Over the years of writing this blog I have put out a Labor Day message to describe any progress in the physician workspace in the past year. The practice environment for physicians has deteriorated significantly over the past 3 decades and those changes are generally locked in by the healthcare business managers backed by both Congress and state governments. I have used the following graphic several times on this blog to illustrate what happened over specific time frames and it is probably time to add some additional details.
The impact of managed care on medical practice has been
clear for the past 30 years. In many
cases that model is being adopted by physicians in private practice settings.
For example, it is common now to see a specialist initially but in follow up
see one of the physician extenders working with them. That can make health care
a lot less personal and it leads me to think about the reason why physicians
are trained to provide continuity of care in the first place.
But even more than that issue is the explosion of online
services provided for flat rates that focus on seemingly basic problems in
exchange for payment. On my streaming services that typically involves a
company that offers prescriptions for depression, anxiety, hair loss, and
erectile dysfunction. A second company
offers beta blockers for performance anxiety.
Given the side effect potential for these medications – I am curious
about how comprehensive the initial evaluations are and the follow up visits.
I was recently hospitalized and had a first hand look at
what the modern hospital workplace looks like.
When I was in training there were discrete teams by specialty and they
consisted of physicians at all levels of training. A typical team might have 1-2 med students,
1-2 interns, a resident, a senior resident or fellow, and the attending. The
work load would depend on whether your service admitted people to the hospital
(typically internal medicine, surgery, neurology, renal medicine, cardiology,
psychiatry) or consulted to those teams (infectious disease, endocrinology, pulmonology,
rheumatology, cardiology, psychiatry).
The admitting services were the most intense because of irregular
admissions and complicated unstable patients. Teams generally had places to
meet, where patients were presented to the attending and there were formal
didactics. Bedside teaching occurred on rounds.
During my hospitalization, I was not seen by a single physician
in my room. When I went out into the hallway, both sides of the hall were lined
by people facing computer screens. There was one consulting team standing
outside a patient door – visible only because it was obvious the fellow and
attending were discussing cases. The level of crowding was striking and it left
me with the impression that all these people could not possibly be physicians. Managed care shaped the form of these teams
and who was in that hallway. First, they eliminated the usual admitting
services and replaced them all with hospitalists. Then they replaced at least
some physicians on those teams with non-physicians. Those moves benefit
business decisions but I have not seen a single adequate study on the impact it
has on medical care.
Training physicians in hospitals has typically involved
hands on learning, consultation from senior and expert physicians, and active
learning environment, and in many cases the opportunity for research. All these areas need to be preserved in the
practice environment in order to stimulate practicing physicians to maintain
high standards. An environment that leads to burnout, sleep deprivation, and
moral injury is not adequate to the task. The question always has been whether
physicians have any kind of leverage that could lead to appropriate
modifications. That question has never been put to the test and in fact,
healthcare organizations in the United States generally flaunt their power over
physicians rather than attempting to negotiate with them.
Will a union make a difference? My experience with unions
started out in my family of origin. My
father was a member of the Brotherhood of Locomotive Firemen and Engineers
(BLFE). He worked as a locomotive fireman and then an engineer. He had to be a union member in order to
work. He generally was not very happy
about it. The railroad industry was run on a seniority system and as railroad
utilization decreased – younger workers like my father had a difficult time
finding job assignments. Even though they were technically employed by a railroad
and reimbursement for the work was good, it seemed like only the most senior
engineers benefitted to the point that they could make a good living. As a result, the contracts negotiated by the
unions did not mean that much to my father. He also tended to see the union as
corrupt because, the union officials clearly made far more than he was making
trying to work in their system. Railroads unions were also compartmentalized - so a strike against one railroad did not mean a strike against all. As a result, workers from the railroad that was the object of the strike could work for competing railroads during the strike. If similar rules apply to physicians a uniform practice environment is no guarantee, but the onerous aspects might be eliminated.
Unions for physicians and residents are becoming
increasingly popular but they have more restrictions that in a blue-collar
environment. The National Labor relations Board (NLRB) enforces the National
Labor Relations Act (NLRA) and decides what public sector employees can form
unions (1). Independent contractors, supervisors, and managers are excluded
because the focus of the act was on laborers. The general categories are loosely
defined so it takes an NLRB investigation to determine who can be in the union.
Tenure and tenure track employees were eliminated by a Supreme Court ruling.
Only salaried employees who do not do a significant amount of supervision are
allowed to be union members. If a union is allowed, the goals in terms of
collective bargaining, representation, and impact on hospital policies need to
be determined. Although the momentum for
unions is building, there is a considerable amount of inertia from the managed
care era. During that time, we had many physicians who were eager to escape a
deteriorating practice environment to become administrators and basically
enforce business policies. It remains to be seen if unions can have a favorable
impact on local health care policy and practices – but just establishing more
is a step in the right direction.
More resistance to Maintenance of Certification by various
boards and the American Board of Medical Specialties is also growing. I went to
the alternate system National Board of Physicians and Surgeons (NBPAS) certification
in 2018 and have not looked back. At the same time, I realize that I was
outside of any system demanding that I recertify through an ABMS board and as a
result – in a unique situation relative to younger colleagues. A petition was
started in July to end ABMS MOC and so far there are 20,000 + signatures. There
was an initiative in the APA to stop MOC about 10 years ago, but the administrative
process prevented it from being put on a ballot. The basic problems with MOC
is that there is no evidence it is necessary for quality care, in fact most
health care organizations have abandoned true quality programs. Second, it is
not reflective of clinical practice. Most physicians – even generalists end up
in a niche and focus their educational efforts and mastery in that area. It
makes no sense to keep taking examinations outside of that area. Third, it is a
substantial time and financial commitment and it clearly generates a lot of
revenue for ABMS specialty boards. Fourth, there is some suggestion that MOC
should be tied to state licensing (Maintenance of Licensure or MOL). This
would allow states and health care organizations even more power in controlling
physicians – even during their private times when they would need to spend time
studying for barely relevant examinations. Elimination of MOC is another
positive step in the direction of restoring a more reasonable practice
environment.
Beyond a better practice environment and what it takes to
make that politically – the profession of medicine is at stake. I have written about a lot of the
technicalities – but this is deeply personal. Going to medical school and
studying medicine was the best thing I could have done with my life. By
identifying with the practicing physicians in my various training programs I
learned how to live and breathe medicine and psychiatry 24 hours a day. Always
thinking about it, never far from a journal article that I wanted to read, and always
focused on how that translated to clinical practice – usually a very hard
problem I was seeing in practice. From the very first patient contact, the importance
of communicating with people in an empathic, unhurried and comprehensive way was obvious.
We cannot afford to lose that
transformative effect that medicine has on people. We cannot dumb things down for the business world
and make human biology less complex. I know there are many docs out there that
think like me. Whether we can unionize
or cancel MOC – we can never lose sight of the fact that we need to preserve a transformative
profession for the sake of future generations of physicians and their patients.
George Dawson, MD, DFAPA
References:
1: Bowling D 3rd,
Richman BD, Schulman KA. The Rise and Potential of Physician Unions. JAMA. 2022
Aug 16;328(7):617-618. doi: 10.1001/jama.2022.12835. PMID: 35900755.
