650. The Doctor Won’t See You Now

Summary

Podcast Summary: Freakonomics Radio — Episode 650: "The Doctor Won’t See You Now"

Date: October 24, 2025
Host: Stephen J. Dubner
Key Guests: Dr. Rochelle Walensky (former CDC Director), Karen Clay (economic historian, Carnegie Mellon), plus numerous listener physicians

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Overview

This episode investigates the worsening shortage of physicians in the United States, tracing its historic roots, current barriers to expanding the physician workforce, and the ripple effects for both medical professionals and the public. Host Stephen Dubner leads conversations with Dr. Rochelle Walensky—highly-respected former CDC Director—and Karen Clay, who studies the consequences of 20th-century reforms in medical education. The discussion spans daunting debt, barriers to entry, historical policy missteps, physician burnout, and the future of care access.

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Key Discussion Points & Insights

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The Physician Shortage Crisis

• US Physician Supply: The U.S. has about one physician for every 340 people, a lower ratio than other high-income nations. Maldistribution and specialty imbalances make shortages geographically and clinically uneven.

  • Dubner: “Some cities have a surplus, while some rural areas have a shortage. There are also mismatches when it comes to specialties.” (01:58)

• Listener Physician Voices

  • Dr. San Joy Dutta: Highlights drastic increases in workloads, AI-driven documentation, and relentless digital patient communication.

    "I used to do two bariatric operations a day and now I do a minimum of five… I see twice the number of patients in a day that I used to." (02:24)

  • Dr. Sarah Rahal: Describes battles with insurance denials, complexity, and bureaucratic hurdles.

    "We are often stuck in a maze of phone systems and transfers, arguing our case to no avail." (02:57)

  • Dr. Jeff Wood: Critiques insurers dictating care and the intrusion of AI into clinical judgement.

    “What was the point of becoming a doctor if you're just going to be told what you're supposed to do?” (03:34, paraphrased)

Demand Drivers: Aging Population

• Aging Boom: By 2050, 17.5 million Americans will be 85 or older—a threefold increase.

  • Dubner: "If the supply of surgeons stays constant... every orthopedic surgeon will have to double their caseload in order to meet the demand." (13:51)

• Preventive Care Gap: Emphasized as both a cost and demand mitigator—structural barriers and lack of focus on prevention currently exacerbate demand (52:08–52:54).

Barriers to Expanding the Physician Workforce

Medical School Access

• Limited Medical School Slots: Despite huge numbers of qualified applicants, there are fewer than 200 U.S. medical schools, heavily concentrated in populous states.

  • Dr. Walensky: “We are systematically turning away…incredible talent…It's an expensive process." (14:41)
  • On the expense and difficulty: "Kids are suggested to apply… to 18 schools. Many kids are applying to 25 and 30… MCATs are over $350 or so. Each application is $150 or so..." (14:41)

• Economic Barriers: Application and education costs disproportionately deter lower-income students, further skewing physician demographics (15:39–15:46).

• Residency Bottleneck: Federally capped graduate medical education (GME) slots have not kept pace since the 1980s, stalling training throughput despite increased med school applications.

  • Walensky: "Those slots for training are capped…since back in the 1980s, 1990s when there was an anticipation that we would have too many physicians. We are not there." (40:00)

Historical Roots: The Flexner Report

• Flexner Report (1910):

  • A third-party evaluation, commissioned by the AMA and Carnegie Foundation, led to the closure of many "low-quality" medical schools.
  • Karen Clay: “[Flexner] recommends keeping only 31 medical schools… which it deemed would be enough to train enough doctors for the entire US… That’s not what happened, but it was still really, really surprising.” (28:01)
  • Impact: Schools that closed were disproportionately those serving Black students; of 13+ Black medical schools, only 2 (Howard and Meharry) survived a decade later.
    • Clay: "It is a fascinating and tragic part of the Flexner Report in terms of impacts of why are there not more black physicians?" (30:27)
    • Walensky: “By virtue of closing five out of seven HBCU medical colleges, we now have about 30,000 less black physicians than we might have had.” (30:27)

• Evidence of Harm from Low-Quality Doctors:

  • Flexner closures correlated with 8% drop in infant mortality, 4% drop in non-infant mortality (1900s data).
    • Clay: "Many parts of the doctor quality distribution are more likely to harm patients than to help them, even today." (33:45)

• Unintended Long-Term Effects:

  • Debate remains: did the stricter standards, slow expansion of medical schools, and consolidated training unduly throttle workforce growth?
    • Walensky: "It's so hard to open medical schools that it is not obvious…that might have done harm by not having the capacity to bring people in to continue to train and improve that training." (36:02)

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Physician Burnout, Bureaucracy, and Changing Culture

• Falling Prestige and Satisfaction:

  • Listener Dr. Evelyn Kim: “I have definitely seen… the attitudes of physicians change, and society’s attitude toward physicians change… Nowhere near feeling like I want to retire because I still feel like I have a lot to contribute. But I don't think that that is the prevalent attitude amongst physicians these days.” (41:40)

• Burnout & Insurance Hassle:

  • Tech and insurance bureaucracy sap joy and autonomy for doctors.
    • Walensky: "There was one… study that demonstrated that in an 11.5 hour workday, almost six hours… was spent in front of the computer, or what they call pajama time." (50:39)
    • Example: A patient denied insurance coverage for vital treatment, leading to preventable hospitalization (51:12).

• Economic Pressures: Debt and Lost Talent

  • Student Debt: 70-90% of medical grads carry $200k+ debt. Maximum allowed borrowing threatens to exclude would-be doctors from less affluent backgrounds.
    • Walensky: “If... more than half of students have debt and that debt is over $200,000, you’re going to lose half of your medical students if you don’t allow them to borrow money.” (46:01)
  • Alternative Careers: Talented med students increasingly divert to consulting, tech, or finance.
    • Colin Larkin (listener): “A lot of what you end up doing [as a doctor] is clerical work. It’s very algorithmic… so I ended up… as a Silicon Valley life sciences and health tech investor at SoftBank.” (43:24)
  • Free Medical School: Some philanthropic efforts to make top programs tuition-free haven’t yet measurably diversified specialties or increased primary care uptake (46:01).

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Policy Implications and Possible Solutions

• Increase Medical School and Residency Slots: Easier said than done—expense, hospital partnerships, and political will required.
  • Walensky: "We certainly could open more medical schools. Just to be clear, it's extraordinarily expensive…" (17:16)
• Better Distribution Incentives for Rural/Underserved Areas: Current incentives ineffective; new financing models and robust partnerships needed.
  • Walensky: “I think we need to incentivize folks to go into rural areas…The things that have been done over 50 have not necessarily demonstrated that they’re working.” (48:33)
• Unintended Policy Consequences: Social issues (e.g., abortion access) affect where young physicians are willing to train or settle.
• Reduce Physician Demand Through Prevention:
  • More investment in public health and preventive care would shift the balance.
    • Walensky: "The best way to decrease demand is to work on prevention… We pay to treat diseases. We do very little to invest as a country in prevention interventions." (52:08)

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Notable Quotes & Memorable Moments

• Walensky on Hope During COVID:

  "I remember where I was when I got the CNN news alert that the vaccine actually worked. It literally stopped me before the door of the hospital because there was hope. There was finally hope." (08:26)

• Flexner Report’s Paradoxical Legacy:

  "It would appear that…having a bad doctor can be worse than having no doctor at all." — Dubner (32:49)

• On the Long Road to Becoming a Doctor:

  “Can you imagine telling a 14-year-old high school freshman that, to be a doctor, it'll take 15 years and maybe $100,000 in college debt plus $200,000 or more in medical school debt?” — Dr. San Joy Dutta (04:01, repeated at 45:01)

• Chronic Optimist’s Approach:

  "You know what? Perhaps to my detriment, I'm a chronic optimist. I like calling it the I live in the land of yes, not the land of no…if it was easy, somebody else would have done it." — Dr. Rochelle Walensky (54:13)

• Wicked Problems:

  "You know, people started in the last whatever bunch of years to use the phrase wicked problems." — Dubner
  "Well, I'm from Boston, so everything's wicked here." — Walensky (53:46)

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Key Timestamps

• Reasons for Physician Shortage, Initial Data: 01:52–04:11
• Workforce & Supply Debate (Rural vs. Urban): 10:34–12:35
• Demand Surge: The "Silver Tsunami": 12:06–14:01
• Barriers to Med School Entry / Cost: 14:41–16:17
• Flexner Report’s History and Modern Impact: 21:11–36:19
• Training Bottleneck—Residency Constraints: 40:00–41:28
• Burnout, Changing Social Prestige, Lost Talent: 41:28–45:36
• Debt and Socioeconomic Filters: 45:01–47:11
• Distribution Regrets & Rural Shortages: 47:49–49:47
• Access and Prevention as Alternative Solution: 52:08–52:54
• Ending on Optimism: 54:13–54:28

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Tone and Style

The episode combines deeply informed, candid expert testimony with accounts from front-line physicians and policy analysts. Dubner’s trademark blend of curiosity, wry humor, and open skepticism brings warmth to the complex debate. The mood shifts from frustration and anxiety—over workforce gaps and physician burnout—to cautious optimism, grounded in the belief that bold reforms are not only possible, but necessary.

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For listeners who missed the episode, this summary provides a comprehensive look at why accessing a doctor is harder than ever—and what it will take to fix that.

Transcript

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[Stephen Dubner]

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[Rochelle Walensky]

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[Stephen Dubner]

A home pro, you just have to hire one. You can hire top rated pros, see price estimates and read reviews all on the app. Download Today hey there, it's Stephen Dubner. Quick announcement. I will be doing a live event on Sunday, November 2nd in Washington, D.C. at 6th and I, which is a great room if you've never been. I will be in conversation with Jeff Bennett of PBS NewsHour, celebrating 20 years of Freakonomics and talking about what's next. Hope you can make it. For tickets, go to Freakonomics.com liveshows and now, here is today's episode. Have you ever tried to make an appointment with your doctor and been told it would be weeks or even months before you could get in? Or maybe you were referred to a specialist and it turned out that the nearest specialist isn't at all nearby? One obvious cause of this problem is good old supply and demand. We have around a million working physicians in the US or one for every 340 people. That is a much lower ratio than other high income countries.

[Rochelle Walensky]

I'm telling you, we're 180,000 doctors behind. It's not going to get us to where we need to be.

[Stephen Dubner]

There are also mismatches in where physicians work. Some cities have a surplus, while some rural areas have a shortage. There are also mismatches when it comes to specialties. Some places have plenty of cardiologists and oncologists and psychiatrists, while others have very few. And how about the physicians themselves? How are they doing? We decided to ask our listeners.

[Dr. San Joy Dutta]

My name is San Joy Dutta. I graduated Harvard Medical School in 1993, and I've been a practicing general and bariatric surgeon since 2003. My job today is Vastly different from when I started 20 plus years ago. Operating room productivity and efficiency is much higher. I used to do two bariatric operations a day and now I do a minimum of five. With the electronic medical record replacing paper charts, dictation software, and now AI scribes, I see twice the number of patients in a day that I used to, and on top of that, I am answering patient emails throughout the day.

[Dr. Sarah Rahal]

Today, my staff and I spent countless hours appealing denials for essential imaging or medication, trying to prove a patient meets criteria that often don't make sense. The health care system has become increasingly complex and we are often stuck in a maze of phone systems and transfers, arguing our case to no avail.

[Rochelle Walensky]

This is Dr. Jeff Wood and I live in a rural area in southern Kansas. From my perspective as a doctor in private practice, it seems like we're facing.

[Stephen Dubner]

A pretty perfect storm of challenges. Insurance companies are a huge part of the problem, in my opinion.

[Rochelle Walensky]

They're starting to dictate what treatments we can provide, sometimes even suggesting AI based alternatives before we can even use our own clinical judgment. What was the point of becoming a doctor if you're just going to be told what you're supposed to do?

[Stephen Dubner]

Today on Freakonomics Radio, the docs are not all right and therefore neither are the rest of us. We will look into the factors that limit the supply of physicians.

[Dr. San Joy Dutta]

Can you imagine telling a 14 year old high school freshman that to be a Doctor It'll take 15 years and maybe 100,000 in college debt plus 200,000 or more in medical school debt.

[Stephen Dubner]

And we'll look at the factors driving the demand.

[Rochelle Walensky]

17.5 million people will be over the age of 85 in 2050.

[Stephen Dubner]

We'll also hear about a moment in medical history that is still having a ripple effect.

[Karen Clay]

Low quality doctors were actually harming people.

[Stephen Dubner]

This episode will attempt to do no harm. And it starts now.

[Rochelle Walensky]

This is Freakonomics Radio, the podcast that explores the hidden side of everything with your host, Stephen Dubner. I knew I wanted to be a physician, like when I was 10 or something.

[Stephen Dubner]

Did you really?

[Rochelle Walensky]

Yes, I really did. I had this wonderful pediatrician named Dr. Judith Osha. I had no idea at the time that she was a giant in her field. She was what made it possible for me to see that women in medicine could be. She was revered. I just didn't know it.

[Stephen Dubner]

That is Rachelle Wolensky. Today, she too is revered in the field of medicine. She was director of the cdc, the Centers for Disease Control and Prevention during the Biden administration. Before that, she Ran the Infectious Diseases Division at Massachusetts General Hospital and taught at Harvard Medical School. She's back at Harvard now and does some consulting too. Wolensky is perhaps best known for her research contributions to HIV screening, testing and treatment.

[Rochelle Walensky]

I became an HIV infectious disease clinician because I was an intern in inner city Baltimore in 1995. That was the year that the FDA approved the third drug of what would become the HIV cocktail. If you're at the bedside for the first six months of 1995, you understand that having AIDS and HIV is for certain a death sentence. And in that moment when the FDA approved that third drug, we could tell patients that if you took dozens of pills three times a day, you might live. It was just an incredibly motivating time. The science was moving so very fast. That we could actually tell patients that you had a chance was incredible. And then all rolled up into that conversation was, can you afford it? Will it be available to you? What are the stigmas associated with that? Do you have a place to go? Do you have a place to store your meds? Do you have a place where they won't be stolen? Even when the science was available, we had to take care of the patient, who had also sorts of challenges in making that science available to them personally.

[Stephen Dubner]

So you've had a pretty eventful career when it comes to infectious disease, I would say. Who would have thought, as you mentioned hiv, AIDS, toward the beginning of your career, you became head of the CDC while Covid was still raging. I think raging is an appropriate word.

[Rochelle Walensky]

I think Most raging, yeah. 4,000 deaths a day. When I was sworn in.

[Stephen Dubner]

I read that when I was reading about you. 4,000 deaths a day. I can't believe how quickly I forgot how many it was. It's such a massive number. Can you just take us inside that for a moment? I mean, you were appointed by President Biden. You took over right at the start of the administration, correct?

[Rochelle Walensky]

Yes, I was sworn in several hours after the President was sworn in.

[Stephen Dubner]

Just describe the state of the CDC at that moment, but especially the state of COVID at that moment. And walk us through those first couple weeks or months.

[Rochelle Walensky]

I was working really hard at Mass General. We were still in really difficult times in these Covid waves. I remember early on in the pandemic walking to the hospital and seeing a morgue sitting outside because we needed to increase morgue capacity at the hospital. That period was so very dark. My faculty, some had family members who were immunocompromised, but they were at the bedside. It was really a Stressful, scary time for all of us. This was, of course, pre vaccine. I remember where I was when I got the CNN news alert that the vaccine actually worked.

[Stephen Dubner]

Where were you?

[Rochelle Walensky]

It was a rainy day. It was at around seven in the morning and I was walking into Mass General. It literally stopped me before the door of the hospital because there was hope. There was finally hope. I was cold, called by the administration. I did not apply for the job.

[Stephen Dubner]

Do you know how you got on their radar?

[Rochelle Walensky]

I had done a lot of work in HIV policy. I was a pretty well respected infectious disease clinician. I had done some. I'd done some work in the policy realm in hiv. I'd known a lot of people in many of these policy circles.

[Stephen Dubner]

And was your HIV AIDS background considered a leg up because Covid was still raging?

[Rochelle Walensky]

I don't know, to be honest. I had sat on guidelines committees. I had done a lot of work in costs and cost effectiveness, which means that I had never taken a penny from industry. I had absolutely no conflicts. And they needed somebody who knew infectious diseases. In this moment at cd, having started.

[Stephen Dubner]

Your career with HIV aids, having gone through Covid at cdc, what are you worried about now?

[Rochelle Walensky]

Workforce. If you're an infectious disease doc in 2018 and somebody says to you, what do you do? And you say, I'm an infectious disease doc, they say, what does that mean? But in 2020, while at Mass General, as we were knee deep in some early days, there were so many companies reaching out and saying, can you come talk to our organization about what we should do? Airlines and cruise ships, all sorts of folks were reaching out. And I thought to myself, where are all the infectious disease dogs? So we created a map of the United States and realized that 80% of counties in the country did not have a single infectious disease doc in the middle of COVID in some of our darkest days, I am in my office as the director of the cdc and I'm hearing hospital beds are closed because they don't have staff and personnel. And so I said, I really need to understand what's going on with the healthcare workforce. And that's what led me down this research endeavor.

[Stephen Dubner]

This research endeavor that Walensky's talking about culminated in an article for the New England Journal of Medicine, which she co authored with Nicole McCann. And that's the article that made us want to speak with Walensky. Here's what they wrote. An urgent healthcare workforce crisis is looming. Many potential reforms require congressional action and account, which have been all too slow to enact meaningful change. So when you began to put together this data. How surprised were you by the magnitude of the physician shortage?

[Rochelle Walensky]

I had seen it in pieces, so I wasn't surprised by any singular piece. But putting it all together, sort of recognized that at every step of a consecutive path there were challenges. We were weeding people out along the way and we were getting to a workforce that is burnt out, retiring smaller. We have an anticipated 187,000 deficit by 2037. That's a huge number.

[Stephen Dubner]

As I mentioned earlier, the physician shortage is not uniform. Over the next decade or so, rural areas are expected to have a 60% shortage compared to a 10% shortage in metro areas. The specialties with the biggest expected shortages are family medicine, vascular surgery, ophthalmology and respiratory medicine. So what exactly is going on here? Let's start by looking at the demand for physicians. There is one issue here that's bigger than the rest.

[Rochelle Walensky]

We will increase the population that is over the age of 85 in 2050 by threefold. One question is, who will take care of them?

[Stephen Dubner]

Our life expectancy has increased so much over the past hundred years especially, but in recent years as well. If you're healthy, you tend to live real. I think the most common age of Death in the US today is 87, which shocked me when I read it, but I'm pretty sure that's actually true.

[Rochelle Walensky]

Yeah, that sounds about right.

[Stephen Dubner]

Do you expect that there will be a fall off in lifespan if we don't increase the supply of physicians and especially gerontologists?

[Rochelle Walensky]

Well, first I want to say that there are a whole host of physicians that can treat the elderly. It is very helpful to have gerontologists, but we have primary care doctors. We have others who don't necessarily have to have a geriatric specialty in order to treat the geriatric patient. And it is also the case that while many people are living that long, we have a challenge in getting all populations to live that long. If our goal is to improve health by increasing life expectancy in this country, we actually have to focus on those folks who have the most life expectancy. Lost people who die of early or cardiovascular disease, hypertension, stroke, diabetes, those kinds of things. And those happen differentially across populations.

[Stephen Dubner]

We recently published a three part series called Cradle to Grave, which looked at various angles of this big lifespan change. And when we asked listeners for input for this episode, we heard a lot about that. Here is Paul Goodwin, an orthopedic trauma surgeon in Texas.

[Colin Larkin]

There's a huge silver tsunami coming of.

[Stephen Dubner]

Patients needing joint replacements.

[Colin Larkin]

The estimate is that every orthopedic surgeon will have to double their caseload in.

[Rochelle Walensky]

Order to meet the demand if the.

[Colin Larkin]

Supply of surgeons stays constant. Also, interestingly, the incidence of hip fractures in the coming decades is supposed to approximately double.

[Stephen Dubner]

That is a lot of patients to take care of. If you think about medicine as a business, which of course it is, at least to some degree, and if the demand for this business is growing, why is the supply of physicians having such a hard time keeping up? In her New England Journal paper, Rochelle Walensky identifies one big factor, the scarcity of slop in American medical schools. Over the past decade, there's been a 10% increase, but given the need, that's not enough.

[Rochelle Walensky]

We have some extraordinary young people. And in fact, if I had one bright light about the future, it would be the incredible talent that's applying to medical school right now. We are systematically turning them away by some of the difficulties in getting into medical school. I wrote a paper with my husband, who is also a physician scientist, and we talk about how to watch a child, our own child, apply to medical school and what that process looked like. Kids are being suggested to apply, I think on average to 18 schools. Many kids are applying to 25 and 30. It's an expensive process. MCATs are over $350 or so. Each application is $150 or so. The secondary applications are somewhere between four and eight essays. So if you do all that math, you see these incredible talented kids who are writing somewhere between 50 and 100 essays or may not get in.

[Stephen Dubner]

You're also starting to explain the fact that lower income people are much less likely to become physicians.

[Rochelle Walensky]

Yes, absolutely.

[Stephen Dubner]

When we think about the medical school standards in the US they are famously high, for which I think everyone is really grateful. On the other hand, it's been argued that there are plenty of people who are smart enough to meet those standards, but that the number of slots in medical schools and residencies has just not kept up with the demand. And are the kids who are not getting into medical school not getting in because they are not smart or capable enough or simply because there aren't enough slots?

[Rochelle Walensky]

More the latter than the former. We gave an example in the piece of an extraordinarily talented young woman who applied to 33 medical schools at the cost of almost $5,000. She had gone to an elite Ivy League school. She got 96th percentile in her MCATs. She applied to 33 schools, got interviewed at 2 and was rejected. All of her safeties as they assumed she'd never come. And was wait listed and never got in. Now, you take somebody like that and many people would simply say, I'm done. I'm going to pursue another incredible career. She, to her great credit, said, I'm going to take another year off and apply again. And she got a full ride at a top medical school.

[Stephen Dubner]

But if it weren't for her grit, she would have become an investment banker or something, right?

[Rochelle Walensky]

Exactly.

[Stephen Dubner]

So. So there are not as many slots as one might want. But who is constraining the number of slots?

[Rochelle Walensky]

First of all, we have only a finite number of medical schools. Right.

[Stephen Dubner]

But that's not a permanent situation. Correct?

[Rochelle Walensky]

That is eminently fixable. We certainly could open more medical schools. Just to be clear, it's extraordinarily expensive to open these. Right. Teaching at a medical school is not the compensation of seeing patients. So you have to pay these faculty. And then those schools have to be affiliated with hospitals that can train the students. Because it is not just about the didactics in the classroom. It is about going to the bedside and training those students. So there has to be this partnership with a hospital that allows students to come in and to be trained and where there are faculty and doctors who can train these students.

[Stephen Dubner]

There are fewer than 200 medical schools in the US today, with many of them concentrated in the most populous states like New York, California and Texas.

[Rochelle Walensky]

So.

[Stephen Dubner]

So other than the expense, why aren't there more medical schools? One reason goes back over 100 years.

[Karen Clay]

We were surprised. This paper took a while. And part of the reason it took a while was because we were surprised.

[Stephen Dubner]

That's coming up after the break. I'm Stephen Dubner. This is Freakonomics Radio. We'll be right back.

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Disease.

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[Stephen Dubner]

Before the break, we heard about some of the factors that put a strain physician workforce. There is the big rise in the share of the elderly population. There's the urban rural divide when it comes to physician supply, and there's the relative scarcity of medical schools. Let's stay with that last one for a bit. If you want to understand the current medical school landscape, there is a bit of history you should know.

[Karen Clay]

The Flexner Report is so important and has such a huge legacy. Everybody in medicine knows about the Fluxn Report and yet we really don't know that much about it.

[Stephen Dubner]

That's Karen Clay. She's an economic historian at Carnegie Mellon University and she is one of four authors of a new working paper called Medical School Closures, Market Adjustment and Mortality in the Flexner Report Era. Okay, there's a lot to unpack here. Let's start with the Flexner Report itself.

[Karen Clay]

I had heard about it a little bit. I knew that there was this report and a bunch of medical schools shut down.

[Stephen Dubner]

So Karen Clay and her co authors set out to measure the effects of this Flexner Report One of her co authors, Grant Miller at Stanford, had been doing research on the low quality of physicians in developing countries.

[Karen Clay]

It's not that all doctors in developing countries are of low quality, just that there are significant numbers of them. So there had been some floating of ideas of whether they should try and address these low quality medical schools that are turning out these low quality doctors in order to bring the standard up.

[Stephen Dubner]

I guess that gets you to the question central to your paper, which is, is a low quality doctor better than no doctor at all?

[Karen Clay]

It's really, what is the impact of having these low quality doctors? Some people would then not go to any doctor. Some just weren't aware that there was a higher quality doctor nearby. But it looks like the answer, at least based on what we have in the paper, is low quality doctors were actually harming people.

[Stephen Dubner]

Okay, so they found that low quality doctors were actually harming people. That's a big deal and we will get into it soon. But let's set the stage a little bit more. The Flexner Report was published in 1910.

[Karen Clay]

This is a period in which the US is growing rapidly. The standard of living is rising, and one of the things people want to consume is medical services. So there's demand. People often would go to a medical school in their town and then set a practice in their town.

[Stephen Dubner]

What kind of people were starting these schools? Were they entrepreneurs? Were they do gooders?

[Karen Clay]

They're entrepreneurial physicians. It's a way to make some extra money. It had some prestige attached to it. That is, I was a founder of a medical school and it signals to people that I am a very good physician and therefore you should come to me.

[Stephen Dubner]

So there were medical schools around that did not require even a high school education, correct?

[Karen Clay]

That is correct.

[Stephen Dubner]

As you can imagine, with all these medical schools starting up, the quality of training was uneven. The American Medical association began to take notice. But the AMA back then was different than it is today.

[Karen Clay]

The AMA in the late 19th century is primarily an organization by and for elite physicians. And the early 20th century, these physicians realize that if they want to have political power, they need to be much more inclusive. They need to harness the fact that there are many, many, many doctors out there. And many of those doctors are also concerned about quality. They're also concerned about the fact that they're not making a ton of money. They then reorganize so that if you become a member of your state medical society, you automatically become a member of the American Medical Association. And so the membership goes up very quickly and they establish a Council on Medical Education. They publish educational standards beginning in 1905 and then start to visit medical schools and start publishing quality ratings.

[Stephen Dubner]

So the ama, alongside the Carnegie foundation, commissioned a well regarded educator and reformer named Abraham Flexner to examine the state of medical education in the US and Canada.

[Karen Clay]

Abraham Flexner is an interesting guy. He had already done some work studying the American college system. This was partly in light of the fact that Europe had what was widely considered to be, on average, better education at the university level. But he actually had no experience with medical school. It turns out that he was hired through some connections, basically by the Carnegie foundation, and was sent to collaborate with the ama, although the collaboration was kind of hidden. To look at the status of medical.

[Stephen Dubner]

Schools in the US was the AMA's connection to the Flexner Report downplayed?

[Karen Clay]

I think that everyone understood that they had commissioned it. The thing that they did not maybe fully disclose was that first of all, Flexner wrote this report very rapidly. And so he received significant assistance from the ama, in part because they had already done evaluations of all the medical schools, but because it was politically complicated to criticize medical schools, they decided that it was better for this objective third party to do it.

[Rochelle Walensky]

What he did is he evaluated each medical school to say this is too poor to salvage, or this is something we can work with, or this is the gold standard.

[Stephen Dubner]

That again is Rochelle Walensky, the physician and former CDC director.

[Rochelle Walensky]

And he compared at the time gold standard, interestingly enough, to Johns Hopkins, interestingly.

[Stephen Dubner]

Enough, Walensky says, because Johns Hopkins is where she went to medical school.

[Rochelle Walensky]

One of my professors in medical school was a descendant, was a Flexner.

[Stephen Dubner]

Abraham Flexner, while preparing his report, visited nearly 150 medical schools in the US. He was accompanied by Nathan Colwell, who was a physician and an official at the American Medical Association. So what were they looking for?

[Rochelle Walensky]

One of the things that they were really focused on was the biomedical sciences. They wanted to have a really robust scientific basis and laboratory sciences in their curriculum. Another was whether they were collaborating with hospitals and whether training in those hospitals was up to par. The strength of the physician scientists, faculty relationships to those hospitals, how close were they? How committed were they to the medical schools?

[Stephen Dubner]

In his report, Flexner argued that the vast majority of medical schools did not meet these standards and he suggested closing many of them. Not surprisingly, his report got some buzz. Here are a couple of headlines from back then. Poor Medical Colleges, A Danger and Country Flooded with Quacks. And here again is the economic historian Karen Clay.

[Karen Clay]

The Fluxner Report didn't just shock people. At the time, I found the fact that the Flexner Report recommends keeping only 31 medical schools, which it deemed would be enough to train enough doctors for the entire US to be really radical. That's not what happened, but it was still really, really surprising.

[Stephen Dubner]

So during the period after the Flexner Report, what share of medical schools in the US closed?

[Karen Clay]

By 1915, the number of medical schools has fallen to between 90 and 95.

[Stephen Dubner]

Wow.

[Karen Clay]

So big decline. It eventually does continue to fall a little bit and stabilizes at around 70.

[Stephen Dubner]

In the paper, you explain that the schools ended up shutting down. They weren't forced to shut down. They were were pushed out by market forces. Essentially the Flexner ratings came out and if you were running a school that was poorly rated, students just stopped applying.

[Karen Clay]

That is correct.

[Stephen Dubner]

Describe the primary characteristics or demographics of the schools that did close. Were they mostly in smaller cities or rural areas?

[Karen Clay]

They're mostly not in rural areas. They tend to be in medium and larger cities. Some cities just had a lot of medical schools. Cook county, for example, which is where Chicago is, had had many medical schools.

[Stephen Dubner]

I read here that before the report there were more than a dozen black medical schools in the US several of them at HBCUs, but that within a decade there were only two. Howard University College of Medicine in DC and Meharry Medical College in Nashville. So tell me about that. Since a lot of medical care at the time was segregated, how did those closures affect black patients and would be black physicians?

[Karen Clay]

A lot of these black medical schools, a lot of medical schools in the south, full stop, are taking people who don't even have a high school education. That's just because the pool of people at the time who have a high school degree is relatively small and the pool of people who have some colleges even smaller in the black community. The other thing about the black medical schools is they tend to be a bit smaller. There is surely a decline though, in slums. It is a fascinating and tragic part of the Flexner Report in terms of impacts of why are there not more black physicians?

[Rochelle Walensky]

By virtue of closing five out of seven HBCU medical colleges, we now have about 30,000 less black physicians than we might have had.

[Stephen Dubner]

That's Rachelle Walensky again. She says the Flexner Report had a number of long lasting effects.

[Rochelle Walensky]

It also created a divide, and this divide is relatively unique to America between medical schools and schools of public health. That is really a challenge for our country that we have the silos of public health departments and medicine.

[Stephen Dubner]

I never thought about the Fact that the US is unique in Europe and elsewhere. You're saying they're bonded together, they're more.

[Rochelle Walensky]

Fluid relationships, for sure, from a Covid standpoint. I vividly remember people saying to me, how come you're relying on data from the UK in Israel for our vaccine effectiveness? One of the beauties of being an infectious disease doc is I have infectious disease friends across the country. I called a handful of different hospitals while I was CDC director and I said, can you tell me who in your hospital has Covid and is vaccinated? And they said, no, we can tell you who's hospitalized and we can tell you who's hospitalized with COVID but the vaccination data are in the departments of public health and they don't actually connect.

[Stephen Dubner]

Okay, so those are some of the long term effects of the Flexner Report. But what about the one that we really care about? At least the one that I first wondered about when I read this new paper. What were the health effects of all those medical schools closing? You might think that fewer medical schools means fewer physicians, which means less access to physicians, which means trouble. But that's not what the data said. The data that Karen Clay and her colleagues analyzed showed that medical school closures after the Flexner Report led to an 8% drop in infant mortality and a 4% drop in non infant mortality. And keep in mind that mortality rates back then were much higher. So how many people does this translate into? It's an estimated 16,000 infant lives saved per year in the US and 38,000 non infant lives lives. If you find this result surprising, and Karen Clay says that she did, you need to remember that the whole purpose of the Flexner Report was to get rid of low quality medical schools. So it would appear that A, it worked and B that having a bad doctor can be worse than having no doctor at all. I asked Clay how this Flexner effect compares to other life saving medical interventions.

[Karen Clay]

Putting in water and sewerage in the Boston area reduced infant mortality by 23%. Municipal water filtration reduced infant mortality by 11 to 12% in cities between 1900 and 1940. Prohibition caused infant mortality to decrease. And the lifting of prohibition actually increases infant mortality by 4 to 5%. Today, if you did something that reduced infant mortality by 8%, you would be winning the Nobel Prize in meta.

[Stephen Dubner]

Karen Clay told us that it took a long time for her and her colleagues to convince themselves that these research findings were robust.

[Karen Clay]

We really had to spend a lot of time thinking about, are we doing this estimation correctly? Is there something we haven't looked at. We sort of thought that any result would be interesting. My personal skepticism about the fact that doctors were harming people was allayed somewhat when we went back to the developing country literature where they have done extensive work on doctor quality. Many parts of the doctor quality distribution are more likely to harm patients than they are to help them, even today. Today, of course, a not very good doctor in a developing country can still give you IV fluids, they can still give you antibiotics, but these are doctors who don't have that. This is also a period in which, although germ theory has been well known, the practicing of hygiene is not uniform. If you are a low quality doctor, you may not be paying that much attention to those sorts of things. You could easily, quote, help someone by stitching them up, but give them some terrible infection in the process.

[Stephen Dubner]

And I went back to Rochelle Walensky to get her thoughts on the Flexner Report page.

[Rochelle Walensky]

I think it's a super interesting story and it is not necessarily the one that I would have anticipated. The methods seem really sound and I applaud the authors for what they've done. Many of those deaths that were probably averted were infectious. They were related to hygiene.

[Stephen Dubner]

So Walensky doesn't doubt the research findings, but she does wonder if the solution at the time was the right solution.

[Rochelle Walensky]

What happens if we fast forward the clock and instead of closing those medical schools down, we improve what they learn about hygiene? We do all the things that we should be doing to improve the training. Even if it wasn't at the level of Dr. Flexner's Johns Hopkins. Where would we be now, 100 plus years later in terms of that training? Would we still see the decreases in infant mortality or would we actually be in a better place than we are now?

[Stephen Dubner]

On balance, though, do you think that the Flexner Report was a success in that it closed down schools that were subsidized?

[Rochelle Walensky]

I'm agnostic there. I'm not sure we see that it's so hard to open medical schools that it is not obvious to me that that might have done harm rather than not having the capacity to bring people in to continue to train and improve that training.

[Stephen Dubner]

In other words, the Flexner Report and the American Medical association, by being so strict, may have contributed to the current dilemma. Too few medical school slots and too few physicians for too many patients. Still, this is just one of many factors behind the current situation. If you're looking for another cause, you might want to think about doctor frustration and burnout. We heard a lot about that. From our listeners. And you might especially want to consider the private equity revolution, where smaller medical practices are often rolled up into large groups, corporate practices that too can make the life of a practicing physician much less attractive. So this is all sounding pretty grim. Coming up after the break, we hear about a few solutions to the physician shortage. A few maybe solutions anyway. I'm Stephen Dubner. This is Freakonomics Radio. We'll be right back.

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[Stephen Dubner]

The number of physicians being trained in the US Is constrained not only by the number and location of medical schools and the number of slots at each school, but by another layer of oversight, our country's gme, or graduate medical education system. Here again is Rochelle Walensky.

[Rochelle Walensky]

Once you leave medical school, you can't go and practice. You need to train, as we call it, internship, residency, fellowship. Those slots for training are capped federally. It's run out of CMS and Medicare. They were capped since back in the 1980s, 1990s when there was an anticipation that we would have too many physicians. We are not there.

[Stephen Dubner]

I read that in your paper and I have to say I chuckled because I've never thought about a world where we were worried about having too many physicians. So can you briefly take us back to the what created the environment where we thought there would be a glut of physicians?

[Rochelle Walensky]

Physicianhood was revered. People were going into medical school, we had fee for service, people were being financed and compensated really well. And this was a really great field to be in. There was this concern that we were in a place where, oh, we might have too many. And so Congress came in and constrained the numbers by constraining the training numbers. You're given federal slots in these hospitals for your entire training programs, and that's everything from PDF and neurology and internal medicine and cardiology to surgery. States can supplement those, hospitals can supplement those, but they're expensive to do. Over the last 20 years, we've really only increased our GME training slots by around 15,000. So I'm telling you, we're 187,000 doctors behind. It's not going to get us to where we need to be.

[Stephen Dubner]

If you look at survey data from the public and from physicians themselves themselves, it's clear that respect for the profession has fallen, as has trust in the profession. A lot of our listeners commented on this.

[Dr. Evelyn Kim]

Here's one My name is Evelyn Kim, and I'm an emergency physician. I started probably at the beginning of the wave after the show. ER brought a lot of people into our specialty, but I originally went to medical school following the path of my father, like so many of my colleagues, colleagues whose parents were physicians. And I have definitely seen the work itself change, the attitudes of physicians change, and society's attitude towards physicians change. I come from an era where I was happy to identify as Being a physician, it is who I am, it is a part of me. And I'm not afraid to admit that oftentimes I have no work life balance. That wasn't even a concept for my father or for me throughout my career. I'm nowhere near feeling like I want to retire because I still feel like I have a lot to contribute. But I don't think that that is the prevalent attitude amongst physicians these days.

[Stephen Dubner]

And here's another listener.

[Colin Larkin]

My name is Colin Larkin and I'm part of the problem.

[Stephen Dubner]

Larkin studied chemical engineering in undergrad at the University of Rochester with a plan to become a physicist.

[Colin Larkin]

Society does a really good job of convincing our young people that it's a really good idea. You get to save lives, you are revered by society. You're very well educated, you get to make a good living. You see House and Grey's Anatomy and all these things that glorify physicians in the media.

[Stephen Dubner]

Larkin got a master's at Oxford and then enrolled in medical school at Northwestern University. His plan was to become a neurosurgeon, but once he got into an actual hospital setting, his plan changed.

[Colin Larkin]

I just realized that I didn't like it. A lot of what you end up doing is clerical work. It's very algorithmic in a lot of ways and hyper repetitive and all these different things that I didn't really realize until I got there. So I ended up taking some time off. I worked in management consulting at Boston Consulting Group through actually a program that they have specifically for med students to try to recruit them into consulting. Went back, finished up my degree, did a couple different things during the fourth year, including starting a medical device company, applying to residency, and then applying into venture capital roles, which is ultimately where I am ended up. I graduated in the spring of 2024, and now I am a Silicon Valley life sciences and health tech investor at SoftBank.

[Stephen Dubner]

So if you are someone who is concerned about the physician workforce, losing someone like Colin Larkin to venture capital has to hurt. If you're someone like Rochelle Walensky, for.

[Rochelle Walensky]

Instance, physicianhood used to be a somewhat revered field. Over the last several years, that has certainly no longer been the case. You see physicians under you see science under attack. You see compensation not close to what people are hoping, certainly not close to what would make up for the extraordinary loans that these students have to take out. They're thinking, why would I take another deferred year of compensation for a on average $200,000 loan when there are other great ways to pursue a career?

[Stephen Dubner]

Yes, yes. The cost of Medical school. Here is another Freakonomics radio listener John Clark, who is an urgent care doctor in Colorado.

[Dr. San Joy Dutta]

I've been hearing dire predictions about physician shortages since I was in medical school in the mid-1990s. By way of demographic context, I've had experience in rural and suburban emergency departments, an academic teaching environment, traditional office based primary care, and for the last several years in an urgent care setting. I think you've covered the cost of higher education very well in the past. Can you imagine telling a 14 year old high school freshman that to be a Doctor It'll take 15 years of formal education and training, maybe 100,000 in college debt plus 200,000 or more in medical school debt. Don't think a lot of kids would eagerly sign up for that path.

[Stephen Dubner]

I went back to Rachelle Walensky to talk about med school tuition debt and what looks to be one encouraging sign. There is a movement lately from private philanthropists to make some top tier medical schools free tuition free. I would think you are in favor of that idea or no?

[Rochelle Walensky]

Yes and yes.

[Stephen Dubner]

And what's the end?

[Rochelle Walensky]

We are making it free, but we are not changing the cost of producing a doctor. It does matter who's paying. Certainly it's helpful to have it be free. Some of the motivation around doing that is to bring in people from less affluent communities to bring in people into primary care and that people do not leave in debt and therefore that they go into the lower paying specialties. The jury's still out on that. Some of the earliest data from the free medical schools are not panning out that way. I don't think that alone is going to fix the issue. One of the things that I'm very worried about is a policy in the big beautiful bill that speaks to how much loans one is allowed to take. The average loan of a graduating medical student is in the $200,000 range. 70 to 90% of students have debt. So if it is the case that on average more than half of students have debt and that debt is over $200,000, you're going to lose half of your medical students if you don't allow them to borrow money.

[Stephen Dubner]

What are the borrowing constraints?

[Rochelle Walensky]

I believe a maximum of $200,000.

[Stephen Dubner]

We recently published a series on air traffic control in the US A lot of the problems you're describing sound similar to those problems. A kind of outdated training infrastructure, not enough slots to train new entrants. There's some congressional sludge in both cases. There's also just complications in making this market. If you want to call It a market work. Well, do you have any thoughts on that or perhaps otherwise, are there parallel systems you look to to increase the supply and the status of physicians?

[Rochelle Walensky]

Yeah, I think the one that you highlight is actually a really sound one. I think that that very much resonates. I also think that there is a geography problem. What is it that we are going to do to address the paucity of physicians in rural areas? Now, some of those issues relate to medical school closures back in 1910. Some of those relate to many physicians once they've want to stay at the places that they've trained.

[Stephen Dubner]

And to be fair, more people want to live in urban areas than ever before. That's just the way it is. It's not just here, it's around the world. So that leaves rural areas wanting for physician care. Have you seen anything useful, practical that started to reverse that?

[Rochelle Walensky]

I think we need to incentivize folks to go into rural areas.

[Stephen Dubner]

I mean, we do that to some degree already, don't we?

[Rochelle Walensky]

We do. We increase Medicaid payments, I think by 10%. The things that have been done over 50 have not necessarily demonstrated that they're working. We have a partnership here in Massachusetts with a tribal nation out in the Dakotas. And our residents love going out there. They love learning, they love caring for that patient population.

[Stephen Dubner]

But do they want to live there?

[Rochelle Walensky]

Many of them would be willing to go there for months. The challenge is financing it after they're done training. Who's going to pay for that? There are models to explore, but you need the finances and you need the political will. I do also want to just comment on unintended consequences of policies, whatever one wants to think about the Dobbs decision. There have been surveys about physicians, not just obstetricians or training obstetricians, but about physicians who are interested in going to states where there will not be abortion access. Now, if you look at a standard resident, they are generally between the ages of, let's call it at 26 and 35.

[Stephen Dubner]

And what share of female these days?

[Rochelle Walensky]

There's probably a little bit more than half and half. But that doesn't matter because many of the men are partnered with women and they move to an area that doesn't have abortion access just at the time that they might want to have children. That is a driver. However it is one feels about the policy, it may have unintended consequences of not having people wanting to go to those areas of the country at the time that they're of childbearing age.

[Stephen Dubner]

Another driver you write of the physician shortage is physician exodus. You know, COVID 19 was hard on a lot of physicians. Burnout, as we know, and suicide rates. And there are all sorts of negative indicators for physicians and others in the medical field. Do you have any thoughts whether it's drawn from your practice, your teaching, your CDC service on how to make the daily life of a physician?

[Rochelle Walensky]

There's so much that we get and can do as physicians. That said, physician hours are extended and much of that is not satisfying hours. There was one 2017 study that demonstrated that in an 11 and a half hour workday, almost six hours of it was spent in front of the computer, or what they call pajama time. This is the time after 7pm when you've seen your last patient and you're going home after a long 12 hour day day. You finished dinner, but you have 10 notes to write. So you're spending all of your evening time just catching up on the paperwork from the day. Those things really are exacerbating the challenge. One of the other big challenges is the churn of patients in the hospital. I took care of a patient who had an inflammatory disease that needed a monoclonal antibody infusion as an outpatient. She could not afford this infusion. It was several thousand dollars. Her disease flared. She ended up with a three day hospitalization. We tried to give her an infusion as an inpatient and insurance declined. So the burnout is not just the long hours, because actually doctors knew they were going to get in for long hours. It was that the things that we're doing for our patients are actually not working to help make them better because the system is failing them.

[Stephen Dubner]

You've written that solving this shortage requires not just increasing the supply, but also decreasing the demand. Tell me how you see the demand part change.

[Rochelle Walensky]

This is going to take time. We're not going to see decreases in demand immediately. But the best way to decrease demand is to work on prevention. We talk about healthcare as if we pay for health. We actually pay for disease. We pay to treat diseases. We do very little to invest as a country in prevention interventions. There's a lot that we could do by just maintaining prevention interventions. How is our breast cancer screening rates in rural America? How are our colonoscopies? While I was at cdc, I had the great pleasure of visiting Alaska, which has one of the highest rates of colon cancer in the world. It's very hard to screen for colonoscopy in Alaska. It's two flights. There's stuff that we could do on the prevention side that we simply can't access and do.

[Karen Clay]

So.

[Stephen Dubner]

Are you still seeing patients?

[Rochelle Walensky]

Yeah. Funny that you ask. Back in July, I put on my white coat for the first time after a very long time. And it was just wonderful to be back and to remember my passion for taking care of the patient.

[Stephen Dubner]

Do you have a next move? I realize you have all kinds of affiliations and opportunities and so on, but is there something big that you'd like to get toward next?

[Rochelle Walensky]

I am keeping my options open at the moment. I suspect that there's another big job ahead of me. I hope I like going to places that are hard so that I learn something. I'm working on more papers like the challenges to the workforce, areas that are really important to me that I think should be highlighted. I've never shied away from a hard job.

[Stephen Dubner]

Yeah. You know, people started in the last whatever bunch of years to use the phrase wicked problems.

[Rochelle Walensky]

Yeah. Well, I'm from Boston, so everything's wicked here.

[Stephen Dubner]

There you go. But I always wonder about that because, you know, the definition of the wicked problem is pretty much an unsolvable problem problem. And I'm just curious how you think about that because if you think something's unsolvable, you're going to be maybe going for a second best solution or something. But have you been able to remain optimistic or optimistic, ish. At least in the face of all the turmoil of the last decade or two.

[Rochelle Walensky]

You know what? Perhaps to my detriment, I'm a chronic optimist. I like calling it the I live in the land of yes, not the land of no. I once had a research mentor say that if it was easy, somebody else would have done it.

[Stephen Dubner]

Well, you're either optimistic or delusional or.

[Rochelle Walensky]

A little bit of both.

[Stephen Dubner]

That, again, was Rachelle Walensky. Thanks to her as well as to Karen Clay and all of you physician listeners who wrote in to everyone else, I would love to hear your thoughts on this topic. Our email is radioreconomics.com Coming up next time on the show, we begin a series on one technology, if you want to call it that, that helped create the modern world.

[Karen Clay]

Everything in this country was either produced by or moved by horsepower.

[Stephen Dubner]

That technology has by now been rendered mostly obsolete. But there are still around 7 million horses in America. So who's riding them? Who's buying them, selling them? And what are those horses horses do all day? They can eat grass, get sunshine, roll around. That's what they do between breedings. It's their version of smoking a cigarette. Everything you've always wanted to know about the economics of horses, but were afraid to ask.

[Karen Clay]

How do I say this without a hit being put out on me?

[Stephen Dubner]

That's next time on the show. Until then, take care of yourself. And if you can, someone else too. Freakonomics Radio is produced by Stitcher and Renbud Radio. You can find our entire archive on any podcast app [e-mail] where we publish transcripts and show notes. This episode was produced by Dalvin Abu Aji and edited by Ellen Frankman. It was mixed by Eleanor Osborne with help from Jeremy Johnston. Special thanks to Bapu Jenna, Rebecca Allensworth and Ezekiel Emanuel for research guidance. The Freakonomics Radio Network staff includes Augusta Chapman, Alina Coleman, Elsa Hernandez, Jasmine Klinger, Gabriel Roth, Greg Rippon, Morgan Levy, Sarah Lilly, Teo Jacobs, and Zach Lipinski. Our theme song is Mr. Fortune by the Hitchhikers, and our composer is Luis Guerra. As always, thanks for listening.

[Rochelle Walensky]

What I can say to that patient is let's make a deal. You're going to smoke 15 cigarettes a day, and instead of that other five, you're going to have a pretzel. Okay, let's see if we can do that.

[Stephen Dubner]

Can I smoke the pretzel?

[Rochelle Walensky]

You can smoke the pretzel if you'd like.

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[Stephen Dubner]

Dsw.Com trading@schwab is powered by Ameritrade, giving you even more specialized support than ever before. Like access to the trade desk. Our team of passionate traders ready to tackle anything from the most complex trading questions to a simple strategy. Gut check. Need assistance? No problem. Get 24. 7 professional answers and live help. And access support by phone, email and in platform chat. That's how Schwab is here for you to help you trade brilliantly. Learn [e-mail] trading hey there. I'm Stephen Dubner, host of Freakonomics Radio. If you love the podcast podcasts in the Freakonomics Radio Network, I want to tell you about a way you can get even more from us to hear our shows without ads and get exclusive access to Freakonomics Radio bonus episodes. Please subscribe to Sirius XM podcasts plus on Apple podcasts or sign up at siriusxm.com podcasts plus. Start a free trial today.