This is my annual Labor Day greeting to my physician
colleagues. I had to go back and look at last year’s greeting to see if I had
factored in the pandemic or not. It
appears at the time that I was fairly enthusiastic about telepsychiatry and its
applications during the pandemic. Ironically, I will be giving a presentation
on telepsychiatry later this year and in reviewing a fairly massive amount of
information my initial enthusiasm has been tempered. Although it appears to
have had a semi-permanent effect on the regulatory environment there are still
unanswered questions about its optimal applications. How it will be used by the
business community is also unknown at this point.
One of the articles I reviewed in New York Magazine
- outlined a pattern of questionable business practices at least as it was
applied to therapists. Direct interviews with therapists suggested that they
were being exploited by being paid much less than their going rate with the
expectation that they would be more available after hours and by texting.
Preliminary surveys indicate that there are psychiatric clinics popping up
looking for psychiatrists to staff telepsychiatry visits. There are many
unknowns about their practice. In another article, some employers were asking
therapists to see people outside of the state they were licensed and hope that
the regulatory environment would catch up with the employment practice. Those
are not good signs for the labor environment.
I noticed in my 2020 post that I had an initial drawing of
how the practice environment had changed and now that drawing has been expanded
and includes many more details. It captures most of what I have endured as
employed psychiatrist. I include a graphic below and hope that as physicians we
can reverse the trend at some point.
The pandemic has clearly been demoralizing for physicians
in general but much more for frontline acute care physicians responsible for
COVID-19 patients and their frontline colleagues in nursing and hospital
support. There has been a shortage of personal protective equipment (PPE),
beds, adequate ventilation, and supportive services. There have been deaths and
resignations compounding the personnel problem. As the staffing ratios worsen - the emotional stress is at an all-time high. Local disasters compound the
COVID crises in many areas. All the
descriptions I see indicated that the healthcare system will end up permanently
altered by this pandemic and probably not in a positive way. There seems to be
no effort to incorporate a public health approach into the current subsidized
business rationing approach that dominates American healthcare. That is not
only detrimental to physicians and their coworkers but also the public health
infrastructure in general.
A new dimension to the demoralization has been the misinformation
industry associated with the pandemic. Physicians trying to provide information
in good faith have been attacked and even threatened by some of the zealots
associated with or affected by that misinformation. That includes some of the
top experts in the world who have been active in research and teaching
immunology, epidemiology, virology, and vaccine production. Physicians are given the message that is up to them to communicate to the zealots and convince
them that the pandemic is real, it is a really a virus, and that immunizations
are the best approach. There appears to be no convincing a large group of people that wearing masks may reduce viral transmission even though that practice was widespread in the 1918 epidemic in the US and is currently widespread in many parts of the world. Physicians are getting the message that they have
to magically find a way to communicate with this group of people who have
rejected all of the usual channels.
It seems obvious to me that physicians are the only group
that are excluded from empathic communication. The expectation is that
physicians will be all-knowing, all understanding, and that somehow will correct
most of the anti-vaccine, anti-science, anti-expert, and anti-COVID sentiment
out there. I think that is a fairly naïve approach and what physicians need is
concrete help from politicians, community leaders, and regulators. Social media is gradually coming around but has responded at a glacial rate.
I also notice in my greeting from last year that I
commented on an APA Presidential Task Force on Assessment of Psychiatric Bed
Needs in the US. I saw no further
action and that and was not able to find it in a search. That potential bright
spot maybe on hold due to the pandemic, a lot also depends on the conclusions
if they are available.
Progress against the burnout industry has been maintained
but it is clearly a war of attrition. Physicians in general reject the idea
that burnout is due to some inherent personal deficiency and are more likely to
see it as the real product of an unrealistic work environment. In many cases
that unrealistic work environment has increased many-fold due to the pandemic
and all of the associated problems. I hear from physicians every day who are
able to exercise minimal self-care due to overwork and limited time away from
work. Weight gain is common due to unhealthy diet and no time for exercise. A
solution for some has been to leave those work setting behind even if it means
early retirement or taking an undetermined period of time off. Many physicians
who could easily have worked into their early to mid-70s are retiring at age
65.
Employers seem to be doubling down in this adverse
environment. I quit my last job in January 2021. Since then, I have been
actively looking for new positions. There has been a recurrent pattern of
highly leveraged job descriptions, that I would accept only if I really needed
employment. By highly leveraged I mean that the job description contains
anywhere from 20 to 30 bullet points, the majority of which have nothing to do
with being a clinical psychiatrist. To cite one example, many of the
applications describe a “leadership role” where the really is none. No
organization that I am aware of wants a frontline clinical psychiatrist to
attempt to correct their obvious administrative problems. I received a cold
call one day from a recruiter who asked me if I was interested in a “very good”
inpatient position. I asked him what the productivity expectations were and he
said I have the options of seeing 18 or 22 patients per day. He quoted a
disproportionately greater premium for seeing 22 patients a day. He seemed convinced
that I would accept the position until I asked him “When am I supposed to live
or sleep?” I had the thankless job of covering inpatient unit of 20 patients
for an entire year with the help of an excellent physician assistant and that
almost killed me.
The unrealistic expectations being placed on physicians are
still out there and they are as bad as they ever have been. It is why I used a
heavy lifting graphic for this post again. Despite the pandemic the business
leverage against physicians is not letting up and that is not a good sign. To
make matters worse, there always seems to be room for it in the medical
literature. The latest example I can think of is a recent essay in the New
England Journal of Medicine claiming that digital healthcare
fee-for-service payments are unsustainable and there must be a capitated
system. That seems to be part of the master plan to continue a rationed-for-profit
system that guarantees over-employment of bureaucrats and business managers as
well as corporate profits at the cost of treating physicians like highly paid laborers as depicted in the above diagram.
I don’t think physicians will have any reason to celebrate
Labor Day, until that rationed- for-profit system is dismantled. Until then do what you need to do to take care of yourself and survive. Help from professional organizations would be useful, but there are too many conflicts of interest for that to be realized. I am still hopeful that we can get back to the stimulating clinical environment of the 1980s, but I will be the first to admit - there is no obvious path back in the face of a trillion dollar healthcare rationing business - largely invented by Congress.
George Dawson, MD, DFAPA
Graphic Credit:
Robert Yarnall Richie, No restrictions, via Wikimedia Commons. "Workers Adjusting Tracks, Texas Gulf Sulfur Company."
