The physician's future: A profession rewritten

As recently as 2023, a physician who wanted help with documentation either hired a scribe or finished the note at the kitchen table after the kids went to bed. That year, 38% of physicians told the American Medical Association (AMA) they used artificial intelligence (AI) in their work. The technology had been public for barely a year.

This year, 81% do, and the average physician has incorporated AI into more than twice as many aspects of their work as in 2023. Medicine does not usually turn over that fast. Drug approvals can take a decade, payment rules move on Congress’ schedule and the standard of care shifts one specialty at a time.

Most of the profession still runs on those longer timelines. A student entering medical school this fall will not finish residency until the mid-2030s. The payment cuts that will shape that physician’s income are already on a published schedule. Several states have already rewritten the rules on who can own a practice.

Congress, the Centers for Medicare & Medicaid Services (CMS) and a few dozen state legislatures have already written much of the next decade. Much of it is still unwritten.

The question facing the profession is not whether physicians survive the next 10 years, but how much of the job they still control when they get there.

From practice ownership to reimbursement policy to the technology tools they are being asked to use — many of these decisions are being made by people who are not physicians, on timelines physicians did not choose. Who ultimately holds authority over the work of keeping patients healthy? And how can physicians take back some control?

Who will be in the room?

Physicians 65 or older make up 20% of the clinical physician workforce and another 22% are between 55 and 64, according to the Association of American Medical Colleges (AAMC). Within 10 years, the country will have more people over 65 than under 18.

How large a gap that leaves is contested. The AAMC, running multiple scenarios for retirement timing and training investment, puts its 2036 shortfall at 13,500 to 86,000 physicians. The federal Health Resources and Services Administration, using a different methodology, estimates that the shortfall could be as many as 187,130 physicians by 2037.

The two organizations agree, though, on where the shortage will hit hardest: primary care and nonmetropolitan areas.

Replacements take between seven and 11 years to produce, which makes the 2026 Match a staffing report for the middle of the next decade. It was the largest on record –– 41,482 positions filled. Family medicine still fell to an 83.6% fill rate, with 899 unfilled positions, a second consecutive annual decline even as the specialty matched a record class.

The National Resident Matching Program is convening a panel this year to study why, but the reasons are not particularly mysterious.

Primary care draws 4.5% of total U.S. health care spending, down from 4.6% the year before, according to the 2026 Primary Care Scorecard from the Robert Graham Center and the Milbank Memorial Fund. Commercial spending fell the most, from 5.5% to 4.9%, whereas Medicare and Medicaid each ticked up slightly, to 3.7% and 4.7%, respectively.

The share of new physicians entering primary care rose to 22% in 2023, up from 18.6%, though the Scorecard’s authors call the gains fragile and warn that market forces will keep pulling clinicians toward better-paid specialties unless primary care is funded differently.

There are two other movers: Non-U.S. citizen international medical graduates, who have long staffed underserved primary care, matched at 56.4%, which is a five-year low. And federal borrowing for medical students was capped at $50,000 a year and $200,000 total as of July 1, 2026.

In Panacea Financial's 2026 survey of 269 of its customers –– a mix of physicians, dentists and veterinarians –– 53% said they either would not choose to pursue medicine again or were unsure if they would, if federal loans were capped at $200,000.

Somebody fills the gap. Advanced practice providers already account for 40.6% of the provider workforce, according to Kaufman Hall and Vizient’s Physician Flash Report, and 27 states plus Washington, D.C., grant nurse practitioners full practice authority, according to the American Association of Nurse Practitioners, up from 22 in 2020.

Training all of them falls to the physicians with the least time to spare. An August analysis by the American Association of Colleges of Osteopathic Medicine found 73% of responding deans say developing clinical sites or recruiting preceptors has become harder over the past five years, with obstetrics and gynecology, pediatrics and psychiatry the hardest rotations to fill. Schools are casting wider nets and paying more.

Eighty-three percent are expanding their geographic reach, and deans expect preceptor fees to climb about 30% over three years. MD-granting schools, other osteopathic colleges and physician assistant and nurse practitioner programs are all bidding for the same community physicians.

“As medical education becomes more complex and medical practice more difficult, they are telling us the arrangement is straining,” said Robert A. Cain, D.O., the association’s president and CEO. “It is more than a scheduling or compensation problem. It is a time problem.”

The physicians already in practice are also practicing less often. Lisa Rotenstein, M.D., a primary care physician who directs the Center for Physician Experience and Practice Excellence at the University of California, San Francisco, led a study of 37,112 physicians at 160 organizations. The results, published in JAMA Network Open in May, revealed that intent to reduce clinical hours fell between 2022 and 2024, from 25.6% to 22.5%. That still leaves more than one in five physicians planning to cut back.

A Doximity poll found that more than 63% of physicians were either working locum tenens or considering it within five years.

Where physicians will be spending their time

The work that reaches a physician changes as the team around them grows.

When everyone on a care team practices at the top of their license, the cases that arrive at the physician are the most concentrated, hardest ones, notes Shannon Sims, M.D., Ph.D., FAMIA, chief product officer at Vizient. The routine visit that used to be a breather is handled elsewhere. Cognitive density rises over the same number of hours.

Onto that, add verification.

Adoption is nearly settled, but what the tools get used for is far from it. In the AMA’s 2024 survey, 21% of physicians used AI to document billing codes, charts and visit notes, while 13% used it to look up medical research and standards of care. Those two have since traded places.

Research summaries reached 39% this year, a 26-point jump and the fastest growth of any use the AMA tracks, while documentation rose to 28%. Doximity's survey of 3,151 physicians found the same reordering on a nine-month clock, literature search climbing from 22% to 35%.

Writing the note may happen after the decision, but looking up the standard of care for a 62-year-old with three comorbidities happens during it. Both surveys measure use rather than reliance, so the numbers say less than they appear to, but the direction is clear enough. The tool has moved from the record of the decision to the decision itself.

Keeping a human in the loop is the standard safeguard. It assumes the human is paying attention. Robert Wachter, M.D., chair of the Department of Medicine at the University of California, San Francisco, doubts that holds up at volume.

“Am I really going to be fully attentive as I review note number 50?” he said. “If I’m human, the answer is no.”

In addition, most of this is happening outside the institution's line of sight. “Right now, it’s mostly shadow AI,” said Sarah Matt, M.D., MBA, a physician executive, Medical Economics editorial advisory board member and clinical assistant professor at SUNY Upstate Medical University.

“Most docs are using their phone. Most docs are using whatever they find the most helpful.” Enterprise tools, she said, are often the clunkiest in the building.

Physicians know the risk they are taking. Seventy-one percent report privacy concerns about AI tools their institution does not provide or sponsor, compared with 42% concerned about institutional tools, and choose outside tools anyway.

Patients arrive having done the same thing. Roughly 66 million U.S. adults, one in four, have used an AI tool or chatbot for physical or mental health information, according to the West Health-Gallup Center on Healthcare. Physicians see only part of it. Eight percent say a majority of their patients disclose using AI. Thirty percent believe a majority are.

A visit that starts mid-argument runs longer than one that does not, and no schedule has been rebuilt to hold it.

New paperwork arrives on top of the old kind, as the Texas Responsible Artificial Intelligence Governance Act, effective Jan. 1, 2026, requires practitioners to give patients conspicuous written notice when AI is used in their diagnosis or treatment.

As of Aug. 1, Louisiana requires a verbal disclosure before any part of an appointment is recorded for transcription, enforced by the licensing board. Seven states restricted payer use of AI in prior authorization this year, and five prohibited AI chatbot therapy.

The hours ahead look like fewer easy cases, more supervision, more verification and more disclosure. Unfortunately, almost none of that is billable.

What physicians will be paid

On Jan. 1, 2026, Medicare cut the work relative value units (RVUs) and intraservice time for nearly all non-time-based services by 2.5%, on the premise that technology and improved techniques allow physicians to perform them faster than when the values were set.

CMS did not measure whether that happened. It arrived at 2.5% by adding up five years of productivity adjustments in the Medicare Economic Index, an economy-wide figure unrelated to how long any particular procedure takes.

The adjustment affects roughly 7,700 codes, including services for which physician time and work were surveyed within the past year and for which no estimate had gone stale to begin with.

The AMA called it arbitrary and offered alternatives. CMS finalized it anyway and will recalculate it on the same basis every three years, next in the 2029 fee schedule, then 2032, then 2035.

Specialty groups have warned that reapplying a cumulative index-based cut on that cycle risks a compounding decline, with no evidence that further efficiency is there to find.

Physician employment contracts are commonly denominated in work RVUs. When the value of the unit falls, compensation falls with it, and none of the actual work goes away. Thirty-eight organizations made that argument in a February letter backing the Efficiency Adjustment Delay Act, warning that the unpredictability makes employment agreements harder to write fairly and that the likely response is more consolidation.

So somebody captures the gain when a physician gets faster. For most of the profession, it is not the physician.

Josh Umbehr, M.D., cofounder of AtlasMD in Wichita, Kansas, described the current system as “pitting AI against the doctors, where if we help you chart faster, then we just make you see more patients."

More of the same is scheduled. CMS proposed 2027 conversion factors of $33.17 for qualifying alternative payment model participants, down 1.19%, and $32.84 for everyone else, down 1.68%, as the one-year increase Congress provided for 2026 expires.

The Ambulatory Specialty Model becomes mandatory in 2027 and runs through 2031, putting individual specialists in two-sided risk. CMS has also opened a request for information questioning how physician rates get set at all, including the role of the Current Procedural Terminology coding system.

The baseline underneath keeps eroding. Adjusted for practice-cost inflation, Medicare physician pay declined 33% between 2001 and 2025 while the cost of running a practice rose 59%.

“Docs are working harder, but what they’re making per unit of work is actually going down,” said Matthew Bates, M.P.H., managing director and physician enterprise service line leader at Kaufman Hall.

Who will own the practice?

As of January, 82% of U.S. physicians were employed by hospitals or corporate entities, according to Avalere Health's analysis for the Physicians Advocacy Institute.

Approximately 253,000 moved into employment between 2018 and 2026 — roughly 48,100 of them in the past two years. Employment is the safest prediction available about the next 10 years, and it is now drawing organized resistance.

California's SB 351, effective Jan. 1, 2026, codified corporate practice of medicine restrictions in statute for the first time, barring nonphysician owners from setting diagnostic testing, referrals, physician schedules or appointment quotas, and voiding contract terms that do.

Oregon began phasing in restrictions on management services organizations the same day, with existing structures required to comply by Jan. 1, 2029. Washington expanded pretransaction notice requirements in March.

So physicians have started organizing.

In late July, attendings across the University of California’s six academic medical centers launched a campaign to organize nearly 10,000 doctors, which organizers say would be the largest union of attending physicians in the country.

About 8% of U.S. physicians are covered by a union. But a 2024 JAMA analysis counted 33 physician union petitions filed in 2023 and the first five months of 2024, covering nearly as many doctors as the previous 22 years combined. Of the campaigns whose motivations could be documented, 85% cited working conditions and 81% cited having no voice in management. One cited pay.

The Committee of Interns and Residents grew from 17,000 members in 2021 to more than 40,000 in 2025. Those residents become attendings over the next decade and bring the expectation with them.

A smaller number are leaving the payment system altogether for direct primary care, trading insurance billing for membership fees and panels a fraction the size of a conventional practice. For everyone else, scale is the usual answer.

Andy Colbert, senior managing director at Ziegler, puts the threshold for standing alone at roughly 40 to 50 providers, the point where a group can afford real administrative infrastructure and negotiate credibly with payers. Below that, the choices are hospital employment, a private equity or management services organization partnership or a slow squeeze.

“It’s no longer enough to just do your clinical work and go home every day,” Colbert said. “If you want to be an owner in one of these businesses, you’ve got to be out thinking like a business person as well.”

Rotenstein has also found that physicians who work for themselves report higher satisfaction with their electronic health record regardless of which record they use, and that clinician-owned practices show lower burnout.

“We have to figure out how to give physicians back control, even when the trends are moving against that,” she said. Her research has also revealed that female physicians leave clinical practice at a median age of 49, compared with 64 for male colleagues, a gap that holds across specialties. Turnover runs $500,000 to $1 million per physician.

The rest is still unwritten

Beyond this, much of the rest has no date on it, and the rest is what would actually reshape the work.

Let radiology serve as a cautionary case. In 2016, Nobel Prize laureate and “Godfather of AI” Geoffrey Hinton said medical schools should stop training radiologists, that the technology would outperform them within five years.

In 2025, radiology offered a record 1,208 residency positions and remained among the highest-paid specialties. The Bureau of Labor Statistics projects the field to grow by about 9% through 2034.

Of the 1,451 AI-enabled devices the U.S. Food and Drug Administration (FDA) had authorized through the end of 2025, 1,104 were radiology tools. The capability arrived close to on schedule. In hindsight, the number of radiologists was never limited by the algorithm, but by a residency cap Congress set in 1997.

That makes liability the variable worth watching. In January, Utah’s regulatory sandbox authorized an AI agent to renew prescriptions for 192 medications for chronic conditions and approved a second pilot three months later covering psychiatric refills. That same month, Wachter and colleagues proposed in JAMA a licensure framework for autonomous clinical AI, built on standardized testing, defined scope of practice and layered accountability. Neither is a national rule yet.

Also undetermined is who is responsible when the tool gets it wrong. Asked to rank seven possible regulatory actions, physicians in the AMA survey put clear liability frameworks first, ahead of FDA oversight and patient consent rules.

“It’s 100% certain that [when it comes to] the technology which is integral to the practice of medicine today, and which includes AI, … the legal system will not keep up,” said Richard E. Anderson, M.D., FACP, chairman and CEO of The Doctors Company and TDC Group. "The legal system will be completely out of step with the realities of medical technology."

Which leaves physicians in a bind; follow an AI recommendation that departs from the standard of care and a bad outcome makes the deviation the case against you. Decline a tool that has become common in your specialty and the argument runs the other way.

“To the extent that we have humans in the loop, I guarantee you the humans will be sued,” Anderson said. “We still haven’t really figured out how we're going to be suing AIs.”

How can physicians take back control?

Eighty-five percent of physicians told the AMA they want to be consulted on or responsible for the adoption of AI into their practice, and 92% want more education and training on it. Those are terms a group can put to an employer before a vendor contract is signed rather than after a tool appears in the workflow, and they cost nothing to ask for.

The efficiency adjustment works the same way. CMS set the 2.5%, but it reaches a physician through work RVUs, and the formula converting RVUs into dollars sits in an employment agreement. That formula is negotiable at renewal, but the fee schedule is not.

Beyond the contract, the instruments that have worked lately are old ones: medical staff bylaws, specialty societies and state law.

In February, PeaceHealth handed its emergency medicine contract in Eugene, Oregon, to ApolloMD, an out-of-state staffing company, and offered the physicians it displaced their old jobs back as 1099 contractors. Eugene Emergency Physicians had been independent for 35 years.

“We took a vote. Anybody who doesn’t want to work for ApolloMD, would you be willing to sign a document saying, ‘I will not even talk to ApolloMD for 90 days after that contract begins,’” said Dan McGee, M.D., Ph.D., a partner in the group. “100% of people signed it.”

The medical staff voted 93% no confidence in PeaceHealth Oregon’s two top executives and 99% to restore the group. Administrators replied that they would undertake deep internal reflection. Letters to city councilors, the mayors of Eugene and Springfield, state legislators and the governor drew supportive responses and no change.

The statute did the work. Oregon’s SB 951 appeared to bar the out-of-state shell arrangement ApolloMD was using, and the group hired four lawyers, one of whom had helped write the law, to seek a preliminary injunction against a defense team of 12. PeaceHealth returned to the table, Eugene Emergency Physicians negotiated a new contract, ApolloMD withdrew, and the American Academy of Emergency Medicine covered half the legal bill.

McGee, who testified as a named plaintiff, said the judge told the staffing company’s executives they were not being honest on the stand. PeaceHealth came back to the table. Eugene Emergency Physicians negotiated a new contract, and ApolloMD withdrew.

They kept what they already had, and it took months of work nobody in the group had trained for. They were also defending a role someone else had already redefined for them. The harder version is doing the defining first.

“Role definition is going to be the trick in determining what people do with their time and what they don’t,” said Matt. She is optimistic, and clear about the prerequisite: “We have to be ready for change. We have to be comfortable with that. And sometimes health care has not been comfortable with fast-moving change.”

Of course, that discomfort has an upside.

Slow institutions argue before they move, and right now the arguments are all still open — the competencies defining what a physician should know in 2036 are being written this year by physicians, liability frameworks are in draft and scope rules get reopened every session.

The doctors who will be practicing in 2036 are in training today, arriving with expectations about hours, ownership and being consulted that their predecessors did not have.

Medicine has taken a technology shock before and kept the job intact. This time, it can see the shock coming.