Saturday, September 1, 2018

Happy Labor Day 2018!

I have posted Labor Day greetings here since 2013 and did not want to miss this year. The previous posts highlight the problems of being a physician in the USA including being treated like production workers, mismanagement by managed care and their backer in the US government, the electronic health record as a physician burden, maintenance of certification and burnout.  There was continued concern over the past year about burnout and physician suicide. Like my last posts there was very little positive to report. Physicians are still laboring under a ridiculous productivity system that reimburses them a trivial amount with the expectation of physicians who can form their own independent groups and escape the burden of management by health care corporations.  Healthcare corporations in turn seem quite content to hire non physicians to replace the doctors who have left.  The question is:  "Have there been any bright spots?"

On the whole the answer is "No." In one of my previous posts I pointed out the number of young colleagues in Minnesota who were going into private practice and I considered that to be a plus.  Let's take a look at the scorecard:

1.  Physician productivity - physicians directly employed by healthcare companies or those who accept private insurance are still working under a rationed system that expects excessive productivity to make up for both insufficient reimbursement and the fact that physicians have to waste at least half of their time as clerical workers or working to legitimize and insurance or pharmaceutical benefit managers rationing decision.  I am seeing more paperwork rather than less and that is a hot topic on Physician Twitter.  In addition to prior authorizations and denial of care, these companies are now sending out notifications about prescriptions and prescription patterns.  They frequently get the prescribing physician wrong and they issue warning for medication  that are antiquated like: "Doctor did you know that your patient is on two medications form the same class?" Or "Doctor - did you know that your patient did not refill their antidepressant at the expected time?"  The vast majority of these warnings are irrelevant - but they want a return fax upon receipt but warn that all personal health identifiers must be shredded.  A new way to harass physicians with irrelevant faxes and mailings.

2.  EHR -  there have been no breakthroughs in the EHR.  It is still a repetitive stress disorder clickfest that produces unreadable documents.  The major EHR companies continue to have monopoly power and the ability to charge outrageous licensing fees for some of the poorest quality software ever written.  They have no incentives to change anything. At least members of Congress are no longer talking about how the enhanced productivity from this software will result in cancellation of medical inflation.  None of that has happened.  The only potential bright spot is that some regulators are talking about bringing some high tech companies into the area because the existing companies have done as poor a job at interoperability as they have about everything else. 

3.  Pharmaceutical benefit managers -  every physicians nightmare has stayed about as bad as ever with the exception of the forms I mentioned that seem to be a very crude attempt at saying they are engaged in pharmacovigilance.  Of course they are not because quality is a distant memory when you are monitoring a medication that the physician may not have wanted in the first place.  It may be a medication that the PBM got the patient to take because they denied the physician's first choice or erected a steep enough copay that the patient could not afford the physician's first choice.

4.  Managed care/Health Insurance companies - they continue to run the healthcare system in the USA as proxies for the irrational ideas from Congress.  The most irrational of these ideas is that a systems that has led to a 3,000% increase in administrators in the past 30 years can shortchange patients and physicians enough to in some cases turn a profit for shareholders.  The coexisting political myths that this is about "market choice" or "single payer/socialized medicine versus capitalism" don't help anyone but apparently reassure Congress that these proxies are doing what they want them to do. 

5.  Maintenance of certification - The American Board of Medical Specialties and the respective specialty boards continue to have a stranglehold on physicians with this arbitrary expensive and time consuming recertification process.  In combination with the work expectations and inefficiencies, MOC is a significant contributor to burnout and there has been no gain in patient treatment or outcomes related to this process.  Life long learning has been the mainstay of physician education rather than arbitrary exams that seem suitable for prep school rather then working professionals.  There have been some decided bright spots in this area.  The National Board of Physicians and Surgeons (NBPAS) has more visibility as an organization that supports the longstanding tradition of life long medical education as the standard for recertification.  It is gaining support in some states and some physicians in states where it is not formally supported have learned that they can get NBPAS certification and use it nonetheless.  Make no mistake about it - this is a hot political issue and there are many organizations with a clear interest in using MOC to sink physician autonomy once and for all.  To me this is reminiscent of when a manged care company took over a hospital I worded at and the physician department heads were either fired or replaced by administrators. Every politician and bureaucrat out there knows that the best way to squelch physician dissent is to work them to the point they have no time to do anything else. MOC burns bright as the last tool they need to make this happen.

6.  Burnout - number 1 - 5 above directly lead to physician burnout.  The only bright spot in this category is rhetorical.  Articles suggesting that self-management or a yoga deficiency are less likely to be advanced as causes of burnout.  Physicians are not longer accepting this propaganda and I was an early proponent rejecting those arguments.  The only meaningful way to improve on the burnout situation is by improving the work environment.  Now that we have rating scales for burnout, there is a real danger that we will see groups rated from year to year and any random fluctuation on a hardly used scale will be taken as a sign of improvement.  If there have been no concrete improvments in 1-5 above - be assured that burnout is unchanged.

The other bright spots here are the Cardiologists who have stepped up with both NBPAS and the Practicing Physicians of America initiative to go after the organizations behind this MOC movement from an antitrust and fraud perspective.  I never thought Cardiologists were that politically active but these initiatives have clearly changed my mind.  The incongruency in this process is that physicians everywhere belong to professional organizations often more than one.  Physicians in the trenches everywhere support traditional life long medical education and not the MOC appraoch and yet none of our expensive professional organizations will make that stand or for that matter take a stand on any of the above matters.  This is a classic example of what happens when a few special interests get in positions of power in professional organizations. 

That is the summary for this year. I am really hoping that the NBPAS and PPA can make differences and make the lives of physicians everywhere somewhat easier.  I did not touch on the subject of physician suicide.  It is a topic that requires a more detailed discussion and improving the work environment for physicians is likely to have an impact.

Every week I talk with doctors in very stressful circumstances who are trying to solve difficult problems.  None of them should have to work in the present work environment for physicians. 

George Dawson, MD, DFAPA



  1. Massive improvement in the quality and cost of medicine and academia will necessarily involve mass unemployment of middlemen and admins in those fields.

    1. Agree - complete reversal of how we ended up in this mess. I remember to the day what happened when the multispecialty group I worked with was acquired by a managed care company and the immediate disenfranchisement of legitimate depart heads occurred.

      They eventually replaced them with "managed care friendly" MDs whose job it was to just tell us what management wanted us to do. No advocacy at all for quality or what the MDs wanted.

      Recent articles about the increasing salary gap between MDs and these administrators is a clear indication of the power these business types have. They also have no accountability at all. Medical costs have increased drastically and pharmaceutical costs - even for insulin are out of control. A clear indication that these systems are managed by carpetbaggers intent om extracting every last cent from their subscribers.

  2. Forgot to mention that the all powerful managers have an unlimited supply of bad ideas.

    One after the other.

    The expected process of managers who don't know a thing about what they are doing.

  3. Trying to be tasteful here per the issue of Medical organizations run amok:

    Power corrupts, and everyone else is f****d!

    If you don't print it, won't be offended.

    Wow, and don't you want to be a US Senator after the last 3 days of confirmation hearings...

    Joel H

    1. I like the quote attributed to John Kelly in Woodward's book and had the exact same thought about the way medical and psychiatric systems were managed in the last 30 years.

  4. Medicine and academia seem to think more layers of middlemen lead to greater efficiency. Unreal stupidity from supposedly smart people. Contrary to human experience in everything else. I don't know whether to laugh or cry when I read articles by doctors describing how scribes have made their practice more efficient.