Doctors look after the mental condition of others. Who would look after the doctors?

A number of health and professionals from other industries have been studied in recent years and many, not unsurprisingly, also show high levels of stress

A new study from Cardiff University has revealed nearly 60% of doctorshave experienced mental illness and psychological problems at various stages in their career. That is bad enough in itself, but what is much worse is that very few of the 2,000 surveyed said that they had sought help.

A number of health and professionals from other industries have been studied in recent years and many, not unsurprisingly, also show high levels of stress. Sadly, however, it seems that this failure to seek help is not a phenomenon that is confined purely to the medical profession.

Findings from the British Psychological Society and New Savoy, for example – reporting on their 2015 staff well-being survey – showed that nearly half of psychological professionals report being depressed, along with admitting feelings of being a failure.

Work again was a culprit, with 70% of those who responded saying that they were finding their jobs stressful. For both medical doctors and psychological doctors, therefore, the current climate in the NHS is not, sadly, a healthy one. Workers on the front line of care are becoming governed more and more by contracts and targets rather than by the imperative of caring for people. The threat of cuts, often presented as efficiency savings and the imposition of contracts on junior doctors are just two of many current examples.

Risk and resolution

Across the caring professions – medical, psychological, nursing, professions allied to medicine, and caring – there is, overall, a picture of worrying levels of depression and stress leading to low morale and burnout.

Burnout is something experienced by people who have been working on the front line of human services in a context where they are caring for, and committed to providing services to, others. Its features are a combination of high levels of depersonalisation – where a person no longer sees themselves or others as valuable – and emotional exhaustion together with low levels of feelings of personal accomplishment. This is exactly what we are seeing reported here in the Cardiff study.

The Cardiff study found that the likelihood of doctors reporting mental health problems differed between different stages of their careers: young doctors and trainees were least likely to disclose any problems. Female doctors were found to be particularly at risk of burnout, as were GPs and trainee and junior doctors.

Almost certainly, the reason why is stigma. People throughout society – particularly frontline professionals – are afraid of disclosing that they are having problems because they fear the repercussions and possible effects that disclosure may have on their careers.

This was also recently demonstrated in a wider paper by Sarah Clements of Kings College London who, with colleague Graham Thornicroft, carried out a meta analysis of 144 studies involving more than 90,000 people. Their resulting global report showed that although one in four people – both inside and outside the healthcare profession – in Europe and the USA have a mental health problem, as many as 75% of people do not receive treatment.

How can we care for our carers? 

What – if anything – can be done about this situation? Do we really want to consult with professionals who are less able to confront their own difficulties than we are? How can we help them confront their own issues to help others in society overcome the stigma?

There have been moves towards a more open mental health culture within the health professions, with some senior members of staff sharing their experiences. Retired GP Chris Manning, for example, has been greatly involved in the promotion of doctors’ psychological health and self-care after experiencing depression and burnout.

Clare Gerarda, former chair of the Council of the Royal College of General Practitioners, has also been a long-time advocate for doctors’ health and is the medical director of the practitioner health programme– a free and confidential NHS service for doctors and dentists who are experiencing psychological or physical health concerns. Additionally, Dr Gerarda established the Founders Group and Founders Network, a coalition working together to promote psychologically healthy environments within the NHS.

new Charter on Psychological Staff Wellbeing and Resilience was also launched recently by the British Psychological Society and New Savoy. Building on this, a collaborative learning network of employers in health and social care has been established and will have its first meeting on June 21 in order to begin working together to establish and maintain psychologically healthy working environments.

Fundamentally, though, there has to be a change in culture. People need to be able to speak freely about their feelings of stress and psychological needs – and be supported to seek help. I have tried, personally, to model this as the president of the British Psychological Society over this past year and have talked openly about my own experiences of burnout, stress, depression and bipolar disorder while working as a clinical psychologist.

It is my belief that this culture change could begin to be enabled for doctors, both medical and psychological, nurses, allied health professionals and all in the caring professions too, if senior additions and managers begin to talk openly about their own psychological health.

To do so is a sign of strength and humility.

How Doctors Are Treated Nowadays

A trader was going by boat. On the way, his boat started sinking. He saw a fisherman on a nearby boat and asked him to take him aboard and save him. He told the fisherman that otherwise he would drown and die. And that if he took him aboard, then he would give him all his property.

The fisherman agreed. Once the boat started moving safely towards the shore, the trader regained his senses and started repenting for having offered all his property to the fisherman. Then he told the fisherman that although he was ready to give him all his property, his wife would not agree to it, so he would only give him half of it, as he had to give the other half to his wife and family. For that he was helpless, as they also needed the property. The fisherman kept silent and continued rowing towards the shore. Then the trader wondered why he had offered him half his property. What great thing had he done by saving him from the river? It is his duty to ferry people across, and, after all, protecting others is only humane.

He was just doing his duty and would have committed a sin if he had not saved him. He had actually protected the fisherman from committing a sin. So he told the fisherman he would only give him a quarter of his property. The fisherman did not make a sound. Then, when they reached the shore, the trader gave him a five rupee coin and said “you take this. Have tea for yourself and get some biscuits for your children.’ The fisherman is the Doctor and the merchant is the patient and relatives. The boat was sinking means patient has come to the casualty due to some emergency.

They are ready to offer Doctor anything to save patient’s life. The boat safely started to move towards shore means the patient is stabilised by the doctor. At this point, Doctor is still being thanked because still a lot depends on him but they start thinking about money and billing at this point. They decide in their mind that they will not pay the full bill. The boat moves more towards shore means the patient is now in very good shape and being transferred from ICU to ward. The patient and relatives think there is nothing great a doctor has done. It was his duty. And doctor is going to get half of their property (bill).

So they decide that they won’t pay even that much. Now the boat is at the shore and patient is being discharged. Relatives and patient go to Doctor’s office and thank him and give him 5 Rs to buy tea for himself and say that he can even buy some biscuits for his children. Don’t you think this has become the ultimate destiny of a doctor nowadays? Share Your Ideas & Experience in this context.

Doctors today prefer short, summarised clinical takeaways

Majority of clinicians are neither interested nor trained to read and comprehend these exhaustive data, and use it clinically.

A more informed doctor is better positioned to make clinical decision and it subsequently results in overall improved healthcare. In conversation with ETHealthworld, Phanish Chandra talks about his attempt to enrich and empower the doctors by way of precise clinical content offered by Docplexus.

Today, there is no dearth of knowledge or information that a doctor may be seeking. Are there any gaps that you see and try to address them through Docplexus?

Our motto is to “Empower Doctors” in India and to do so, we have to consider several geographical and socio-economic factors that are different across the country. From our learning, we have worked and optimized on the following 4 concern areas, which if addressed can truly empower Indian doctors.

Content Format
There are currently 1 million+ scientific journals. Only 10 people are reading an average journal article. Moreover, a medical journal article is on an average 7-8 page long and full of statistical data. Majority of clinicians are neither interested nor trained to read and comprehend these data, and use clinically. In addition, in internet and digital age, the attention span is only 2-3 minute. You cannot read eight page long journal articles on your mobile phone in that period. What is more useful for a doctor is a short summary and clinical takeaway with which he can improve the patient outcome from very next day. We focus on exactly that format of information that doctors need.

Peer to Peer discussion based learning
There is a lot to learn by exchanging knowledge from peer group. What we have created with Docplexus is an online community for doctors of India, which is based on trust and where every doctor has a voice. The knowledge-based community discusses clinical cases and share their expertise. So the learning is both social and is fun for the participants.

Aggregation of information
The medical information available online is vast but is unorganized. For a doctor, it is extremely difficult to keep track of all source of reliable information and keep himself updated. The Docplexus editorial team takes that pain away by aggregating and presenting the relevant information for doctors in a timely fashion. At Docplexus, we have created a database of 4500 medical guidelines from different scientific bodies, which is a great resource.

Flexibility of Time and Space
Current offline CMEs and workshop have time and location constraints. With online format of CME and webinars on Docplexus, doctors can now access this content from the comfort of their location and at the time when they want to. In the age of consumer empowerment, a doctor must decide what information he wants to consume, and when he wants to consume at an affordable cost.

Tell us more about Docplexus? How did the idea originate?

I am from the family of doctors and many of my family members are doctors. My grandfather was a doctor and my sister is a Gynaecologist. Both younger brother and me chose engineering over medicine and went do earn our degrees from IIT. After a few years in his job, my younger brother Manish fell sick and we desperately tried to diagnose his illness. It took almost 8 months to find out that he was suffering from Neurocysticercosis. However, by the time he was diagnosed, it was too late. We lost him on an unfortunate day. It was a big shock for a family where many members were doctors themselves.

I wanted to do something in healthcare and I thought of harnessing technology to empower doctors for better diagnosis and treatment of patients. I could not save my brother but maybe I will improve the patient outcome for 100 million patients every year if I can help the Indian doctors treat their patients well. However, there were different sources of learning already, but I found there is a huge scope of improvement. I thought of creating an online community where we could make learning both social and fun for Indian doctors.

How is this platform different from other similar venues?

Facebook is for casual networking. LinkedIn is for professional networking but it does not focus on one domain. Quora is for discussion but it does not focus on a domain. What we have created is LinkedIn and Quora for Indian doctors.

Unlike other platforms, at Docplexus we exclusively focus on discussions related to medicine and health policy decisions. Our members too have been inclined to avoid casual discussions, discussions that are never going to help others to empower other doctors.

Secondly, with our strict registration process, we ensure doctors from Allopathy or Modern Medicine join the Docplexus. Cross-pathy is a big problem for both doctors and patients, and at any cost we want to avoid that. In this aspect, we are far ahead from other similar venues.

We are the only Doctors’ Network in the world where doctors have an option to either login from Android, iOS or desktop. In this age of consumer empowerment, we have ensured that doctors can make the choice of the way through which they would want to connect with their peers.

What are the challenges that you encountered in building this platform and how did you resolve them?

First problem was to convey our idea to our prospective users about the value of our platform and how different it was from other solutions and players in the market.

To solve this issue, instead of telling our users what Docplexus is, we invited them with limited membership initially to the platform and let them use it. They experimented on their own and once they had the experience, they found it useful. These early users became the biggest advocates our platform and invited others to join and then we started growing.

Another problem while building a platform and online community is like solving chicken and egg problem. Unless there are many people, no new person joins and for having many people already, you need people to join. To overcome this issue, we were very aggressive on acquisition side and we created an in-house editorial team to create and push engaging content from our side. Once we reached 25,000 doctors on the platform, it went into auto mode and doctors started engaging and producing content on their own.

How do you see the future of this networking in medical domain?

As mentioned before, the peer-to-peer based networking has many advantages and there is a lot to learn by exchanging knowledge from other practitioners. Building trust within and about the healthcare sector is the major challenge. That is why we have created Docplexus aimed to boost trust with knowledge sharing.

When every doctor’s voice is heard, solutions for many issues in both clinical domain and policy are easier to achieve. The knowledge-based community extensively discusses clinical cases and share their expertise. Learning has become both social and is fun for the participants.

Recently we have tied up with Academy of Family Physicians of India(AFPI). Our collaboration will give access to family doctors who are based in rural and remote areas and help them connect even with the experts and specialists in the big cities. Doctors in tier II and III cities and smaller towns and villages are biggest are the beneficiaries of our initiatives.

The medical domain is set to get the much-needed change where the gap between urban and rural healthcare will be narrowed much faster with our initiative.

How does this impact or empower a patient?

Almost every day 10 to 12 thousand doctors log on our website to learn medicine and manage their clinical practice well. Each doctor on an average comes in contact of 25 patients per day. Therefore Docplexus helps create better patient outcomes for 2,50,000 patients on daily basis.

Our ultimate vision is to empower each and every doctor of India so that they learn something new every day and treat their patient well that will ultimately lead to 100 million improved patient outcomes every year.

What are your future plans and how would you like to carry this forward at a time when technology is changing so often?

Though from future and strategic perspective it is important to plan for future, we believe in being future ready but making the best use of present. As Master Oogway in movie Kung-Fu Panda explains – “Yesterday is history, tomorrow is a mystery, and today is a gift… that’s why they call it the present”.

As a tech enabled company, we always focus on how best we can provide solutions, and what it takes to do that. We were mobile first from day one and we have always used the state of the art technology for implementing our solutions. It is very easy to be carried away with technology, as there is new buzzword every day.

For us it is the “healthcare problem” where we keep our focus without being emotionally attached to the technology used for providing solution. This certainly helps us keep ahead of the curve.

Money And Doctors, Shame Or Pride

Born to three generations of government employees, I was so full of ideology when I finished my medical school. I wouldn’t practice, I said. I would only serve the poor, I proclaimed; a good teacher would I become, I yearned. And so was it, over the next few years. I wasn’t unhappy at all. I had very few needs and no serious financial commitments. Life was good, and little things kept me happy. But over time, I started feeling uncomfortable. Was I doing enough? I fancied myself a good surgeon-to-be, and as and otolaryngologist, I needed technology to go a step higher. But that needed money. I decided to work for it, but also balefully remembered my classmate in school, a perpetual cynic, who told me once, without mercy- “soon, you will be just the same as everyone else- do things only for money, and rot inside”.

I so badly wanted to prove him wrong. Then, as if by sheer chance, I happened to watch a TV interview of the well-known psephologist. He said, and I felt it strike a chord inside me – “the middle class are often bought up thinking that making money is bad- we need to get out of it and understand that to make money well is actually satisfying and benefits a lot of people”. Voila, I thought- I can actually relate to that. Lets now fast forward thirty years. I now am a surgeon with considerable repute, have a really good, well equipped hospital, employ over a hundred people. No, I didn’t have any inherited wealth, I didn’t marry for money, neither did I have wealthy friends who would pitch in for me. I also didn’t, much to my childhood friend’s surprise, make money the wrong way. All of us here work to protocol, never prescribe a drug, or order a test unnecessarily, refuse more surgeries than we do and there’s a strict no-no to pharma funding of any kind. How was this possible?

There’s no magic here, no providential hand. Just a formula that can just as easily be adapted by anyone else with reasonable skill and a little bit of guts. Let me try and enumerate what made me do well. We must remember that for most of us, our only earning comes from the patient. This money is never given thankfully- illness is a burden and the expense related to it’s alleviation is given grudgingly. Understanding this basic equation must make us strive to make each rupee of that money count for the patient. So, the first recommendation from my side to an aspiring entrepreneur is to make sure that you give value. We have long been caught in a vortex of trying to undercut our charges to gain practice. It is a losing game. We have to add value, albeit slowly, for everything we do. A better waiting room, more efficient patient management, transparency and education, everything counts for the patient, and they would actually like paying for it. It is simple economics. If you intend to spend an x amount of money to increase the facility in your clinic/hospital, you need to spread it over the patients that you see now, and look at the increase in patient flow due to the better system to make your profits. You just can’t work the other way, it is foolish to invest heavily and think they would come pouring it just because the waiting room rivals a luxury suite.

The increase in your professional worth is what should give you profits. Let us take an imaginary scenario. There are often patients who present with a symptom that could be because of two different conditions. Doctor A, is cautious, ill trained and afraid of failure. He would investigate heavily, and when that too doesn’t give him enough clues, gives the patient medications for both conditions. The patient gets better, yes, but the doctor would never know which medicine has made him so. The spiral begins, and patients get investigated more and more, medicated more and more, side effects of treatment spirals and skill acquisition is minimal. Let us look now a doctor B. He is shrewd, well trained and is not afraid to experiment. He starts with the same uncertainty. He, by using an analytical, but yet unskilled brain, thinks in favor of one. He doesn’t investigate much because he trusts his instincts. If the patient gets better, he is elated- he is proven right. If he doesn’t, there’s always option 2. To prevent the discomfiture of an irate patient irked by the delay in treatment, he uses kind words and counseling to reassure the patient that he is only trying to avoid unnecessary medications and investigations. Over time, doctor B gets more and more skilled. He now has acquired that sixth sense which tells him what the patient might be having instead of over investigating. If the doctor B has entrepreneurial skills, he will now increase his charges. What the lab gets and what the pharmacy gets is now his. Money, now flows into the coffers, and a beaming patient praises the doctor. Doctor A is, unfortunately, still despondent.   The same goes for investing in surgical equipment.

If you think that a particular instrument would greatly add to your results, buy it, but do not look at charging for it every time you use it to repay your loans. It creates stress and stress reduces your results. You would buy a Laser, simply because the salesman would pitch in with a formula “Sir, you might have ten laser cases a month, so x times ten times twelve, your loans are over in so many years” It is a gambit we fall for. I would buy a Laser only if it significantly improves my results. I would never even advertise or boast about it. I would use that in my counseling for a surgery if I think its absolutely necessary. But I would increase charges over my entire operation list for the month to make sure I am not pressurized to use it when I don’t really need it. Thereby I have only marginally increased charges; I have no stress if I don’t have any laser cases for a month, and if I do get one, I do a pretty damn good job. And this creates more patients, while shouting from the rooftop that I have an expensive laser would only have created suspicion, and sometimes, jealousy. We have to prioritize our investments- I would rather buy a good equipment than say, a fancy car or a palatial house that I can very well do without. If my choice of the purchase was founded on good grounds, it is often that the house and the car would follow, even if you can’t really count on it! Similarly, we must understand that a well run professional medical establishment offers far greater returns that those fancy stock market juggle.

I was once told about this by some one who I consider my mentor and hold that close to my heart. My only real investment is my hospital- and if I retire, that should give me returns in decent terms for as long as I live. Another important lesson I received early on in life is from a senior neurosurgeon colleague. He once told me that it was a dangerous ploy to keep referral patients over 10%. It surprised me then, but the logic was irrefutable. Referrals are fickle. A doctor who refers to you can stop referring to you, even if he is not unhappy with you. But your patients, those who come to you for solace and comfort, are your real saviors. They bring more convinced patients who in turn, become your well wishers again. Many doctors spend a lot of efforts on placating the referees, little knowing that it is really not worth the effort. If you spend a quarter of that time with your own patients, the results are astounding. Nearly thirty years in practice, my referrals are still less that that magical figure. And I am in no way unhappy. A very good financial trick is to stick to the things you do best, or add someone to the team who would do something better than you. I have often seen people holding on to patients too long, and not referring out of fear of losing them. Referrals should be made early and to the appropriate person, not someone who calls you home for a weekend treat! Over time, you might lose friends, but keep only the good ones who value your intention. As I have surmised before, earning trust is worth its weight in gold, and nothing improves your stature more than the feeling you create that if you can’t do it, you will send them to someone who can.

You also need to plan a retirement. For many doctors, this is unthinkable. To prevent burn outs, and to improve your family and social life, this is of paramount importance. A simple formula is to calculate how much you need now, once your loans are paid off and then plan to have that over the next twenty years, giving 10% to inflation. So, after you have reached the fifties and if you’ve been successful, you need to delegate your practice to deserving youngsters who respect your principles of practice and think about a system which gives you a share of the practice you have so painfully built up. You should, at that time, put yourself at a premium. Reducing your consulting hours and increasing your charges will allow you to work less for the same amount of money. And, for your social responsibility to be satisfied, you can also use your free time, involving your family too, to do your mite to the society, what appeals to your heart. Finally, you need to invest in your health. Eating properly, exercising regularly and reducing stress will help you to enjoy what you’ve reaped. And for those unfortunate times when ill health can strike without warning, it is important to be properly insured. An ideal health insurance should cover even the costliest procedure done, and should cover your family too. I am currently insured for 95 lakhs, and feel safe under its umbrella, even if I don’t even have a health issue at present. It might look an overkill, but considering the peace of mind it offers- priceless.

Even more adequate should be your life insurance. This should give your family the same income even with you not being around. And do junk those policies that offer you a lot of investment benefit. The health and life insurance policies are useless for me if I am in good health and if I am alive- but I would rather be happy that I am healthy and alive! What made me want to pen this all down? Being a person who cannot resist being on social media for doctors, I see a lot of frustration and angst. I see many who feel that they are being hunted, victimized for no fault of theirs. I see people who feel that they do not receive their due. At the other end, I see the public who are critical, and out to malign the medical community for the wrong doing of a few. And there seems to be no way to make these radically different view points meet. It appears that the level of frustration is related to the failure of the medical profession to make it pay, and for the customers to realize what they are paying for. Let us not kid ourselves anymore- medical profession is just another profession, and it is no more noble than that of a lowly servant nor any worthier than that of a soldier. We have only one small difference- we aren’t in control of many things that we deal with. We deal with uncertainties and changing patterns of  ever increasing knowledge that rival most other professions. But we cannot, under the cloak of that nebulousness, neither wallow in self pity, nor puff out in artificial pride. We have to deal with this as a profession, and aim to give our very best, and by making sure we are doing so, to get in return what is due. Once we realize this, most our our helplessness should disappear. I do not consider myself a special person, and I do not ever want to think I am indispensable to many. I am here to do a job as best as I can, and with that, take my due. No one, I think, should ever suspect that I am taking more than I could, or attempting to do more than I should. This is all that I ever need.

Why Doctors Are Sick of Their Profession

American physicians are increasingly unhappy with their once-vaunted profession, and that malaise is bad for their patients.

All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I’d be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals.

It could be just a midlife crisis, but it occurs to me that my profession is in a sort of midlife crisis of its own. In the past four decades, American doctors have lost the status they used to enjoy. In the mid-20th century, physicians were the pillars of any community. If you were smart and sincere and ambitious, at the top of your class, there was nothing nobler or more rewarding that you could aspire to become.

Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of 12,000 physicians, only 6% described their morale as positive. Eighty-four percent said that their incomes were constant or decreasing. Most said they didn’t have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether.

American doctors are suffering from a collective malaise. We strove, made sacrifices—and for what? For many of us, the job has become only that—a job.

That attitude isn’t just a problem for doctors. It hurts patients too.

In a survey of 12,000 physicians, only 6% described their morale as positive.
In a survey of 12,000 physicians, only 6% described their morale as positive.

Consider what one doctor had to say on Sermo, the online community of more than 270,000 physicians:

“I wouldn’t do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotguning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don’t need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a moneymaking game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade.”

The discontent is alarming, but how did we get to this point? To some degree, doctors themselves are at fault.

In the halcyon days of the mid-20th century, American medicine was also in a golden age. Life expectancy increased sharply (from 65 years in 1940 to 71 years in 1970), aided by such triumphs of medical science as polio vaccination and heart-lung bypass. Doctors largely set their own hours and determined their own fees. Popular depictions of physicians (“Marcus Welby,” “General Hospital”) were overwhelmingly positive, almost heroic.

American doctors at midcentury were generally content with their circumstances. They were prospering under the private fee-for-service model, in which patients were covering costs out of pocket or through fledgling private insurance programs such as Blue Cross/Blue Shield. They could regulate fees based on a patient’s ability to pay and look like benefactors. They weren’t subordinated to bureaucratic hierarchy.

Read more from The Wall Street Journal: Five Things To Know Today.

After Medicare was introduced in 1965 as a social safety net for the elderly, doctors’ salaries actually increased as more people sought medical care. In 1940, in inflation-adjusted 2010 dollars, the mean income for U.S. physicians was about $50,000. By 1970, it was close to $250,000—nearly six times the median household income.

But as doctors profited, they were increasingly perceived as bilking the system. Year after year, health-care spending grew faster than the U.S. economy as a whole. Meanwhile, reports of waste and fraud were rampant. A congressional investigation found that in 1974, surgeons performed 2.4 million unnecessary operations, costing nearly $4 billion and resulting in nearly 12,000 deaths. In 1969, the president of the New Haven County Medical Society warned his colleagues “to quit strangling the goose that can lay those golden eggs.”

If doctors were mismanaging their patients’ care, someone else would have to manage that care for them. Beginning in 1970, health maintenance organizations, or HMOs, were championed to promote a new kind of health-care delivery built around price controls and fixed payments. Unlike with Medicare or private insurance, doctors themselves would be held responsible for excess spending. Other novel mechanisms were introduced to curtail health outlays, including greater cost-sharing by patients and insurer reviews of the necessity of medical services. That ushered in the era of HMOs.

In 1973, fewer than 15% of physicians reported any doubts that they had made the right career choice. By 1981, half said they would not recommend the practice of medicine as highly as they would have a decade earlier.

Public opinion of doctors shifted distinctly downward too. Doctors were no longer unquestioningly exalted. On television, physicians were portrayed as more human—flawed or vulnerable (“M*A*S*H*,” “St. Elsewhere”) or professionally and personally fallible (“ER”).

As managed care grew (by the early 2000s, 95% of insured workers were in some sort of managed-care plan), physicians’ confidence plummeted. In 2001, 58% of about 2,000 physicians questioned said that their enthusiasm for medicine had gone down in the previous five years, and 87% said that their overall morale had declined during that time. More recent surveys have shown that 30% to 40% of practicing physicians wouldn’t choose to enter the medical profession if they were deciding on a career again—and an even higher percentage wouldn’t encourage their children to pursue a medical career.

There are many reasons for this disillusionment besides managed care. One unintended consequence of progress is that physicians increasingly say they don’t have enough time to spend with patients. Medical advances have transformed once-terminal diseases—cancer, AIDS, congestive heart failure—into complex chronic conditions that must be managed over the long term. Physicians also have more diagnostic and treatment options and must provide a growing array of screenings and other preventative services.

At the same time, salaries haven’t kept pace with doctors’ expectations. In 1970, the average inflation-adjusted income of general practitioners was $185,000. In 2010, it was $161,000, despite a near doubling of the number of patients that doctors see a day.

While patients today are undoubtedly paying more for medical care, less of that money is actually going to the people who provide the care. According to a 2002 article in the journal Academic Medicine, the return on educational investment for primary-care physicians, adjusted for differences in number of hours worked, is just under $6 per hour, as compared with $11 for lawyers. Some doctors are limiting their practices to patients who can pay out of pocket without insurance company discounting.

Other factors in our profession’s woes include a labyrinthine payer bureaucracy. U.S. doctors spend almost an hour on average each day, and $83,000 a year—four times their Canadian counterparts—dealing with the paperwork of insurance companies. Their office staffs spend more than seven hours a day. And don’t forget the fear of lawsuits; runaway malpractice-liability premiums; and finally the loss of professional autonomy that has led many physicians to view themselves as pawns in a battle between insurers and the government.

The growing discontent has serious consequences for patients. One is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners. Try getting a timely appointment with your family doctor; in some parts of the country, it is next to impossible. Aging baby boomers are starting to require more care just as aging baby boomer physicians are getting ready to retire. The country is going to need new doctors, especially geriatricians and other primary care physicians, to care for these patients. But interest in primary care is at an all-time low.

Perhaps the most serious downside, however, is that unhappy doctors make for unhappy patients. Patients today are increasingly disenchanted with a medical system that is often indifferent to their needs. People used to talk about “my doctor.” Now, in a given year, Medicare patients see on average two different primary care physicians and five specialists working in four separate practices. For many of us, it is rare to find a primary physician who can remember us from visit to visit, let alone come to know us in depth or with any meaning or relevancy.

Insensitivity in patient-doctor interactions has become almost normal. I once took care of a patient who developed kidney failure after receiving contrast dye for a CT scan. On rounds, he recalled for me a conversation he’d had with his nephrologist about whether his kidney function was going to get better. “The doctor said, ‘What do you mean?’ ” my patient told me. “I said, ‘Are my kidneys going to come back?’ He said, ‘How long have you been on dialysis?’ I said, ‘A few days.’ And then he thought for a moment and said, ‘Nah, I don’t think they’re going to come back.’ ”

My patient broke into sobs. ” ‘Nah, I don’t think they’re going to come back.’ That’s what he said to me. Just like that.”

Of course, doctors aren’t the only professionals who are unhappy today. Many professions, including law and teaching, have become constrained by corporate structures, resulting in loss of autonomy, status, and respect. But as the Princeton sociologist Paul Starr writes, for most of the 20th century, medicine was “the heroic exception that sustained the waning tradition of independent professionalism.” It is an exception whose time has expired.

How can we reverse the disillusionment that is so widespread in the medical profession? There are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.

The challenge in dealing with physician burnout on a practical level is to create new incentive schemes to foster that meaning: publicizing clinical excellence, for example (public reporting of surgeons’ mortality rates or physicians’ readmission rates is a good first step), or giving rewards for patient satisfaction (physicians at my hospital now receive quarterly reports that tell us how our patients rate us on measures such as communication skills and the amount of time we spend with them).

We also need to replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves, or pay for performance, which offers incentives for good health outcomes. We need systems that don’t simply reward high-volume care but also help restore the humanism in doctor-patient relationships that have been weakened by business considerations, corporate directives and third-party intrusions.

I believe most doctors continue to want to be like the physician knights of the golden age of medicine. Most of us went into medicine to help people. We want to practice medicine the right way, but too many forces today are propelling us away from the bench or the bedside. No one ever goes into medicine to do unnecessary testing, but this sort of behavior is rampant. The American system too often seems to promote knavery over knighthood.

Fulfillment in medicine, as with any endeavor, is about managing hopes. Probably the group best equipped to deal with the changes wracking the profession today is medical students, who are not so weighed down by great expectations. Doctors ensconced in professional midlife are having the hardest time.

In the end, the problem is one of resilience. American doctors need an internal compass to navigate the changing landscape of our profession. For most doctors, this compass begins and ends with their patients. In surveys, most physicians—even the dissatisfied ones—say the best part of their jobs is taking care of people. I believe this is the key to coping with the stresses of contemporary medicine: identifying what is important to you, what you believe in and what you will fight for. Medical schools and residency programs can help by instilling professionalism early on and assessing it frequently throughout the many years of training. Introducing students to virtuous mentors and alternative career options, such as part-time work, may also help stem some of the burnout.

What’s most important to me as a doctor, I’ve learned, are the human moments. Medicine is about taking care of people in their most vulnerable states and making yourself somewhat vulnerable in the process. Those human moments are what others—the lawyers, the bankers—envy about our profession, and no company, no agency, no entity can take those away. Ultimately, this is the best hope for our professional salvation.

Miraculous save: Doctors deliver baby after mother dies in car crash in US

After the accident, doctors performed an emergency cesarean section and delivered Sarah Iler’s daughter, Maddyson.
The newborn, who weighed 4 pounds and 15 ounces and was full-term when she was born, was immediately put on a ventilator. (Photo: Pixabay)

 The newborn, who weighed 4 pounds and 15 ounces and was full-term when she was born, was immediately put on a ventilator.

Cape Giraradeau, United States: Missouri doctors managed to deliver a baby whose mother was killed in a crash on her way to a hospital to give birth.

Sarah Iler and the baby’s father, Matt Rider, were headed Wednesday from Cape Girardeau, where they lived, to a hospital in Poplar Bluff, a city about 60 miles southwest where she grew up, when his SUV was struck by a tractor trailer, theSoutheast Missourian reported.

The collision pushed the SUV into the median, and Iler and Rider were ejected, Cape Girardeau police Sgt. Adam Glueck said Monday. Upon arriving at the scene, officers began performing CPR on Iler in an attempt to save her and the baby, but Iler was declared dead upon arrival at a Cape Girardeau hospital, he said.

Doctors, though, performed an emergency cesarean section and delivered her daughter, Maddyson.

The newborn, who weighed 4 pounds and 15 ounces and was full-term when she was born, was immediately put on a ventilator. She was able to come off of it on Friday.

Iler’s sister, Kasandra Iler, said Maddyson opened her eyes and grabbed a nurse’s finger. Still, doctors don’t yet know if she suffered brain damage due to lack of oxygen after her mother’s death, relatives said. A hospital spokeswoman would say only that the baby is in fair condition.

Matt Rider suffered extensive injuries but is recovering. He was flown to a St. Louis hospital with several broken bones. He has been upgraded from critical to fair condition, a hospital spokeswoman said.

Iler’s family has set up a account to raise $5,000 for her funeral expense. More than $4,200 had been raised as of Monday morning.

“She had her whole life ahead of her,” Iler’s mother, Patricia Knight, told the newspaper. “And now the baby has to grow up without her mother.”

Doctors Need A Life Too

This past week I caught a really bad flu on a day that was, quite unfortunately, my day in the emergency. Apart from the peaking fever, the thought of having left my colleagues alone, in a setting already scant of doctors, kept vexing me all day long. Such odd hours, when the only thing you can do is idle all day lying on your bed, pull into your mind certain gems of thought that are otherwise repelled by the bustle of daily life. This time, as I was compelled to take some time off the commotion doctors witness everyday, I realized how flat my life has become. It’s about everyday that my plans of reading Hume, envisaging my first book, giving 30 religious minutes to fitness and even writing a sensible blog post are killed off by the constraints of time. Still, I reckon myself to be in the relatively fortunate bunch. Around me, it’s no rarity to find young doctors witnessing a crescendo of frustration that culminates into sickness absenteeism. Today, as I found the picture below somewhere in my gallery, I was prompted to write this article. Couldn’t find the person who took the picture of this newspaper cutting- anyways, thanks to him/her for providing this timely thing:

To summarize the above for those of you who are having trouble with the print, the cutting adumbrates the stress that doctors in general, and internal medicine specialists, pulmonologists and anesthetists in particular, come across due to an acute shortage of specialists in the country, and which leads quite a few to alcohol and anxiolytics. The recent attempt at suicide by a resident doctor in KEM hospital, Mumbai, said to be frustrated over the inhumanly working hours, bespeaks the veracity of this report. To cite one more of it’s kind, the June 14, 2015 print of mint on Sunday, besides highlighting how Indian doctors are amongst the most stressed in the world, brings out impressively the way corporatization of healthcare imposes repugnant pressures to generate profits. And there are many more.

It’s one thing to lead a busy and responsible life, and I feel a rational and industrious mind would have no problem with it- but slogging away days and nights with little leisure in between and covering it up with a pretense of ‘sacrificing profession’ ain’t going to take us a long way. Anyone taking a closer look at medical professionals today, especially those in their early years, would recognize how extortionate working hours rob them of the flavor of life. Hobbies die out; extracurriculars get decimated; personal life, and often food and sleep suffer cuts. Do we need high toned, high fidelity research to convince us how calamitously this could affect healthcare? Even a primary school student would appreciate the need of diversion, in proportion with work, to balance physical, mental and spiritual energies. What surprises me is that we need to resort to strikes and walkouts to ring the ears at high places asking for this very fundamental prerequisite. It reminds me of Robert Owen, who would slogan ‘Eight hours labour, eight hours recreation and eight hours rest’ during the industrial revolution. Unsurprisingly, the application of this principle saw the industries scale up their efficiency quite convincingly, in comparison to the earlier 12-16 hour shifts.

Now, I believe there are few who would misspend their energies expecting 8 hour work days. Still fewer would find it sensible to draw comparisons with Western European nations with 35 and 40 hour work weeks. The widespread disregard for labour laws in our country, which mandate a maximum of 48 hours of work per week and atleast one weekly off, is something we have become immune to; it’s something that has been swallowed and digested by people over time. But the fact that we’ve taken it to such an extreme that we have no problem throwing resident doctors into over 100 hour weeks- while we simply cannot allow other professionals like train drivers (who require good mental acuity) to work for even half of that, is something that staggers me to my core.

Over and above, you have to subjugate your dread and work in an environment that affords little security from rampaging patients (which reportedly, has prompted 4000 Mumbai doctors to hire security covers). Ruckuses while dealing with VIP patients (and their cronies) are sadly so predictable that it keeps hospitals frequented by them from using costly fixtures and furnishing. And then, those who decide to take the already blustery road to a US residency are welcomed with shackles, attributed to rather half-baked figures of brain-drain. How long can one envision this to continue? Eventually, I can foresee the splendid image of the medical profession implode, sending forth a bitter bang that would resound across schools and colleges, precluding every top notch student from even thinking of taking up a career in medicine.

Don’t take this write up as a rant coming from a frustrated doctor, neither assume that I am trying to make my fraternity look like a martyred hero. There are plenty of reports and articles all over the media trying to put forth convincing figures, evidences and formal appeals regarding the travails doctors take due to ills like doctor shortage. I don’t intend to present another list of evidences; neither do I feel I’m the right person to cite them. I wish this article to let out a rather informal, close to the heart voice that conveys the terminal effect of the problems plaguing us today. We can’t keep shoving men into a system that would give a hard time even to androids. Laws, policies and logistics aside, the final link in healthcare is a soul dressed in flesh and blood, and to preserve it’s sanity should take precedence over every other consideration. It’s high time we do something to add zest to the life of the doctor- and prevent this profession from turning into a ramshackle, haunted house for the generation of students and doctors to come.

How Doctors Deliver Bad News

The doctor in the grainy video is standing up, shifting uncomfortably as he spouts medical jargon that members of his patient’s family don’t understand.


When the reality sets in—that their father and husband is dead—the family’s intense emotions fluster the doctor. He awkwardly suggests an autopsy before rushing away to respond to his chirping beeper.

It is a low-budget training video that Andrew Epstein, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, uses often as he teaches medical students the art of breaking bad news.

“If you don’t balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you’re at risk” of alienating patients and their families, Dr. Epstein tells a group of students at a training session last week.
Doctors are trying new ways of solving an old problem—how to break bad news, which is as much a staple of doctors’ lives as ordering blood work and reviewing scans. One issue: Patients and their families, of course, aren’t all going to respond in the same way. Research into the effectiveness of training doctors in how to deliver bad news has turned up mixed results, with patients often not noticing any benefit.

“How much do people want to know? What techniques should be used? It’s a moving target,” says Dr. Epstein, who is also trained in palliative medicine.

Among pointers his students are taught: Always deliver bad news in a private, quiet area. Ask patients what they already know about their medical situation and if it is OK to share the news you have. Use silence to acknowledge sadness or other emotions. Avoid medical jargon. Speak clearly but sensitively.

And empathize. “This is clearly terrible news that I have given you. I can’t imagine what you’re going through,” says Dr. Epstein, giving the students an example of empathetic statements.

The skills can also be useful in daily life outside medicine as most people find themselves at times having to deliver unwelcome news.

“Breaking bad news is actually a golden opportunity to deepen the patient-doctor relationship,” says Nila Webster, a stage-IV lung-cancer patient in Revere Beach, Mass. “For a doctor to be willing to be emotionally available is a tremendous gift for any patient.”

Ms. Webster, 51 years old, left the cancer center at Massachusetts General Hospital this year because she was saddened at how a doctor told her about a setback. A drug trial was under way at the hospital that might have helped her, but she was told there was no room for her.

The oncologist “suggested I go try a couple of other hospitals,” Ms. Webster says. “It was like this long relationship was over and the doctor was ready to pawn me over to another hospital.”

Dr. Andrew Epstein, left, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, leads a monthly seminar for medical students on how to discuss bad medical news with patients and their families. ‘If you don’t balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you’re at risk’ of alienating patients and their families, Dr. Epstein tells the students at a recent session. ENLARGE
Dr. Andrew Epstein, left, a medical oncologist at Memorial Sloan Kettering Cancer Center in New York, leads a monthly seminar for medical students on how to discuss bad medical news with patients and their families. ‘If you don’t balance out the physiological basis of disease and treatment of disease with the psychosocial side of medicine, you’re at risk’ of alienating patients and their families, Dr. Epstein tells the students at a recent session.
Perhaps no specialty deals with having to break bad news to patients more than oncology. One study estimated an oncologist breaks bad news as many as 20,000 times over a career. Patient and family reactions can run the gamut from extreme sadness and weeping to shock and disbelief to anger. Some doctors tell of patients—or more frequently their family members—punching walls, yelling at them or even threatening to shoot them, in extreme cases.

“Often what happens is clinicians just keep talking and it’s just white noise for the patient,” says James Tulsky, chief of Duke Palliative Care at Duke University. “You need to attend to the fact that this is really serious news and attend to the emotion.”

Dr. Tulsky is one of the developers of VitalTalk, a nonprofit that trains medical professionals in communication skills and empathy, with the aim of developing healthier connections between patients and clinicians. He says doctors delivering bad news should be brief, clear and to the point. “Pause after delivering the bad news. Allow the patient to process that. Generally the patient should be the first one to speak after you deliver the news.”

At Sloan Kettering, Dr. Epstein’s session includes teaching two mnemonics, acronyms often taught in medical school to help students remember information like treatment protocols. One mnemonic he uses is SPIKES, aimed at helping doctors break bad news to patients, and NURSE, for exploring emotions. Dr. Epstein said he includes the memory prompts “because I think we need all the help we can get.”

(SPIKES stands for setting, patient perspective, information, knowledge, empathize/explore emotions and strategize/summarize. NURSE stands for name emotion, understand, respect, support and explore emotions.)

Kate Hogan Green, on right, holding Lorelei, decided to continue with the pregnancy despite learning the baby had Down syndrome. But she says she left her perinatologist after being abruptly told the fetus had a separate, fatal condition. The condition eventually cleared up, and Lorelei is now 14 months old. On the left are Ms. Green’s husband, Bryan, and 3-year-old Adelaide.
Kate Hogan Green, on right, holding Lorelei, decided to continue with the pregnancy despite learning the baby had Down syndrome. But she says she left her perinatologist after being abruptly told the fetus had a separate, fatal condition. The condition eventually cleared up, and Lorelei is now 14 months old. On the left are Ms. Green’s husband, Bryan, and 3-year-old Adelaide.
Kate Hogan Green, of Westerville, Ohio, was 12 weeks pregnant when she learned she was going to have a baby girl who had tested positive for Down syndrome. The 40-year-old decided to continue with the pregnancy. At 18 weeks she saw a perinatologist who told her at an ultrasound appointment that her baby also had nonimmune fetal hydrops, a separate condition in which fluid accumulates and that often results in death.

“I’m sitting there with jelly on my stomach and he’s telling me the baby has this condition. I didn’t have a clue what that was,” she recalls. “He said the baby will likely not survive. He said that we could terminate.” Ms. Green recalls being handed scratchy paper towels as she sobbed.

She switched specialists and about a month later the fluid cleared up. She now has a 14-month-old daughter, Lorelei Clair Green, who has Down syndrome.

A 2011 study in the Annals of Internal Medicine found that giving oncologists feedback on recorded conversations they had with patients made them twice as likely to use more empathic statements in future talks than were doctors who didn’t receive feedback. Patients also reported greater trust in the doctors who had gotten feedback. The study, led by Dr. Tulsky, involved 48 oncologists and 300 recorded conversations with patients.

However, a 2013 study found that doctors and nurse practitioners who received communication-skill training focused on end-of-life care were rated no higher by patients than medical professionals who didn’t receive the training. The study, published in JAMA, included 391 doctors and 91 nurse practitioners.

Another study, published online in February in JAMA Oncology, found the majority of about 100 cancer patients who watched videos with actors playing doctors preferred the on-screen physicians who relayed a more optimistic message. The finding appears to run counter to most doctors’ advice that bad news should be given sensitively but not sugar coated. The researchers said the study underscores the importance of doctors building a relationship with patients so delivering bad news doesn’t have too much of a negative impact.

Helen Riess, a psychiatrist at Massachusetts General Hospital, says she has seen the importance of empathy training for doctors. “I noticed that my patients were spending way too much time feeling upset after their medical visits,” she says.

Dr. Riess, who is the director of the hospital’s empathy and relational science program, founded Empathetics, which offers online empathy courses. The training includes interpreting and managing patients’ emotions through facial expressions and body language. It also teaches doctors how to manage their own emotions during serious patient discussions. “Delivering bad news unsettles everybody, not just the patient,” she says.

Are Doctors Being Exploited?


Physicians have seen their incomes fall, their clout with insurers shrink, and their practices weighed down by a plethora of new requirements. As some doctors see it, this is the direct result of exploitation by payers, hospitals, policymakers, and other groups that have become more powerful than their own profession.

Some say the lower payments and new requirements are the natural result of a society trying to reduce national healthcare costs. But others, including many doctors, say that too much of the burden is being foisted onto physicians. Some reasons cited: Doctors have no way to fight back; they’re not going to refuse to treat patients; some people resent doctors making “too much” money and feel that they should earn less.

What are some of the forces making it so tough on doctors? Here, these physicians explain how they feel that medicine has been taken to the cleaners and what might be done about it.

Problems Trying to Increase Reimbursement

Payers have forced physicians into a flawed business model that is starting to really hurt, said Jerry D. Kennett, MD, a cardiologist at Missouri Heart Center in Columbia, Missouri. For practices, unlike in almost any other line of work, “there is no ability to modify what you charge, based on what your costs are,” he said. Medicare and Medicaid won’t allow physicians to negotiate reimbursement rates, and private payers have forced physicians to sign contracts that limit what they can charge.

Physicians have made do with this business model for many years, but in the past decade or so, costs have generally exceeded reimbursements for many practices, according to Dr. Kennett, the immediate past Chair of the American College of Cardiology Advocacy Committee. In the 2013 Medscape Physician Compensation Report,[1] slightly less than half of physicians felt that they were fairly compensated.

Jeff Goldsmith, PhD, President of Health Futures, a health policy analysis firm in Charlottesville, Virginia, has studied the divergence between physicians’ practice costs and income. “Each new federal initiative seems to require more paperwork,” he said, adding that reporting and billing requirements were a key factor in practices adding 165,000 new positions from 2007 to 2011, according to the Bureau of Labor Statistics.[2] On the income side, he noted that lagging reimbursements were coupled with a 0.9% decline in office visits from 2011 to 2012, according to IMS Health.[3]

One way to escape this downward spiral is “to move into the risk-taking space,” said Lawrence Kosinski, MD, Chair of the Practice Management and Economics Committee at the American Gastroenterological Association. He recommended that doctors explore alternative forms of payment, such as bundled payments and shared savings in Accountable Care Organizations.

Stripped of Negotiating Clout

Scattered in separate practices, most physicians have no clout when negotiating with insurers, said Jeffrey M. Kagan, MD, an internist in Newington, Connecticut. “Doctors never got organized enough to stand up to managed care,” he said, adding that other professions didn’t let insurers limit what they could charge patients. Dentists, for example, are still free to balance-bill the patient whatever amount insurance doesn’t pay, Dr. Kagan said.

A major payer commands so many patients that physicians can’t afford to walk away from them, he said. Insurers have been consolidating, reaching overwhelming market dominance. In 2012, the American Medical Association (AMA) found a significant absence of competition among health insurers in 70% of the metropolitan areas it studied.[4]

Lack of negotiating clout is forcing physicians to abandon small practices, said Steven T. Kmucha, MD, an otolaryngologist in a 4-member group in Daly City, California. This year he expects to leave his small group and find work in a larger organization. “Physicians are becoming more and more frustrated with trying to stay solo or in small groups,” he said.

The AMA has tracked a 22-point decline in the percentage of physicians in solo practices over the past 30 years, from 40.5% in 1983 to 18.4% in 2012.[5] “In the past, reports of the death of small practices were ‘greatly exaggerated,’ to quote Mark Twain, but it may be time now,” Dr. Kmucha said. Many agree. In a 2012 poll[6]cosponsored by Sermo, an online physician discussion board, 81% of physicians said they did not see a viable future for independent practice, a 19-point increase over 2011.

Dr. Goldsmith said physicians can find refuge in larger groups that have real negotiating clout, such as Atrius Health in Massachusettsand Hill Physicians in California”Doctors can keep some degree of independence within the larger group,” he said.

Another approach is to drop insurance contracts and open a concierge practice, charging patients a monthly fee. According to a 2012 survey for the Physicians Foundation,[7] 9.6% of practice owners were planning to convert to concierge practices in the next 3 years. Concierge practices, which often are solo or partnerships, could rejuvenate the small practice.

Turned Into Captives of the Insurance Industry

Rob Lamberts, MD, an internist in Martinez, Georgia, cut his insurers loose and opened a solo concierge practice in 2012; looking back, he wishes he had done it sooner. “Doctors have been turned into tools of the insurance industry,” Dr. Lamberts said. “You always work for whoever pays you. When you work for an insurer, you are constantly under pressure to do a lot of things that don’t improve the care of the patient.”

According to Dr. Kagan, one key way insurers exert their control over physicians is by requiring prior authorizations for certain therapies. These requirements often wear physicians down, and they’ll stop asking, the Connecticut internist said. He says he has to continually request prior authorizations for every MRI and CT scan, even though 99% are approved.

Sometimes the insurer requires him to have a peer-to-peer discussion with one of its physicians. “It ties me up and costs me money,” Dr. Kagan said, adding that he thinks insurers should have to pay physicians for the extra time they have to spend. In a recent study[8] in the Journal of the American Board of Family Medicine,researchers estimated that the mean annual cost of prior authorizations ranges from $2161 to $3430 per physician.

Pressured to Sell Healthcare as a Commodity

Mark Shelley, MD, a family physician from Port Allegany, Pennsylvania, decried what he calls the “commoditization” of healthcare. “The art of medicine has been turned into the business of medicine,” he said. “Rather than trying to make patients functional and happy, the physician gets caught up in financial issues, such as whether Medicare will pay for a wheelchair.”

Feeling unable to make an income charging for necessary services, some physicians begin charging for procedures patients don’t need, he said. “Yes, you need to make money in order to see patients, but you shouldn’t see patients in order to make money,” Dr. Shelley said. “I know doctors who earn a lot of money and are absolutely miserable.”

Howard P. Forman, MD, a radiologist and a professor at the Yale School of Management in New Haven, Connecticut, has a different definition of “commoditization.” To him, it is about standardizing healthcare services as part of the trend toward healthcare consumerism — and he sees it as generally a good thing. “Someday we’ll treat physician services as a commodity,” he said, adding, “a commodity is basically interchangeable, like milk or gasoline, but it can also have great value, like gold or platinum.”

Pushed to Abandon Clinical Judgment

Dr. Shelley said insurers and other corporate interests have too much control of healthcare, and the result is that “the physician becomes accountable for what other people have decided.” A key example of this, he said, is forcing doctors to give up their medical intuition in favor of clinical practice guidelines, which are often used to determine prior authorizations, are embedded in electronic medical records, and are the basis of many pay-for-performance standards.

Rather than resort to guidelines, Dr. Shelley said he primarily relies on his intuition when diagnosing patients. If he is not satisfied with that, he said he reverts to analytic methods, such as ordering tests and consulting guidelines. But he sees this as an awkward and time-consuming way to approach clinical problems, “like having your car in 4-wheel drive all the time,” he said.

Moreover, he said practice guidelines have to be interpreted because they are often off the mark. Several studies[9,10] have questioned the validity of guidelines, and close to half of doctors in a 2012 Medscape survey[11] said quality measures and guidelines would have a negative impact on care.

Dr. Forman, on the other hand, supports guidelines and is skeptical of intuition. “There was a time when we allowed physicians to act like artists,” he said, but in the future, “practice styles will be more equal. Everybody will be expected to have basically the same diagnosis and treatment.”

Dr. Kennett, the Missouri cardiologist, said he supports voluntary use of clinical guidelines. “I’m a fan of appropriate use of clinical criteria — not for every single thing you do, but mainly for high-cost, advanced treatments,” he said.

Under Hospitals’ Thumb

In a 2011 survey[12] of final-year medical residents, conducted by the recruitment firm Merritt Hawkins, 60% wanted to be employed and only 1% wanted to go into solo practice. Hospitals, in particular, have been a magnet for these young physicians. In 2012, almost 30% of physicians worked in practices partly or wholly owned by a hospital, according to the AMA.[13]

Dr. Shelly thinks employed physicians are at risk of being co-opted by the hospital’s interests. “Their actions have to reflect the will of the organization,” he said, adding that an employed primary care doctor is expected to refer to the hospital’s own specialists.

Dr. Kennett said he is concerned that young employed physicians “expect predictable hours and outpatient practice only” and gravitate to “shift work.” Rather than following patients through treatment, they are happy to hand them off to the next physician, and that’s “a bit disappointing,” he said. Many physicians share these views.

Shunted Aside by Policymakers

Many physicians feel strongly that policymakers haven’t been listening to the physician perspective.

The Affordable Care Act (ACA) is often cited as an example of when policymakers turned a deaf ear to physicians’ interests. As many physicians see it, the law lacks substantive tort reform, failed to repeal the sustainable growth rate, and doesn’t seem to improve healthcare. In a 2013 survey[14] by the publishing company Wolters Kluwer, 62% of physicians thought the law would either have no impact or negatively impact patient care and outcomes.

Feeling powerless in the lawmaking process, “physicians fear what the ACA could lead to,” said Wayne Lipton, managing partner of Concierge Choice Physicians in Rockville Centre, New York. “They are concerned about more government involvement, such as a mandate for participation in Medicaid or Medicare.”

Who’s Advocating for Physicians?

If it’s true that physicians are getting a raw deal, who can protect them from further abuse? Many doctors have soured on the AMA for supporting the health reform law, though the national doctors’ organization did have some reservations.[15] A 2011 poll[16] of physicians by the recruitment firm of Jackson & Coker found that 77% disagreed with the AMA’s position on health reform, and 74% disagreed with the statement that the AMA is “a successful advocate of physicians issues.”

The 166-year-old organization has been patching up relations with its critics, and in the past 2 years it has turned around an enrollment decline that followed passage of the ACA. But Dr. Kagan believes that the organization has enormous challenges ahead. Although he recently became a member, he feels that the AMA would have a hard time improving reimbursements, even though “one role of the AMA is to lobby for higher Medicare fees.”

Dr. Kennett fears that many employed physicians might drop membership in organized medicine. He warned that groups like the American Hospital Association (AHA) won’t serve them well. “With all due respect to the AHA, they are going to be lobbying first and foremost for hospitals,” he said.

By contrast, Alexander Ding, MD, a young radiologist who recently started employment at a large group practice in the Bay Area, believes that employed physicians will stay with organized medicine. In a hospital, “there will be times when employed physicians will butt heads with leadership and will need to go to the AMA or their medical society,” said Dr. Ding, who served as a resident trustee on the AMA board and now is on the board of his county medical society.

As physicians look toward the future, Dr. Ding said the AMA’s nationwide perspective would serve them well. “Most doctors across the spectrum feel a sense of disempowerment,” he said. “They feel like they’re running on a treadmill. They don’t have the time to step back and view issues at a higher level.”