians.
• To gain political power, the AMA broadened membership by making membership in a state medical society automatically confer AMA membership.
• Membership rose rapidly, and the AMA established a Council on Medical Education.
• Beginning in 1905, the AMA published educational standards and then visited medical schools to rate their quality.

Abraham Flexner's role and methodology

Flexner's background and relationship with AMA[25:22]
• Abraham Flexner had studied the American college system and how it compared with European universities but had no direct medical school experience.
• He was hired by the Carnegie Foundation, via connections, to collaborate with the AMA in evaluating medical schools in the U.S. and Canada.
• The collaboration involved the AMA providing assistance and prior evaluations, but criticism of schools was easier coming from an ostensibly independent third party.
Evaluation criteria and gold standard[26:32]
• Walensky notes that Flexner evaluated each school as either too poor to salvage, workable with improvement, or a gold standard.
• He used Johns Hopkins as the gold standard for medical education at the time.
• Flexner and AMA official Nathan Colwell visited nearly 150 U.S. medical schools.
• They focused on robust biomedical and laboratory sciences, collaboration with hospitals, the quality of hospital training, strength of physician-scientist faculty, and hospital-school relationships.

Immediate impact: school closures and market adjustment

Flexner's recommendations and media reaction[27:56]
• Flexner argued that the vast majority of schools did not meet standards and suggested closing many of them.
• Headlines at the time included "Poor medical colleges a danger" and "Country flooded with quacks."
Scale of closures after Flexner[28:40]
• The report radically recommended keeping only 31 medical schools to train enough doctors for the entire U.S.; this extreme recommendation was not fully implemented.
• By 1915, the number of U.S. medical schools had fallen to between 90 and 95, from a much higher pre-report number.
• The number eventually stabilized around 70 schools.
Mechanism of closures: students avoiding poorly rated schools[29:12]
• Clay emphasizes that schools were not directly forced to close; instead, after low Flexner ratings, students stopped applying.
• Schools that closed tended to be in medium and larger cities, not mainly rural areas; some counties like Cook County (Chicago) had many schools before closures.

Disproportionate effect on Black medical schools

Reduction in Black physician training capacity[29:43]
• Before Flexner, there were more than a dozen Black medical schools in the U.S., several at HBCUs.
• Within about a decade, only two remained: Howard University College of Medicine and Meharry Medical College.
• Clay notes that many Black and southern schools admitted students without high school degrees because so few in those communities had such credentials.
• Walensky calculates that closing five out of seven HBCU medical colleges resulted in about 30,000 fewer Black physicians than might otherwise exist.
• She calls this a fascinating and tragic part of the Flexner era and a factor in why there are not more Black physicians today.

Flexner-era separation of medicine and public health

Unique U.S. divide between medical schools and schools of public health[31:08]
• Walensky says the Flexner era created a divide between medical schools and schools of public health that is relatively unique to America.
• She views this siloing of public health departments and medicine as a major challenge for the country.
• She notes that in Europe there are more fluid relationships between clinical medicine and public health.
Example from COVID vaccine data access[31:47]
• Walensky recalls people asking why CDC relied on U.K. and Israeli data for vaccine effectiveness.
• When she called U.S. hospitals to ask who was hospitalized with COVID and vaccinated, hospitals said they could not link vaccination data (held by public health departments) with hospital data.

Health effects of closing low-quality medical schools

Measured mortality impact after Flexner closures

Findings on infant and non-infant mortality[32:38]
• Contrary to an expectation that fewer doctors would reduce access and worsen outcomes, closures after Flexner were associated with improved health outcomes.
• Clay and colleagues found that medical school closures led to an 8% drop in infant mortality and a 4% drop in non-infant mortality.
• Given higher baseline mortality at that time, they estimate about 16,000 infant lives and 38,000 non-infant lives saved per year.
Comparison to other major public health interventions[33:24]
• Installing water and sewerage in the Boston area reduced infant mortality by about 23%.
• Municipal water filtration reduced infant mortality by 11-12%.
• Between 1900 and 1940, prohibition decreased infant mortality, while lifting prohibition increased infant mortality by 4-5%.
• Clay says that today, an 8% reduction in infant mortality would merit a Nobel Prize in Medicine.

Why low-quality doctors were harmful

Skepticism and evidence from developing countries[34:16]
• Clay says they spent a long time checking whether they were estimating correctly because she was initially skeptical that doctors were harming people.
• They drew on literature from developing countries showing that many parts of the doctor-quality distribution are more likely to harm patients than help.
Historical context: limited technology and poor hygiene[34:58]
• Early 20th-century low-quality doctors lacked modern tools; even today, low-quality doctors in developing countries at least can give IV fluids or antibiotics.
• This period, despite widespread knowledge of germ theory, did not have uniform hygiene practices.
• Low-quality doctors who did not pay attention to hygiene could easily cause life-threatening infections, for example by stitching wounds without proper sterilization.

Walensky's reaction to Flexner findings and counterfactual

Agreement with results but questions about alternative path[35:20]
• Walensky calls the Flexner story "super interesting" and says the methods in Clay's paper seem sound, especially given that many averted deaths were likely infectious and hygiene-related.
• She asks what would have happened if, instead of closing those schools, their training (e.g., hygiene practices) had been improved, even if not to Johns Hopkins levels.
• She is agnostic on whether Flexner was a success or net harm, partly because it is now very hard to open new schools and capacity remains limited.
• She suggests that strictness from Flexner and the AMA may have contributed to today's dilemma of too few medical school slots and doctors.

Graduate Medical Education (GME) caps and training bottlenecks

Residency and fellowship as required steps after medical school

Need for postgraduate training before independent practice[40:05]
• Walensky explains that after medical school, graduates cannot practice independently; they must complete internship, residency, and often fellowship.
• Training slots for this Graduate Medical Education (GME) are federally capped and run through CMS and Medicare.

Historical origin of GME caps and limited growth

Past fears of a physician surplus[40:23]
• GME caps were put in place in the 1980s-1990s when there was concern the U.S. might have too many physicians.
• At that time, physicianhood was highly revered, many people were entering medicine, fee-for-service payments made it lucrative, and medicine was seen as a great field.
• Congress responded to surplus fears by constraining training numbers via federal funding caps.
Current constraints and shortfall[40:56]
• Hospitals receive a fixed number of federally funded slots for all training programs, across specialties.
• States or hospitals can add slots, but this is expensive.
• Over the last 20 years, GME slots have grown by only about 15,000, which Walensky says is far short of what is needed given the projected deficit of 187,000 doctors.

Changing status of physicians, burnout, and alternative careers

Emergency physician Evelyn Kim on work identity and shifting attitudes

Generational differences in work-life balance[42:26]
• Evelyn Kim is an emergency physician who began her career after the TV show "ER" attracted people to the specialty.
• She followed her father's path, as many physician children do.
• She has seen the work itself, physicians' attitudes, and society's attitudes toward physicians all change over time.
• She identifies strongly as a physician and says she was not afraid to admit she had no work-life balance; this concept did not exist for her father or for much of her career.
• She personally is not close to retirement and still feels she has a lot to contribute but believes this is not the predominant attitude among physicians now.

Colin Larkin: from med student to venture capitalist

Initial motivation for medicine and media image[43:13]
• Colin Larkin studied chemical engineering at the University of Rochester with plans to become a physician.
• He says society strongly encourages young people to pursue medicine due to its life-saving impact, reverence, education, and good income.
• TV shows like "House" and "Grey's Anatomy" glorify physicians.
Career pivot after clinical exposure[42:30]
• He obtained a master's at Oxford and enrolled in medical school at Northwestern, planning to become a neurosurgeon.
• Once in hospital settings, he realized he did not like the work, which he describes as highly clerical, algorithmic, and hyper repetitive.
• He took time off to work in management consulting at Boston Consulting Group through a program that specifically recruits medical students.
• He later returned to finish his degree, worked at a medical device startup, applied to residencies and venture capital roles, and ultimately became a life sciences and health tech investor at SoftBank in Silicon Valley.
• He graduated in spring 2024 but chose not to practice clinically, calling himself "part of the problem" regarding physician shortages.

Walensky on declining respect, compensation, and loan burden

Erosion of reverence and attack on science[44:29]
• Walensky notes that physicianhood used to be revered, but in recent years physicians and science have been under attack.
• She says compensation is not what people hope for, especially relative to the size of educational loans.
Loan burden and alternative career incentives[44:38]
• She cites average medical student loan debt of about $200,000, with 70-90% of students carrying debt.
• Given deferred earning years and heavy debt, students may ask why they should add more years of training instead of pursuing other strong careers.

Tuition-free initiatives, borrowing caps, and financial policy

Tuition-free medical schools funded by philanthropists

Goals and early evidence[44:58]
• Dubner notes a movement where private philanthropists make some top-tier medical schools tuition-free.
• Walensky supports the idea but adds a caveat: it does not change the underlying cost of producing a doctor, only who pays.
• One motivation is to attract students from less affluent communities and encourage more graduates into primary care and lower-paying specialties by reducing debt pressures.
• She says early data from tuition-free schools are not clearly showing that graduates are disproportionately entering lower-paying specialties.
• She concludes that free tuition alone will not fix the overall workforce issue.

Federal borrowing limits and risk of reducing access

Loan caps vs. actual student debt levels[47:10]
• Walensky is concerned about a policy limiting how much students can borrow, with a maximum around $200,000.
• Because more than half of students have debt over $200,000, she worries that strict borrowing caps could eliminate access for about half of potential medical students.

Rural-urban maldistribution and policy complications

Geographic preferences and training location stickiness

Why rural areas struggle to attract physicians[48:05]
• Walensky says many physicians want to live in urban areas, a pattern seen globally, which leaves rural areas lacking physician care.
• Many doctors prefer to stay where they trained, which tends to be in urban centers with academic hospitals.

Incentives to serve rural and tribal communities

Existing and experimental models[49:13]
• Some policies increase Medicaid payments in rural areas by about 10% to incentivize practice there.
• Walensky notes that many interventions over 50 years have not clearly demonstrated success.
• She describes a Massachusetts partnership with a tribal nation in the Dakotas where residents enjoy going to learn and care for patients.
• Residents are often willing to go for months, but long-term financing and compensation after training remain unresolved.

Dobbs decision and unintended effects on physician location choices

Abortion access as a factor in residency selection[49:59]
• Walensky notes surveys indicating that physicians, not only obstetricians, are wary of training in states without abortion access.
• Typical residents are around age 26-35, and many are women or partnered with women who may want children during that time.
• She argues that limitations on abortion access may discourage young physicians from moving to those states, regardless of one's views on the policy itself.

Physician exodus, burnout drivers, and daily frustrations

Urgent care doctor John Clark on pipeline discouragement

Long training and high debt as deterrents[51:06]
• John Clark, an urgent care doctor in Colorado with varied practice settings, recalls hearing dire physician shortage predictions since the mid-1990s.
• He asks listeners to imagine telling a 14-year-old that becoming a doctor requires 15 years of education and training, plus around $100,000 in college debt and $200,000 or more in medical school debt.
• He doubts many teenagers would eagerly pursue that path given the costs and time.

Non-clinical time, bureaucracy, and "pajama time"

Administrative overload vs. meaningful clinical work[51:56]
• Walensky says physician hours are long, and much of that time is not satisfying because it is spent on computers and paperwork.
• She cites a 2017 study showing that in an 11.5-hour workday, nearly six hours were spent in front of the computer or doing "pajama time" (after-hours documentation).
• Pajama time refers to evenings after a long day seeing patients, when doctors must finish notes at home.
Insurance denials undermining patient care and morale[53:08]
• Walensky describes a patient with an inflammatory disease needing an outpatient monoclonal antibody infusion that cost several thousand dollars and was unaffordable.
• The patient's disease flared, leading to a three-day hospitalization.
• Doctors attempted to give the monoclonal antibody as an inpatient treatment, but insurance declined coverage.
• She says burnout is not only about long hours-doctors expected those-but also that the system often blocks them from effectively helping patients.

Reducing demand through prevention and public health

Strategic focus on prevention rather than disease treatment

Reframing what the healthcare system pays for[53:58]
• Walensky says solving the physician shortage requires both increasing supply and decreasing demand for medical care.
• She argues that the best way to reduce demand is through prevention, but the U.S. invests little in preventive interventions.
• She notes that while people talk about "healthcare," the system primarily pays for treating disease, not maintaining health.

Examples of prevention gaps and logistical barriers

Screening rates and rural obstacles[54:21]
• Walensky raises questions about breast cancer screening and colonoscopy rates in rural America as areas needing attention.
• She visited Alaska, which has one of the highest rates of colon cancer in the world.
• Screening for colon cancer by colonoscopy in Alaska is logistically difficult; it can require two flights and limited access to necessary facilities.

Walensky's return to clinical work and outlook on "wicked" problems

Reconnecting with direct patient care

Emotional significance of putting on the white coat again[55:02]
• Walensky says that in July (after her CDC tenure), she put on her white coat for the first time in a long time.
• She describes it as wonderful and says it reminded her of her passion for taking care of patients.

Future plans and appetite for difficult jobs

Keeping options open but attracted to challenges[55:22]
• She is keeping her options open but suspects there is another big job ahead of her.
• She likes going to hard places where she can learn and is working on more papers about workforce challenges and other important topics.
• She says she has never shied away from a hard job.

Optimism vs. "wicked problems"

Attitude toward seemingly unsolvable issues[55:45]
• Dubner mentions the term "wicked problems" for issues that are essentially unsolvable and asks how she stays optimistic.
• Walensky describes herself as a "chronic optimist" who lives in the "land of yes" rather than the "land of no."
• She recalls a mentor saying that if a problem were easy, someone else would have already solved it.
• Dubner jokes that she is either optimistic or delusional; she replies that she may be a bit of both.

Outro and teaser for next episode on horse economics

Listener feedback request and credits

Request for audience thoughts on physician shortage[56:48]
• Dubner invites listeners to email thoughts on the topic to radio@freakonomics.com.
Production credits[57:32]
• He notes the show is produced by Stitcher and Renbud Radio, with archives and transcripts available at Freakonomics.com.
• He lists staff involved in production, editing, mixing, and research guidance.

Preview of upcoming series on horses

Economic role of horses in U.S. history and today[55:26]
• Dubner says the next series will focus on a technology that helped create the modern world: horses.
• He notes that historically, everything in the U.S. was either produced by or moved by horsepower, but now there are about 7 million horses whose roles have changed.
• The teaser asks who rides, buys, and sells horses today and what those horses do all day.

Lessons Learned

Actionable insights and wisdom you can apply to your business, career, and personal life.

1

Quality control in professional training can save lives, but overly strict or inflexible standards can also constrict long-term capacity and equity in the workforce.

Reflection Questions:

  • • Where in your field or organization might quality standards be unintentionally limiting access or diversity without proportionate benefits?
  • • How could you distinguish between truly harmful low standards and areas where incremental improvement, rather than exclusion, would yield better long-term outcomes?
  • • What is one process, rule, or gatekeeping mechanism you could revisit this month to balance quality with opportunity more thoughtfully?
2

System-level bottlenecks (like capped training slots or limited school capacity) can silently shape entire labor markets for decades, regardless of frontline demand.

Reflection Questions:

  • • What hidden capacity constraints exist in your own industry that could be shaping supply, pricing, or access more than you realize?
  • • How might your strategic planning change if you mapped the full pipeline from entry to senior roles and identified where people are being "weeded out"?
  • • What is one step you could take this quarter to either expand a critical bottleneck or creatively work around it?
3

Individual career choices respond not just to passion or status but to concrete trade-offs like debt, work conditions, and alternative opportunities.

Reflection Questions:

  • • How have factors like financial risk, workload, and perceived respect influenced your own career decisions, even if you framed them as "following your passion"?
  • • In what ways could you redesign roles or career paths in your organization to make them more attractive relative to competing options?
  • • What single change to compensation, training length, or day-to-day work could most improve retention in your team or profession?
4

Burnout often stems less from long hours than from feeling blocked in doing meaningful work by bureaucracy, misaligned incentives, and broken systems.

Reflection Questions:

  • • Where do you most often feel that your effort is wasted or undermined by processes that don't actually serve your mission?
  • • How might you redesign one recurring workflow so that a higher share of your time goes to work you find meaningful rather than administrative friction?
  • • What is one small but concrete system-level obstacle you could challenge, automate, or delegate in the next month to reduce your own "pajama time"?
5

Investing in prevention and upstream solutions is a powerful way to relieve overloaded systems, but it requires changing incentives away from crisis response toward long-term health.

Reflection Questions:

  • • What problems in your life or business do you consistently treat at the crisis stage instead of addressing their root causes earlier?
  • • How could you reallocate a portion of your time, budget, or attention this year from reactive fixes to preventive measures with compounding benefits?
  • • What is one preventive habit, metric, or safeguard you could implement this week that would meaningfully reduce future emergencies or bottlenecks?

Episode Summary - Notes by Sage

650. The Doctor Won't See You Now
0:00 0:00