Yves here. Dr. Roy Poses finds evidence suggesting that the sudden display of hand-wringing by health care firm CEOs over physician burnout is driven by the profit motive rather than concern about patients or doctors. A key bit of supporting information: the cost of replacing a physician who retires early.
By Roy Poses, MD, Clinical Associate Professor of Medicine at Brown University, and the President of FIRM – the Foundation for Integrity and Responsibility in Medicine. Originally published at Health Care Renewal
Physician burnout is in the news again. Late in 2015, an article by Shaneyfelt and colleagues in the Mayo Clinic Proceedings showed an increase in the proportion of physicians reporting at least one symptom of burnout to 54.4% in 2014(1), up from the 45.5% they reported in 2012(2). A March 28, 2017, post in the Health Affairs blog based on the latest article warning about burnout and suggesting how to address it got considerable attention.
Background – Physician Burnout
However, physician burnout is hardly new. As we wrote in 2012 about the predecessor the 2012 Shaneyfelt article, this is just the latest in a long series of studies showing physicians’ growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(3) In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(4) In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(5) In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(6) I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. Yet the 2017 Health Affairs post garnered headlines declaring physician burnout to now be a crisis.
Whether the current attention to burnout will lead to any real improvements is doubtful. In particular, I am concerned that the Health Affairs blog post that sparked all the attention was at best misdirected. It avoided discussing more than a few of the most immediate, proximate causes of burnout. It seemed more motivated more by concerns about money than about patients and the physicians that try to serve them. It read like a top down diktat uninfomed by the concerns of physicians or patients, maybe because all of its authors were CEOs of large health care organizations, all but one large hospital systems.
I will venture to go through the issues point by point in the hope of sparking a discussion more focused on the physicians subject to or at risk of burnout, and ultimately the effects of their burnout on their patients.
For the Love of Money
While the blog post began with a nod towards improving the quality of, lowering the cost of, and improving access to health care, there was a subtext. Consider some quotes, first, stating that one cause of burnout is,
profound inefficiencies in the practice environment
Also,
The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time.
Also,
Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner.
Also,
As leaders, we must recognize burnout in physicians and other health care workers as a serious problem and respond vigorously. This is especially true if we want to maximize the effectiveness, productivity, and longevity of clinicians.
Also,
More than words are needed. Leaders of health care delivery organizations must embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations. We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success.
To interpret these passages, note that the authors of the blog post were John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, and Dean Harrison (links are those supplied by the post.) All but Dr Madara are CEOs of large, nominally non-profit corporate hospital systems. Dr Madara is the CEO of the American Medical Association (AMA).
I would suggest that to a business CEO, efficiency refers to a state in which goods and services are produced with a minimum of costs. Furthermore, many business managers follow the business dogma first called the shareholder value theory, which seems mainly to be interpreted to mean managers should maximize short-term revenue as their first priority (look here). This is part of the larger financialization of all spheres of life, including hospital systems.
The focus on relentless revenue maximization may be reinforced by large incentives for top managers, particularly CEOs, based on revenue and other financial, not clinical outcomes. Such perverse incentives have resulted in huge increases in executive compensation for hospital CEOs. For example, as we recently discussed, author Dr John Noseworthy, CEO of the Mayo Clinic, received more than $2.3 million in total compensation in 2013, and was just reported to have received more than $2.5 million in 2015. Author Dr Delos (Toby) Cosgrove, CEO of the Cleveland Clinic, received more than $4.8 million in 2015 (look here).
Thus, too a hospital CEO, efficiency might mean the ability to provide services as cheaply as possible, and such efficiency is likely to be a top priority. The quotes above suggest that hospital CEOs mainly want to combat burnout to increase efficiency. One quote above refers directly to the monetary costs, again presumably to the hospital, of losing physicians to burnout. One quote refers to burnout as hampering physician productivity, which to a hospital CEO might mean the ability to produce maximum billing, that is revenue, in the minimum amount of time. Finally, one quote suggests that to the authors, burnout is a business problem, not a human problem, or a clinical problem.
Even stranger, two quotes suggest that the CEO authors believe inefficiency might cause burnout. That would appear very strange to employed physicians who may be increasingly pressured by top management to be more efficient, and thus to increase revenue. I would guess that many employed physicians would attribute their burnout to this relentless push for productivity and efficiency by top management.
So reading not between the lines, but the lines themselves suggests that the CEO authors might be more interested in reducing burnout to increase hospital revenues, and thus their total compensation, rather than to make physicians happier or more fulfilled, much to less improve patient care. Such a focus on revenue might not be reassuring to burned out physicians, especially those who feel forced to shortchange time spent with individual patients to fuel revenue. The repetitive discussion of efficiency and productivity in the Health Affairs blog post should worry any physician who feels his or her first responsbility is to take the best care of each individual patient.
Hear No Evil,…
Proximal Versus Organizational, Leadership and Governance Causes of Burnout
Here is what the blog post said about the causes of burnout:
The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.
We dealt with the curious citation of inefficiencies as a cause of burnout above.
The rest of the items seem more plausible. However absent from the post is consideration of why physicians lost control over work, have been subject to performance measurement (often without good evidence that it improves performance, and particularly patients’ outcomes), and have been forced to use often badly designed, poorly implemented EHRs. Particularly absent was any consideration of whether the nature or actions of large organizations, such as those led by the authors of the blog post, could have had anything to do with physician burnout.
Contrast this discusion with how we on Health Care Renewal have discussed burnout in the past. In 2012, we noted the first report on burnout by Shanefelt et al(2). At that time we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing burnout. Instead, burnout etc has been addressed as if it were lack of resilience, or even some sort of psychiatric disease of physicians.
In fact, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes. Our first crude qualitative research(8) suggested hypotheses that physicians’ angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting this viewpoint.
We found some corroboration of these hypotheses from other research. Written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: “too much emphasis on the bottom line. Taken over by large corporations. Quality of care and interaction now subsumed by productivity and profit,” and “the once most noble profession has become a factory job with a facade of ethics”(4) Pololi and colleagues’ qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(9) (Also, see our comments on this paper.)(10) Pololi and colleagues’ large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(11) We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians’ perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(12)
Yet at best most studies of physicians’ burnout, angst, or dissatisfaction only vaguely allude to “system factors” and not greedy, money-focused, preversely incentivized, self-interested, or corrupt leadership, etc as its causes. “System factors” such as bad EHRs and performance measures suggested by the Health Affairs bloggers were more likely to have been imposed on physicians by bad organizational leadership than by the physicians themselves. Of course, the CEO authors of the post likely would be made very uncomfortable with the notion that bad health care leadership, including of hospital systems like their own, might be a major cause of burnout.
Furthermore, there clearly have been leadership problems at many of the blog post authors’ institutions that could have made them more uncomfortable. Cases involving some of the authors’ institutions have appeared on Health Care Renewal.
Most recently we noted that Mayo Clinic CEO Dr Noseworthy had raised questions of mission-hostile management by suggesting that the Mayo Clinic should give some patients with commercial health care insurance priority over those with less well paying government health insurance (look here). Not long ago we noted the controversy generated by Cleveland Clinic CEO Dr Cosgrove’s lukewarm approach to the Trump administration’s “Muslim ban,” even though that ban had affected one of the Clinic’s own house-staff, while the Clinic was planning a fund raising event at Mr Trump’s Mar a Lago resort, raising yet more conflict of interest questions (look here).
We have also disccused issues occurring at the American Medical Assocation, and particularly its RBRVS Update Committee (RUC) (CEO Dr Madara), Sutter Health (CEO Ms Krevans), Johns Hopkins (CEO Dr Rothman), Duke (CEO Mr Sowers), Partners (CEO Dr Torchiana), and Northwestern (CEO Mr Harrison).
Finally, several of the Health Affairs authors have “board level” conflicts of interest. In 2006, we first blogged about a “new species of conflict of interest” which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care. We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to “demonstrate unyielding loyalty to the company’s shareholders” [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]
Three Health Affairs blog authors have such conflicts. Dr Paul Rothman is on the boards of Merck and of Cancer Genetics, a biotechnology company specializing in DNA based testing. Dr David Torchiana is on the IKS Health Advisory Board, apparently a health care consulting firm. Dean M Harrison is on the board of Northern Trust, a wealth management firm. He was on the board of Ikaria Inc, a biotechnology company now part of Mallinckrodt, and is a special advisor to Merrick Ventures, a private equity firm (look here).
Thus, how can one regard as credible an article on physician burnout which ignores how large organizations’ nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Corporate Employment as a Cause of Burnout
Finally, the Health Affairs post mention of “loss of control over work” deserves special attention. It could represent a catch-all of more “system factors” as noted above. However, the biggest cause of physicians’ loss of control over work may be the rising power of large health care organizations, in particular the large hospital systems that now increasingly employ physicians, turning them into corporate physicians.
In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit corporations. The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and “managerialists” who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.
We have also frequently posted about what we have called generic management, the manager’s coup d’etat, and mission-hostile management. Managerialism wraps these concepts up into a single package. The idea is that all organizations, including health care organizations, ought to be run people with generic management training and background, not necessarily by people with specific backgrounds or training in the organizations’ areas of operation. Thus, for example, hospitals ought to be run by MBAs, not doctors, nurses, or public health experts. Furthermore, all organizations ought to be run according to the same basic principles of business management. These principles in turn ought to be based on current neoliberal dogma, with the prime directive that short-term revenue is the primary goal.
Again, the authors of the Health Affaris post included some generic managers: Mr Edgeworth, whose highest degree was an MBA, and who had a long career as a hospital manager; Ms Krevans, and MBA with an MPH, who also had a long career as a hospital manager; and Mr Harrison, an MBA, who also had a career in hospital management. Doubtless all of the authors lead organizations whose upper management is frequently generic and managerialist. It is likely that the hospital systems they lead increasingly employ physicians, who thus have become corporate. So the Health Affairs blog authors might not be comfortable with the notion that a major cause of burnout may physicians’ new status as hired employees sometimes of their own hospital systems, rather than autonomous practitioners.
To repeat, how can one regard as credible an article on physician burnout which ignores how large organizations’ nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?
Summary
I am glad that physician burnout is getting less anechoic. However, in my humble opinion, the last thing physicians at risk of or suffering burnout need is a top down diktat from CEOs of large health care organizations. The CEOs who wrote the Health Affairs post not have any personal responsibility for any physicians’ burnout. However, the transformation of medical practice by the influence of large health care organizations run by the authors’ fellow CEOs, particularly huge hospital systems, often resulting in physicians practicing as hired employees of such corporations likely is a major cause of burnout. If the leaders of such large organizations really want to reduce burnout, they should first listen to their own physicians. But this might lead them to realize that reducing burnout might require them to divest themselves of considerable authority, power, and hence remuneration. True health care reform in this sphere will require the breakup of concentrations of power, and the transformation of leadership to make it well-informed, supportive of and willing to be accountable for the health care mission, honest and unconflicted.
Physicians need to join up with other health care professionals and concerned member of the public to push for such reform, which may seem radical in our current era. Such reform may be made more difficult because it clearly would threaten the financial status of some people who have gotten very rich from the status quo, and can use their wealth and power to resist reform.
Despite the fact that the current US president has stated he is for the “forgotten people” rather than the elites, do not expect such reform from him. He has sought advice on health care policy from the same people who wrote the Health Affairs post, as per the Washington Post, December 28, 2016:
On Wednesday, his guests were health-care executives, many of whom represent companies or institutions that have a big stake in the outcome of Trump’s ambitions to dismantle the Affordable Care Act. According to a pool report, the group, all men, met with him at 11 a.m. at the Mar-a-Lago estate in Palm Beach, Fla. They included John Noseworthy of the Mayo Clinic, Paul Rothman of Johns Hopkins Medicine, David Torchiana of Partners HealthCare and Toby Cosgrove of the Cleveland Clinic.
We truly live in interesting times.
See original post for references
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I can think of numerous interactions with doctors that were brisk and abrupt, apparent that the doctor had somewhere else he needed to go, very quickly.
Not good for the patient’s health, or the doctor’s either.
My German-trained integrative medicine doctor seems to have plenty of time and head-space to thoughtfully consider issues. But she doesn’t take insurance, so everything is paid (handsomely) by patients out of pocket.
All of this corporate medicine bullsh!t is never even felt by a physician in private practice who does not take insurance. It is felt somewhat less-so by physicians in private or group practice who set up a VIP program based on an annual fee paid by patients for access. In the DC area we all see lots of this, often when our beloved long-time doctors transition to a VIP program and ask for $1,500 a year to keep seeing them. But the place everyone gets screwed is in the ER — no way to be independent in a hospital setting.
The market has a solution for all this burnout. Pay up, or die quickly.
I had a “grokking moment” watching a youtube talk by Dr John Bergman (Osteopath). He said that modern medicine was based on “achieving and maintaining homeostasis”.
https://www.youtube.com/watch?v=p3V3TITSDxc&t=413s
So, you go to the doctors and they take heaps of blood tests, your blood pressure, your BMI etc. Say you blood pressure is above an arbitrarily decided “normal range”, you get medications to lower blood pressure. Say your iron levels are low, you get medications to raise them. Your blood sugar is high, medicines to lower them. Say the medicines start interacting and you get migraines- pain killers to deal with that. and on and on and on…….Oh God, now my bilirubin levels! It all seemed so simple when we started with one or two medications?
The entire set up is like some Mad, Steam Punk Scientist (physician) running a crazy (bells, whistles, dials….), out of control Rube Goldberg Machine (your precious body) by constantly trying to control, increasingly complex drug/environment/psychological/physiological interactions- Primarily using drugs.
This manner of treatment suits the drug companies because, once you start down that slippery slope to “homeostasis” (hell), using drugs- a person ends up taking 15 to God Knows how many different drugs, everyday.
I, myself, take absolutely nothing! I was taking baby aspirin everyday, until my retina tore, and I discovered an association between NSAIDS and macular-degeneration. oh my
I don’t follow Bergman’s dietary advice (POV), but his description of how modern medicine works, blew my mind. It is such a simple, mechanistic model, dressed up to look “scientific” and impressive.
In closing, I believe that the doctors are burning out because what they are doing is fundamentally Anti-Health and Anti-Life. utterly, stupid. And they know it
The “Health Care/Drug Care” Industry will have to invent a “more humane” way to kill/bankrupt, so that their henchmen (doctors) can sleep quietly at night, and not burn out?
Both of my parents (Hopkins Grads) were Professors of Medicine, both “ate their own cooking” (got the full treatment), and both died horrible, premature deaths.
My grandmother (Mum’s Mum), lived to 98 yo, hated doctors, and only consulted homeopaths. She kept my granddad alive until he was 97 yo.
NSAIDs and MD associated? Would you say more? At first glance, googling doesn’t show much of a link.
https://www.google.com/search?q=NSAIDS+and+macular-degeneration&rlz=1C1LENP_enUS539US540&oq=NSAIDS+and+macular-degeneration&aqs=chrome..69i57j0l2.1654j0j7&sourceid=chrome&ie=UTF-8
My friend told me of the association. “Damn, I can’t even take aspirin!” was my thought. “I am going to have to live clean, whether I want to or not.”
Long-term Use of Aspirin and Age-Related Macular Degeneration
“Conclusions; Among an adult cohort, aspirin use 5 years prior to observed incidence was not associated with incident early or late AMD. However, regular aspirin use 10 years prior was associated with a small but statistically significant increase in the risk of incident late and neovascular AMD”.
http://jamanetwork.com/journals/jama/fullarticle/1486830?version=meter%20at%20null&module=meter-Links&pgtype=Blogs&contentId=&mediaId=%%ADID%%&referrer=&priority=true&action=click&contentCollection=meter-links-click
From the link
‘the study population is almost entirely white of European ancestry, so the extent to which our results may generalize to other races/ethnicities, particularly groups at elevated risk for CVD, is unknown.’
I think/presume, the race and the genetics play an additional IMPORTANT and less appreciated role in numerous pharmaceuticals and their effect of individuals, across the globe. I am south Asian, taking aspirin over 20-30 years with no ill effect of any significant kind. I took them intermittently one in two and or three days.NEVER DAILY! I used take 2 adult tablets (20 yrs) but switched to one adult tablet! Caution:This is NOT for every body and out of conventional advice. I am an MD! (ret)
Aspirin has TWO factors – Coxa inhibitor 1 and Coxa inhibitor 2. One is the blood thinning agent! Coxa 2 is the ANTI-inflammatory agent, is ‘supposed’ to have long term protective effect on Cardiovascular systems, cancer of colon, pancreas and other(?) cancers. Also against gingivitis, gall stones. Cannot site any solid studies backing these 100%. My ‘hypothesis’ is mild, fulminating chronic inflammation is precursor to many disease mentioned above. Coxa 2 suppresses it! Also intermittent ingestion varies/fluctuating serum level ‘supposed’ facilitate transfer of glucose from muscle back to blood circulation (? anti-Diabetes)
These are my personal beliefs, some supported by scientific studies and some are NOT. So it is NOT a medical advise. I also believe ‘LESS is more’ and most ‘medicines’ (herbs/spices)needed should be part of our daily food.
NSAIDs do much more than this. They inhibit regulatory T-cells and stem cell repairs of damaged and eroded tissues. Regular use can raise the risk of both rheumatoid arthritis and osteoarthritis. They also increase infection rates.
On the other hand, some of these same effects make them excellent chemotherapy drugs.
Links please for these assertions?
Retinal tears and macular degeneration are pathophysiologically distinct entities.
You clearly have a very tenuous grasp on human health and disease. I am glad your grandmother lived a very long and healthy life. We don’t want to see you in our clinics or hospitals either.
However, if you get colorectal cancer or urosepsis or get T boned at a 4 way intersection, good luck having your homeopath fix that one for you.
Despite your parents’ education, it seems they didn’t teach you the most important lesson of all: a little knowledge is a dangerous thing. Given your tenuous understanding of health and disease, it should be no surprise that a drum as empty as yours bangs so loud.
For the record, I happen to sleep pretty fucking great at night, when I get the chance.
Excellent, excellent (n^2) article, i/m/humble/o.
An economy of people, for people and by the people seems to be a way forward.
(And we should keep in mind good housekeeping: minding our environment and our fellow creatures.)
And I learnt (learned) a new and very useful word: anechoic.
Good day, so far.
Cue the medical robots; humans simply can’t keep up with the industry’s business model!
Paging MedRobotics Flex … MedRobotics Flex … you’re wanted in surgery suites 1, 2, 3 and 4.
Semi nonsequiter- One thing I have noticed in the last few years, is that folks here around Boston have no qualms about joining expensive health clubs. As fast as they can build them, people join. And it’s because people know the health care system is beyond repair. Stay healthy or you’re screwed.
Being self employed, I have to pay $1900 per month for my health insurance for my wife and me. What’s another $230 for the gym? If we can avoid taking Rx’s and paying the $4k deductible we come out ahead. Stay healthy my friends.
Good advice. I exercise, although not enough. Maybe I’ll do something about that this evening. Diet is also important: eat plenty of fruits and vegetables, and avoid trans fats like the plague. And don’t smoke! Say yes to broccoli, kale, beans, blueberries, raspberries, tomatoes, etc.!
But accidents happen, and sometimes we don’t even know that it is occurring. In the US, the EPA has been weakened by Congress and by regulatory capture, and they allow far too much poison in our food, air, and water. Just a few days ago, industry stooge Scott Pruitt decided to continue allowing the use of the poison chlorpyrifos on US crops. There are plenty of other poisons in our food, and we all know about the problem of lead in drinking water.
So it’s impossible to guarantee good health by having a healthy lifestyle. Healthful living improves the odds, but sometimes even the healthiest people get sick or injured.
Stay healthy. Yay, good advice, until you’re not.
This is what happened to my next door neighbor, a full time truck driver. Then he starts getting sick. He takes a day off here, a day off there. And because he is at the bottom, while he can call in sick, he doesn’t get paid. Besides, he wants to work. Weeks go by and he just gets sicker and sicker. He takes too many sick days and loses his job. He is able to find another, but then starts taking sick days right from day one.
He goes to the doctor, but the doctor says it’s all in his head. He is coughing, vomiting fluids, always existed – but it’s all in his head. And it was causing some very severe stress at him, his wife was thinking about leaving him.
He finally gives up trying to work. But he can’t afford the Cobra, so he is without health care for three months, and becoming increasingly bed ridden.
With the New Year, he finally qualifies for Medicare and can finally go back to see the doctor. Diagnoses, advanced pneumonia. His lungs had become infected with an opportunistic fungus that was leaching toxins into his blood. His kidneys were at real risk of shutting down. And what is worse – it was 100% preventable. Likely a minor cold was not properly treated while he kept working. His immune system overtaxed, and the fungus moved in and started eating holes in his lungs. He was within days of dying. And it all would have been in his head.
Now that he is getting proper treatment, he is nearly back to his old self. His kidneys are back, all be it damaged. (This will cause him problems later on.) His lungs are clear and slowly healing. Last I heard he is back to about 50%. So he is now out, doing yard work, and trying to get back into the work force. (Key word is trying.)
His new doctor was baffled how the old one missed it. Apparently she saw the symptoms the moment he walked into the office.
With our current healthcare system, once you get sick, it’s so easy to keep deteriorating until your dead. You never have a chance to get healthy.
And then there is my condition. For reasons not yet understood, I lost the use of my leg. My friends are saying I displayed my hip. But the doctors don’t know, and can neither confirm nor deny the prognosis. I finally got an X-ray last Monday. But it will be two months before a doctor will even look at them. So what the hell am I supposed to do in the mean time?
What isn’t mentioned, and is a more cynical take perhaps, is that a large portion of medical students that entered since the 80s went in for the money. 70s were peak wealth for blingy doctors and since then many immigrant groups (Asia, Middle East) have pushed their kids forcefully into medicine as a means of stable high income, and status. Now they’re realizing their expectations aren’t being met, they’re in a profession they hate, and aren’t even earning much anyways compared to their friends who became Professional Rent Seekers. I was a part of this phenomenon and am observing it happening all the time amongst peers.
Read ‘transformation of Alerican Medicine by Paul Strong.
I went to medical school in early 60s in India. Came to USA in 1970, got further training for additional 6 years (intern residency +fellowship-RADIOLOGY) became Diag Radiologist. I was forced into ‘involuntary retirement’ due to Hospital politics and backstabbing junior partner. Took break of almost 10 years to fight both. Partially won against partner and the Hosp. During the deposition stage I learned A LOT re how hospital functions, to say the least NOT KOSHER! I went back for a couple years as locum tenens. in various private and VA hospitals.( it’s same all over!) And now I am retired, THANK GOD! I know literally know what ‘burn out’ means!
Ret MD
So if they would choose something else, what would it be… investment banking?
It just seems to me that they want their cake and eat it too… top dollars in a great work environment.
I’m amazed that so many people don’t get it yet: big money does not lead to freedom but a special kind of slavery.
With the amount of money they are making, it just seems to me that they have some wiggle room… if they went in for the love of medicine and helping the sick, why don’t they go out on their own and make their own rules?
This is great commentary in line with the critics in the article above. Burnout defined as an “efficiency problem” is so striking to me…
Obsession with money (efficiency, productivity competitiveness in economic talk) should be considered a social disease of pandemic magnitude.
I wonder if in the US, a physician can even practice her/his job for the love of medicine and helping the sick. It seems medicine is the art of keeping the sick alive for the beloved money.
MEDICINE has become a BUSINESS with NO medical ethics just bottom line mentality! This is a an unfortunate unintended of effect of entry of 3rd party payers since Medicare in 1965! Doctors have NO control on ‘how they can practice’ Medicine!
This is NOT being told by the academics at the training centers or the universities! They more ‘sheeple MDs to run the factory”
Been there,done it and seen it!
Ret MD
Please see the actual definition of BURNOUT below!
STRESS is reality is a REALITY for only those who are in touch with it. So is BURNOUT!
My doctor says that the insurance companies have made his life miserable and that they dictate every aspect of his practice. He also didn’t want to sell out to the local hospital monopoly. His solution was to go Concierge but I couldn’t afford to keep him. I also don’t want to support MDVIP which is run by a private equity company. Of the $1800/yr that they charge, $500 goes towards marketing!
if you want to be cynical and wonder about ulterior motives, smells like astroturfing for visa reform re. cheaper foreign MDs/RNs.
(As if not enough Americans are applying to medical/nursing schools) Think of the children!
This is a timely article and Dr. Poses adds a missing dimension to the corporate take of burnout. As a physician in a non-for profit physician run medical practice and a child of a physician I can say that what both are alluding to is the transformation of medicine over the last 50 years. Prior to the 1990’s the large majority of physicians were small business owners/or partners in small group practices where they were in total control of their practice and management of patient’s. After the 1990’s the transformation of medicine from the historical independent physicians to managed care and eventually salaried positions with loss of control occurred.
Some managed to evolve to the new system, especially those that had the financial security to “sell out” to hospital or insurance company by-outs of their practices. I trained in the 2000’s and I noticed the older guard with physicians with “old” expectations of what their work life would be like were the most dissatisfied. They were well aware of “how good” their predecessors had it and were the first to see the changes a comin’. My cohort had their expectations tempered by our mentors. I recall numerous mentions that I shouldn’t enter medicine “for the money” and I would be disappointment if that was the only goal in entering this career. That being said, change is slow and what my mentors/elders were warning us of is only now manifesting.
Of my current cohort, there are two tiers of physicians with different types of burnout. There is the front line physicians in primary care that are meeting the brunt of the serious stressors mentioned by the CEO’s above. Essentially they are overworked and underpaid. I cannot see how they manage. That is why, I suspect, much of primary care medicine is currently filled by Foreign medical graduates. There are a few native raised physicians who go into primary care for noble, altruistic reasons but for the most part the majority of medical graduates in this country join specialties.
Specialties pay better but many of the stressors are still there. In this cohort, the complaints are more of the “not making as much as during the golden years”, and much of the push back with insurance companies exerting too much control in medical decision making. Here, the burnout is due to loss of control to MBA management rather than being worked to the extreme.
The solutions as I see them, are alluded to by Dr. Poses and include more medical backgrounds in the C-suites as well as tempered expectations of what medicine should look like in the 21st century. If we are to have universal health care, our medical delivery system will end up being multi tiered with a base (hopefully high base) of universal health coverage as occurs in Canada, England, Germany, and a higher tier of medical care for those who wish to pay more. This is currently manifesting with concierge or “boutique” medicine as is found in Manhattan, Washington DC, or Beverley Hills. These people are paying a premium to be catered to by those physicians willing to deal with these types of “clients”. Is this egalitarian? No, but it is inevitable in a society where incomes are tiered. I would argue most people in this country would be comfortable with this. As long as there is quality universal coverage, I am comfortable with this too.
‘the burnout is due to loss of control to MBA management rather than being worked to the extreme.’
The cumulative growth of Hospital ADMINISTRATORS in last 40-50 years is almost 1000% vs the rate for physicians just around 100%! No wonder MD has become a slave to MBA!
A good illustrative and revealing chart is available if one searches @ofttwominds.com by Charles Hugo Smith (blogger)
Anymore, all it comes down to is more money for the top 10%. The rest of us can go rot.
I recommend that everyone do their best to insure that best health outcomes for yourself – by leading as healthy of a life as possible – bc most of us aren’t going to get good actual care via our current system of “how much can rip off from this sick person.”
Donald Trump ran on the notion that he was going to look out for the little guy. Nothing like believing what a con-man tells you. Trump’ll go along with whatever can be rammed down our hapless throats by the Republican-led, Ayn Rand-loving Congress, no matter how horrible it is for the 99%. Why should Trump care? He’ll have platinum plated health care for himself and his family, no matter what.
“I love the poorly educated.” Donald J. Trump
I still think Trump could be ego stroked into better changes than HRC would have been. It’s a shame so few are considering this method. We should at least try. Go ahead, be teh awsomest!
Tell him Single Payer would make him among the most famous, bestest, greatest Presidents of all time. Offer him a spot on Rushmore, or a gold Statue larger than Liberty herself.
It just seems so obvious… it doesn’t even have to be in a form of protest, but simple clear relentless encouragement. H.R. 676!
It’s worth a try, but the haters are sabotaging themselves and the rest of us.
ISTR that Nixon was pushed into doing a lot of things that he wasn’t planning to do when he first took office.
And, looking further back in history, there was FDR’s famous “make me do it” comment. We The People made him do quite a few things that weren’t on his list.
It’s up to 84 co-sponsors:
https://www.congress.gov/bill/115th-congress/house-bill/676/cosponsors
That’s 43.5% of the number of Democrats in the House, and 19.3% of the total number of Representatives. There were only 16 co-sponsors in the House for H.J. Res. 86, which curtailed the privacy of internet users, and that passed both houses and was signed into law by President Trump (as the companion resolution S. Res. 34). So there’s plenty of steam behind HR 676; unfortunately, unless a few Republicans sign on, it won’t go anywhere.
https://www.congress.gov/bill/115th-congress/house-joint-resolution/86/cosponsors
” This is part of the larger financialization of all spheres of life,”
That’s part of the rise of monopoly access/middleman power of pharma benefit manager corps, HMO corps, insurance corps, hospital corps, etc. The doctor and patient are given little choice in this system. The idea of replacing Dr. managed care with HMOs to save money has morphed into gigantic near-monopoly middlemen that’s raise costs more and more, with little or no benefit for patients and doctors, imo.
This article describes what is happening in EVERY procession, not just medicin. Burnout, disengagement, frustration. People who want to do a good job but are hog-tied by shareholder value, CEO bonuses, and making the numbers. Physicians are just experiencing the same things everyone else is.
My own physician quit Sutter Health last year and has left the practice of medicine. She was sick of being treated like an assembly-line worker. The last straw was being forced to work in an “open” space with no private office, but MBA’s looking to extract insurance payments had been dictating her practice for quite some time. Sutter’s monopoly on clinic access and insured patients made it virtually impossible to practice medicine anywhere else. Meanwhile, the “leadership” were paying themselves millions for crappifying patient care.
I also agree with the “Astroturfing for H1-B’s” comment above. The mantra of “efficiency” and “cost-containment” is simply code for driving down wages in order to divert revenues to executive compensation.
This. When my practice gets taken over by a national group, and I’m given the choice of either becoming their employee, leaving the state, or quitting medicine – I will be done.
I didn’t spend my 20s going through hell to become some MBA’s boy. There are plenty of other things I could do with my life outside of medicine…
The system is producing stagnation. It has been captured by the same kind of mechanistic catagoristic thinking that has overtaken our culture. The CEO idea conquered the territory and would maintain
ownership. Sometimes I think those who are embedded in the current hierarchical perspective truly
do not understand that just because they have achieved a certain status or some kind of knowledge
that they can be sorely limited in many other respects. They don’t know what they don’t know and
much of the time they don’t realize that can be informed by people who experience very different
perspectives. Burnout is created by the absence of the opportunity to learn and to experience the
creativity that comes with your own experience when you are fully engaged in what you are doing.
To mechanize a person deadens aliveness and joy and the fruits of the contributions that come
from the engagement of the whole person. I believe medicine (and enviornmental medicine)
would look very different if the process had not been arrested by the vice of this aggressive
takeover. no time to feel, no time to think
The Medical ethics demands that the physician DO what’s best for the patient but in BUSINESS ethics, ‘Bottom line’ is the master!
The noose around the necks of burned out docs is debt.
https://www.usnews.com/education/best-graduate-schools/the-short-list-grad-school/articles/2015/05/19/10-medical-schools-where-students-pay-a-high-price
That debt grows as payments are deferred.
http://www.kevinmd.com/blog/2011/04/real-life-medical-school-debt.html
https://www.amainsure.com/physicians-in-focus/medical-school-student-loan-debt-by-the-numbers.html
Training? Really? When they hire a physician, he or she will have completed medical school and a residency. What training is needed? I suppose the practice’s electronic medical records system could require some training, if the new physician hasn’t previously used that software. But if a lot of training is needed, perhaps the corporation made a huge blunder when they chose their software system.
As for recruitment, well, that should be easy, because the corporation is a great place to work, right? It will practically sell itself! [sarcasm]
Corporate practice of Medicine, it’s ethics and bottom line mentality = is the anti thesis why most went to Medicine!
BURNOUT definition
(Christina Maslach PhD, prof of Psychology @ Univ of California -Berkeley developed Maslach ‘Burnout’ inventory in the 70s!)
is defined as an ‘ an EROSION of the SOUL caused by deterioration of one’s VALUES, DIGNITY, SPIRIT and WILL”
—
The end result without prevention, is a predisposed to major Depression ++ ! If one admits burnout or depression, it is a career suicide for physicians!
Been there and seen it
Ret MD
Or literal suicide. I worked in an academic health center in the late 90’s early 2000’s. We had 3 physician suicides in our department in one year.
I heard from one doctor as far back as 2001 that she was burnt out. She was even considering quitting and switching to Accountancy and taking classes to that effect. She felt she was overworked & underpaid. Once she went to a meaningless conference held out of town just because otherwise her HMO would make her work those days. Atleast she could tune out in the conference… Then Sep 11 2001 happened and then she was just glad to have a job and stayed put.
‘Burnout’ phenomenon is going on long before it became a common word.
I practiced medicine (Diag Radiology) for almost 30-40 years and now retired.(more in another comment) When HMOs came in early 90s, we started losing control of ‘practice of Medicine. It progressed downward to the detriment of majority of Physicians, especially primary doctors!
STRESS is reality is a REALITY for only those who are in touch with it. So is BURNOUT!
Yeah,, I’ll believe the shark Insurance CEO’s care about practitioner burn out when they get rid of the hated “Prior Authorizations”. You know, the nifty way they pad their bottom line by having your doc have to advocate on their patient’s behalf for free — sometimes a hour or more — trying to convince the know-nothing at the insurance co. that Jane Doe really does need a Brain MRI.
Make sure your doctor asks and puts the name of the person who denied the authorization, in one’s chart or PC, for future ref. Once the doc tells that person that his/her name will be part of the record, that person will promptly refer the doc to a REAL doctor! If he also denies, do the same!
Patients ( or their relative/friend as an advocate) have to become well informed and be pro-active in taking Ins.
Thanks for this inside tip!
BURN OUT can happen to any one, in any profession or Corporate jobs, where is demand of ‘responsibility and accountability but NO authority’!