Physician burnout widespread, especially among those midcareer, report says

It struck me as very sad, as I've heard similar things from other physicians.

We have to switch to largely seeing mid-level providers like PAs or RNs and maybe push even lower. The doctors can be there for the tough cases and to consult and monitor. It is already starting to happen and is one way we can reduce the cost of health care.

There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).

Maybe things will get better down the road, 20-30 years from now; But as it is now, a lot of the good paying companies will be very hesitant in hiring you once you're old enough.

My friends who are now doctors make much more money that I do, they are more respected, they don't have to deal with some annoying hierarchy, and their job is meaningful. As for working hours, it really depends on the speciality, and the hours they chose to work. I know some dermatologists who work 4 days a week for instance.

In the end, I don't regret that I chose a different path as I loved maths and programming and I did some interesting things as well. But nowadays I feel just like a worthless pawn, developing crappy programs, who is starting to suffer from age discrimination...

The more layers get forced in between the people providing a service and the people receiving the service, the worse things seem to get.

Ideally we would increase the amount of Medicare residencies too. Then everyone could get a residencie and we would also be able to import MD from around the world.

https://www.ama-assn.org/press-center/press-releases/ama-fun...

I have a feeling that your observation that, "Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives." is dead on.

Further I think the technology side really has to start servicing the physician. A GP's office doesn't have to be the place to get an ECG, and a GP doesn't even necessarily have to see the readout barring some kind of change over time. So much of that should be automated and/or done in specialized clinics. I know how it's complicated by data format standardization, privacy, security, and regulation but it's a shame that we can help doctors be more efficient. I will spare the rant about slightly (and slighty justified if I'm being fair) Luddite tendencies among physicians.

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"Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.

I know it's only anecdotal but my brother in law is a doctor at a large hospital (employed physician) and he sees patients 9-5 but he's at the hospital from 7am-8pm doing prep, research and patient notes. That also doesn't count the nights/weekends when he's on call for the ER (usually takes calls from home but occasionally has to go in too). He basically only sees his kids on the weekend.

I worked similar hours for a few years while coding and I expect he will (but hope he doesn't) burn out eventually. It's obviously not sustainable.

Is this still true?

It seems like the days of the independent physician are drawing to a close. Many independent practices have become physician groups which in turn have been bought by hospitals. (Perhaps specialists are still largely independent, but general outpatient medicine seems to have become largely corporate.)

Many physicians I know have a boss, and have to meet metrics about how many patients they see ever year in order to get their incentive bonus. Physicians who work for hospitals are viewed as "loss leaders", and find their appointment times squeezed to twenty, fifteen, or even twelve minutes per patient. (The idea is that for every n visits, a patient will be referred to a profitable service provided by the hospital.)

Independents likely have it easier as their EMR are less complex and they have fewer people to coordinate with.

EMRs in general have little to do with patient care. They are glorified billing systems.

I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.

If you see the same primary care physician and the same specialists (or is it just a random specialist in the US?), wouldn't that establish a long-term relationship with each? Plus your medical file should give any of them more context on your preconditions, history and general health.

(That's the case here in Israel and -- after googling -- the US too, but feel free to correct me)

So they’re applying “agile project management” then?

We need to open up the medical profession to competition and allow the # of doctors to meet the demand.

The problem with medicine is that you have a culture of perfectionism in a field where random bad shit naturally happens all the time, and there's a great amount of human suffering. On top of that, perfectionism helps a lot, in the short run, even though it may be toxic in the long run.

But, from what I understand, the number of residencies is the big choke point.

There is also the money. Sure you can train 10-100x physicians, but total compensation won't grow as fast, and so you should see lower overall wages (supply and demand). But it's still more complicated than that, because some people choose not to undergo X or Y procedure for various reasons, insurers don't cover or whatever. So even if you could train enough doctors to fulfil the whole population's needs, that doesn't mean you will have: 1. enough equipment, material, operating rooms, etc to do the procedures 2. enough supporting staff, and on and on.

The most common reason I hear from MDs against training much more doctors is the first one I gave you: less practice means a more dangerous practice.

My own opinion is relatively simple. Medical schools should stop screening applicants as much and let students join freely.

Medical schools are all about getting well-rounded individuals who did extra-curriculars etc. They usually view it as a good thing that you have life experiences outside of medicine, like working or studying an entirely different subject. However it works one-way: you can't (generally) just go to med school, learn the subject matter and then move on to another field, enriching _that_ one with your experience. I have come to believe that if we are to see any improvement, med school will have to open up just like every other discipline. The current system of stressing out students for a few years before even being allowed in the classroom is, IMO, partly responsible for the job dissatisfaction that you see.

Now freeing up med school admissions does not mean allowing everybody to _practice_ medicine. Prospective students would actually get a chance to learn the material for a few years before having to interview for internships. So instead of filtering _before_ med school and forcing a huge sunk cost psychological barrier to students, you can let the students figure out by themselves if they actually enjoy the subject matter. It's not a perfect solution but I am quite certain that society as a whole would benefit. It is entirely unfair that medical knowledge (not practice) is restricted to a lucky few.

Less than 80% of candidates match into a residency. That means 1 in 5 doctors are blocked from practicing.

Has this ever materialized? I thought it was the other way.

That's not necessarily a bad thing. Safety in herds and shared risk pools work to limit individual risk for physicians.

This can take the form of larger private practice groups like Kaiser Permanente's physician group (a distinct entity contracted with the Kaiser Permanente hospital/managed care corporation).

It can also take the form of NHS in the UK which employs the vast majority of physicians there and represents them in malpractice cases.

The risk inherent in medicine is real and has to be borne somewhere. Better by shared risk pools, however they are organized, than by individual patients or doctors.

From the consumer end I like this more because their new group has a wide variety of specialties so you don't need to keep filling out the same paperwork and they also can afford to maintain an electronic system so you receive text notifications for appointments and can make appointments online and such.

Now, does this differ from any other profession where we take on debt to get a degree in a profession that we don't like just to work that profession to pay off the loan? For the most part, no. I think the distinguishing feature for physicians is the debt is higher and it takes more years to get into a position to pay off that debt, so the exit point is farther away. I do think physician hours suck far more than most professions. I also think the profession is far more abusive than most white collar professions, but that's debatable.

This also makes physicians a target for every spending adjustment measure. Physicians are not the primary driver of cost growth in america: new procedures and changes in drug prices are (when was the last time an internist raised his prices 5000%? Never, because his reimbursement is set by Medicare). But they do write the prescriptions and orders and referrals. This means that the entire system converges on controlling physician activity.

This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.

So why are physicians burning out? Why are fewer and fewer "best and brightest" applying to medical school?

- Increased accountability with decreased authority. As the centerpoint for changes in documentation and prescription patterns, everyone is twisting physicians' arms to act in very precise ways, whether or not those ways are what the physician believe is good for the patient. Physicians get the scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!" "why are doctors doing Y?!" - and none of the power to actually decide any of this.

- Decreased authority in the hospital. Hospitals are suffering the invasion of the MBAs (and MPHs, and MHAs), and have more and more people with zero clinical knowledge setting policy. The big trend has been in nurses getting MBAs (and MHAs and MPHs) and going into administration, combining "I saw what doctors do from the side, I must totally know what's going on in their heads, right?" with MBA acumen. It's deeply problematic. "This patient has depression, and you didn't give them an SSRI! Malpractice! What's wrong with you?"

"This patient has multiple comorbidities that are more serious than their depression. I have them on medications for those comorbidities, and those drugs are all second-line therapies for depression. Time has shown that this combination has been effective for controlling their depression, and as a bonus, I avoided risking the side-effects of putting this patient on a third medication."

You cannot imagine the absolute pleasure of being regularly second-guessed by someone with a tiny fraction of your training. I imagine it's rather like a senior engineer having their code regularly criticized by someone that just finished "learn python in one week!". And they will then go to the EMR folks and have them add an alert, so that I can never place an order w/o SSRIs for a patient w/ depression without going through a whole Alert! rigamarole. There are so, so many alerts that alert fatigue is ubiquitous.

Additionally, in (fair) response to bad behavior of physicians in the past, nursing and other auxiliary services have moved into parallel reporting structures.

So, when patients are mad at something that has happened in the hospital, they call the doctor and yell at them! How could the hospital have done such a thing! I have no authority over the nurses that did it, or the nurse MBAs that made the policy, but I will get to take the scolding, the risk of malpractice suit (because patients don't sue over errors - they don't know enough medicine to identify errors - they sue over breakdowns in relationships with physicians), have zero authority to change or fix anything, and if I say a word, it's outside of my operational stovepipe and I will be both ignored and ultimately ignored by nurses. The latter means that my future care orders will be ignored or given low priority, and I can rely on that ultimately affecting my patients. So I have to keep my mouth shut over anything less than egregious problems.

- Increased time doing things unrelated to patient care. There's a myth that somehow all this new documentation is meant to improve patient care. It does not. The three major reasons have absolutely nothing to do with patient care:

---Many of the increases in documentation have to do with increasing specificity that strictly increases opportunities for error, and thus reimbursement denials.

---CMS wants increasing information on practice patterns, and wants to extract this from EMRs. Because they can't spend any money to collect this information (as I said above, they are required to be budget neutral), they shift this cost onto hospitals, which shift it onto physicians (it's worthwhile for hospitals to comply, because otherwise CMS brings out the reimbursement stick.)

---EMRs make billing more reliable, and reporting data to CMS more easy, and are required now as part of the ACA. EMRs are slow as fuck, because the end-user is not the customer. Their UIs are just fucking atrocious. There aren't words enough to relate how bad they are. Most can't even present lab results in a decent way.

The result is more documentation, done more slowly, for reasons unrelated to taking care of the patient in front of me - but that none the less take time away from seeing the patient in front of me.

And there is a constant media barrage about how terrible physicians are, which studiously ignores that 99% of the things they are describing and criticizing are systems-level issues physicians have no control over.

On top of all this, I have only rarely met a physician without a real sense of professional pride. That we are ordering tests we don't want to order, creating delays we don't want to create, hiring shitty front desk staff we don't want to hire, creating massively packed waiting rooms we'd rather not have, while patients are being bled dry by their pharmaceutical companies, all while working our asses off, getting scolded for it, and having trouble paying off our ever-growing student loans is... it's fucking heart-breaking.

It's heart breaking.

You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career." If anyone was willing to pay me my current salary to see a dozen patients a day rather than thirty, to give every single one of them the extended visit to collect a rigorous history and give them the scrutiny they deserve, I'd take it in a heartbeat.

You want me to be that doctor. I want to be that doctor. The delta between that, and what the system allows me to be, hurts us both.

Notice how people 65 and over have no issues getting their healthcare paid for. That group of voters has a very high voter participation rate.

And it's a well known fact that the extreme residency model was pioneered by a cocaine addict [1], but yet no progress has been made. It's fucking absurd.

1: https://en.wikipedia.org/wiki/William_Stewart_Halsted

[0] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS

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