Happy Labor Day

 

Happy Labor Day

 

“It should be evident to all students, residents, and practicing physicians that the enormous investment in time, money, and commitment typically necessary to become a physician makes no sense if practicing medicine frequently fails to be interesting and enjoyable.”  Samuel B. Guze, MD 1992 (1)

 

Every year I try to post something about my impression of the physician work environment. That has been a progression of depressing posts as the work environment deteriorates every year largely due to micromanagement by managed care companies and various governments that has resulted in a trillion dollar overhead, quality as an advertising meme rather than a clinical reality, poorer reimbursement for physicians, massive numbers of wasted hours for the bureaucracy and its documentation requirements, and the negative feedback loop of using the healthcare system as a jobs program for business administrators.  Each of those iterations moves use farther and farther from Dr. Guze’s reality of an enjoyable and intellectually stimulating career in medicine.  Interestingly – enjoyability is not an obvious factor in the most frequently used scale to detect burnout in medical staff.  Those scales tend to be focused on a learned helplessness/loss of personal efficacy model.  Lack or loss of enjoyability is probably the first step toward that extreme conclusion.

It is equally frustrating for patients who have seen access get markedly worse.  Just this month I tried to assist a friend in finding a therapist either inside or outside of her insurance plan. And there were none. I am not talking about a waiting list and an appointment 2 or 3 months out.  I am talking about no access at all.  The clinics would not even place her on a waiting list.  I saw a consultant myself back in January who told me he was referring me to another specialist to be seen this August.  When that did not happen, I called and my calls were not returned. Eventually by sending enough messages to my primary care MD they called me and set up an appointment on September 2.  I was called yesterday and told that appointment was cancelled.  They gave me another appointment in mid-November with the qualifier: “We have you penciled in but there is no guarantee that this won’t change again”.

I am very aware of the strain the pandemic and its mismanagement has put on the system.  Also aware of physicians and nurses resigning in droves (2). In the case of primary care specialties and psychiatry there was a serious shortage before the pandemic hit.  The pandemic itself is an insufficient explanation for what has happened over the past three years. The lack of an adequate pre-existing public health infrastructure had a lot to do with it (4).  Inadequate protection for front line workers and an inability to scale as the morbidity and mortality increased in some cases exponentially. In the case where public health officials were doing what they could they often found themselves threatened and attacked by pandemic deniers, anti-vaxxers, and let’s face it various elements of the right wing (3). The same people basically responsible for building out America’s immense for-profit and inefficient health care system. What could be more depressing than to try to treat a pandemic while a political party is basically denigrating standard public health measures and either verbally attacking or threatening public health officials to the point that many had to get security personnel for protection. When you have a big enough platform – I consider acts of omission-like not taking a stand firmly against political violence as bad as the people making the threats. I also don’t make any distinction between threats from the average man or woman on the street and members of Congress making clear threats.  Many seem to act like they have immunity in those situations.

The politically designed medical systems of care that is basically run by unqualified business people was ramped up to even worse performance by the associated political anarchy. That anarchy continues. Who could blame physicians for bailing out in those circumstances?  I think there is a legitimate concern about whether the system will every get back to its baseline prepandemic inefficiency.

Some have considered the increased use of telemedicine and telepsychiatry to be a positive correlate of the pandemic. I gave a continuing medical education presentation on it in November of 2021. For various reasons – I think the eventual outcome of telemedicine is uncertain. The main reasons have to do with businesses taking over and managing the visits for profit and to the detriment of any therapists or physicians involved. A review of what can happen was published in the New York magazine (5). I see television ads all the time for rapid access to all kinds of prescriptions just by calling a business running a specialty telemedicine site. Some of these sites are already controversial and there appears to be very little transparency when it comes to comparing these sites to the even meager quality of care offered by in-person managed care.  Payer gaming at all levels is another possibility. During the pandemic reimbursement for care delivered was at the standard rate.  We are just starting to see decreased reimbursement or no reimbursement for televisits. I have also seen very disadvantageous contracts for physicians and therapists attempting to do televisit work at the levels of reimbursement, risk, and required access. That is consistent with the decade’s old observation that medical practice environments deteriorate in quality with increasing business involvement.

On a positive note this year – the main alternative to maintenance of certification by  American Board of Medical Specialties (ABMS) is the National Board of Physicians and Surgeons (NBPAS). This year the NBPAS was given recertification status by the Joint Commission and hospital accrediting agencies. The NBPAS model is the original “life long learning” model proposed for all physicians since the Flexner era. I have personally been recertified every two years by the NBPAS, but until this year realized that most younger physicians were not in a position where they could abandon much more costly and some would say overly involved ABMS recertification procedures.  The change this year apparently makes it easier to make that transition, but a lot will depend on hospital committees and local accreditation procedures. ABMS recertification is onerous enough to tip the balance in favor of leaving the field for retirement of a different occupation so that this change may also lead to physician retention.  But a lot will depend on how all of this unfolds.

I can still recall reading about why Paul Tierstein, MD came up with the original idea for NBPAS. He noticed a colleague who was an electrophysiologist cramming for a recertification examination and learning details he would never use in his day-to day practice.  Most physicians – even within their own specialty or subspecialty develop a knowledge base for that practice.  That knowledge base is not consistent with a preparatory based knowledge learned in medical school or as a resident. Relearning irrelevant material for the sake of taking an examination is another unnecessary drain on a physician’s time and finances. Life long learning is a better way to acknowledge that physician’s highest level of certification and ongoing efforts to maintain that specialized knowledge.

All things considered it has been another very stressful year for physicians. There is a glimmer of hope on the recertification front that will hopefully alleviate a lot of unnecessary stress.      

We still have a very long way to go to reach Dr. Guze’s suggested practice environment that is both fun and intellectually stimulating.  Like he says in his book – I was taught about that is medical school and experienced it only in the very first years of practice. We need to make medicine interesting and enjoyable again and that’s a very tall order.

 

George Dawson, MD, DFAPA

Supplementary:

 Explanation of the graphic: sometime ago I posted that heavy lifting is a metaphor for what has happened to medical practice in the US. This is another example. 

References:

1:  Guze SB. Why Psychiatry Is a Branch of Medicine. New York; Oxford University Press: 1992: p. 118.

2:  Abbasi J. Pushed to Their Limits, 1 in 5 Physicians Intends to Leave Practice. JAMA. 2022;327(15):1435–1437. doi:10.1001/jama.2022.5074

3:  Ward JA, Stone EM, Mui P, and Resnick B, 2022:Pandemic-Related Workplace Violence and Its Impact on Public Health Officials, March 2020‒January 2021.American Journal of Public Health 112, 736_746, https://doi.org/10.2105/AJPH.2021.306649

4:  Bishai DM, Resnick B, Lamba S, Cardona C, Leider JP, McCullough JM, Gemmill A. . Being Accountable for Capability—Getting Public Health Reform Right This Time. American Journal of Public Health 0, e1_e5, https://doi.org/10.2105/AJPH.2022.306975

5: Fischer M.  The Lunacy of Text Based Therapy (And other technological solutions for a nation in trauma).  New York Magazine March 29-April 11, 2021.

Image Credit:

National Archives and Records Administration, Public domain, via Wikimedia Commons https://commons.wikimedia.org/wiki/File:Girls_deliver_ice._Heavy_work_that_formerly_belonged_to_men_only_is_being_done_by_girls.

Heavy work that formerly belonged to men only is being done by girls. The ice girls are delivering ice on a route and their work requires brawn as well as the patriotic ambition to help. - NARA - 533758. https://upload.wikimedia.org/wikipedia/commons/0/0a/Girls_deliver_ice._Heavy_work_that_formerly_belonged_to_men_only_is_being_done_by_girls._The_ice_girls_are_delivering_ice_on_a_route_and_their_work_requires_brawn_as_well_as_the_partriotic_ambition_to_help._-_NARA_-_533758.gif