Top 5 Reasons Why Your Doctor is Quitting

 

 

Being a doctor isn’t what it used to be – the Golden Age of medicine is dead.  Yes, that’s a pessimistic statement.  And yes, I realize that this attitude makes it difficult to embrace what I used to consider my calling, but now consider my job.  In fairness to what I still consider a noble profession, my feelings about where I lay on the spectrum between “calling” and “job” change with how frustrated I am during any given week.  This week has not been good.

First, let’s get the obvious disclaimer out of the way.  I don’t expect anyone to feel sorry for physicians, with our six-figure incomes and fancy degrees.  But a fat paycheck does not always have the power to make the job suck less.  Sure, it’s a lovely consolation prize, but anyone who has ever hated her job can probably relate to a disenchanted doctor.  And, because every person reading this will need a doctor at some point, you should all care about this issue.  I don’t want or need your pity; rather, I just want you to understand why you’ve gone through three primary care doctors and maybe a couple of Endocrinologists in the last 5-10 years.

With that preamble, here are the top five reasons why your doctor is leaving medicine, going part time, moving to the “float pool” or walk-in clinic, or just plain retiring early:

1. Patients’ expectations are unrealistic.

There have been numerous comments on my prior posts from patients, eloquently explaining how their doctors and the medical system have failed them.  Believe me when I say, I hear you and I get it.  I am certainly not suggesting that people should accept shoddy, substandard care.  I  am saying: somehow, people have gotten the message that they are entitled to be thin, energetic, and happy.  News flash: that trifecta requires hard work on your part – not mine.  I can try to help stack the deck in your favor a bit by optimizing your thyroid hormone dose and counseling you about the most efficient methods of exercise, but you will need to do most of the heavy lifting.  I cannot make you eat well, meditate, see a counselor, go to the gym, get in bed at a reasonable hour, be kind to your spouse and kids, handle stress better, or be introspective.

Unfortunately, our attention-deficient, supermarket-rag-headline-reading culture has cultivated totally unrealistic expectations when it comes to health.  According to headlines, if you haven’t found THE answer to what ails you, it’s because your doctor is an idiot; undereducated when it comes to the newest, natural, cure-all remedies out there; or my favorite – doesn’t want you to know the secrets that will lead you to better health.  I spent 9-10 years of my life in training programs so that I could learn the path to good health…and then keep it to myself?  I’ve heard of the long con before, but this is just Machiavellian.  What could my motivation possibly be?  Not to mention – the alternative medicine community can’t have it both ways – I’m either ignorant or I’m the Yoda of medicine, dispensing secrets in tiny aliquots to those most deserving of my knowledge.  Pick one.

I’ve said this before, but it bears repeating: patients spend an extraordinary amount of time, energy, and money searching for the smoking gun that will explain all of their problems.  Then, they want the magic bullet that will fix it all.  Most chronic problems (weight gain, fatigue, depression, etc) will not have a single cause with a simple solution.  These problems can only be adequately addressed by doing a deep dive into diet, exercise, sleep, stress, relationships, and your own psyche.

But that sounds hard!

Darn right!  Derek Sivers said it best: “If [more] information was the answer, we’d all be billionaires with perfect abs.”  It’s not about running umpteen additional blood tests or ingesting more of the latest wonder-herbs from the depths of the Amazon rainforest.  We already have enough information to become healthy.  The problem is that it takes hard work – on your part.  And most of you, sadly, are not willing to put in that work.  You want someone to “figure you out” first, so then you can feel better.  I would proffer an alternative: if you’ve spent months or years receiving no answers, perhaps it’s time to do the deep dive and figure out how much better you can make yourself.

When you refuse to take personal responsibility for your health and simply deposit yourself in my office (or your PCP’s office) demanding to be fixed, that makes me tired.  When enough of you do that, day after day, it burns me out.  One of these days, I’m going to just stop going to work,  Office Space-style.  My group may fire me, which my haters will view with delight and vindication, but it’s going to feel sooooo good.

2. Patients value their research more than my opinion.

There is no quicker way to make your doctor question her raison d’être than to explain why her years of training and experience don’t measure up to your google search.  Don’t misinterpret me.  I have no problem with patients who are armed with questions based on their research.  But, when you are convinced of your diagnosis, tell me what tests to order, and demand a certain treatment course, I have a big problem with that.

Part of the problem with medicine in the U.S. is our incorporation of “shared decision making.”  Like many other modern buzz-phrases (e.g. patient safety, quality improvement), it sounds great on the surface.  I mean, who thinks that we should revert to the paternalistic doctoring of the 1950s?  Nobody, right?  It’s essential to involve patients in the decision-making process.  They’ll better understand what’s happening with their bodies, and they’ll be more invested in the plan if they helped create it.

In typical, American, more-must-be-better fashion, many patients have taken advantage of doctors’ good faith efforts to involve them in the decision-making process.  They arrive at the office with “research” from blogs and forums that promote quackery.  On the rare occasion they bring an actual scientific paper, it – more often than not – doesn’t actually apply to their particular situation.  This wouldn’t be such a problem if they were willing to listen to why their conclusions are incorrect.

Unfortunately, people nowadays become invested in their “diagnosis” before said diagnosis has even been made by a physician.  And they hate being told that they’ve been reading rubbish.  They react as if I am calling them stupid.  Honestly, I don’t expect laypeople to be able to distinguish between good and bad information.  I’m happy to educate them.  But in order for me to educate them, they have to listen to me.  No listen, no education.  No education, unhappy patient.  Unhappy patient, unhappy doctor.  Unhappy doctor, stop going to work.

For a wonderfully insightful and humorous exploration into why patients trust the internet more than their doctors, read this.

3. Doctors are professionals, making decisions of tremendous magnitude every day, yet we are treated like revenue-generating widgets by our employers.

When I first started working for my multispecialty group, it was awesome.  The support departments made it clear that their reason for existing was to – wait for it – support me.  If I noticed a process that needed to be improved or an inequity that needed to be rectified, I could walk into the Chief Medical Officer’s office and get the ball rolling.  I felt appreciated by my colleagues and valued by senior leadership.

Cut to the present.  Our organization has ballooned in size, so the amount of red tape involved to get anything done could strangle a boa constrictor.  We have several “support” departments that make Dilbert’s nemesis Mordac The Preventer look like a beacon of positive energy.  I have issued an edict that, under no circumstances, should anyone in my department engage these support departments without running it by me first.  Despite the fact that these teams consist of smart, capable people, their first question is always, “how can I exert my authority in this situation?” instead of “how can I help this doctor, who generates the revenue that pays my salary, do her job?”

Years ago, our group was always profitable.  Now, not so much.  A discussion of the economics of healthcare is outside the scope of this piece; but, it will suffice to say that when expenses are increasing and reimbursements from insurance companies are flat to declining, that’s bad.  So, of course we need to focus on money more now than in the past.  However, our leadership has adopted a strategy of relentless focus on the budget, to the point of being penny-wise and pound-foolish.  Our clinical departments are critically under-resourced, which has caused morale to tank even further.

If that’s not bad enough, where once I was appreciated and valued, now all I hear is “how are you going to increase visits/revenue/number of hours worked?”  As bad as it is for subspecialists like me, everything is always an order of magnitude worse in primary care.  The attrition rate among Internal Medicine physicians in my group is approaching that of Navy SEALs during Hell Week.  Some are leaving to become “floaters,” filling in for other doctors on leave or vacation; this does not come with as many crushing responsibilities.  Some are joining the Urgent Care department, where they do not have any long-term responsibilities for patient care.  Others are simply leaving our medical group entirely.

I can’t blame these poor bastards in primary care – they’re getting hammered harder than any other department.  We all know that doctors in the U.S. don’t get paid as much to use their brains as they do when they use their hands.  Unfortunately, Internal Medicine is a cognitive specialty, in which very few procedures are done.  At least in Endocrinology, a primarily cognitive discipline, we do thyroid biopsies, which generate a decent amount of revenue for the group.  The poor Internists are expected to handle mountains of paperwork; see complex patients with many active problems in 15 minutes and complete the documentation of the visit within that time; and work an electronic medical record in-basket that operates like a bottomless basket of fries at Red Robin, with telephone encounters, refills, lab results, imaging results, prior authorizations, notes from subspecialists, and patient emails.  If that’s not enough, primary care doctors are also expected to help the organization achieve Medicare 5-star quality, a quasi-mythical state of nirvana in which a boatload of cash should flow from the government to our group (though the PCPs will probably never see any of this money).  Internists do all this, only to be given the message by senior leadership that they’re failing, as defined by lack of profitability.  Is it any wonder they’re completely demoralized and want to stop going to work?

4. We spend more time charting and billing than we do talking to our patients.

Electronic medical records are amazing.  I can access and quickly view years of lab results in table format.  I can view thyroid ultrasounds and CT scans right there on the computer screen, comparing this year’s study with last year’s.  I can read my colleagues’ notes and know exactly what’s happen – oh wait, no I can’t.  Sure, I can read their notes.  But good luck to me figuring out what the heck has been going on with the patient in front of me.

There was a time when the medical record was a way for doctors to communicate with each other, as well as a way for us to communicate with ourselves, so we could easily review a patient’s clinical course at future visits.  Now, the medical record is a billing document, a Double Stuf Oreo bursting with extraneous information that has little purpose other than to justify a certain level E&M code (how much we bill the insurance company).  It takes so much time to create this useless note that there is little left to actually create a proper “assessment and plan” section – the only section that other physicians taking care of the patient want to read.

It has gotten to the point where primary care and urgent care “assessments” are just an imported list of ICD-10  codes (e.g. hypertension, fatigue, abdominal pain) with little to no description of what the physician actually thinks about what’s happening.  The “plan” is simply an imported list of the orders generated during that visit (e.g. basic metabolic panel, complete blood count, TSH, consult Endocrinology), leaving me to infer what the physician was thinking.  Honestly, I barely read my colleagues’ notes anymore.

One of the most distressing downstream effects of the time wasted charting is that it steals our attention away from the patient in front of us.  If a PCP can’t get a sense of what’s going on with the patient within about 7-8 minutes, chances are the patient is going to leave without answers.  But don’t worry, my Coding and Compliance colleagues, the nonspecific symptoms will all be neatly imported as ICD-10 codes, and the therapeutic labs that were ordered will be imported into the plan.

Because I am a consultant whose opinion is sought by PCPs, I refuse to send a note back to them that is just a list of ICD-10 codes.  So, in addition to the hundred-plus clicks I need to execute per note, I also dictate a very detailed assessment for most patients.  This means that sometimes I need to cut the visit a bit shorter than I would like, so that I can create a meaningful addition to the medical record.  So, I am improving the quality of care through stellar documentation, but one could argue that I decrease the quality of care by spending less time with the patient.  As much as you’ve heard me complain about patients who drive me crazy, I actually like talking to the majority of my patients.  Even when I don’t enjoy it, I still need sufficient time with them to figure out what’s going on.  There are days when I feel incredibly resentful that I am staring at my computer screen instead of speaking with my patient.   Some days, I see several complicated patients consecutively, which means I can’t get my note done within the time allotted for the visit, which means more stress, more frustration, more resentment, and a burning desire to do this.

5. We spend a ridiculous amount of time trying to justify our prescriptions and imaging tests to insurance companies.

This problem has risen to soul-crushing levels over the last few years.  Insurance companies have no incentive to make it easy for physicians to order increasingly expensive medications and imaging tests.  As a result, they have been “kicking back” almost everything we order that isn’t dirt cheap.  We then need to complete a “prior authorization,” which our staff can help with – to some extent.  Inevitably, the PA will come across my desk for one or two additional pieces of information, plus my signature and a date.

This state of affairs means that I am dealing with many patients twice – once when I see them in the office and then again when my orders are rejected and I need to submit a PA or come up with a new plan.  If I could open up the time-space continuum to accomplish this additional work, it might not be as bad.  Sadly, I am not Hiro Nakamura from Heroes, so it’s pretty bad.

Prior authorizations are one of the most irritating examples of non-value-added work that I have to do on a daily basis.  While I understand that the costs of medical care have spiraled out of control, the current system for managing these costs has placed an unsustainable burden on physicians.  Not to mention that it’s infuriating to be forced to justify why “covered” therapies are inappropriate for a patient.  If I thought that a less expensive therapy was appropriate, I would have prescribed it in the first place.

Conclusion

I am a highly-educated, highly-intelligent physician who knows more about Endocrinology than 99.99% of people on the planet.  Yet my day is filled with patients doubting my advice and motivations, support departments thwarting my efforts to run my practice efficiently, senior leadership questioning my work ethic because my brain is not as valuable as a surgeon’s hands, insurance companies doubling my work load, and a computer that hates me.

There has been a movement afoot by some in Administration to right the financial ship by having us work Saturdays, too.  All under the guise of, “that’s what our patients want,” of course.  Well, I’m pretty sure that if you give my patients the choice between me coming to work versus me not coming to work, ever again, I know what they’ll choose.  If you keep pushing me, my next move is out the door with my middle finger raised as I exit.

 

Are you a physician who fantasizes about quitting?  What burns your muffin the most?  Are you a patient with some insight into numbers 1 and 2, above?  Comment below!

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97 Replies to “Top 5 Reasons Why Your Doctor is Quitting”

  1. From the perspective of the patient, numbers 3, 4, and 5 are a large part of the reason why you’re seeing more of numbers 1 and 2 (2 moreso than 1.) Patients know they are getting the short end of the stick when it comes to their doctor’s time and attention so they’re venturing out on their own more to find answers, and the Internet gives them the “tools” to do it. The reality we’re all dealing with is that the quality of health care in this country is declining relative to what we’re paying for it, and patients and doctors are frustrated with a system that keeps getting worse for everyone.

    1. Reading this article (well-written, thoughtful, on-target, incisive) makes me want to call in sick for a few weeks. Since I get no sick time, and I’m ridiculously broke, I guess I’ll go in. Ugh. Good luck to all who feel the pain, fight the fight, and keep getting back up again and again to do it all over. I salute you!

      1. Thanks for chiming in, Michele. I realize this isn’t the main point of your comment, but to address your point about being broke, if you haven’t checked out White Coat Investor, you should. The ER doc who runs this site has dedicated a huge chunk of his time to helping physicians and other high-income professionals improve their finances.

    2. Unfortunately that money you pay into the system isn’t making it to the people you are trying to get help from. It pays the salaries of insurance executives, hospital executives, shareholders, etc. we need to go back to the old way where patients paid doctors directly for routine care and insurance was for catastrophes and surgery.

      1. I actually agree that moving towards direct pay would improve our lot significantly. Of course, we’d still be filling out prior auths for meds and imaging…

      2. As a nurse I agree with the “where the money is going” comment. However, as a patient with primary immunodeficiency, I believe the solution is not to omit insurance for noncatestrophic issues and reinstitute direct payment to physicians. After all- you would make more money, but I would be catastrophically poor and homeless. I receive very expensive IVIg infusions monthly and frequently have to be seen by my immunologist and primary care physician (all of which cost more than both my husband and I make per month). Concerning insurance- while it admittedly causes an ungodly amount of work on the part of the physician, unless wealthy, most of America wouldn’t be able to afford healthcare. I’m not talking about the low paid working class of America. I’m talking about nearly everyone who had even a decent paying job. The problem with insurance is stated within your comment. Overpaid executives are breaking the balance in hard work versus fair pay. They are bankrupting you and the country as a whole. The cost of insurance combined with ridiculously paid hospital/corporate executives are stealing pay from doctors and other healthcare workers. They are grossly overpaid while further damaging a broken system. They force YOU to send patients home before they’re ready (and yes, the nurses feel sorry for you when they see it), and that just results in readmissions and increased morbidity/mortality. They force YOU to spend hours trying to navigate each hospital’s individual poorly structured documentation systems (though we know they are the most inexpensive systems hospital execs voted on) so that you’re frustrated, distracted, and pressed for the time of which you already have a deficit. So who suffers? No, the answer here is not the cliche “the patient”. EVERYONE who isn’t an exec suffers. Patient, doctor, nurse.
        As for direct pay- well there’s one big problem with this in my opinion. Ethical behavior. Most doctors would likely charge good, but not unreasonable prices for care. However, we all know that one doctor here or there who would drain the last dime out of a broke saint. Set pricing is a good idea, to an extent. There is no such thing as reasonable pricing right now. Pricing isn’t physician targeted. It’s greedy wealthy executive targeted. So until we change he common denominator in this country, our phenomenally skilled physicians with good hearts and intentions will continue to fail. It’s so very sad. Don’t forget the government’s part in all of this. There’s is an equally sad parallel in nursing. this. (HCAHPS- the reason NURSES are quitting nursing!). Nurses are forced to work understaffed for far too long and far too frequently, then are beaten down by hospital administrations for the low HCAHPS scores (gee I wonder why they’re low). If we are going to incorporate HCAHPS into the solution for all these problems, they could increase most of the scores by focusing on
        1. nurse retention with adequate staffing and giving us the tools we need
        2. by shaving less cash off the top- thereby allowing more bedside time for both nurse and physician
        3. by internally hiring adequately compensated and competent housekeepers
        Etc. etc. etc.
        Or the wisest solution is to just get rid of HCAHPS altogether- which was established to set us all up for failure so the government can keep their unearned cut. Unfortunately though, as the old adage goes- you can’t beat city hall. The governemnt won’t likely deconstruct a system that largely benefits them alone. (Patients can believe it benefits them, but as we know- like the internet searches, they are fed that line for a reason that had nothing to do with their own benefit.)
        It’s time to restructure payment tiers in the hierarchy of hospital organizations, insurance companies, pharmaceutical companies, and eliminate shareholders who have nothing to do with bedside care determine pricing and profit.

        All of this is why I now work in outpatient centers only (even though patient satisfaction scores are coming to outpatients centers, I am fortunate to work in one physician-owned outpatient procedure center with amazing doctors and one small employee family-centered surgery center, both of which have excellent patient satisfaction records since we actually have control over what we do and how we do it.) Hospital work was killing me physically, mentally, and emotionally, and tearing the fabric of my family. I know it has the same effect on physicians too.

        I’m sorry for the good old doctors. I’m hopeful that someday you get your lives back, so you can use the gift you’re given to grant others more quality of life in the manner you should be allowed. Thank you for toughing it out.

  2. The administrative load that insurance companies place on medical offices is unbelievable.

    I worked briefly as a pharmacy technician for one of the large mail-order pharmacy conglomerates. I was brought in as one of a large group of temp workers around the new year, to “help” patients adjust to new formulary changes, given a few days’ training (none of which regarded medication itself; just our internal systems and phone manners), and set to work calling patients to either 1. Ask them if they would like to change to a “lower-cost formulary alternative” or 2. Call them to tell them they HAD to switch to a “lower cost formulary alternative.” I was later promoted up to a department that communicated with doctors offices (mostly via fax) to process prior authorizations.

    The entire time, it boggled my mind that any of this was allowed to go on. The few times I spoke with doctors, they always yelled, and I began to understand why. Prior authorizations got lost constantly; the lowest tiers of the call center didn’t even know how to access them. Patients who had completed the “step therapy” of using a list of lower-cost alternatives before getting a prescription for the expensive non-preferred drug often found themselves getting the calls anyway due to improper coding. It was a solid disaster for patient care, but we literally couldn’t keep up with all the insurance companies who wanted to move over to using us.

      1. Don’t worry, my karmic debt came due– my thyroid medication required a prior auth., and my insurance provider used the same pharmacy benefits manager I used to work for.

  3. Very well written view into your world. I don’t have answers but want you to know that I would greatly appreciate you as a doctor if I needed to see you.

    The pressures of revenue and profits are ubiquitous, of course. It’s driving everyone crazy. But that’s no excuse for patients, clients, … people, to be rude, refuse to accept their own responsibilities (for health, wellbeing) and yet we all see this as drivers run red lights to shave a few seconds off their trips.

    I hope your writing your piece helped you. I think you should post it as an opinion article in The NY Times.

    1. You flatter! It would be awesome to be published in the NYT, but I’m sure I’d have to edit both the content and the length to ever get in there. And I’m much too overly verbose for that.

    2. I agree– HD needs a wider platform! This blog has been so badly needed for so long to counter the massive amounts of online disinformation. I would love to see it get some publicity.

  4. i’m sig older than you, i suspect, and have a dinosaur practice – an office of my own, another psychiatrist, an aprn nurse, a social worker, two secretaries, some billing people. i started using a laptop for my patient notes in 1992, shortly after i switched from a mixed therapy/meds practice to straight psychopharmacology.

    i tutor med students who come to my office 1/2 day/wk to see patients with me. twice now, each time after a new intake visit, i’ve had students ask me what emr i was using. i chuckle and say i use text files.

    ohh, they answer, because you never could have done it as fast/efficiently if you used [the hospital system] epic. epic is, as you say, designed to generate as high an e&m code as possible. i find epic files which are sent to me virtually incomprehensible, because the clinical data is scattered and without continuity. i’ve heard of people working on a software program which will ride on top of epic and reassemble a usable medical record, but to my knowledge is doesn’t yet exist.

    no student plans to work in a practice like mine, except perhaps e.g. for a proto-dermatologist or plastic surgeon who expects self-pay patients. [i accept almost all insurances, btw.] they all plan to work in big medical systems like yours, perhaps with the addition of research [and grant-writing] as well. because they are being trained in the current reality, they know nothing different, and accept it.

    the advantage that they will have is that they can clock-out. turn things over to a hospitalist when required. have a minimal if any call requirement. that’s the deal.

    it used to be that the bane of my life were utilization managers. that is no longer the case. i don’t know if they’ve just given up on managing outpatient psychopharm in general, or have decided that i’m not an overutilizer. now the bane of my life are the pharmacy benefits managers.

    otoh, i know that if i were king of medical care, charged with delivering efficient as well as effective care, i’d have to set up some kind of pharmacy benefits management system. [even if i were also allowed to negotiate – hard – with pharma.] it’s a dilemma built into the large scale, and large dollars, of medical care delivery.

    i’ve got no answers, except to suggest that you go part time if you can afford it. dose matters.

    the only things that would allow you truly to escape most of what you describe would be to become an expert in something esoteric and confine your work to that, or to relocate to an underserved area and be the only game in town [for the insurers and pharmacy people; i’m not thinking about the patients here].

    1. Thanks for the perspective and commiseration. Clearly there are no easy or obvious answers, though I agree with you about dose. I have less clinical time now than I did years ago and that has helped.

    2. The downside to part time primary care is that income drops because you don’t see as many patients but all the non revenue generating work stays the same. Very frustrating.

      1. Ain’t that the truth. I know many PCPs and medical subspecialists who have this problem. They cut their clinical hours, just to be able to keep up with the volume of paperwork/charting/etc.

  5. Amen my friend. Amen. You summed it up perfectly how most people want us to fix them, find the one thing to make them happier/stronger/thinner/more energetic. And when we cannot, it’s our problem, not theirs. I wish this was an oversimplification, but too often it is not. It’s no surprise that the quick fix health business is a multi-billion dollar business. It is sooooo attractive to find the one thing to help us. The problem is that those things aren’t actually making us healthier. Thank you for stating it so clearly, and with the awesome links to Office Space and Dilbert. Just promise that if you do quit your job, you have to keep writing!!!

  6. I’m not sure if I can ever quit my job, as it is the ultimate renewable resource of material that fires me up enough to vomit my thoughts all over these pages. You’re welcome for that imagery.

    It’s quite the paradox, when you think about it. I sometimes hate my job so much that all I want to do is quit, but I also really enjoy crafting these posts that riff on what I deal with every day.

    If I do quit, I’m sure I’ll find something else that gets under my skin enough to write about it. My glass-half-empty-and-leaking personality all but ensures it.

    1. That is a little bit of the issue probably. What you see in other people is always something you have in yourself. So maybe you are being too narrow minded and expecting happiness from just your job and just being highly intelligent and specialized when maybe you have to look elsewhere too for happiness (friends, family, community, hobbies).

  7. As an anesthesiologist, I’m mostly shielded from 1,2, and 5, which is not an accident. As a medical student, I recognized I did not enjoy working in a clinic for the reasons you mention (and perhaps a few others).

    Numbers 3 and 4 ring true, but my main motivation for quitting at this point is simply the fact that I can. Ten years of earning, saving, and investing put me in a work-optional position. I’m now in my twelfth year out of residency, and will be working part-time beginning this fall as a beginning of a one-to-two year transition out of clinical medicine.

    Best,
    -PoF

    1. Actually, PoF, I had been thinking about adding a sixth reason for quitting, “Because (s)he can,” as a nod to the FIRE (financial independence, retire early) crowd. Thanks for chiming in.

  8. My favorite recent story of unrealistic patient expectations:

    When I review a patient’s labs, if everything is normal I send a letter with the results and an explanation of the results. If they are abnormal, I usually have the patient come in to discuss the results or I call them if it’s something simple (like an increase in cholesterol meds).

    So I recently saw a patient, did some labs, and everything was normal. She called the office when she got the letter and wanted to talk to me. My MA took the call and asked what the problem was. She wanted to discuss her labs with me. My MA reiterated that all the tests were normal, and did she have a specific question?

    Why yes, she did have a question, “Why didn’t the doctor call me personally to tell me everything was normal.” My MA explained that when there is nothing to discuss, I send a letter, as there is really no need for a phone call. So the patient goes, “Well, she could at least have called me to say ‘congratulations’ on my good lab work!”

    So, not only am I supposed to do all this other bullshit, I’m supposed to call people to congratulate them on normal lab work??? I review around 100 different labs results a day. If I called each of those people, even to just say, “Congrats!!!” I’d never get anything else done.

    And what kind of world do we live in where your good fortune to have normal cholesterol requires asspats and hugs???

    1. Hahaha! I’m no doctor, far from it, but this cracks me up. I don’t blame your feelings one little bit. At the same time speaking as a layperson I want to apologize for all of us for your patient’s behavior. We’re not all like this, at least I’m not. I’m perfectly okay with not hearing from my doctor!

      1. I have my MA explain that it is impossible for me to call all 100 PTs for that week to personally go over their results and it would be unfair to call some but not all but if the patient would like to make an apt to go over results that we would be happy to oblige.

  9. Love this post! I’m also an anesthesiologist for the reasons mentioned by my colleague above. Am in Canada though, so it’s not quite as awful as the only hellish insurance Co we really have to deal with is OHIP, which has unilaterally cut the fees of docs in Ontario from ~6.9-30%ish in the last couple years. They continue to defame us in the media as rich jerks who care more about money than patients though, and then started giving nurses and pharmacists the power to do some of the things that docs do (but at higher cost). So it’s not exactly peachy keen up here either…
    Thanks for writing this!

    1. Thanks, Kate. Up to 30% fee cuts for the evil, money-hungry Canadian physicians?! And I thought Canada was America’s kinder, gentler, more sensible neighbor.

  10. Oh, thank you for summing it all up so well. The only thing to add is often we only don’t leave (in my case for sure) because the debt from med school is so astronomical that we’re trapped. Trapped doctor is unhappy doctor.

  11. Beautifully written….ER PA here 32 years…..the ONLY time I ever hear from ADMIN….is after a hellish 3 or 4 12 hour shifts in a row…..when after running as fast as I can to see everyone in the alloted door to doc time….and door to discharge time….I have charts pending…..if not completed in 24 hrs….the nastiness reaches epic proportions….add to this of course drug seekers…..no security guard….nasty consultants….unrealistic patient expectations……..incessant typing at the keyboard…..no per diem help to facilicitate time off….the current medical director actually sent the group an email threatening to cancel all vacation time unless all shifts were covered by us….and you have the perfect burnout recipe…..CME time and reimbursement for same was taken away…..and ironically.,…most of can only afford the company health plan with a $4500 deductible…..I love taking care of patients…..but Im out soon….before it kills me

  12. As a Canadian General surgeon who retired 7 months ago at age 59, I can agree with all of your points. (Enthusiastically and sadly). Thanks for expressing what I felt for the past several years.

    My debt load from school was small because of scholarships and my lifestyle is modest so my financial requirements are modest, which allowed me to bail out early. I never know what to say to the keen young students who are trying to get into medical school …. Medicine is never boring, but frequently frustrating… Is my usual line.

  13. I’d be classified as a patient, although not one of yours and I want to say you’re so right! We have so much information at our fingertips to be healthy. At 57 I feel like I’m 25, maybe 35. Everything’s normal at the yearly checkups and so thanks to hard work and attention and my Dr.s’ encouragement, I’m kicking ass on the health game. So far I’ve run 398 miles this year, not sure how far on the swimming and I’ve ridden my bike too. With a diet based on the Mediterranean diet,and kefir as well as vitamins and good skin care I feel fantastic. I doubt my Dr. gets nearly as much joy out of it as I do, because I hardly see him. But I really like him and his wife, who’s also my Dr. and I hope my unsurance company isn’t as bad as you described but I bet they are. Hang in there, we do appreciate you!!!

  14. Semi-retired OB/GYN here.
    1. Patient unrealistic expectations. One of the reasons I quit OB was that I got tired of the 8 page birth plans where the patient was telling me what she did and did not want including the type of IV fluid. I Would take a pen and mark through what was unacceptable and unsafe. If a patient left my practice ok.
    2. Patient research is a problem with OB patients and you guessed it patients who gain weight and believe it must be hormonal.
    3. and 4. Not much of a problem for me because I own my practice and do not have an EMR. I dictate notes into my apple laptop and put them in a paper chart. Old school but it works for me.
    5. I have to justify CTs and MRIs and some meds but this is pretty minor for me.

    I recognize my practice days are limited but I constantly have patients tell me how much they like a small personal practice so I keep working just a little.

      1. Nope. I saw many a patient come in with page after page of “birth plan” printed out….and wanted me to sign to “agree” to her “plan”.

        Hatton 1 is serious.

  15. You have summed it up perfectly. I practiced OB until the patient expectations were completely unrealistic (as well as the overt discrimination against male physicians…) retrained into anesthesia…and now I am “selectively employed”.

    I do contract work, short bits at a time, and then pursue an unrelated field part-time.

    The bureaucracy, the inane medical record called “EHR”, and the malpractice threats have taken the joy out of practicing medicine. I am lucky I got to experience a few years of “the golden years”…where patients were happy, and appreciative, and I could hand write a one page note that would allow me to put the pertinent facts, the thought process, and the plan on paper.

    (now…”does the patient have refrigeration in the home? Are there guns in the house? Are there spiritual concerns?” Sure, those points can be pertinent. But the bleeding probably has a higher priority…..)

    Thanks for putting pen to paper….(oh, wait…”thoughts to keyboard”).

  16. What many patients, admin, politicians, etc. don’t realize, and understandably so, is that medicine and biology is not a perfect or exact science. I think most times human expect a certain result for a given input, most problems in our lives have pretty well-defined solutions, but medicine is not one of them, imo. Docs can try to explain it as much as possible despite how boring or routine it may be, but I don’t think many people will understand it unless they actually saw what doctors see. I don’t think there’s anyway around this, fortunately those patients who give doctors issues because of this are in the minority. Likewise, difficult patients in general, like difficult people, are still in the minority as well. The best we can do is learn how to deal with them or just avoid them somehow.
    I feel like #3-#5 are practice/specialty related issues. Take a solo doc who is cash only and likely those problems are minimized. I know of a few older docs who seem pretty low stress and are likely to practice into old age (at least part-time) because they enjoy it. Generally, it seems they are solo or small group and are their own bosses, FI or don’t particularly need every dollar, they take either cash or insurance, but with insurance they have figured it out so they don’t have to battle insurance as much and/or they’re willing to forego some reimbursement in exchange for less headaches.

    1. You nailed it with respect to “medicine…is not a perfect or exact science.” This is tough for laypeople to wrap their minds around, which is understandable, but no less frustrating for us when we can’t successfully educate them.

      I’m becoming more intrigued by the idea of a small, cash-only practice. I recently saw a thread about this on another site, and it sounds like there are others in my specialty making this work, with much less headache (and lower reimbursement, but they seem quite happy). Then again, the grass usually isn’t greener on the other side – it’s just a different shade of brown.

  17. I am an internist and you summed up my feelings/situation so perfectly! I’m saving this post and will be forwarding it to everyone willing to commiserate with me.
    One of my friends/partners is an endocrinologist and has your entertaining, tell it like it is personality. The 2 of you should meet up a society conference someday! 🙂
    Lastly, a thank you to PoF for recommending this post on his Sunday blog.

  18. Good piece for reading – I recently left practice as an employed obgyn for yes the dark side insurance. It has been quite the transition and I have learned in myself that I need the patient interaction and care. If I stay in this nonclinical job, I will have to move into a different role than medical reviewer to feel that I am making a difference. I’m trying to get back to clinical practice but I really wish doctors would take back control of medicine. We understand what it takes, the pressures and stress, the patient relationship but it is all made a mess with hospital corporations, and administrators, medical insurances and all the things you address. Good luck to the doctors… can we take back medicine or did we never have control of it?

    1. I do wonder if there will be a grander movement by doctors to “take back medicine,” in response to all the consolidation/bureaucracy. What that might look like, I’m not sure, but I’d love to be a part of it.

      1. I’m with you! Lets start a movement. I would love the protections that tradespeople have…a lunch? I mean not while having a meeting! No sleep deprivation…oh you have to be off so many hours if you drive a truck or fly a plane, but id you just make life and death decisions or cut oeoole open….no regulations. Of course those with the egos that live for their superiority will smear us as weaklings… maybe we shoyld have a duckling as the mascot ..

  19. What we need is a code for billing insurance companies for the time that we physicians have to spend hassling with insurance companies over our choices. They should have to pay for that just like they pay for other activities related to patient care. Maybe that would be the end of the two-hour lunchtime phone calls with United about why they won’t let me Rx 1/4 Valium instead of 1/2 Valium so that my patient can wean more easily. Maybe we can bill that under the “consulting with other professionals” code?

    1. I didn’t know there was a “consulting with other professionals” code. But I certainly wish we could bill for all the time we spend on patient care issues, not just the face-to-face time with the patient. I suspect there are direct-pay (cash only) doctors out there who have figured out how to do e-visits, bill for paperwork and phone calls, etc. I would think that, if you don’t take insurance, and you set the expectation up front that you bill like a lawyer, you could see fewer patients, spend longer amounts of time with them, then bill for the time spent reviewing lab results and doing prior authorizations for prescriptions and imaging tests. I have no experience with this model of care, but would love to hear more from anyone who has taken control of their practice in this manner.

  20. As a practicing outpatient internist I feel this post and I am so glad I found your site, following from now on. What I am seeing now is this dangling carrot of lumped payments and population management and administrators promising this will take back the profession. Notes will not need to be billing documents anymore because we will not be fee for service. The intellectual titration of insulin via patient portals or phone is reimbursed because that is wrapped into the lumped payment. So, sounds great except I’m sure the lumped payment will not be adequate and the patient expectation to never have to come into the office again for evaluation will increase and I worry about the litigation potential for so much management outside the office and a missed diagnosis because you could not see the full picture. Is any of this talk going around your administrative meetings?

    1. Have we been sitting in the same meetings, Erin? You have articulated my situation precisely. In my group, we are chasing the same carrots: reimbursement for value-based care, enrolling more patients in Medicare Advantage, etc. The concept of taking care of a population of patients for a lump sum – then pocketing the difference between payments and expenditures – has been tried in the past (see 1980’s capitation) and failed. I have not yet heard a coherent explanation of how the “new” system will be any different from the “old” system, so I am skeptical.

      With the 20+ different types of insurance plans we accept, how am I to quickly know if the patient in front of me is on a capitated (wait, am I supposed to use the new term, “risk-sharing?”) plan? If I can figure it out, am I supposed to devise a different workup and treatment plan than I would if she was non-capitated? Does that feel icky to anyone else?

      To another of your points, how are we going to get reimbursed adequately for all the phone/e-mail work we do? Will we have time blocked off to do this work or – more likely – will this work simply be shifted to the end of the day, after we’re done seeing patients (as it is now, which is unsustainable)? I don’t see how my group will be able to afford allocating appropriate amounts of time to this non-face-to-face work, at least while 90% of our business is still fee-for-service. We have to keep the lights on, which means we need to crank through as many visits as we can. No way will e-visits and phone visits ever generate the kind of revenue a 99214 office visit does.

      Is this the kind of talk I hear in my admin meetings? Not exactly. Our senior leadership is focusing on how to motivate us to generate more revenue, all the time. I guess I understand why they don’t perseverate on these issues with lower level leaders, as pointing out all the reasons why our current model is failing and why the proposed solution will also fail probably doesn’t get us any closer to keeping the lights on. It’s not that our leaders don’t recognize these things. But I think they’ve grappled with the issues and this is the best they could come up with, so now it’s full steam ahead. It’s hard to feel like we’re heading in the right direction, though, when the primary solution to our money woes is to flog the physicians to work harder.

  21. Perhaps we (physicians) are partly at fault because we have LET the healthcare system kidnap us. There are several things that we should do more of, but don’t. They are:
    1. We should work together as PHYSICIANS to fight the medical-corporate complex and the often stupid hoops it makes us jump through. We are all in this together.
    2. We should stop fighting with each other…like rats looking for the scraps that are thrown to us.
    3. Individually, we need to work on our lives, and place our lives and our families first…over our practice. We cannot be fulfilled from work alone and that focus will destroy your life.
    4. We need to work on the foundation of relationships, health (both physical and mental), financial health and positive supportive career choices to make our lives better.

    1. To points 1 and 2, yes, physicians should work together. Sadly, we are too busy furiously treading water after the boat capsized, with our jeans and hiking boots still on, just trying to keep our heads above water. Our physician administrators, who supposedly represent our interests, lose perspective very quickly once they stop practicing to become administrators. There should be a universal requirement that any physician administrator reserve at least 30-50% of their FTE for clinical practice. That would help, at least a bit. They need to have some skin in the game if they’re going to be telling us we need to add hours, shorten visit times, and smile while we do it.

      To points 3 and 4, amen. Diet, exercise, sleep, relationships, and meditation (whatever form that takes for you) come before the practice. This will make us better doctors, or at least more equipped to deal with all the crap. And the final point: don’t grow into that physician income. Save your money and invest wisely, so that you will have options as time goes on.

  22. LISTEN to your patients. In over 5 decades I’ve had maybe 1 out 10 doctors listen to me. When they did I got better and when they did not I got sicker. Nowadays our health dollars (If you have them!) don’t go very far so excuse us for trying to figure out stuff on our own.

    Look at the WHOLE person. Blood tests for vitamin and enzyme deficiencies should be done. Don’t roll your eyes the minute someone says rodiola helped her hot flashes or coq10 helped her gums. Open your mind to other healing modalities.

    ADVOCATE for us. We can’t afford you anymore. Healthy people don’t show up anymore because it costs them. If you don’t like the way things are then help change them.

    1. I agree with you, Megan, that doctors should be listening to their patients. It’s a two-way street, though. If I listen to you and then counsel you based on what you’ve told me and my assessment of your situation, you’ve got to really hear me. If I understand what you’re asking, but then explain why there is no “enzyme deficiency” test that is relevant to your situation, please don’t tell me I’m wrong because you read about it on a blog somewhere.

      Similarly, if a patient of mine takes a relatively harmless herb or supplement and thinks it helps with hot flashes or gums, great. But that anecdotal experience does not rise to the level of evidence. While I am fine with people experimenting with harmless remedies, I take issue when the remedies are not harmless, or when they are used to the exclusion of a safe treatment that is known to actually work.

  23. Loved the article!

    Myself and 2 friends are working on a way to connect Doctors like yourself and patients together. The idea is to cut out the insurance man. By linking up doctors who encourage cash payments with discounts , due to not having to deal with Insurance, and patients that want that kind of care or can’t afford to pay insurance every month.

    We started this by creating a subreddit that , with any luck, will encourage people to share info so we can make a list for people to find these kind of doctors.

    It doesn’t address all the points in your article but it helps with a bit of it….I hope.

  24. Thank you! This was so well written and spot on. I’m a FP and know I should be happy with what I do, but the BS is exhausting. We are definitely treated like peons who are there only to produce revenue.

  25. I went from working PT in a large city academic HIV clinic as an ID specialist, (which I mostly loved) to a PT IM/PCP in a suburban practice /hospital affiliated with a community IM residency program . I experienced all of the things you describe in your post to a T!! I refused to generate an emr note that was useless, so I ended up spending many many hours at home working on my notes to include a thoughtful discussion of my reasoning, differential diagnosis, even including data references to support my assessment and plan. Alas, this is how I was trained AND what I love(d) about the field of IM and related specialties!! I could not keep up AT ALL with the gadzillion phone calls, prior auths, lab issues, patient demands, and the ridiculous emr requirements/checkboxing (which changed very frequently). I became so demoralized and anxious and depressed, that I actually began passively fantasizing about suicide. That is when I quit (but still do some teaching at same program – the other aspect of medicine I love and cherish). I never know how exactly to respond when people ask me why I’m not seeing patients/working. Your post is THE answer to that question. Thankfully my husband’s salary was/is enough to allow me the financial freedom to quit. But I miss the ‘golden age’of medicine and style of practice and am currently searching for a position that allows me to be more of a ‘academic-minded doctor’ again – admittedly this will likely mean volunteer work at an underserved, free clinic type of environment- which I’m sure I would love. However, I am still holding out, hoping to find such an environment that pays a salary before committing to a volunteer position. But I seriously doubt that will happen (I guess I’m being naive!). Thank you again for the post – you can’t imagine how cathartic this was for me to read!! Hang in there and know that you are most certainly not alone!!!

    1. I’m with you! I’m trying to stay in there and remain positive. Hoping to see the light at the tunnel. I think we need to speak up as doctors and basically refuse the current structure that has been forced upon us. It is not too late.

    2. Lisa, I’m really glad this piece provided a much needed catharsis for you. When you shared that you had “passively” considered suicide at one point, I felt sad, then I wanted to reach out and give you a hug (I’m not usually a hugger), then I was angry – angry that this job could lead you (and too many of our colleagues) to such a dark place. I’m glad you chose quitting, compared to the alternative. I hope that you can find that dream job of yours, which sounds remarkably similar to my dream job. I would love the time to help residents and fellows work through tough cases, feeling like I’m contributing something useful to the fabric of society. I get that feeling with many of my patients who appreciate my help, but unfortunately there is a significant minority that sucks the life out of me.

  26. I have the countdown app on my phone. I am so looking forward to retiring. I love the patients but all of the other junk that does not improve patient care one bit is wearing me down. Peer to peer requests to justify scans for my cancer patients, needless paperwork and Prior Auths are ridiculous. Why don’t the insurance companies just tell the patients the truth – you’ll pay me big bucks but we’re more than likely not going to cover many things that are approved by the FDA. Luckily, I am single because since I have access to our EHR from my home computer, I get to finish my work there. I have taken my dictaphone home many times. The workload never ends. Fortunately for me, we own our practice so I don’t have some millionaire administrator breathing down my neck about our production or lack there of. And don’t even let me talk about how insurance companies can take back money they’ve already paid us up to 4 years after we saw the patient. The future of medicine scares me with regards to the doctor shortage. The government seems to be trying to fix this by increasing the number if seats per class in medical schools. They need to address why the current docs are leaving. There’s your shortage. Once those medical students get into the real world, they’ll be counting down their days until retirement too.

    1. Excellent point, Miriam. If society churns through new doctors like Big Law churns through fresh associates, we’ll be swimming upstream forever. Not to mention that doctors get better with experience, so we don’t want doctors burning out at precisely the time that they’re at the peak of their careers.

  27. Thank you, thank you, thank you for this honest, well written article. I bust my butt everyday at work. I love what I do, and I’m extending passionate about medicine. I became a physician because I knew this was it for me. I’m now a primary care doctor after being a hospitalist. I can tell you neither side is greener, and frankly the grass is dry and yellow on both sides. Doctors are burned out. We cannot continue on like this. It should never feel like a thankless job! But it sure does right now. I know my patients love me as I love them, but they are still somehow unhappy and expectations are truly unreaslistic as you said. Patients discuss their medical bills with me during the visit (taking up precious time from my work and other patients), as they complain about getting a $50 bill from my office. I later learn that their insurance plan paid me nothing for that visit because of a diagnosis code (smoker/tobacco cessation counseling). Does this make any sense at all? This is a sure way to make you want to quit right then and there (especially because this is no longer a rare event). Serenity now…..
    I did not spend 12 years in school and $200,000 in student loans to be dealing with this??? No wonder we now have the highest suicide rates of any profession.
    We need to be more vocal. We need reform. We need doctors to go to congress. Let’s go! Please join my group “People for pharmaceutical reform” in order to start educating people on big pharma and maybe we can do something about cost in order to help everyone involved.

  28. To all frustrated physicians:
    I am with you on all of this. I am within a few years of the end of a 40+year experience in laboratory medicine. I can confirm what all of you are saying. It’s simply not the same. It is a horribly broken system. And the “reforms” that ignorant administrators, systems, insurance companies and government representatives put in place are not in our best interest. They are there for system profits or the “purchase” of re-election votes. Make NO mistake about that.
    Yes, we should band together and look to take back medicine from the medical-corporate complex. But realistically that will take a long time..unless there is a radical movement by physicians…something that is unlikely.
    In the meantime, what we CAN do…starting right now (as some of you have already done), is to no longer put ourselves last. No, we need to put ourselves and our families FIRST. We cannot take care of patients effectively if we ourselves are physically or mentally hurting.
    I have a site (relatively new) where physicians who are looking to make this change can gather and discuss such issues. It’s where we can share thoughts and ideas with each other about how to work and LIVE while being a physician, or if so desired, support those who look to leave medicine for another career, or any area through that entire spectrum.
    It is focused on helping each of us in our relationships, our health, our financial situation and our career choices.
    I applaud this site for this wonderful post and bringing out this discussion. However, I don’t believe that this site’s focus is really on this one element. It’s more true health related. For that reason I invite all to :
    http://physicianv4.wpengine.com

    and the related Facebook group:

    https://www.facebook.com/groups/physicianV4/

    to continue and build on this discussion. The focus of that group is to foster positive support for physicians who are looking to improve their lives by taking back control.

    To the host of this site: Thank you for this wonderful post. I invite you too to the physicianV4 sites and discussions. This invite is not to steer individuals away from this site (which has valuable information), but to add a different site which is more focused on the elements of this thread. Perhaps we can provide a link back to this site from PhysicianV4 to help get individuals interested in this specific topic connected with this site. We all benefit from this knowledge and connection.

    Come and join!

    1. You’re right. A radical movement by physicians is unlikely. We’re fragmented and siloed, and there is no one body that can adequately speak for us. I applaud anyone who is fired up enough to try to improve their own situation, and more power to you if you have an idea that can help the greater physician community.

      It starts with taking care of yourself and your family, and then focusing on the job.

  29. I couldn’t agree more. I think about quitting every day. I’m a psychologist, and we face an additional set of problems that I’m too exhausted to go into.

    I worry a lot about health care in this country, to the point that I do everything I can (mostly through diet and exercise) to avoid chronic health conditions. I recommend everyone in this country do the same,to the best of their ability.

    And I work for a “non-profit…”

  30. In my opinion….the very best thing any physician can do is to become financially independent. Note…I did not say “wealthy”. Financial independence is the point at which you can live off your “passive income” (from whatever source) at a sustainable level. It took me way too long to realize this.

    Once that is reached, it is possible to use the magic word “No”. “No” to a bad contract, “no” to unrealistic demands, “no” to work hours and conditions that are unacceptable. Always polite, just simply “no”.

    When I finally realized the value, I sold stuff, downsized the lifestyle, and became much happier. I now do “agreed upon” work….the scheduler and I discuss what needs they have, and I then agree to work the days that I wish to work. The income is much less, but the happiness is much greater.

    It has also allowed me to pursue work outside medicine, which allows me to return to medicine with a fresh outlook, and a better attitude. I also work part-time in my own office, doing specialty physicals, cash only, setting my own hours.

    While a massive group uprising is appealing, I believe that it’s only when each of us politely, but firmly, set boundaries for all the entities that try to squeeze us that we will change “our world”.

  31. As an IM physician, this was the burn out that I felt two years ago after only 3 years in outpatient medicine. As soon as I could leave, after completing scholarship repayment years, I did. I am now most happy with my contractual position as a nocturnist working 10-12 days per month and some years off all summer and 1 month in the winter. I found that this is the best way for me to deal with the mounting patient satisfaction surveys, documentation demands, and impossible administration that has formed in medicine. I often times beat myself up for my thoughts on the subject because I begged, prayed, and cried a many night to get to this place of being an attending physician. But I quickly began to wonder how all other physicians were doing it, not just for 3-10, but some for 30+ years. I could not understand how they deal with this life for so long. I was afraid to even acknowledge it, let alone express it. But then I confided in a fellow colleague who shared my same sentiment and I made the change. I have never looked back and don’t regret one thing. I initially started with locums Hospitslist which gave me control of my schedule which is paramount to me. But I follow POF, WCI, Dave ramsey and therefore have a strong plan to be exited within 5-6 years. I’ll be 45.

    1. Good for you, India. You’ve carved out a sustainable schedule for yourself, with the backup plan of an early exit due to frugal living and a high savings rate. Smart, smart, smart.

  32. What a whiner. I am an MD internist in practice for 30 years and I get so tired of listening to doctors whine about how hard they have it and how their patients don’t listen blah blah blah. I do agree that insurance companies are making it tough to order tests and treatments, but otherwise these are the same complaints I heard from doctors that I talked to even before I decided to go to med school. Time to get over yourself, realize that people are like this and you have to soldier on. I love my job. I love my patients. I am not frustrated. I do not fantasize about quitting. Don’t be so snivelly. Mercy.

    1. Glad to hear you love your job. It would be great if most docs shared your enthusiasm. Based on the traffic to this most recent post and the comments, however, I suspect you’re in the minority.

  33. thank you for this- i have been a family doctor in a partnership for about 35 years- i have deep relationships with many patients but i can’t do this anymore- it is not like it once was-i am not a GP in the traditional sense anymore- i feel like i am doing tertiary care in every medical specialty- the amount of information i need to know /follow is impossible to keep up with- i have constant dread about missing something that could have made a difference in outcome because i have so much to keep track of/ to screen / to discuss/ to review in such little time with such extraordinarily difficult complex patients who come in with multiple often vague complaints and all of this has to be done in under 15 minutes- i used to come in to work wondering how i was going to help someone today- now i fear what will i do or not do that may cause harm- i see about 16-20 patients/d- have 15-20 documents/ imagings/ letters to review/ 20 patient questions/20-30 multiple lab results to review- 20-30 medication renewals each day- i leave work 2 hours after my last patient to do data entry- usually get home about 730pm- and i am exhausted- i have doing this for 35 years now and i can’t do this anymore- at this point i feel i am probably the best doctor i have ever been- i keep learning all the time from books/ online sources but especially from my dear patients- but i am running out of steam- i want to get out before i get ill- that will be the end of this year-

    1. I feel for you…big time. I hope that you meant you’re getting out of the game before the end of the year, not that you expect to be ill by the end of this year. This underscores the message of physician finance gurus like WCI, which is that we should all be pursuing financial independence, so that we have options when the going gets rough. Live below our means, pay off debt quickly, and save vigorously by investing in low-cost index funds.

    2. I have just a few words for you.
      First….it sounds like you have been an excellent doctor, resource and supporter for your patients for 35 years.

      Enough is enough.

      It’s time to put YOURSELF and your family first. It’s important to develop a health lifestyle; finances; career (including after-medicine) and relationships.

      You need to remember that YOU have the power of making a difference in your own life. It begins with YOU making a choice for something different. Other physicians are here to support you, in a way, and with knowledge that people outside of medicine simply can’t or don’t understand.

      Lean on this group…or PM me for someone to talk with. (See my other post with reference to a Facebook group (PhysicianV4) that is intended to help physicians make this important decision to put their selves and their families first.)

  34. Well stated and put into words. I’m a PA, PCP which brings its own set of problems to the table as well. Patients want all that you’ve mentioned above, but expect it all from a doctor. Many seem frustrated with me when I explain that my training is light years behind that of an endocrinologist, and I simply don’t know what to do with an elevated thyroglobulin test s/p thyroidectomy, so I’m punting. They all too often see me as a cheeseburger, and you as a bacon cheeseburger. I try to explain to them that I’m the cheeseburger, but the specialist is the filet. They don’t get it… but that could be my poor food references.

    With how we’re supposed to be a PCH or PCPCH or whatever other crazy combo of letters you’ve seen out there, patient care gets lost in the mountains of paperwork we have to file. After we get done asking about drug use/abuse, tobacco, etoh, food insecurity, rent insecurity, suicidal ideation, depression screening, and what feels like a half dozen other questionnaires…. it’s time to reschedule the patient for that sore throat they came in for. I feel like saying “sorry, we’ve used up 20 of the 15 minutes allotted to this visit on bullshit paperwork, so we’re going to have to reschedule you…ohh and I’m booked solid for the next 3 weeks. Yes even my time slots saved for acute same day things are basically booked too (with new patient visits.. don’t get me started down that rabbit hole!).”

    Patients get angry with 3 week wait times, so they go to the urgent care or ER for sore throats and sniffles and get told to follow up with their PCP, who ironically couldn’t see them in the first place, and won’t be able to get them in for follow up for a month.

    One last note on prior authorizations.. doing PAs for things like metformin, levothyroxine, and hydrochlorithiazide have to stop. These meds are first line treatments that have been around since forever and cost $4 cash at Walmart. I want to cut my own fingers off when I get PAs for these things.

    Thanks for the post! Great read this am!

    1. There are so many gold nuggets in your comment, Matt, that I feel like you could’ve written this post! Your writing screams “guest post.” Would love to hear more from your perspective.

    1. That was a good piece. I think his penultimate paragraph sums it up nicely:

      The real culprit here is the fact that physicians have lost control of their profession. We have had an overhyped, inefficient, ridiculously high-priced piece of software foisted upon us by politicians and the businesses that they support. It is really no better than personal database software that I was using in the 1990s and that software produced a more readable and coherent report. The only reason the software works at all is because there are a million physicians out there with work arounds and doing the uncompensated hard work necessary to keep it afloat.

  35. I’m a PCP. I whole heartedly agree with everything in this piece. But I do still love my job…so here’s what I do. I remind myself daily that I am one person and can only do my best. Secondly, I type my HPI amd my Plan out….took typing in high school, and it’s the best class I ever took before medschool. I do both of these while talking to my patient….which is my favorite part. I connect well and develop a loyal panel. Then I give myself 3-4 min after the visit to complete the note. This is my general approach…granted at least twice every day there is someone who needs more time, and I give it. But there are three beautiful little girls at home that need me too, and they get my after 6pm daily and weekends. Period. I will not be pushed to do more. I get it done, sometimes with early mornings, but I will decrease my schedule and revenue before I will take away from my children or my soul. I see a bright amd promising 15 years more in my future (have 13 years behind me)…and I’ve exercised this plan all along. Take note, colleagues…it’s not worth the money. Do your best within a time parameter that suits you and maintain your heart and love of the practice. The public needs us. To hell with the administration…we aren’t in it for them. They can keep their stupid bonuses if that’s the question at hand!!!

    1. You have a great, positive attitude, which should serve you well if you plan to do this for another 15 years. Well done and good luck!

  36. Great blog! I’m not a doctor, but a dentist. Yet everything seems to apply to us as well. Our support office recently has been pushing us to do longer and more complex procedures that have smaller profit margins in order to increase quarterly growth numbers. Then they start wondering why we’re not seeing as many patients! Ever run into this problem? I’d much rather keep margins high, see more patients, more moderate growth, and save my back. Now I’m counting down the days ’til I have my loan and home paid off so I can go part time. And I’m young.

    1. Oh yeah. Our variation on this is to shorten visits to see more patients. But oh, by the way, make sure you hit all your quality metrics, or you will lose your “bonus.” Of course, the bonus is really a holdback of salary, so you’re working to get back the salary that used to be yours in the first place.

  37. I think number 6 would be trying to do all of above while increasing your patient “satisfaction” scores. My group is trying to jam more patients into our schedules but we just had to attend 3 mandatory meetings, after work–at 6pm!, about increasing our pt satisfaction scores. Speaker was a non-physician, who wasted our time telling us useless garbage like, “make eye contact, listen, and to say ‘Do you have any more questions? I have the time!'”

    1. I agree that patient-satisfaction advice is more credible when it comes from a physician who has figured it out. But I do think that ending every visit (as long as there are still 5 minutes left) with “what other questions do you have for me?” is a great patient satisfier. Though I would choke on the phrase, “I have the time!” if I tried to utter it.

  38. I am a primary care physician who agrees with everything you have eloquently and humorously said. A few years back, I wanted to leave clinical medicine altogether, but I instead quit my job and switched to volunteer work (one day per week, while being a full-time mom to three kids) at a Volunteers in Medicine clinic. I know not all free clinics are like ours, but as a volunteer I am in a wonderful environment. We spend lots of time teaching, learning, and collaborating. We spend as much time with each patient as it takes. Our patients are so grateful that we are here to help them, and almost no one has a sense of entitlement. We do not have to argue with insurance companies, pharmacy benefits managers, or clinic administrators about what tests or medicines our patients need. You may not have the financial wherewithal to quit, but you might be able to carve out one half-day per month to volunteer at a local free clinic seeing uninsured patients. It can restore your hope. And cutting back on your other job can decrease your frustration, as you already mentioned!

  39. Regarding #2, how would you suggest a patient respond when a doctor truly does seem to lack knowledge about a particular condition? For example, I have read that even when seeing gynecologists, it’s not unheard of for women with endometriosis to be given somewhat ineffective and outdated treatment suggestions–ablation, get pregnant, go on Lupron, stay on birth control until menopause–despite significantly more promising outcomes from excision surgeries. How could a patient politely respond to a doctor in this scenario without coming across like the offending patients from #2?

    1. This is a great question, MB. I’m always very receptive to patients who say, “I read x on website y. It sounds plausible to me, but I’m not the expert. What do you think, doc?” I am happy to educate the patient whether what they’ve read has merit or not.

      Now, if the response you get from the doc doesn’t mesh at all with what you’ve read, then it gets dicey. You have to use your intuition to discern whether the doc will be receptive to more questioning. Me, I’m fine with more questions…to a point. Once I make it crystal clear that I think something doesn’t have merit, then I get irritated if the person perseverates on it. But this is because my clientele tends to bring me quacky stuff. If you bring your doc something that is evidence-based, she shouldn’t get her back up about it, unless she’s feeling defensive about being unknowledgeable, which is a different story.

      If this is the case, then you probably want to get a second opinion. Most docs who stay current are happy to explain the pros and cons of reasonable alternative treatment options.

  40. Found your site when searching for non-clinical jobs for physicians, after a week that felt like the proverbial last straw. I have a #6, or maybe a 3a… being forced into unprofessional, unethical positions. I’m a 53 year old pediatrician on clinical and teaching faculty at a well respected medical school. I’ve worked in private practice, had a solo practice for 5 years, and worked here for 12 years. I joined the faculty by invitation, because I wanted to pass on my skills to medical students.

    Sadly, thas been a steady deterioration of the commitment to clinical excellence, driven mainly by #3. I read a career article awhile back titled something like “which s**t sandwich do you want to eat?”– meaning every type of work has its annoyances. But when it goes past annoyance into ethical breaches, I don’t think I can do it anymore.

    I’m actually ok with 1 and 2– as a pediatrician, I’ve learned to enjoy helping parents understand bogus medical claims. I love the looks on their faces when I explain what homeopathy is supposed to be, and they say “you mean I bought flavored water?!” I have mainly Medicaid patients, who seem pretty savvy when I tell them they’ve been ripped off.

    And I get a kick out of making insurers back down from denials of service. I’ve been known to write letters detailing the graphic consequences and expense to them if they don’t cover what I’m ordering, with a note that I’m copying the parent for their attorney… works pretty well. Like the time an insurer wanted me to first try an asthma controller with an ingredient the child had anaphylactic allergy to.

    But now we are being told to order medically unnecessary tests in order to meet goals for MIPS. Such as chlamydia testing for all patients taking OCPs, which are also prescribed for non contraceptive purposes. Administration sent out generic medical advice on sunscreen to our patients without asking us– under our names– to meet the secure messaging goals. It wasn’t accurate, and it was badly punctuated to boot.

    Minimally trained staff, instead of RNs, are the rule. So it’s common for me to walk in a room to find a patient gasping with asthma, who had walked in and thus had to wait until scheduled patients were seen, instead of having a nurse run to get me right away. It doesn’t matter how much training I give them, because the low pay leads to a high turnover rate.

    I have decided that I’m not going to be able to participate in unethical, incompetent practice. I’ve set a goal for a career change within 2 years. I’ve spent a lot of my salary helping patients, friends and family pay for medical care over the years, so I have very little savings. I can’t do direct care because in my state, we are required to participate in onerous Medicaid processes for our patients to get prescriptions filled– and I won’t practice if I can’t serve the poorest kids.

    I’m sad because I do love patient care. But medicine may be becoming impossible for ethical people to practice.

    1. This is sad on so many levels. You sound like a committed, altruistic, selfless physician – someone who still approaches medicine as a calling. Yet you feel like the practice of medicine has become impossible to perform to your standards, so you’re looking for the exit. I get that.

      But I would urge you to reconsider your strategy of putting everyone else’s needs before your own. There is a reason why the airline recommends you put on your own oxygen mask before assisting your child – if you pass out from oxygen deprivation while struggling to help your kid first, then you both lose. You must secure your own mask first.

      I’m sorry to be blunt here, but you cannot continue to financially assist your family or friends, and you certainly can’t be paying for your patients’ meds or whatever you’ve been doing that has drained your retirement fund. You are not a rich doctor; please do not allow people to continue to treat you like one.

      If you do only one thing this week, it should be to visit White Coat Investor. There is a wealth of personal finance information there that can set you on the path to actually being able to retire someday.

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