Hiring more specialists alone won't shorten wait times, NEJM Catalyst analysis argues

When health systems hire more specialists to shorten wait times, the new physicians' schedules tend to fill quickly and waits don't fall, according to an analysis published Aug. 19 in NEJM Catalyst Innovations in Care Delivery.

The authors are Leemore S. Dafny, Ph.D., of Harvard Business School and Harvard Kennedy School; Sherry Glied, Ph.D., of New York University's Robert F. Wagner Graduate School of Public Service; and Thomas H. Lee, M.D., chief medical officer at Press Ganey and editor-in-chief of the journal.

They liken the problem to highway congestion, where added lanes attract enough new drivers to keep traffic level or make it worse. They argue that hiring alone is unlikely to shorten waits and could lengthen them.

What did the analysis find?

New patients waited an average of 31 days for appointments in six specialties across 15 large metro areas in a 2025 survey by health care staffing firm AMN Healthcare, up 19% from 2022 and 48% from 2004.

When AMN released the results in May 2025, Leah Grant, president of the company's Physician Solutions division, called the longer waits "a significant indicator that the nation is experiencing a growing shortage of physicians."

Dafny, Glied and Lee looked at four referral specialties: cardiology, dermatology, obstetrics-gynecology and orthopedic surgery. For each metro area, they plotted the 2022 wait for a new patient visit against the number of specialists per 100,000 residents, drawn from the federal Area Health Resources Files.

Those were the referral specialties for which physicians per capita could be identified.

Across all four, having more physicians per capita was associated with longer waits, a link the authors describe as weak. Correlation coefficients ranged from 0.018 for dermatology to 0.204 for orthopedic surgery. Each comparison covers 15 metro areas, and the 95% confidence intervals around both of those figures include zero.

Why would more specialists mean longer waits?

Economists who study highway congestion have long observed that added road capacity leads people to drive more miles, which wears away early gains in travel speed. If a town has more cardiologists, the authors write, primary care physicians may be quicker to refer, patients may look for specialty care more readily and cardiologists may take on work such as risk factor control that primary care could handle.

The authors offer that as a possible explanation for longer waits in cities with more specialists.

"In some cases, primary care has gotten so busy and the agenda of primary care is so busy per patient that the bar and threshold for referral out to a specialist has been lowered," said David Carmouche, M.D., executive vice president and chief medical and commercial officer at health care technology company Lumeris.

Carmouche, an internal medicine physician, made the comments in a May episode of "Off the Chart," the Medical Economics business of medicine podcast.

"I think there's pretty good evidence that nonphysicians, especially ones who have not been in practice very long, nurse practitioners specifically, tend to refer more readily than their physician counterparts," he said.

One health system Carmouche spoke with recently said 30% of its cardiology appointments for the next 12 months were booked for patients with hypertension. "Hypertension is right in the wheelhouse of primary care," he said. He estimated that 90% to 95% of patients with the condition should be well managed there.

Of those cardiology bookings, he said, "That's not the best and greatest use of a cardiologist who trained an extra three or four years after his or her internal medicine training."

What do the authors suggest instead of hiring?

The authors' first set of tactics borrows from public transit by giving patients options other than a specialist visit. It includes education programs with built-in electronic health record support, so primary care physicians can manage common problems instead of referring them; expanded roles and numbers of advanced practice providers (APPs), such as nurse practitioners and physician assistants, for initial and follow-up specialty visits; and virtual group visits when one-on-one appointments are backlogged.

A second set mirrors congestion pricing, which the authors note has eased traffic in New York, London, Singapore and Stockholm.

The health care versions are higher copayments for specialist visits than for primary care, along with lower or no out-of-pocket costs for patients who get chronic disease care from teams staffed by nurses and APPs.

The third set takes after smart traffic signals and GPS routing. Most organizations that let patients book and reschedule their own appointments online see sharp declines in no-shows, the authors write. That leaves fewer empty slots and makes openings easier to fill from a waitlist.

They also point to artificial intelligence (AI) tools that answer patients' questions and catch emerging problems. They caution that the full potential of those tools won't be clear for years.

Carmouche described how AI could check with patients before a visit about whether they've been taking their medications, collect their home blood pressure readings and summarize it all for the physician. "I think if all of us were using AI that way, we would still need specialists," he said. "But instead of them seeing five patients to justify the one that really needs their expertise, maybe they see two patients to see the one."

Wait times would come down as a result, he said. "They're still full, but they're not crowded with patients that would have been managed well in primary care."

Where do advanced practice providers fit?

The authors call the potential role of APPs in care redesign enormous. But they write that many organizations routinely overlook APPs, and that leaders who talk about clinicians usually mean doctors and nurses.

"We have a physician shortage in this country. We're not going to get out of that shortage anytime soon," Matthew Bates, M.P.H., managing director at Kaufman Hall, part of Vizient, said in an interview with Medical Economics earlier this year. He said APPs, particularly nurse practitioners, are entering the workforce at about twice the rate of physicians.

The Association of American Medical Colleges' most recent projections, released in March 2024, put the physician shortfall at as many as 86,000 by 2036.

"Coming hot out of the pandemic era, staffing was the No. 1 thing that our customers told us. Now what we're hearing is that access is the No. 1 thing that they're working on," said Shannon Sims, M.D., Ph.D., FAMIA, chief product officer at Vizient, who joined Bates for the interview. To solve it, Sims said, organizations have to embrace technology and "new practice models, like use of [APPs]."

"From a patient perspective, access is when those tests start getting ordered, not necessarily when the surgical decision gets made," Bates said. Getting patients in to start their workup, "perhaps with an [APP]," matters to them even when a surgeon's first opening is weeks away, he said.

"You want to make sure that [APPs are] practicing at appropriate levels of complexity, so that you don't introduce unfortunate, inadvertent risks to them or to your organization as well," Sims said.

What does it mean for specialists and their practices?

Specialists often enjoy seeing a patient who is doing well a decade after a medical crisis, the authors write, while new patients with complex problems demand far more time and energy. "Practicing at the top of one's license is exhausting," they write, and any redesign has to include support for specialists caring for the complex patients who most need to be seen.

"It's nice to have docs practice at top of license. Of course, that's what you want," Sims said. "That's what the physician wants, generally, and what the organization wants, but it does place an interesting increased cognitive load on them if they're always seeing the most complex patients with the most complex care. That can be draining in an interesting way."

"What we see in the data is very clear: If a patient has a new problem, whoever gets them in in the next five days probably is going to get that care," Bates said. "And even if you have an established relationship with a patient, when they have a new problem, if you can't get them in the door, they're going to go somewhere else."

He said that's especially true of commercially insured patients, whom he called essential to the financial sustainability of independent practices.

Many organizations already use the tactics in the paper, the authors write, though the push to hire tends to overshadow them. Medicine's culture is especially prone to stalling over exceptions, they add, and worry over occasional unintended effects of new approaches can keep organizations from changing anything.

They call today's wait times a crisis that could spur change, while conceding their tactics won't suit every patient or practice. Their case, they write, is "for better leveraging the clinicians we have."