Doctors, patients, corporatization, and moral crisis

In the last few years a fair amount has been published, especially in the medical media, about physician burnout. This term includes everything from frustration, to saying they would not encourage their children to become doctors, to leaving the profession or retiring early, to, in extreme but sadly not rare cases, suicide. The emphasis has usually been on the amount of work that the doctors have to do, the stress of new technologies such as the “electronic medical record” that, rather than simplifying things or making them more efficient, mainly create much more time-consuming work, and the ever-present threat of malpractice suits and other litigation against them. Recently, the NY Times Magazine, in “The Moral Crisis of American Doctors” by Eyal Press (June 15, 2023), presents more balanced and accurate coverage.

The article discusses the work of Wendy Dean, a psychiatrist and administrator at the US Army research center. Dr. Dean was shocked to learn that the rate of suicide in physicians was higher than that of the active-duty military.

The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.

Dr. Dean thought about this issue in terms of “moral injury”, generally thought to affect those who participated in or observed horrible violations of their moral compass in war, such as the murder of civilians.

Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and [her co-worker] Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”

The article goes on at length, comparing the doctors to assembly-line workers who fear for their jobs if they speak out, to non-compete and non-disclosure agreements they are forced to sign, to the way that this manifests in particular specialties, such as Emergency Medicine.

This piece gets to the heart of the matter more than almost anything that has been published in the mainstream media. I would summarize the lesson as: The pursuit of profit is dangerous to your health. The transformation of medical care from control by doctors to control by accountants and venture capitalists means that something other than what is best for the health of people, as individuals and as a population, is the primary consideration driving the structure and implementation of health care. It is not a pretty picture. Yes, doctors make and have always made mistakes. Yes, doctor have often been avaricious themselves. Yes, sometimes people have been hurt or died from unnecessary procedures. But at least in theory most doctors believed that what they were doing was for the best interests of their patients.

We have moved beyond (or backward from) that. We have entered an era in which an assembly-line mentality has been implemented in American healthcare, when doctors and other healthcare workers are seen as replaceable cogs, when the provision of healthcare is, like selling cars or liquor or financial instruments, not mainly about the “product” but is just a vehicle for generating money for its owners and managers. Tough luck, all you “burned out” doctors, probably suffering from moral injury. Tough luck, sick people.

This has been a long time coming. The deprofessionalization of medicine should have been predictable decades ago, and it was. In a recent blog post (Private equity, private profit, Medicare and your health: They are incompatible, May 11, 2023) I cite two books. “American Health Empire” (1971) by Barbara and John Ehrenreich and other members of the HealthPAC collective, showed how even then hospitals and health systems were being corporatized. Paul Starr’s 1982 book “The Social Transformation of American Medicine” focused on the impact of this on the professional role of physicians.

Another huge warning signal was, or should have been, the explosion of the space shuttle Challenger on January 28, 1986. As reported at the time and in multiple more recent articles (e.g., Engineer Who Opposed Challenger Launch Offers Personal Look at Tragedy, and Remembering Roger Boisjoly: He Tried To Stop Shuttle Challenger Launch, both from 2012), engineers for the Morton Thiokol corporation knew that there was a problem with key pieces of the shuttle (the infamous “O-rings”), and had been ignored by their bosses when they called attention to it. And never went public with it for fear of losing their livelihoods. Until after the disaster. At the time, it was noted often how this conflicted with the codes of ethics of the engineering profession. But engineers were no longer self-employed independent professionals; they were employees of huge profit-seeking corporations. Many of us who were doctors pointed to this, saying this trend was not limited to engineering, but was happening to other professions, including medicine. It had not yet progressed that far, but was fast moving down that track.

Independent physician practice, solo or group, single or multi-specialty, had begun to disappear, as practices were acquired by larger companies. Sometimes these were physician-owned, and seemed to continue to carry the same “old” values. But then they were bought out by hospitals, health systems and private investors. So were the hospitals. We got a lot of glitz -- fountains and art work in our entry halls and fancy new machines, and investment in our practices, particularly those “product lines” that had the greatest “return on investment” measured, of course, in dollars and not human health. How could we, as ethical medical professionals, buy into the casual use of such terms as “product lines” and “return on investment” when talking about the health of our patients?

Some of the explanation is greed, and some of it is psychological, as doctor began to think that using corporate-speak meant that they were cool, and allowed them to hobnob with the real power players in control of the industry. Many doctors obtained MBAs.  And now some of them are very rich. Some are even CEOs. It’s not surprising that doctors can be smart enough to achieve this, or that they can be as susceptible to the lure of power and money as anyone else. It also does not mean that all doctors who get MBAs use it to limit care in order for their company to make more money. But that does not make it good for the people of the nation. And it can, and often does, create another moral conflict, perhaps even moral crisis.

Another recent piece, by the Reverend William Barber and Gregg Gonsalves in The Guardian, “The fourth leading cause of death in the US? Cumulative poverty”, is scarcely unrelated, although rather than focusing on physicians it focuses on patients (the medical term for “people”). It clearly and thoroughly documents the impact that poverty has upon health. And while the poor are the tip of the iceberg, the most vulnerable, the cutbacks on care that come from megalomaniacal pursuit of money affects much larger parts of the population.

Because we have a healthcare system that is designed to make money for the corporate entities that control it, that system does not deliver quality care to many (or most) people. As a result it creates unfulfilling, stressful, and sometimes intolerable working conditions for its employees, including physicians. Moreover, in the classic “divide and conquer” technique long used by those in control, it leads to people being angry at their doctors for the frustrations and denials that they experience, which they mistakenly believe the doctors control. The denials of care are made by the insurance companies that they have (and often choose, such as Medicare Advantage). The long delays for getting appointments and the inadequate time physicians spend listening is the result of the management of the health systems that employ them, not only treating doctors as assembly-line workers but patients as widgets to be produced. If it seems impersonal and uncaring, it is.

So what is to be done? Doctors can start by demanding that their professional organizations, beginning with the AMA, condemn and resist this corporate transformation. They also must recognize that they are no longer independent practitioners, but employees, just as the Morton Thiokol engineers were, and that the greatest protection that they – and their patients – have is unionization. You, doctors, may be well-paid workers, but you are workers! Unions can educate people, their members and the public, about how the power is actually distributed and who is calling the shots. Other people can respond by contacting their political representatives and demanding that the power and authority of private corporations over their health care be drastically curbed; this includes insurance companies and health-care companies. A great first step would be to repeatedly demand that every representative and senator, every state legislator, sign on to support a universal health insurance system, such as Medicare for All.

There will still be plenty to do after that, but it would provide a structure for making things better.

Burnout and depression in physicians: Not good for them or for the public's health

For some years now, there has been increasing emphasis in the medical community about “physician burnout”. While there different degrees and kinds of burnout, generally it refers to a feeling among physicians from having little or no enjoyment in their work to feeling unable to continue. At this far extent, it contributes to doctors leaving the direct practice of medicine for a less-stressful area where their medical background is useful (administration or insurance work or consulting) to leaving the profession altogether. It can be for a different career, or, if they are older and more financially able, early retirement. In the case of young physicians, particularly residents who are still doing their post-graduate training, working very long hours and getting paid relatively little – and since many have medical school debt exceeding a quarter of a million dollars, it can be actually little – burnout could prevent them from taking on a full career in medicine.

Of course, burnout can affect any profession, or any job, although that term is mostly used for professionals, who have historically counted on some degree of independence and control of their work lives. Feeling burned out, not interested, overwhelmed, and even resentful is common and maybe even normative in much non-professional wage work, where the assumption is often “of course you are alienated”, selling your labor to a boss whose only interest is in profit and to whom you are only a tool to generate it. It is a more recent phenomenon in the professions, particularly as professionals become essentially employees, and the profession I know most about is medicine.

Historically, physicians have worked very hard, long hours, often through the night, taking call to come in and see people (called, in medical terms “patients”), operate on people, deliver babies. In small towns and rural areas, where there were few other physicians with whom to share call, this was often particularly disruptive to home and family life, not to mention sleep. The compensating plusses were considered to be a good income, a high level of respect from the community, a sense of making a contribution and a difference, and some level of control of your practice. Although, often when coming in in the middle of the night, it might not seem like much control, many or most doctors were self-employed, and even when they became part of larger groups they were among the owners.

Over the last few decades, many things have changed in the practice of medicine, increasing the burdensome characteristics and decreasing the positives. These are mostly related to the increased size of medical enterprises and the corporatization of medical care. On the one hand, in the name of “efficiency” the practice of medicine has become routinized, less varied, less interesting, and sped up. Physicians often feel that they are on a treadmill churning patient visits as if they were widgets, not having the time that they would not only like but would be necessary to understand their patients as people, and to begin to meet their more complex needs – and people are complex, with every aspect of their lives affecting their health. They may be paid more, but they have much less control, and often seem to (and do) spend as much time completing their Electronic Medical Records (EMRs) as in patient contact, and it may feel (correctly) that the purpose of the work that they put into the EMR is aimed primarily at maximizing income and profit for their employers rather than maximizing the health of their patients.

The strategies which have been employed to attempt to address burnout have ranged from the individual (support groups, various therapies) to structural (changing the work situation). Many physicians are seeking to achieve more “work-life balance”, with more time for their families and other non-work life. The ameliorations include shift work (work hard but for a specified period of time, and know when you will be off and that you really will be off), limiting scope of practice, and, certainly, increased reimbursement. But because these “solutions” do not work as well for all specialties, burnout does not affect all specialties equally. Shift work is most effective in specialties in which continuity of care for an individual patient with an individual doctor is not seen as important; thus it works well for emergency medicine, anesthesiology, critical care, and a few other areas. It has also been widely employed in hospital work, with “hospitalists” who care for people who they do not see as outpatients working shifts (including for delivering babies), and has extended to generate yet newer specialties like "nocturnists” and “weekendists”. And has even renamed the doctors who do see people in the outpatient setting as “ambulists”. How well this works depends on who you ask; it is “efficient” for the employer, and the hospitalists know their hospital stuff, but for the patient, not only are you not seeing a doctor who knows you but your hospitalist may change every few days (and nights).

Salaries in medicine are still usually tied to how much the individual physician generates for the organization, which is heavily dependent on how insurers reimburse, and that is far more for surgery and other procedures than for “just” seeing, talking with and examining a person, reviewing lab and x-ray information, and coming to a diagnosis and treatment plan. So doctors who do the latter make less money (family physicians, general internists and pediatricians, psychiatrists) than do proceduralists. Thus, the physicians in the highest paid specialties (particularly those not just highly paid but that have the highest income/work ratios) are more likely to be successful in achieving work-life balance and avoiding serious burnout. And those who have to be most available for the greatest portion of time with the least support, rural family physicians, burnout can be highest. Although these doctors also often retain the most degree of autonomy, with time demands coming from their patients, not the corporations that employ them.

It is also worth talking about serious mental health issues that physicians confront, and especially the continued disincentives for them to receive necessary and appropriate care. A March 30, 2022 Op-Ed in the NY Times, ‘Why So Many Doctors Treat Their Mental Health in Secret’, by Seema Jilani discusses this, and in particular how employers and licensing boards feel free to ask about this, contributing to an atmosphere of stigma so that, in fact, many doctors do not treat their mental health issues at all. It would be outrageous for us to expect doctors to not treat their asthma, heart disease, cancer or myopia, but for mental health conditions this remains a real issue. It is one of the two great examples in medicine of the double-edged sword of “you should do this, but we may punish you for it”. The other is in the area of acknowledging mistakes (or even potential mistakes). There is excellent data showing that admitting and examining mistakes at the institutional level absolutely increases the overall quality of patient care (‘every mistake a jewel’, because we can learn from it; see W. Edwards Deming’s “14 points”). However, physicians who do so risk discipline, license loss or restriction, and even lawsuits. These punitive results (except for egregious cases) should not be there, and most of those who wrote letters to the Times in response to Dr. Jilani’s article (and I) agree that these punitive risks should not face physicians who seek treatment for depression or other mental health issues. Burnout and depression are not the same things, but may, and frequently do, co-exist.

Doctors are privileged workers; they are generally highly paid relative to most people, they still earn a great deal of respect, and they have the opportunity for great personal satisfaction through serving others. But they are often held to the standards of independent professionals while increasingly working for corporations, and they not immune from the stresses of overwork, lack of control, speed-up, and negative aspects of how capital treats its workers.

And they are certainly not immune from mental health issues, and should be able to receive appropriate treatment without inappropriate repercussions.

 

I did not address the issue raised by the recent conviction of a nurse in Tennessee for criminally negligent homicide for accidentally giving a patient the incorrect medication, but obviously this is entirely relevant to the issue of acknowledging errors, and the work situation for health professionals and thus issues of burnout and depression and, indeed incarceration.

A very good discussion of that case, 'Are All Medical Errors Now Crimes? The Nurse Vaught Verdict' appears in Medscape, and I would absolutely endorse this quote from one of the participants:

"A culture of safety is one in which the system that allowed the mistake to happen is changed, not one in which the individual is scapegoated. And a culture of safety correlates with better patient outcomes that we know. This verdict is the opposite." 

Physician frustration and "burnout": A wider breadth of practice helps!

Physician burnout is a topic that is much-discussed in the medical community. It’s not a very good term; most people have stressed, sad, or overworked days or weeks, but it is the one that we seem to be stuck with. It is true that many physicians are often not happy, feel overworked and stressed and unable to spend enough time with their families. Most important, perhaps, they feel that this leaves them unable to do as good a job caring for their patients as they would like to. The main factors are workload, both in terms of the number of people that they have to see in a day, and ever-increasing “administrative” work. A big part of this is charting on an Electronic Health Record (EHR). While this modern method of charting allows quick retrieval of much important information and makes it possible to maximize billing, it is very time consuming.

Primary care doctors, such as family physicians, have among the highest rates of “burnout”, exceeding 30% in some studies and rising to nearly half in younger physicians . A recent study by Young, Burge, and colleagues showed that family doctors spend more time entering data into EHRs than they do face-to-face with patients! Patients are justifiably upset when their doctor spends more time looking at the computer screen than they do looking at them, and it is bad for the physician-patient relationship. However, the charting still has to be done, so those doctors who are not spending time on the EHR during the encounter are staying late to do it after office hours or doing it from home on evenings and weekends, which also contributes to frustration. Studies also show that a higher percentage of female physicians report experiencing “burnout”, likely because in many or most families it is still the woman who bears the burden of household and family responsibilities, even when she has a full-time and demanding job such as a physician.

There are a variety of reasons why family and other primary care physicians are particularly vulnerable to burnout. Reimbursement per visit is lower than for most other specialties, which means there is less money to hire people or buy systems to make things more efficient. Since most physicians are employed, primarily by large hospital systems, rather than in private practice, the system drives the work, not the doctor. Of course, the logic for paying primary care physicians less is, well, non-existent, but there are many non-logical justifications, most of them based upon the tradition of “subspecialist have always made more money” and are self-serving.

One conceit is that the work of subspecialists is “harder” or “more complex” and thus justifies greater reimbursement. This is not always, or even usually, true. As I have previously discussed on this blog (e.g., Can you be "too strong" for family medicine?, March 19, 2013), the work of a family doctor is particularly complex. For each patient, the family physician takes care of, or co-manages, all of a patient’s medical – and psychological and social – issues, as opposed to just one, as subspecialists do. In terms of the day’s schedule, a family doctor sees a wide variety of patients: a person with a new acute illness can be followed by one with several chronic diseases, then a well-child, then a sports injury, then a pregnant woman, etc. I have documented this in an “AAFP One-Pager” published in the American Family Physician in December, 2014.[1]

But, because subspecialists get higher reimbursement, their employers are happier and likely to spend more money supporting them. Some (ignorant but not rare) health system administrators wonder why a family doctor cannot see more patient in a given time, like, say, orthopedic surgeons do. The orthopedist sees someone referred for a specific problem, after x-rays or more extensive (and expensive) tests like MRIs have been done, often after the patient has been seen by another professional such as a physician’s assistant, does a quick exam of the particular area and decides if surgery is needed or not, and has someone else arrange it. It is, of course, the surgery, not the clinic visit, that earns the surgeon money. The family doctor is, as noted above, addressing all of a patient’s chronic and acute medical problems, as well as the social and psychological problems, and often has to fill out forms such as disability, FMLA, etc. even when another doctor (say, that orthopedist) is doing the procedure, because those subspecialists are “too busy” (ie., earning, directly for themselves or for the health system and then indirectly for themselves, too much money per unit of time).

It is, thus, unsurprising that those specialties that are the highest-paid (e.g., orthopedic surgery) and especially those with the highest income-to-work ratios (e.g, radiology, dermatology, anesthesiology) have little difficulty recruiting new doctors, while the lower-paid specialties, like family medicine, have much more. After all, the indebtedness from medical school –typically hundreds of thousands of dollars (which usually requires annual payments of far more than the average American’s total salary) is the same whatever specialty you enter. The higher revenue generated by subspecialists allows them – or the hospital systems that employ them -- to pay for non-physicians to do a variety of tasks, both clinical (nurse specialists and physician’s assistants) and documentation (scribes, coders, etc.) The American Academy of Family Physicians (AAFP) suggests that the root cause of family physician burnout is inadequate team-based care, but the fact is that the members of those teams have to be paid, and the greater the physician reimbursement the more team members there can be.

Given all this, one could reasonably worry that family doctors will no longer be happy doing all the breadth of care that defines the potential of the specialty, such as continuing to deliver babies, or take care of their patients in the hospital, or make home visits. After all, if they are stressed out “just” seeing patients in the clinic, wouldn’t this make it even worse? Take more time? Increase burnout and stress? To me, that would be a bad thing; one of the terrific things about primary care doctors, reasonably defined as “doctors for you” (rather than for a specific condition) is that they can see you, and care for you, in all settings.

Which is why it is gratifying to read the results of a paper just published in the Annals of Family Medicine by Weidner, Phillips, Fang, and Peterson called “Burnout and Scope of Practice in New Family Physicians”. Contrary to what one might fear, it turns out that, at least among younger physicians, having a wider scope of practice – specifically caring for patients in the hospital, delivering babies, and doing home visits – is associated with a lower rate of self-perceived burnout. This is heartening – maybe being able to function at their highest level, care for people in all the settings in which they seek care, provide real continuity, do good medicine is part of the answer. Some of this may be because the breadth of care, the different kinds of problems to care for, the possibility of being there for your patient in whichever venue their care is delivered, the caring for the whole patient, is why people chose family medicine in the first place, rather than a (higher-paid) specialty where you care for only a few diagnoses or do a few procedures over and over again. 

Yes, doctors, even the lower paid specialties, make very good salaries compared to most Americans, and so it is hard for people who have lower-paying jobs, are afraid of losing their jobs, or have no jobs at all to feel too sorry. Yet it is in the interest of their health that their physicians are able to feel satisfaction with their work, most importantly to be able to do the best that they can to take care of a person’s medical needs. Medical care can be made more efficient than it is, especially in eliminating the ridiculous lack of communication between doctors, hospitals, and patients that characterizes our fragmented non-system. All workers feel more satisfaction and do a better job when they have the ability to exercise some discretion and not simply work on an endless assembly line. Medical care especially cannot be reduced to an assembly line, because you are a person, not a widget.

Our medical system needs to cover everyone, communicate within itself effectively, and be flexible enough to meet the needs of all people.

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[1] Freeman J, Petterson S, Bazemore A., Accounting for complexity: aligning current payment models with the breadth of care by different specialties. Am Fam Phys 2014 Dec 1; 90(11):790. PMID 25611714