Saturday, April 8, 2017

Physician Generational Effects of Oppression By The Managerial Class

One of the dynamics that I consider to be essential to the survival of the profession is whether there is any way to resist the manipulations of the managerial class.  Since the profession has been almost completely subordinated to the managerial class, the question may not seem very relevant.  Too much depends on physician independence to give it up that easily.  Without physicians independence there is really nobody advocating for our patients.  Do we really want to be cogs in a government sanctioned business empire that decides when people live and people die or who gets medication or who gets reasonable medical care?  There is no physician I know who is willing to give those decisions up to administrators.  Those decisions are happening by manipulation and default every day.  Administrative representatives sitting in on medical teams with the full blessing of the CEO or department head.  Cross them and you may be out of a job either directly or pressured out by becoming person non grata or a handy "disruptive physician" label.  That is a high price to pay for disagreeing with management, especially when they are making decisions that only a physician is trained to make.

I have had the opportunity to work with residents and early career physicians for about the past 15 years and I noticed that they had a tendency to get a lot less riled up about these scenarios than I did.  It is paradoxical in a way.  Even though older physicians tend to be much more bothered by the managerial class than our younger colleagues, all of the burden of these managers is falling directly on them.  Electronic health record (EHR) mandates, EHR software that is essentially junk, arbitrary maintenance of certification (MOC) requirements, billing and coding requirements to avoid financial penalties, and on and on and on.  The burden of the managerial class on physicians gets worse every year and there is no end in sight.  There has been very little resistance to this burden.  The only exception that comes to mind in the National Board of Physicians and Surgeons - an alternate route to maintenance of certification through standard life-long learning approaches rather than the methods recommended by the American Board of Medical Specialties (ABMS).  The NBPS was founded by Cardiologist Paul Teirstein, MD who graduated from medical school in 1980.

As far as I can tell there is very little research on the generational effects of changing physician demographics.  By that I mean - how are the specific groups of physicians impacted by excessive management, do they react to it, and do they have any success in changing it in a positive way for physicians.  The raw data on physicians based on Census data is fairly interesting.  Looking at the graph below the population of physicians is fairly stable between the current age range of 34-59 with a more even distribution of men to women starting with 32 year olds.  That distribution has been more even in psychiatry than more other specialties for much longer - at least the departments that I have worked in.

Using standard generational nomenclatures that means that there are still physicians practicing who were born in 1945 or earlier (72 yo and greater).  The Baby Boomers are in the 53-71 yo range.  Gen X are the 41 - 52 year olds.  The Millennials are 22-40.  It looks like there are also a total of 34 Gen Y physicians who are currently 21 years of age.  All of the named generations seem to be represented.  I don't put much stock in generational characteristics being applied across standardized age ranges.  Certainly younger physicians are more likely to text and use more Smartphone apps, but it really is impossible for physicians practice these days and not have more than a passing command of basic technology.  If they don't know it and the implications, they will probably have to be trained in it.  

The demographics are available but outside of the burnout literature, there is very little written about the generational effects of management.  These are important questions because non-medical business management has unprecedented influence on medical care in this country.  Business managers determine how long people get to stay in the hospital, how much time physicians have to spend on documentation and record keeping, how many patients physicians need to see each day, and the entire structure of outpatient medical care.  A great example is how psychiatric practice has changed from seeing patients fairly frequently and discussing many aspects of a persons care to isolated brief appointments to discuss a medication that may be only moderately effective.  If you see a medical specialist - you might be limited to one appointment per year.  Business managers have widely implemented team approaches and sold this idea to the public.  What the public does not know is that there are management representatives on these teams who lack medical credentials and given that fact have a disproportionate amount of input into patient care.  Physicians are micromanaged at every decision point.

My real question boils down to what happens when that case manager on your "team" tells you that the patient needs to go and as a physician you know they are not stable and can benefit from continued care?  How does a 53 - 71 year old physician react to that dilemma compared with a 22-40 year old physician?  Are there intergenerational conflicts based on those reactions or the perceptions of those reactions?  What are the reality factors involved?  I know that there are plenty of anecdotes.  It is common to hear that Boomer generation physicians are retiring as soon as possible to avoid oppression by managers.  It is also common to hear that Millennial generation physicians are laboring under unprecedented levels of medical school debt.  That plus a mortgage and a family gives them limited options in responding to oppressive management practices.  That is especially true when short staffed hospitals offer signing bonuses to early career physicians.  There is some intergenerational conflict on the maintenance of certification (MOC) issue.  The Boomer generation is more likely to be incensed and point out that there is really no "evidence" that the requirements made up by the ABMS are necessary.  Some of the younger generation is critical of the Boomers, especially about the fact that many are "grandfathered in" based on age.  There is no more critical issue for all physician generations and the political forces that have the most to gain from MOC are just waiting for a generational split to give them the advantage they need to continue their agenda.

The other movement is an exodus of physicians into private practice and in some cases cash only practices or some variation.  That is a definitive way to escape oppressive management practices, but the managers and their friends in government have a long reach.  The electronic health record (EHR) is one example.  Even though the EHR remains not ready for prime time for a number of reasons, it is mandated for use by physicians and pharmacies.  It is a relatively new cost for any physician or group who wants to try to make it outside of the systems of government payers, managed care organizations, and pharmacy benefit managers.  Finding an EHR that has more value than problems is a daunting task.  It is probably the most imperfect software that you can find anywhere.

Those are a few thoughts on this is this Saturday morning.  Make no mistake about it all physicians are targeted for oppression by managers at some level.  On a daily basis it is not difficult to find some business entity that has made a bad decision about the care of one of your patients or one that is not actively trying to interfere with your care of a patient.  In some cases, the physician is just an afterthought.  They are swept into the battle between pharmaceutical benefit managers and pharmaceutical manufacturers over medication pricing structure and how it is reflected in the written prescription.  But all of that still comes back to the physician when they are ordered to make what amount to trivial but time consuming changes.

The goal of examining these issues would be to get rid of micromanagement initially.  There is no reason why prescriptions for inexpensive generic medications should be micromanaged.  It amounts to harassment.  It seems more complicated if we are talking about teams where a manager is sitting in a team meeting and dictating care, but it is not.  Most of medicine these days is still based on subjective decisions and experience.  That may not seem to fit into the rhetoric of evidence based medicine, but it is the property that currently gives physician the advantage over computers.  Recognizing experienced based patterns in patient diagnosis and care is the reason that medical training is necessary.

Business managers don't have it.  Looking at the generational effects may give physicians some ideas of how get rid of some of these practices and present a more united front to the people adversely affecting our care of patients.                

George Dawson, MD, DFAPA  


1:  Carol A. Bernstein.  The Changing Face of Medicine: The Next Generation of Psychiatrists.  Keynote address.  Minnesota Psychiatric Society October 8, 2010.

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