There has been a disturbing shift in how medical professionals feel about their career. I almost cringe every time I’m at a party or social gathering now and tell people I retired early from my medical practice. I try not to bring it up.
I don’t cringe out of fear for how they will perceive me or whether they will look down upon me with condescending scorn about how I left a profession I trained so long for. Instead, I am finding that more and more physicians are looking for their own way out. This is disheartening to say the least and I wish it wasn’t the case.
I thought at first this was more a problem of “front line” physicians- those in primary care, obstetrics, and emergency medicine. However, more recently, the grumblings have progressed into the fields of anesthesia and radiology. How could this be? They are in the sought-after category of the panacea of excellent pay and lifestyle that is often found in “ROAD” specialties- radiology, ophthalmology, anesthesiology, and dermatology. Is no one safe?
It seems the reach of insurance companies and health care administrators (who are not clinicians) has stealthily worked its way throughout the health care system in the united states and is strangling the lifeblood of physicians. The joy of medicine is being sucked out slowly by increased burdens of pressure to see more, do more, without regard for patient outcome- of course with the caveat of earning more money for the bottom line of the organization, not to the benefit of the patient or physician.
What seems to be the common ground amongst specialties is the loss of autonomy and the stripping away of control from physicians. The percentage of employed physicians continues to grow while the self employed shrinks. Although, there has recently been a small surge in the idea of “direct primary care” as a way to bypass insurance companies altogether and reestablish the doctor-patient relationship without a non-medical middleman deciding what is appropriate medical care. While in theory this model makes sense, I worry that it will be become a solution for health care for the rich but glaringly ignores the poor who cannot afford to pay out of pocket for medical expenses.
So, are doctors to blame for “selling out” and joining an organization and becoming employed? In many specialties it has become almost a necessity to obtain an employed position out of residency. Medical student loans have crippled physicians who could not bear the thought of taking out more loans to cover the expenses of starting a practice. Instead, the lure of an employed position offers coverage for malpractice (an extreme expense that often prohibits self-employment in specialties like obstetrics), an immediate salary that will help make a dent in the student loan burden, and the allure of promised perks such as a more predictable schedule. It becomes a matter of survival from the start as a newly minted attending physician. For many, the prudent choice is indeed to become an employed physician.
Its not all bad to be employed. Good care is given to patients. Fantastic, compassionate, and intelligent physicians are employed. I’m not blaming these organizations for the early career exodus of physicians. It is an all encompassing problem with health care in the United States that reaches all corners of our country and all patients. The problem occurs when health care becomes a business run by people who are not clinicians. Physicians begin to feel like they are running up against a brick wall. A wall of denials for patient care, refusals of requests for adequate visit time with patients, and a blocking of advocacy for patients by the professionals who can help them the most.
Without question, we cannot ignore health care costs which are exorbitant, and strategies must be present to reign in this runaway train. However, for improvement to exist in our health care system, physicians must be involved in the decisions about how money is allocated, what conditions and treatments are covered under insurance, and the appropriate time needed to evaluate and diagnose conditions in real office/hospital settings. These decisions simply cannot and should not be made by MBA’s or politicians who know nothing about the medical implications of their business decisions.
Looking forward, we have the chance to save health care in our country. It starts with physicians (and our organizations such as the AMA, ACOG, AMWA, etc.) speaking up in Washington DC, hospitals and surgical centers being run by physicians instead of business people, and health care organizations being led by doctors first, who will advocate for patients while also being mindful of fiscal responsibility. This is the only way the brick wall, which is putting a barrier between physicians and the highest quality of care they want to provide for patients, will begin to crumble.
I feel the same way an administrator did not care that I said I was burning out. When I sent in my letter of resignation and then about 2-3 weeks later wanted to stay. I wrote a long letter about how I would avoid burnout but to no avail they had offered a contract to a doctor who was interviewing for another of the organization’s medical practices. I’ve moved on but now realize how the power is theirs with a non compete and my need to stay in town because of spouse’s job. It has been harder than I thought getting back to FT practice in my area. We doctors seem to care about burnout but the stigma is still there. We have give the fríe era seat of medicine to administrators, insurance companies and pharma. It is disheartening to see others struggle with this.
Adriana, sorry to hear that happened to you. Unfortunately, we seem to have less negotiating power than in the past. I hope you find a fulfilling position soon- one that allows you to practice great medicine and maintain your autonomy.
AMA? You’ve got to be kidding. Most physicians just want to stay out of trouble and get paid. They won’t change the system. They are the status quo. Its patients that must change the health care system and physicians will follow….as usual.
I agree those organizations have not been behind us in the past, but we need to find a large organizing group to make an impact. I think you are actually right in that it will ultimately be patients who change the health care system. However, we need them on our side- right now physicians aren’t fairing too well in public opinion. Hopefully by discussing frankly the real issues occurring in medicine, the public will ascertain a better understanding of what is happening.
I feel AMA does not have front line physicians interests at heart… this organization sold out long ago. It has retained the financial power of controlling the CPT system and then want’s physicians to sign on to leverage this system…. well large blocks of physicians have shunned the AMA.
I feel perhaps groups like PMG (Physician Mom’s Group) may have the ability to organize large blocks of physicians to simultaneously push for positive change.
I hope so! My wife (an Interist) and I are close to retirement (5 years earlier than was common a generation ago). But I wish for all physicians sake, something starts to give. (or we will all be searching for the lost doctor to care for us in our older years — doctor heal thyself)
As unlikely as it seems, I also believe there could be quite a lot of leverage provided behind a group like PMG. This was truly built by physicians, for physicians and there is a lot of trust and camaraderie that has been borne from this modern day organization of physicians.
AAPS is the only organization on record standing up for physician independence and has been for decades. There are some ‘green shoots’ that the AMA is waking up…too late, of course. When ‘Medicare for all’ kicks in ALL physicians will become government employees.
It is too bad that the focus is on money instead of delivering the best possible healthcare physicians have sworn to do. I see that this is the major cause of unhappiness and dissatisfaction. I met my travels physicians getting together to set up a 7 bed ER within a 35-bed hospital to take only insured patients or self pay patients. They will not take Medicare or Medicaid patients. It is these people who act and who do not blame others. If you fear how much the govt controls healthcare, think about countries like Switzerland, Sweden, UK, France, Australia, Denmark, Canada, and New Zealand who have a single payer system and who spend far less on healthcare with much better outcome.
I agree with this article a 100%. It’s exhausting to wake up every morning to do your best, but every morning I have to fight for the approvals, compliance and spaces to see my patients.
Fortunately I practiced in an era when I had more control–as a partner in the 100+ doctors of Burns Clinic and when that folded after partnering with PhyCor a smaller psychiatric group practice. I had chats with handwritten notes, At hospital orders could be efficiently written and given to a unit clerk who entered them into a computer, In more recent years I experienced the incredible inefficiency of making doctors perform functions of a unit clerk by interfacing with the hospital computer. i remember when chart notes were concise and relevant and not written to satisfy the requirements of some insurance company and thus filled with scores of irrelevant negative that must be recorded. Yes giving over control of medical practices, hospitals and the medical chart to nonphysicians plays a big role in the burnout of current docs.
I just retired from medicine, not expecting to retire this soon due to physician burn out. I agree with you and the article.
My EMR computer logged over 1600 clicks by me Thursday. I am 62 and through April 26.
Burnout seems to be affecting more and more and the best cure I’ve seen so far is to do less medicine. Do less of what is causing you moral injury. Hopefully the tide will soon turn and the path to a more fulfilling career will be more self evident. I think it’s going to take a real crisis in health care for that to happen
I kind of agree that not much will change until we reach that crisis point and then people outside of medicine will begin to understand. We can certainly start the conversation now before it happens. I think it will occur within the next 10 years in primary care with our current health care system collapsing.
I think the focus of physicians are focusing more on money than good quality healthcare. I think if passion is truly in medicine you will be much happier to practice medicine and stand up to do what is right.
Like most complex problems, burnout and job dissatisfaction are multifactorial.
I too have been surprised at how many in the “good lifestyle” fields are near the top of the list.
I think the efforts of more open communication, blocked time off, wellness programs, financial independence, more useful EMRs, and variable clinic loads can go a long way.
I know since reaching FI and going part-time I really love my job even more.
Yes, definitely! If physicians are able to make those changes to their schedule you are describing including blocking time off and variable clinic loads it would certainly improve career satisfaction. I don’t always know that it is burnout that causes physicians to leave though (as I’m not really sure that was the case in my own circumstance) but more gaining back control over our lives. FI makes leaving possible, but I wish it wasn’t the desired outcome for so many. I believe attacking system issues are at the core of solving the problem- even more than focusing on the individual. thanks for your comments.
As one of the members of the “ROAD” lifestyle specialties, I can tell you that there is definitely a lot of dissatisfaction among my colleagues and myself.
Radiology has been in the crosshairs for reimbursement cuts which essentially force us to work harder/read more studies to even try and make up for the losses. This leads to burnout.
In addition the American Board of Radiology has irritated a lot of people, myself included, by changing requirements (I took a 10 year cognitive exam that was supposed to have me certified until 2023 and this year the board invalidated that result and is now forcing me to take weekly quizzes even though I had to take time off, spend money, etc to take the exam in Chicago).
Interesting. Sorry to hear how the rules seem to be constantly changing regarding certification. It seems every specialty has its unique challenges but at the end of the day, they all come back to the same basic concerns of being unable to practice the type of medicine we feel is appropriate, while a “higher up” tells us how many studies to read or patients to see but may have real understanding of how that could affect patient care.
These are the practice killers: 1. CMS has put onerous paperwork requirements on physicians. When directly asked, they admit that their programs will eliminate solo practice and small groups within a few years. 2. Insurance Companies. Ever since the regulators and Medical Boards of each State refused to file against insurance companies deciding on their own drug formulary (based on profits), they dictate medicine. At the same time, they reduce payments to physicians every year. 3. Hospitals use predatory and illegal means to keep the doctors they like (ie: compliant), and prefer to just pay large fines when caught. The doctors who work for hospitals are the “B” team, which administrators prefer. 4. Medical schools expand their enrollment for dollars, and take more foreign medical students each year. Loan programs saddle new doctors with too much debt. 5. Of course, the EMR was a huge waste of money and time, which still has not improved medical care enough to pay for itself, for which doctors never were reimbursed. I could go on, but it is too depressing. Lol!
You nailed a lot of issues Peter. It is depressing if you think about it, but I write about these topics to bring attention to it so that hopefully we can start to address change. If they public doesn’t know there is an issue, we have no support behind us.
agree . EMR. so much documentation, increasing complexity of medical care have made the rewarding part of patient care disappear.
Large organizations (AMA, AAFP, ACOG,AMWA, etc) have the same inherent failings as insurance companies and hospitals. What we are missing is local units (4-10 providers) that manage relationships and financial structures. Also, communities have opportunities of creating local insurance units. The soul of medicine is sucked out of each of us when we submit to the profit masters.
I agree that in the past, the large organizations have not been there for physicians. However, to make any real lasting strides it seems we need large numbers behind us. Certainly you can make a difference locally but I worry about the overall health care climate if we do not address this on a national level.
I quit after 40 years , I am an internist and had a home office. The reason being that the insurance kept on paying less each year for an office visit. Then they wanted me to do my billing electronically. I felt I could not afford the expense and all that personal info about patients out there in the world which people could get ahold of and learn personal info about people. wasn’t worth it
40 years is a great career! hopefully you found it fulfilling along the way. I personally am not against electronic medical records but feel they have a long way to go serve the purpose to physicians of improving patient care. Right now they are used more as a billing collection tool. I can also see how the mandated use would push small practices and solo practitioners out of business, which doesn’t seem fair.
Thank you for this accurate article that articulates the death of the medical field. I have worked in psychiatry since the early 80ties. I experienced my specialty just before insurance DRGs and it was wonderful to provide excellent care without time constraints. I was able to get fantastic supervision and later supervised others as I chose teaching hospitals. The greed of insurance company CEOs has ruined health care. Patients complain but seem to be unaware that insurance reimbursement doesn’t cover their care. I have been in mourning over these changes as I have the most challenging sickest patients and don’t have the time really needed to care for them. I spend half my time at a computer and this isn’t what any of us got into healthcare to do. Unfortunately it will only get worse and that means patients suffer and clinicians will be in jeopardy of being sued. Yes, the wealthy will seek out boutique doctors and the poor will have even less. It’s very depressing.
AMA? You’ve got to be kidding. Most physicians just want to stay out of trouble and get paid. They can’t change the system. They are the status quo. Its patients that must change the health care system and physicians will follow….as usual.
Our beloved “Fee for Service “ system has been weaponized by Medicare and the medical insurance companies, distorted by the MBAs put in charge of us by the integrated health systems and is extracting a large and growing share of the country’s GDP. Yes we are suffering from the system but the patients are bearing this exploding cost. At some point they will junk the whole system for a single payer system, deflate the income obsessed private health systems, obscenely expensive medical schools, the patent protected pharmaceutical companies. And, yes, return us to upper middle class incomes like 50 years ago. It won’t be pretty but for the health of the country both physical and fiscal it will be necessary.
I agree that the current system isn’t going to last. It’s going to be a tough road going forward, but hopefully for our patient’s sake we come out better in the end.
Towards the end of my 37 year career I seemed to have gotten all the chronic pain patients I couldn’t get off opiods. That was a chronic hassle. We had a great EMR which got replaced by a high maintenance model which gobbled up time and created hours of after hours work. The hospital never improved the compensation plan to take account of work produced instead of cash flow coming in so all the older doctors with Medicare Medicaid patients took huge discounts on their salary.
In the end I think they just wanted to get rid of us old guys.
The doctor-patient relationship is suffering from the current problems in healthcare. Reimbursements aren’t making sense and it is frustrating to hear that you feel you were pushed out. After a long career such as yours, I would have hoped for better. Hopefully you look back on your career and remember the good points. I had a relatively short career, but actually loved the medicine and my patients. This is why I continue to write about it.
After 41 years, I had a difficult time in retiring Ob/Gyn; but I loved my patients and medicine. I did not hate medicine; I loved it, but after my wife of 37 years passed w CA metastatic, I changed…am remarried & have 10 g’kids to love and leave a legacy of PAPA. Mission work is ahead for me. I am not just a doctor, but a human made in God’s image and plan on ‘finishing well’ in volunteering, teaching underprivileged kids how to study, preaching to the homeless, and fighting for the unborn as well as other unethical medical intrusions in our society. J Michael Fite, MD
I’m glad you have found your path. I also loved my patients and the medicine. It is why I continue to write about it (fortunately not all of my articles talk about the problems in medicine). My hope is that by discussing and identifying the issues we can start to move forward with positive changes.
Medical providers (note, I no longer am a physician) are an expensive disorganized commodity. With our fragmented medical societies, the provider’s security has been an erosion as the forces of business captured the flag. We have been scattered and cannot mount a response.
Don’t worry. The insurance companies are next. These are business forces at work. What will the insurance companies do when Apple, Amazon and Walmart evolve to provide low cost health care? What will they do when the “Medicare Option” finally passes? The Medicare Option was scrapped to help get the ACA passed. When it passes, the masses (who’s corporations will soon gravitate to that option) will move into that product and leave the commercial insurance companies and their products hanging out to dry. I have to thank those insurance lobbies for my current job, though. If the Medicare Option had passed, the entire commercial insurance industry would likely be crumbling AND the entire large hospital systems that are dependent on the inflated commercial payments for provider’s billing to pay for the layers of compliance staffing (forget the nursing and patient transporters!)
It’s a house of cards and the newest graduating classes will likely be hammered by the explosive transition I suspect is on the horizon.
The business of medicine has been changing all along. The knowledge base expands. The art of medicine remains about the same. Trust, empathy, curing and comforting. It IS what we do. Don’t let that go.
-P
Philip, you make some great points. Indeed, health care (and the business of medicine) has been changing all along. Most of us still love the medicine part, and of course the patients. I know I could simultaneously feel like I had the best job in the world, but also not understand how the business bottom line could be so misguided. I am hoping for positive change for our new physicians and patients who will be receiving care. Thanks for weighing in with your thoughtful comment.
Direct primary care is hardly for the rich. With average monthly membership fee nationally at $77.50, that’s about on par with a cell phone bill or cable TV. Don’t tell me those are for the rich. And compare that to the cost of insurance and many lower income families that cannot afford insurance find that whole a DPC Doctor doesn’t provide the depth of safety net that insurance does, it is certainly better than nothing. For those who truly can’t afford a cell phone bill sized charge to prioritize their health care, there is Medicaid. I didn’t create our social problems that have led to a wealth disparity where so many earn so little and I should not have to practice in the disease care system we have as some sense of moral obligation. And honestly by getting out of the system entirely, that leaves more in-system providers for Medicaid patients to acess. For many, it’s either leave the system entirely and see 0 patients or stay in medicine as a DPC doc, do a great job caring for fewer patients (and relieve the system of the “burden” of “caring for” those patients), and fall back in love with medicine. However, many DPC docs do see a certain percent of pro-bono patients who qualify for Medicaid.
DPC is not concierge medicine. Please don’t perpetuate that misconception.
I fully admit I am probably not as well versed in direct primary care as I should be. I am open to others describing in more detail how it works. Thanks for commenting. I definitely see some of the benefits of this system and how it is allowing many physicians to find joy in their practices while helping patients. No system is perfect and I think we are still struggling to find the best solution.
Nearly every single one of my rads colleagues, including myself, are burned out. So much for that “rads lifestyle” right? I can’t think of one of colleagues that don’t want to retire early or just get the hell out of medicine. We’re tired. The constant push for more RVUs, decreased reimbursement and increased litigious environment just makes for the perfect storm.
Medicine sucks. It isn’t what it use to be, or so I’ve been told. To me, it has sucked as soon as I left residency.
One solution for this is to work less. After 21 years working full-time as a radiologist (including nearly all of that time taking Q2 call for IR), I went part time. I work three days a week and make much less money than my full-time partners, but my lifestyle is much better and I enjoy my work a lot more. Try it, if you can. I will never work full-time again.
After 20 years in full-time radiology practice, including Q2 IR Call for nearly all of that time, I went part time. I get paid much less than my full-time partners, but I enjoy my work more, the quality of my work is better, and the worklife balance is more optimal. Try it, if you can.
Sorry to hear VDT. Yes, the push for more RVU’s and litigious environment was exactly what I was hearing from other radiologists I spoke with. Every specialty seems to have unique their issues, but a common thread seems to join us all together. Hopefully you can find a way to bring joy into your practice so that you don’t want to retire early.
Thank you for this article!
I just wanted to share I’m Family Medicine, almost 7 years out of residency, and I recently gave my notice at work as an employed physician to hopefully open my own Direct Primary Care practice later this year. While DPC can be very individualized, many of the DPC doctors I know are different from what people tend to think of “concierge doctors” in that the monthly membership fees are meant to be affordable; for example, $10-20/month for children up to age 18, and $40-100/month for adults based on age. Some doctors are now able to do more charity work with their time being freed up not doing administrative paperwork related to insurance reimbursement, as they can now chart for the sake of taking care of the patient again and are enjoying medicine much better. One of my friends has a DPC clinic with many working and uninsured folks as his patients. It’s certainly not for everyone, and I’m a bit intimidated by the idea of having my own “business” because we were never trained on how to open a practice in school or residency, but I want to try DPC because after I attended the DPC Summit last year, I saw hope. I saw hope for me as a doctor but also hope for my patients to get better healthcare than the rushed and chaotic care they’re currently getting; to pay the actual healthcare cost, instead of the mysterious inflated prices related to insurance and hospital charges; and to be able to see me when they’re sick, instead of being directed to Urgent Care because the administrative burden and inefficient clinic flow don’t allow me to simply add them to my schedule. It is true my patient panel will shrink from 1200 to around 400, and I feel bad not being able to take care of more patients, but when I think about how it’s either DPC or quitting medicine, even though I’m still young in my career, then I can at least start by taking care of those 400 patients. I have heard of Peds, IM, FM, and also some specialists doing well in this model, so I just wanted to share this perspective for anyone who might be interested in learning more and looking into DPC. If interested, you may search for “DPC Summit” on YouTube, and many of the conference sessions are posted there. Thank you for reading.
Good for you KATY! I don’t think you’ll be disappointed. I was in private practice for 25 years and then sold my practice to a hospital to try and avoid some of the government paperwork, only to find it existed there also. I’ve been a physician for 44 years and still love taking care of patients. If I had it to do over, I would do DPC right out of residency.
Thanks for adding to the discussion regarding direct primary care. I fully admit I am not as familiar with this model but can see some of the positive aspects. Opening readers minds to other options is always welcome here- thanks for contributing. My question regarding direct primary care is regarding catastrophic events- how does this work for patients?
Please keep in mind I’m still in my early learning and planning stages for DPC, but from what I’ve heard and what I understand, patients who participate in DPC either 1) keep their insurance from work to cover for catastrophic events, medications, and ancillary services; or 2) get catastrophic insurance to cover for catastrophic events. Some people do a healthshare-type insurance as another option.
The argument that helped me understand why it still makes sense to have patients get catastrophic insurance when we don’t use insurance is DPC is only providing primary care directly, it’s not anti-insurance; having catastrophic insurance would be truly using insurance the way it was intended. For example, we don’t submit insurance claim for our oil change or small damages to the car, because we don’t want to increase the premium, but we use it for the big hail damage. Another convincing argument for me why people with insurance could still benefit from DPC is so many patients have high-deductible insurance that they’re essentially using their insurance as catastrophic insurance because they avoid going to the doctors and avoid tests or can’t afford medications because they can’t or don’t want to pay the cost before their deductible is met (and all of these can negatively impact their health).
There is also cost saving in being able to see your doctor rather than going to Urgent Care or ER because your PCP can’t get you in for 3-4 weeks, and in DPC you don’t even have to pay a copay to see your doctor. I’ve heard many people say the amount of money their patients save on medication each month by getting the medications from their DPC doc (dispensed from clinic at or close to wholesale price) more than pay for the monthly membership fee (I cringed when I read about pharmaceutical plants stopping production of certain generic medications because the cost has been driven so low they’re no longer profitable; I’m not sure how much DPC movement is contributing to that, but that’s a different problem to solve). These are a couple other reasons why people with insurance may choose to pay out of pocket to use a DPC doctor for their primary care.
I was really encouraged by hearing more about how some insurance policies and employers are more aware of DPC, and some are working with DPC or providing membership for DPC as a benefit, as the model has been shown to decrease healthcare spending/cost and improve patient’s health. If we all agree we can’t leave it to the government, administrations, or others to solve the healthcare system problems we face right now, DPC seems to me a way for doctors to take medicine and patients’ care back into our hands. I admit I sought employed position after residency because I was so daunted by all the regulations and requirements and paperwork in healthcare, but now I feel that fear is exactly what I need to overcome to become the doctor I wanted to be and take better care of my patients. If DPC is something that can eventually develop into a true healthcare revolution for the better, then I really want to give it a try while I can. (Thank you for reading my long post; I hope this answered your question)
I think this model actually makes a lot of sense for health care. I figured patients still had to get coverage for catastrophic events. I think ultimately it would cut back on overall health care expenditure but I still worry how the gap would be covered for patients who could not afford both catastrophic insurance and monthly premiums to DPC. Although it would actually be a lower cost in theory, right now the cost is entirely covered by their employers or the government. It would require a mindset shift, which isn’t a bad thing. thanks for explaining more and good luck in your new practice1
It’s the government folks! The Medicare law says the government was prohibited from interfering with medical practice, but it has taken over. You know the drill. Sure the insurance companies are a problem, but it’s government that has encouraged this system of employer provided insurance paying for everything. Get some courage, doctors! Be your own boss. Treat the patients as you think best. And if you can’t make it in the present 3rd party payment atmosphere, then drop out and go the DPC or concierge route. Others are now out there to show you how to do it. You’ll be a lot happier.
It is indeed interesting that the DPC and concierge route seems to be gaining traction. It is obvious the current system isn’t working and creative solutions are necessary.
Many hospitals employ multiple type practices
and self referrals, creating monopolies and decreasing the competitive market,
and if you are independent practice, chances of survival are slim to none
thus one of the reasons we baby boomers are getting out early
I agree. It seems incredibly hard for those in independent practice to survive. Its almost as if the current health care model is forcing private practitioners out.
I’ve been in private practice in primary care for 26 years. My small primary care group practice switched to the Direct Primary care model 1.5 years ago. We lost 70% of our patients. Most of our “rich patients” are gone. We care for a broad cross-section of our community. Some uninsured, some have good insurance, some with HDIPs, and some on Medicare. My partners and I have re-discovered the joy of practice without the ridiculous”metrics” or patient satisfaction scores hanging over our heads. If you have ANY interest in this model, check out the DPC conference in Chicago in June. AAFP sponsored event.
While I appreciate your passion for the problems we physicians face, I think you are naive to not realize the Federal Government is the central problem making the practice of medicine more and more difficult as the years go by with all the nonsense we have to adhere to. First it was HIPPA and then “meaningful use.” Now CMS in 2019 proposes to change the name to the “Promoting Interoperability” program and institute changes that CMS says would “decrease cost and provider time burden.” Sure, and if you believe that, I just found the cure for cancer and am waiting for the patent to be approved. Same old crap, just different name so that some government bureaucrat or agency can justify their existence at the expense of practicing physicians. While I agree that physician management is important in health care organizations, they, like their non physician administrators are bound by Federal Government regulations that continue to burden and drive physicians out of medical practice. As long as the Federal Government pays the bills, they will continue to make the rules. Rules that force most of us to spend more time on “meaningless use” computer clicks than time spent with patients.
We invested an initial 500k in our EMR about 10 years ago, and a healthy chunk every year since. An EMR is required by CMS/Medicare to practice in 2019. The EMR is a good one (as they go) and helped us achieve our “meaningful use” requirements. CMS just sued our EMR because they didn’t like the way the “meaningful use” metrics were recorded, and cheerfully took 52M in just rewards. The irony is maddening. The obvious solution is to stop seeing government covered patients, for whom we stick our necks out, make accommodations for and obey unfunded mandates for very little reimbursement. We really need to wake up.
I do worry everyday not as a physician but as a patient. Who will take care of us? A specialist who needs to generate a certain number of RVUs to keep his job and make his bonus? Or the “cancer specialist” who will advice radiation in gray areas just to keep the “system administrators” of his back.
Unfortunately even when we get out, quit or retire as providers, the health care system we allowed to prevail will be there to strike again when we become the patients.
This will be the ultimate price we will pay for settling, for giving in, for not standing up as advocates of our patients and our beloved profession.
I call for all employed physicians to see themselves as patients first, that could set them free and proud! Or get them more depressed.
You left out the encroachment of midlevels.These poorly trained, lesser trained, and in the example of direct entry midwives, non-trained individuals are creating more work, and diimininsing the satisfaction of the work we do. It is hard to have sacrificed to earn my degree, sacrifice sleep, relationships, my youth, to train to care for my fellow women, only to have people take side steps, and half measures, then have legislators and hospital administrators decide these individuals are just as good as us, while we continue to save people from their mistakes. Honestly, more than EMRs, more than fighting insurance companies, these midlevels, and the physicians who support their watering down of our education/profession for personal gain, are wearing me out.
You bring up some really important issues. This is a particular concern in the area of women’s health. A topic for another article for sure…thanks for commenting.
Doctors change when in administrative position. They are harder on us than business people.
I have seen that sometimes, too. However, it is imperative to have physicians who understand the clinical implications of business decisions at the helm. It seems to help when administrators are required to maintain a clinical component to their work to maintain a realistic understanding of front-line physicians.
It seems those willing to acknowledge and speak about this epidemic problem are those carrying the problem on their own backs. Which also means positions of power who could help are working blindly or intentionally to protect what their own assets. And yes, the outcome is powerless of the provider within “the system” that is dependent upon him/her and a growing problem in our U.S. health system. Without providers, there is no system. Physicians, PA, and APRN’s will benefit now and in the future by cutting threads to regain control. Initially, it will be a financial loss with life gains that are more valuable than perceived losses. Our patients pay thousands in premiums every year plus thousands in copays before insurance steps in to help them pay what they have already paid for. Then, the insurance company reserves the right to designate the portion they will pay, which is never 100%. Where is the money going? I think we know about the six figure bonuses that are doled out at the top of a system which is truely the bottom of it. An inverted pyramid with providers and patients at the bottom. The collapse is already gradually occuring.
I think we all experience different reasons for feeling less than enthusiastic about careers in medicine. As a primary care doctor I find increasingly that patients, in this era of 24/7 access want to receive care for free without regards to the time expense and energy that it takes us all to deliver this . In the past year I have received approximately 6000 patient advise requests about medical symptoms as well as patient calls. I am simply not willing to allow this imbalance between patient access and my own Time and health to continue: All patients who are for anything more than a very simple question need to be seen. While this would seem to be an obvious step it’s not as easily instituted in the context of unreasonable patient expectations and administrative prioritization of patients welfare and over physicians’.
As a family practice doc with over 25 years of clinical practice, I am one of those who has chosen the Direct Primary Care route. You don’t fully grasp the workings of this model. On the contrary to your suggestion that it will become something that only the rich can afford is totally wrong. Our town has Medicaid for those who qualify and a “free” clinic to those with no means, but those aren’t the ones seeking direct care. We have large numbers of people in the area who work for businesses that don’t provide insurance. Others have their hours just below the level to qualify for insurance and another group that has insurance offered but the $800 a month from their paycheck plus copays and a $5000 deductible make the healthcare useless and unaffordable. In my case my office has monthly memberships that are $79 per person for unlimited visits. Just about all routine primary care office needs are covered for that. So does that sound like something only the rich can afford?? The direct care doctors work one on one with their patients with no one telling me how long my visit has to be or how many i must see in a day. We keep the practice size small ( about 500 patient max) to give quality care. We know our patients very well and they can reach us anytime. We are not told what tests can and can’t be ordered and unlike most of our industry that is driven on disease care we focus more on wellness and prevention along with traditional disease care. So before anyone judges this growing movement of doctors to take back the reigns of health care, look deeper.
Thanks for weighing in on direct primary care. Many of us who are not as familiar with this model can benefit from learning more. I still have the question for patients who could face financial ruin from a major catastrophic event, how does this work with direct primary care? for those patients whose employers don’t provide insurance but they also don’t qualify for Medicaid? Obviously DPC is providing a great service for these patients for routine care, but I am trying to learn more about all aspects of this care. is a separate policy bought for these events? Is there a safety net? Honestly asking, not trying to discount the excellent care you provide.
Here is my skinny,the practice of Medicine hit the fan in early 1990s, greedy doctors signed up with Managed care ,doctors did it themselves-early signers offered exclusive access to patients-“I will have all the patients ,you will not have any”.I do not think I would call this completion, just greed. Then there are the international graduates-you signed up to get patients because you did not have an American pronounceable name. Patients moved from one practice to another-frightened other doctors signed up -I need patients I will do anything-useful idiots we are,Then every year the reimbursement decreased,you can not negotiate your contract-well your fees are set.Then we let them call us Providers not Physician or Doctor of Medicine. Complete demoralization and capitulation.In 1983-I was paid $3000 for TAH extra for BSO,extra for A&P repair,1992 $1200,now $950.The practice of
Medicine will have to fail before resurrection occurs-cash or check or credit card ma’am. Government run Medicine is rationed like UK has.Total crap.
If “The problem occurs when health care becomes a business run by people who are not clinicians” then organizations run this way are the problem and with all this ACO business we now have HUGE monopolizing networks across several states which control health care delivery in the region. These are all run this way so what’s an individual clinician to do?
Also it’s demoralizing to have individuals who are the least qualified being the ones who are determining what is quality care through garbage metrics like “satisfaction”. No wonder so many physicians are trying to find a way out.
Yes, satisfaction scores are a whole other topic. We have seen how prescribing patterns (for antibiotics/narcotics) can be influenced by these scores. I agree that it is not a way to measure quality care.
It’s “rein in”like a horse not “reign in” like a king. Perhaps the metaphor is lost on the writer and reader who have only ridden in a horseless carriage and never on a horse that needed to be reined in.
Several of my colleagues under 55 left clinical family medicine for niche practices (PRP injections, cosmetic procedures, opioid detox/maintenance), non-clinical (admin, informatics), or who just left health care entirely.
I think it’s technology (and our obsession with it) that fuels much of this trend. And I’m not even referring to EHR’s.
The doc who hired me into my first job about 20 years ago (just before he retired) remarked how good my practice would be thanks to new drugs like Prilosec, and the new diagnostic tools that he never had.
For example, a patient with a headache reads on the internet that it might be caused by a cancerous tumor or an aneurysm. An aneurysm might be treated via coiling, while the tumor might be treated with gamma knife radiation. These treatments would have low morbidity, and may prevent an untimely death. If the patient has one of these and suffers harm, there is the uncertainty of litigation even though the physician did an appropriate history and physical, and relied reasonably upon guidelines against MRI. Even if the patient has no aneurysm or tumor, the physician must live with this uncertainty if the MRI is omitted.
The patient’s insurance (which the physician didn’t select for the patient) decides whether to pay for the MRI. The physician wants to appease the patient to avoid a bad review, a complaint to administration, or to reduce anxiety over missing a bad but treatable problem.
If the insurance company says “no” the patient could still elect to purchase the MRI but would rather not…the so-called “moral hazard.” But after some time spent writing letters and calling the medical director for the HMO, the PCP prevails and the MRI report comes back as “non-specific white matter change.”
The radiologist, who never gets to speak to or examine the patient, fears liability for calling a brain MRI normal if there’s any chance it’s not. So there’s a new set of worries over this incidental finding. Depending on what the internet says the patient may want yearly MRI’s and/or referrals to neurology, ID, rheumatology, or genetic counselor. But at least the MRI (and subsequent MRI’s) don’t expose the patient to ionizing radiation.
This sort of diagnostic dilemma happens all the time with all manner of common symptoms such as cough, back pain, “hemorrhoids,” chest pain, etc. “If the doctor had just ordered the test/referral sooner…” The stress and anxiety over each one of these clinical scenarios is cumulative.
On the treatment side there’s always the risk that a drug’s toxicity isn’t known until after it is marketed and widely prescribed…Prilosec, for example.
Yep, lawyer managed healthcare is quite expensive and wasteful. But hey, the tort guys sure have nice boats !
What is the root cause of organized medicine’s angst? The industry has been given an impossible task. Provide the highest quality medical care to everyone regardless of cost, but then limit the resources available. We all know many cases, representing many if not most people, who in their lifetimes utilize far more resources than they have ever produced in their entire lifetimes, much less actually paid into insurance or taxes. You don’t get ICU care, biologic anti tumor drugs, nursing care for years, heart surgery, etc cheap. Medicaid doesn’t cover costs, it can’t, yet its current and easily foreseeable short term future costs are already bankrupting states across the nation. The feds pick up half the tab, which is a main reason for a 21 Trillion dollar debt and quickly rising. Health care is a right. We cannot afford nearly as much health care as we are currently providing. The dichotomy, the contradiction of the unchallenged paradigm of the former and the absolute truth of the latter filters through the system. Politicians won’t face it, they don’t get elected if they do. Lawyers parasitize the system to their own benefit. Until we accept that no, many patients will NOT get 21st state of the art medical care, we will not control costs, no matter how many prior authorizations we demand.
I agree, costs have to be a factor. However, I think you would agree that physicians should be the ones deciding who gets what care instead of insurance companies.
So explain to me why hospitals are building huge inpatient buildings or building multiple outpatient access centers (endoscopy, surgi-centers, urgent care, multi-physician offices) if there is no money?
Explain to me how hospitals have the money to afford TV/Radio spots or beautiful written publications that are in my mailbox?
Explain to me how hospitals have the money to build shopping centers, hotels and other non-healthcare delivery structures?
Explain to me how hospitals have enough money to hire an army of non-care delivery personnel such as HIPAA officers, chart auditors, discharge planners and etc?
As I remember it …. the hospital came into existence as a place where physicians could place their patients into a facility where personnel can oversee the care …. mostly nurses.
Why did governmental agencies create so many rules that they have driven healthcare into a huge business? Why must we compete so hard to attract patients?
How did hospitals become huge business organizations? Is it just a reaction to these governmental interventions or is it now a self-sustaining, non-IPO business?
Could it be that hospital systems are spending their money in the wrong places? Is functioning medical equipment, adequate bedside personnel to deliver care becoming less important than business expansion?
I think many of the assets that empower us to become physicians have become liabilities on the other side of training. Independence, control, competition, hard work and avoidance of risk may have attracted us to this profession and enabled us to succeed but when docs take a job to avoid risk, they surrender control, independence and suffocate the drive that got them there. Suddenly, they are checking boxes, following rules and no longer leading when our spirits thrive on learning, growth and progress. The medical profession is in the midst of a disruption but it is a call to physicians to make choices that feed our drive and purpose. It is a call for docs to not live and work on an island of independence and isolation but to share vulnerabilities and challenges, to collaborate with each other towards success and to surround ourselves with other docs doing the same to make our destination better. social Media contains so many docs doing this with their own blogs, podcasts and mastermind groups. Most docs manifest qualities that are gold for success if we are willing to take a risk and redefine what we accept and how we are valued and create a life that we dream of, inside or outside of medicine.
Fantastic post! Thanks for this comment. Your sentiment rings true and I think many will identify with this.
Just sold my practice. No physicians get to approve/disapprove what tests, medicine and surgeries we recommend. Insurance companies control how we get paid giving the lions share to hospitals and insurance companies. We have to worry about law suits even from just a phone call with a patient. Reimbursements are going down not up. Overhead in the office is going up not down. Only so many services and time you can provide an hour without quality suffering. Have to be concerned all the time about reviews on the internet which are usually anonymous . Last but no least the hours and hours we spend in front a EMR for which we are after the fact judged by insurance companies and lawyers. Its sad but true most physicians are not really that happy.
Yes, you nailed a lot of frustrations many are facing. Time for a change in health care!
Just gave my opinion and comment about this topic, would like to have it posted
Great post and comments, and kudos to you for responding to most of them. The one thing that I would disagree with is insurance not caring about outcomes, rather they care too much about outcomes, stats, data and treat it like the holy bible, without regard to differences in patients. Dinging doctors if they don’t meet certain metrics without regard to the entire patient story, treating patients like a number, etc. Certainly leads to more burden and stress for doctors to meet this often ridiculous or erroneous standards, affecting patient care, or doctors/hospitals gaming the system.
Thanks, jsa. I think you make a good point that insurance companies are perhaps focusing on the wrong outcomes as human beings cannot always be drilled down to data points. There is always more to the story and the oversimplification is not good for our patients or physicians.
It’s the system, not the job.
So true. I actually really loved my job (the medicine, the patients)- just not everything else surrounding it. Probably true for most clinicians.
It is good that so many doctors have taken the opportunity to vent their frustrations on this post. I burned out of running my own practice and finally sold when the future became too unpredictable and the complexity of staying in practice increased. I was fortunate, I planned well. I took off from medicine for just over a year and went into another, unrelated, business venture and learned a lot. I then went back part time to by specialty, GI, and worked for over a year for the practice I sold to, although not in my original office. It showed me the complexity and frustrations of working for a large corporate practice. I now work part time, 10 days a month, for a nice practice and do GI hospitalist work. I have a nurse practitioner I see patients with. The APRN writes most of the notes and enters the orders. I do procedures and round and discuss patient care. I am able to be fairly isolated from insurance issues and other concerns. Oh, and I’m in Florida with a condo overlooking the river and ocean with beautiful sunrises every morning. You see, I didn’t need to make the most money anymore, I still wanted to work although I didn’t actually need to work. So, I took the better position and work for a great doctor and his group.
The article ignores the root cause of the ills which beset doctors: the lack of a pre-paid, single payer system for financing medical care and paying doctors, funded with public funds, , such as is the case in most of the rest of the world. None of the problems described will be resolved until all our professional organizations insist on the development of such a system here, as exists, throughout the world.
I don’t understand. How can you say there is a lack of pain? In emergency medicine, the physician groups make a lot of money, whereas the worker bees get the scraps. You should see the millions of dollars of profit they make.
There are many layers of problems, but when you call the root cause a lack of socialized health care, you’re either disingenuous or lack familiarity with the fact that the USA “currency” system is a USURY based system as a result of a hostile takeover of the issuance of the “currency” by the people running the private bank called the “Federal Reserve”. They kill the value of the currency over time by continuing to print it and loan it at interest to the USA government, which prior to the takeover, printed or minted currency for itself, with no interest owed to a private bank.
Socialized health care could be very useful to the people, but not with the rotten scum running the system now. The same scum who print the money have used it, among other methods, including blackmail, and extortion, to acquire command and control positions all through government and various positions of power.
I don’t expect most professionals to be remotely familiar with these facts and issues as this has been going on since the Federal Reserve was created in 1913 with little limelight; however, I am well aware of the open conspiracy by groups tied in with the kosher racket the Federal Reserve is running, and the push for various things that will increase power and centralization of control over those of us in the majority, who are the “out groups”.
I look at your surname and issue you’re pushing and I’m immediately suspicious of you and you’re intentions.
Whoever wrote the article is to be congratulated: the comments are all too appropriate for what has been happening during the last decade. I am a psychiatrist and psychoanalyst – and now have to do battle with lawyers and third-rate physicians employed by insurance companies – to pass judgment on whether to approve the frequency of visits my patients (those that rely on insurance) need. They invariably disapprove, and deny coverage adequate to the needs of my patients. Things are as bad as Britain’s National Health Service (NHS), where medical care is 2nd rate unless you are well-off and can afford private Harley Street MDs. I also do a lot of forensic work, custody cases, and the like – and I see where the money goes. It goes in obscene amounts to attorneys – who know nothing about medicine, but who make four to five times as much as a physician, though they have only 3 years beyond college, as against 16 of mine: medical school, internal medicine residency, psychiatric residency and psychoanalytic training. And who sits up all night at the hospital with a dying patient? Doctors do. Lawyers do not. I had wanted my sons to go into the noble profession of medicine. They didn’t. How sad that they and other young men and women are having second thoughts about the career of medicine in our country.
It’s too late. We have already lost control. Bean counters and non-physician specilalists have long since wrested it from us. I’m a Psychiatrist. I was let go from a job last summer in a jail[!] by the administrator who is a social worker because I was not meeting their daily quota, which was based on psychiatrists in outpatient clinics. She turned a deaf ear to my explanation about all the time-consuming obstacles in the jail. I realized that I could have met the quota if I did quick sloppy work. Anyway, every job is all about numbers and documentation; quality of care is meaningless. I understand the need for productivity, but I wish there was some middle ground. The AMA? What a joke. They have sold themselves out to other side.
Right on,right on,right on!Acutely and accurately reported-well done!
Keep ‘spreadin THE NEWS’.
Thanks so much.
Randall R Hurst MD
Windsor, Ontario
Canada
I totally agree with Dr Cantazaro….the physicians of today are in a tough spot…the costs of a medical education is through the roof….reimbursements not inline with the overhead and malpractice insurance…when ii decided to throw the towel in, my insurance premiums soared to $80,000.00/ annum for $250,00.00 coverage….hard to stay afloat with those numbers….and we never get tort form relief…I agree be employed…
When i graduated,I was awarded Doctor degree and i was addressed as a Doctor,later it became customary to be addressed as a provider.Now, some insurance companies are referring to physicians as a “downstream entity”.
Medicine is a noble profession, part art and part science.The word ” Industry ” does not belong there.Those big organizations mentioned above do not represent and protect institution of medicine as one would expect.Holding a position in these organizations should be a service,not a carrier or business.Domain that once belonged to physicians is now over runed by
extenders,NP’s PA’s and such and most of all businessman.
We are expected to give 110 % ( where I came from 100 % is most one could expect)
more efficiency and productivity,again what is a definition of efficiency? If you feed your goat with portions for a rabbit and expect it to give milk like a cow,would be the best way to describe it.
Yes ,burnout is real,those who exit early are smart and lucky ones,those who end up in despair and suicide are less fortunate.Over worked,with immense weight of responsibility,loss of autonomy and on top stripped of dignity is taking its toll.PTSD is real but it is not reserved only for our service mans. Meaningful help is not available,not without a risk to one’s carrier.That department also fell victim to unscrupulous exploit and lucrative business for some.The system allows them.
What would it take to change?I guess similar shake down like Vatican is now in the middle off,for all the transgressions committed by its servants which exploited the sanctity of the church for personal gain.Medical profession is also violated exploited and some cases down right molested by some individuals.{ and in case you wonder that my tone is bit strong,please google what is take home pay and severance packages of CEO’s of insurance companies e.g Aetna,Empire and such,80 cents on the $ stays in the company,barely 20 cents spent on the patient and 17 billions are spent on lobbying,to keep things the way they are.
After 50 years in medical profession I closed my solo practice.
EMR with its redundancy,never ending requests for chart reviews,(none of which contributes to quality just a collection of data for different purpose,using cheap labor as physicians are.}
that among other things certainly motivated my decision.
OK1KSP M D
I graduated 50 years ago at the end of what I call the “golden era” of medicine, post WWII. Some of our professors were world famous. I attended a top – rated state med. school with a full tuition scholarship (instate tuition was $950/yr, out of state was double that). A Grant’s Atlas of Anatomy cost $20 and my Keeler Ophthalmoscope was $65. After graduation I took a three year FP residency taught by 60 private physicians at a 250 bed hospital in a small city that had a stable economy. I also served my obligatory two years in the military. I passed the FP Board Exam and opened up a solo practice that included Ob in a rural area. The county was happy to give me free office space. I owed $3400 for a government loan and I borrowed $5000 from a local bank. These were soon paid off. I saw Medicare, Medicaid, BC/BS, insured and uninsured. I used “Problem Oriented” medical records. Of course there was no EMR then. I had a “peg board” bookkeeping system, adding machine, copier, postage meter and employed a very efficient secretary/receptionist and a nurse. I was in non-medical employment 1990-2002. I missed the transition to the EMR and corporate take over of medicine. From 2002-2017 I was outside the US in a “developing nation” in SE Asia where I was an unpaid clinical instructor at a public hospital, volunteer physician for UNHCR and had part-time work at a small private outpatient clinic. Thus, I avoided the transition in medical care provision that occurred in the US. When I returned to the US, fully retired, I soon learned what I’d missed. The “golden era” where the Art of Medicine (as it says on my diploma) had disappeared. It had been taken over by some sort of predatory business model. At the 50th year reunion of my medical school class there were speeches about “burnout” and on Doximity all sorts of negative articles. The immense cost of medical education and student indebtedness is just unreal. I’m so thankful that I got my MD when it was affordable, when you could have a rewarding private practice, when physicians were respected members of a local community. During my internship I once told the DME “If I were independently wealthy, I would practice medicine as a hobby”. I’m not wealthy but have been “generous to a fault” in providing educational opportunities to several foreign students, and care to my friends and refugees in SE Asia. My advice to the new doctors: work at a clinic and pay off the loans, Live a very modest life-style and save up funds. Quit being a clinic/hospital employee and do DPC and maybe some volunteer work or teaching. Retire.
The article failed to mention the rise of entrepreneurial doctors whom once their practice is set up and running never see a patient but staff the practice with junior doctors, nurses and PA’s. While there is nothing wrong or illegal about this model one should consider the question as to how are such doctors any different from the MBA’s and administrators criticized in the article? All practices are businesses whether they are individual, corporate or government. Someone must pay the cost of service for the service to continue. More young doctors today fresh out of training have considerable debt more than ever before and such debt can constrain residency, specialty, fellowship, and practice location choices and sometimes these are unhappy choices. But then this is the real world and young doctors must live in it just like everyone else.
Take care,
Morgan.
Rising cost of health care? I have to ask, what is increasing the cost? I know the nurses at our health system did not have a cost of living adjustment for over 5 years. I know the doctors in my department are working with and being offered the same contract we were offered 13 years ago, not a penny more. So if the money is not going to the health care providers, where is the money going? Is it going to the non-clinicians, MBAs, and administrators?
Yes, Ty, I believe it is going to what you mentioned above plus (and probably even more so) to overpriced drugs and hospital charges and insurance companies. Price transparency is nonexistent in health care and that should change for the benefit of our patients.
What ever happened to the laws against the corporate practice of medicine?
Everyone?! Please
Totally agreed with you and thanks for sharing your knowledge with us.
Change will occur when congress gets the same insurance that the majority of people have. When they hurt , they change the rules regardless of the cost. The golden rule. Those who have the gold make the rules for everyone unless a nation wide revolt is organized, which is not likely to happen. Medicare for everyone is an attempt to cure the problem.