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
