Hard Medicine

The U.S. has doctors, but they’re not distributed where the needs are greatest. We are in short supply of primary care physicians, especially in rural communities. In this episode, Dr. Yurkiewicz speaks with policy analyst Lawson Mansell about the incentives — largely from the government — that influence what doctors choose to practice and where. These incentives systematically steer doctors away from the medicine patients need most.They dissect several sources: payment that rewards episodic care over long-term relationships, outdated residency funding that favors hospitals over clinics, and underutilizing internationally trained physicians already living in the U.S. They also discuss hopeful initiatives, such as a bipartisan bill that would let Medicaid support a model known as direct primary care.How can policymakers rewrite incentives to reflect workforce needs? How can we help more doctors choose to practice where they’re needed most? 0:06 Opening Monologue: Where Doctors Go Is a Policy Choice1:52 Why Are Primary Doctors Paid Less Than Specialists?19:20 Lobbying from the AMA and Unintended Consequences24:18 The Pipeline In: Residency Funding Is Outdated39:39 Wasting International Physicians’ Time45:26 Bipartisan Support for Direct Primary Care51:04 How Do We Get Doctors Where They’re Needed Most? Get full access to Hard Medicine at ilanayurkiewiczmd.substack.com/subscribe

What is dependence, and is medicine built to handle it? That’s the question at the center of this conversation between Dr. Yurkiewicz and Leah Libresco Sargeant, a writer and thinker. Sargeant’s latest book, The Dignity of Dependence, argues that society treats autonomy as the default, when in reality our lives are shaped by need. Does healthcare, of all places, fully accept this? They discuss the vulnerabilities that even healthcare struggles to hold — chronic illness, pregnancy, end-of-life — and the costs of treating these as exceptions: financial loss, employment discrimination, and compassion fatigue. What would it take for medicine to meet real human need?0:06 Opening Monologue: Healthcare’s Blind Spots on Dependence1:22 What Is Dependence?2:29 Does Medicine Overlook Need?7:22 What Economics Misses About Caregiving10:14 Workplaces Don’t Accommodate Being Human17:57 Nine Months of Illness: Failing to Account for Pregnancy23:21 The Myth of the Invincible Clinician29:02 The Range of Human Experience and Tradeoffs36:45 The Dignity of End of Life39:16 What Is Our Obligation When Quality of Life Is Irreversibly Lost?44:08 Compassion Fatigue46:25 Is Physician Aid in Dying Dignified?55:30 Can Medicine Make Peace With Dependence? Get full access to Hard Medicine at ilanayurkiewiczmd.substack.com/subscribe

All of life, in a way, is decision-making with a deadline — paired with deep uncertainty about that deadline. For people living with stage IV cancer, both the deadline and its uncertainty are radically heightened.Cancer is one word, but it’s not one disease. Thanks to targeted therapies and evolving treatments, some people live for years with metastatic illness. They must make ongoing choices about work, relationships, and meaning, without knowing how many days they have or what those days will look like.In this episode of Hard Medicine, Dr. Yurkiewicz sits down with Dr. Bryant Lin, a primary care physician and clinical professor who was diagnosed with stage IV lung cancer just shy of his 50th birthday. How did he decide what to continue and what to let go? How much detail about prognosis did he seek? Does time itself pass differently when you know there’s less of it?0:06 Opening Monologue: Living with Compressed Time1:43 Life Before Cancer4:01 Lung Cancer in Non-Smoking Asians8:09 First Symptoms and Getting Diagnosed18:27 How Much Did You Want to Know About Prognosis?22:14 Making Decisions Under Uncertainty27:42 Finding Joy and Passing Time38:25 Choosing Hospice or Clinical Trials41:29 Insurance Hell50:20 “Sunshine” — What Makes a Good Life with Stage IV Cancer? Get full access to Hard Medicine at ilanayurkiewiczmd.substack.com/subscribe

Despite being one of the only parts of American medicine that consistently improves outcomes, primary care is in crisis. In this episode, Dr. Yurkiewicz talks with Dr. Lisa Rotenstein, a primary care physician and health systems researcher, about why modern primary care leaves doctors both chronically overworked and functionally unavailable.They unpack the structural mismatches driving this crisis: payment for visits but not the work in between, patient practices in the thousands, and the ever-expanding burden of electronic medical records. They also explore solutions: What is the ideal team, and is AI part of it? What’s the right number of patients for one doctor to see? And is fee-for-service payment simply incompatible with primary care today?0:06 Opening Monologue: Primary Care Is a Design Failure2:01 The Good — Why Doctors Choose Primary Care6:15 What’s Wrong with Primary Care?8:47 Distorted Math: 2,500 Patients and 27-Hour Days13:56 Electronic Medical Record Burdens21:44 When “Part Time” is Full Time24:43 Consequences of an Unsustainable System27:09 Is Fee-for-Service Payment a Non-Starter?31:00 The Ideal Team and Continuity37:29 What AI Can and Cannot Fix44:08 Direct Primary Care48:34 Can Primary Care Be Saved? Get full access to Hard Medicine at ilanayurkiewiczmd.substack.com/subscribe

Healthcare is one of our most important institutions. But it’s no secret it’s deeply broken. Hard Medicine is a monthly podcast tackling the hardest questions facing medicine today: Can primary care be saved? What does a good life look like with stage IV cancer? Why does it take months to see a doctor?Hosted by Ilana Yurkiewicz, MD, Stanford physician, professor, and journalist, and the author of Fragmented: A Doctor’s Quest to Piece Together American Health Care.First episode drops January 12. Get full access to Hard Medicine at ilanayurkiewiczmd.substack.com/subscribe