If you think you’re waiting longer in the emergency room, or to get an appointment with your doctor, you’re not alone. It’s a simple supply and demand problem – increasing demand as our population grows and ages and decreasing supply as doctors retire earlier and faster than new doctors can be trained.

This is nothing new – but it is getting worse. Primary care and emergency medicine are the two areas hit the hardest. The average wait time to see a doctor has increased since 2017 and continued to rise after the demand spike brought on by the Covid-19 pandemic.

Autumn Spredemann, writing for The Epoch Times, tells us a survey conducted by AMN Healthcare in 2022 of 15 large metro markets revealed that the average time to see a physician was 26 days – an 8 percent increase from 2017 and a 24 percent spike since 2004. Staff constraints are also felt in hospital emergency departments. Nearly 140 million Americans visited a hospital emergency department in 2021, based on data from the Centers for Disease Control and Prevention (CDC). Of those, about 13 percent resulted in hospital admission, and thousands waited hours to see health care providers. Many patients leave before being seen by doctors.

One study analyzed more than 1,000 hospitals between 2017 and the end of 2021 and found that those with the worst performance had 4.4 percent of emergency room patients leave before a medical evaluation was conducted. At the end of 2021, that number had risen to more than 10 percent. Compounding the problem is that nearly half of the doctor population will reach retirement age within the next 10 years and career burnout is hitting the rest harder than ever, according to data from the Association of American Medical Colleges.

Just how bad is the problem?

Almost 50 percent of doctors report that they feel burned out, according to a 2024 Medscape report. Physician Thrive’s 2023 study states that the United States may have a shortage of 124,000 doctors by 2034.Within that shortfall, up to 48,000 will likely be lost from primary care, while the industry is projected to lose another 58,000 specialists, surgeons, and nurse practitioners.

What’s causing this shortage?

There are many reasons for this shortage, to name just a few:

• Increasing insurance company restrictions on the practice of medicine – which frustrates physicians and leads to burnout.
• Increasing percentage of doctors employed by hospitals and corporations – who control the way physicians practice medicine.
• Increasing numbers of patients enrolled in Medicaid – who can’t get in to see their doctors and resort to emergency rooms for primary care.
• Increasing time physicians must spend on paperwork and data entry – which keeps physicians from actually seeing patients.
• Increasing population aging with greater healthcare needs – which increases the demands for physician time.
• Decreasing respect for physicians in general – which adds to burnout
• Declining medical school applications – as medicine becomes less attractive
• Inadequate expansion of medical training programs – due to high cost and capital expansion demands

All of this should make you appreciate your doctor more if you have a good working relationship. But if you don’t, you’ve got lots of company!

As an orthopedic surgeon, I’m often called to serve as an expert witness in personal injury and malpractice litigation. Over the last 40 years, I’ve given hundreds of depositions and appeared in court on numerous occasions. During that time, I’ve learned the importance of knowing what you’re saying and being sure you’ve got the facts, and the science, to back you up.

There’s something called a Daubert challenge that every expert witness must be aware of and ready to defend. The term comes from a case in 1993, Daubert v. Merrell Dow Pharmaceuticals, which was decided by The Supreme Court. The case concerned the drug Bendectin, commonly used to ease morning sickness during pregnancy. Epidemiological studies consistently found no association, let alone causation, between the drug and birth defects. Yet plaintiffs in one case consulted with a cadre of experts who sliced and diced existing data to conclude otherwise. Their findings were never published in a peer-reviewed journal.

Robert P. Charrow, writing in The Wall Street Journal, tells us the court, adhering to a federal statute, instructed federal trial judges to act as gatekeepers by permitting testimony about scientific opinions only if it amounted to “good science,” developed in accordance with the scientific method. Such opinions, the justices added, must also “fit” the issue before the court. If a case were about whether a drug caused a disease in humans, its effect on animals likely wouldn’t suffice. The high court instructed the lower court to consider the propriety of the plaintiff’s expert testimony in light of its opinion.

When the lower court reconsidered the evidence in light of Daubert, it held that reanalyzing existing data for litigation and failing to publish such analysis in a peer-reviewed journal fails to ensure its reliability and isn’t consistent with the scientific method. Most states have adopted this approach.

Requiring a judge to act as a gatekeeper ensures that testimony is scientifically sound. It likewise ensures that judges follow the same rules when evaluating scientific evidence. Daubert doesn’t require that every expert have the same opinion—it simply ensures that judges will maintain guardrails. As in baseball, abiding by the same rules ensures that if a player hits a ball into the bleachers behind home plate, every umpire would call it a foul. The rules make the game, much as the scientific method makes science.

This brings us to the current situation where two mass products liability cases – in Florida federal court and Delaware state court – have had two different outcomes. Both cases concern the drug ranitidine, the active ingredient in the heartburn medication Zantac and its generic counterparts. Thousands of plaintiffs claim the drug caused them to develop at least one of several types of cancer. Both courts consider Daubert controlling precedent. Both analyses therefore should have been nearly identical. In practice, however, they were diametrically opposed.

Mr. Charrow tells us in a December 2022 opinion, federal judge Robin Rosenberg of Florida examined the plaintiffs’ expert opinions, which claimed that Zantac and other ranitidine-based drugs caused cancer because their active ingredient can degrade into the carcinogen NDMA, which is also found in smoked meats.

Yet to prove that claim, one must demonstrate the drug exhibits consistent positive associations with certain cancers across a series of human studies. No such relationship existed. The human studies didn’t show a consistent statistically significant and valid association between ranitidine use and cancer, let alone causation. Based on these, along with another study from the Food and Drug Administration, the agency and its European counterpart concluded that ranitidine poses no risk of cancer. The judge followed these assessments and excluded the plaintiffs’ expert testimony.

The Delaware court on May 31 reached the opposite conclusion in In re Zantac (Ranitidine) Litigation. Judge Vivian L. Medinilla’s opinion discounted epidemiology studies and the FDA’s conclusions. She relied instead on studies of NDMA—the chemical, not the drug—which showed a positive association between certain workers’ exposure to NDMA and cancer.

The FDA’s fellow public-health agency, the Agency for Toxic Substances and Disease Registry, reviewed at least one of these same studies and decided it couldn’t draw the same dispositive conclusions from it. Its limitations, the agency noted,“make it difficult to establish clear associations between NDMA exposure and mortality from specific cancers.” The studied workers were exposed to scores of carcinogens, which made linking cancer to one chemical scientifically impossible.

Mr. Charrow responds, “Yet these expert decisions didn’t trouble Judge Medinilla. In her view, the jury could second-guess federal agencies, as well as those who conducted the independent epidemiology studies, so long as other experts disagreed. The court effectively put a foul ball into play.”

Clearly, the Delaware judge is not following the science. The Daubert decision was supposed to make this impossible.  It is the judge’s responsibility to keep the expert witnesses in line and prevent unproven scientific theory from deciding cases.

I’ve never had a Daubert challenge to my testimony in 40 years. But if I ever start testifying based on my theories, and not the proven science, I should.

People are having knee and hip joint replacements at younger ages. In the past, doctors usually recommended putting off joint replacement surgery until patients were in their  sixties or seventies, but that seems to be changing.

Alex Janin, writing in The Wall Street Journal, tells us the average life expectancy is ticking up and the average age of joint replacement surgery is going down. He says many Americans are no longer willing to sacrifice decades doing their favorite activities, such as skiing, hiking or playing pickleball, to sit in pain, according to doctors.

Certain intense, high-impact fitness activities can increase the chances of injury and arthritis—leading to more procedures. “In the past, people would just say, ‘I don’t run, I have bad knees,’” says Dr. Ran Schwarzkopf, an orthopedic surgeon at NYU Langone. Now, he says, “they’re not willing to accept limitations that arthritis gives.”

The other reason younger people are getting replacements is the growing prevalence of obesity in the U.S. More than 40% of U.S. adults have obesity, the Centers for Disease Control and Prevention says, up from roughly 30% in 1999. Excess weight puts more pressure on the joints—roughly 4 pounds for each additional pound of body weight—leading more patients to need replacements earlier in life.

For patients ages 45 to 64, there was a 211% increase in inpatient hip replacements and a 240% increase in inpatient knee replacements between 2000 and 2017, according to data from the U.S. Department of Health and Human Services’s Agency for Healthcare Research and Quality. (Records after 2017 are less accurate due to changes in Medicare coding.) There was also an increase in joint replacements for patients ages 65 to 84, but the rise wasn’t as steep.

This tracking doesn’t include the growing share of replacements that are outpatient surgeries, which allow patients to go home the same day as their procedure. More than a million hip and knee replacement surgeries are performed in the U.S. every year.

“Back in the day, patients were told they had to wait until they were 70 or 80 to undergo this procedure because implants did not last long enough,” says Dr. Antonia Chen, an orthopedic surgeon at Brigham and Women’s Hospital. “Now, implants last 20, 25 or 30 years, and quality of life means a lot more.” Chen estimates that patients under 65 account for roughly 50% of her practice now, up from roughly 30% in 2014.

All this sounds great but there is another side to this story. Many surgeons still recommend minimizing or altogether avoiding running and other high-impact exercises after surgery, because it can put extra pressure on the prosthetics. Our joints are like tires; the more weight the tire carries, the quicker it wears out. These procedures are largely elective, and surgeons caution they still shouldn’t be considered preventive. They carry risks including infection, dislocation or joint instability.

As an orthopedic surgeon myself, I can tell you it’s more complicated than it seems. I once performed a total knee replacement on a 33-year-old man, but he would have been in a wheelchair otherwise. I wasn’t trying to get him back to running marathons! Anyone can undergo a total joint replacement at an early age and improve their level of function. But the real test is how long before you have to repeat that procedure because the artificial joint has worn out, or more commonly, has become loose.

If a person in their forties has a knee or hip replacement, and lives a normal life expectancy, it is almost guaranteed they will have to have that joint replaced a second, or even a third time. And if obesity is their problem, those repeat joint replacements will happen even more frequently. While this is certainly possible, the incidence of complications with repeat replacements goes up significantly. I doubt the surgeons doing many procedures in patients under the age of sixty-five are being fully candid about the drawbacks of repeat total joint replacements. No improvements in the materials used or the surgical techniques employed can change that reality.