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.
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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