The Doctor Crisis

The Doctor Crisis

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the doctor crisis photoDoctors get blamed a lot these days — blamed for aversion to change, for obstructing innovation, and for being self-centered. This familiar litany asserts that in the nation’s drive to transform health care, physicians are part of the problem.

While it is undeniable that doctors are part of the problem in some places, it is equally undeniable that they are leading innovation in many places and must be part of the solution everywhere.

We may well be in the midst of the most unsettling era in health care and that turbulence is bone-jarring to physicians. We argue that there is a doctor crisis in the United States today – a convergence of complex forces preventing primary care and specialty physicians from doing what they most want to do: Put their patients first at every step in the care process every time.

Barriers include overzealous regulation, bureaucracy, liability burden, reduced reimbursements, and poorly designed care delivery systems.

On the surface the notion of a doctor crisis seems altogether counterintuitive. How could there be a “crisis’’ afflicting such highly educated, well-compensated members of our society?

But the nature of the crisis emerges quite clearly when we listen to doctors. Ask about the environment in which they practice and you hear words such as “chaos,’’ “conflict,’’ and “dysfunction.’’ Based on deep interviews with doctors throughout the country, the research firm Harris Interactive reports that a majority of physicians are pessimistic about their profession; a profession Harris describes as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’

Have terms this extreme ever been used to characterize the plight of physicians in our nation? Burnout, chaos, conflict, dysfunction, minefield, under assault. How can the nation transform its health care system under such disturbing conditions?

The existence of the doctor crisis demands that the broad community of health care stakeholders recognize the import of the crisis and acknowledge that solving it is a prerequisite to achieving excellence in access, quality, equity and affordability.

Important steps toward a solution have already been taken and we will be writing about these in the weeks and months ahead. Innovative organizations are shifting the burden of non-doctor work to other team members enabling physicians to focus on more complex cases and manage population care while medical assistants, nurses, receptionists, clinical pharmacists all work to the peak of their considerable skill.

A foundational belief of this blog (and of our new book) is that fixing the doctor crisis is a prerequisite to achieving access, quality, and affordability throughout the United States.

Ridding the lexicon of the burnout-chaos-conflict-dysfunction-minefield-under assault syndrome requires not only recognition and acknowledgement of the crisis, but also a belief that solving the crisis is one of the most patient-centered steps we can take.

What Defines a Physician Today?

The evolution of the physician’s role in our society has accelerated rapidly in recent years. The days when a doctor’s responsibility to patients began and ended within the clinic walls are gone.

In the Information Age, physicians take responsibility not just for individual patients but also for managing populations of patients. Physicians serve as healers on a much broader scale than ever before.

At one time, the healer did his or her work in the exam room. The new healer works in a clinical team with electronic medical records, clinical registries, and a team of skilled staff.

The old promise was we are sorry you are sick and we will use our skill to make you well. The new promise is we will do everything we can to make sure you do not get sick in the first place, but if you do get sick we will provide compassionate care that is supported by the best available knowledge and science.

In our new book, The Doctor Crisis, we define the new physician role as that of a healer, leader, and partner. This is an ambitious and necessary expansion of the doctor’s portfolio taking responsibility for all six of the Institute of Medicine’s essential elements of quality – care that it is safe, timely, effective, efficient, equitable, and patient-focused.

Is this fair? Is it reasonable to ask doctors to become something more than they have been? Most physicians already feel overwhelmed–understandably so. They are asked to do too much in a system that too often thwarts their efforts as much as it enables them.

We will blog about physician as leader and partner in the coming weeks, but we want to emphasize that physician as healer possesses the strong clinical skills needed to deliver excellent care in a compassionate, healing way. In many ways, physician as healer embodies many aspects of the traditional definition of a good doctor.

The healer role extends from the patient to his or her family and recognizes both the physical and emotional issues at stake. The healer acknowledges that great clinical care must always be patient-centered and that shared decision making with the patient is essential. The healer understands the concept of nothing about me without me.

Skilled healers are deeply knowledgeable about the best practices for the most common ailments, and they apply standard work–proven, reliable treatments–in such cases, knowing that it is safer and more reliable and that unwarranted variation means care that is not only suboptimal but also unnecessarily expensive.

Healers also know that many of their patients do not fit easily into a best-practice category. These doctors are skilled at personalized, customized care for each individual patient who needs it.

Our colleague Dr. Amy Compton-Phillips of Kaiser Permanente sums it up well: “Skilled healers–no matter their specialty–take care of the person, not the problem. Orthopedic surgeons, for example, are not physicians for a body part. They are physicians for a person. This is complete care. It’s when physicians across the spectrum take the position that a healer’s role isn’t to heal a problem, it is to heal a person.”

Jack Cochran, MD, FACS(@JackHCochran) is executive director of The Permanente Federation, headquartered in Oakland, California.

Charles C. Kenney is a former reporter and editor at the Boston Globe and author of several books on healthcare in the United States. 

Cochran and Kenney are authors of The Doctor Crisis: How Physicians Can, and Must, Lead the Way to Better Health Care. Both write about physician leadership at kp.org/physicianleader, where this post originally appeared.

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52 Comments on "The Doctor Crisis"


Guest
Barry Carol
May 14, 2014

I’ll contribute my patient’s perspective here. My primary care doctor is part of a six doctor group practice. They all use electronic records and are part of an ACO. I like electronic records conceptually but I know the docs complain a lot about them especially when the system doesn’t function smoothly. The most important thing for me, though, is that I get to see the same doctor each time I come in. I like him and he knows me. I wouldn’t like it nearly as much if I had to see whichever doctor was on duty that day which may be how some of the large HMO’s work.

With respect to managing population health, I think a lot of this work gets done by support staff with the help of electronic records. One example is sending out reminders that it’s time for a checkup or screening. Another might be an in home assessment by a nurse to determine what support is needed or to teach patients and family members to monitor weight, blood pressure and other metrics.

Maybe doctors spend some time answering e-mail inquiries from patients which may eliminate the need for a visit in the office. That doesn’t mean that the doc doesn’t give his full attention to the patient in front of him when he has a patient in front of him. A Brian notes, patient health and population health are not mutually exclusive concepts. I do think, however, that a salary plus bonus compensation model is better than fee for service for managing population health and it’s also better if we want to let NP’s handle the easier cases and focus doctors’ time where his or her expertise can add the most value.

Guest
May 14, 2014

Clearly my primary responsibility is to my patients, but that noun is plural. I should be looking at entire population of my patients, not just the one who happens to be sick enough to be contacting me. We are called to do population health, not public health. The problem, of course, is that we are (in the system as designed) not rewarded for this at all. That’s one of the main reasons the system must be changed in a major way. It’s far better for me to be available to interact with my patient population and to initiate that contact when care is needed than to wait for people to get “sick enough” to merit a visit. Even after a year of direct care practice (which emphasizes preemptive care), my patients still have a hard time grasping that they don’t need to get “sick enough” to see me.

Guest
Granpappy Yokum
May 15, 2014

Increasingly, direct pay looks like the only way to practice medicine that is free of conflicts of interest. Hey, isn’t that how lawyers, accountants, and other professionals keep their noses clean? The rest of us are in an ethical cesspool that is only going to get more polluted.

Guest
Perry
May 15, 2014

If you want to see FFS abuse, just look to lawyers. If docs charged like that the country would go broke.

Guest
May 15, 2014

Granpappy, the more salient issue is how the physician/organization gets paid. If they’re still on fee-for-service, the dominant payment paradigm, there is a financial incentive to deliver unnecessary services.

A better model has emerged in the clinic sector, including in my firm, that passes through the operational costs with no markup. This removes the clinician’s financial stake in the care delivered, and liberates them to practice the most appropriate care. Then there is a per employee per month management fee to cover the costs of administration, marketing, IT and margin.

This model moves a clinician from getting paid to deliver more products/services to getting paid to manage a process. Big difference that creates a financial incentive to drive appropriate care, not only in the primary care setting, but downstream throughout the continuum.

Direct Primary Care models may also be disconnected from a larger network of services that are critical to meet the comprehensive care needs of patients, making it difficult to steer to the best care options. Most are not mature care alternatives.

Guest
Granpappy Yokum
May 15, 2014

“there is a financial incentive to deliver unnecessary services”

But isn’t that how every other profession works? And every other business? And isn’t that how just about all the healthcare systems around the world that produce better results work?

Do you really think primary care docs are churning their patient panels to generate more E&M codes, as that’s about all they get paid for? Even if some do, that’s an infinitesimally small drop in the bucket.

The problem isn’t FFS, it’s a FFS system that’s totally corrupted by the RUC, the hospital-industrial complexes that demand highway robbery fee schedules, and the insurers that willingly cooperate.

Guest
May 14, 2014

Thanks for your comment, Perry. Of course small practices by deeply committed PC physicians are still desirable. I certainly have never disparaged those. My own physician of 25 years is in a practice like this, and I receive excellent care.

But the fact remains that, probably like your doctor, he’s busy tracking all of his patients’ care gaps and other concerns so he can try to stay ahead of their issues. That’s the real core of population health management. You don’t need a big staff to do that and, in fact, we have a relatively streamlined clinical operation.

In other words, in medical management as in most things, the trick is to work smarter, not harder.

Hope this is helpful.

Guest
Perry
May 14, 2014

Brian,
Can it be that there are many types of care models that can be helpful and appropriate for patients? I can certainly see the value of the PCMH for all around care, but let’s face it, how many small practices can really afford to provide this? Are the traditional small practices not acceptable anymore?
For instance, my primary care doc is a solo practitioner with a small office and few employees. Her office is nice but nothing fancy. She sees a full spectrum of patients from insurance to Medicare, and probably Medicaid also. She still does hospital rounds. I don’t see her being able to provide a huge roster of clinical staff to have a PCMH, but she seems to provide good care and her patients like her. Is she a bad physician because she retains the old-fashioned practice model?
If all the solo docs left and sold out to hospitals, then we’re left with large organizations providing care. Maybe that’s where all this is going, but I fear it will be akin to Walmart care instead of a medical home with a doctor you like and with whom you can establish a rapport. I don’t think the PCMH model has been perfected either, but does that mean we throw that out too?

Guest
May 14, 2014

Allan,

I am an owner an Principal in a primary care/medical management company that employs many primary care clinicians, both physicians and nurse practitioners, and that manages the care of many employees and their family members.

The two things – care of the patient and management of the population – are complementary rather than mutually exclusive disciplines. The failure to properly attend to one or the other degrades both the patient experience and outcomes. Mission-driven professionals and organizations that are focused on obtaining better health outcomes at lower cost must be able to attend to both the individual patient and the group in the course of their work.

This is not just my view, but the prevailing view within the patient-centered medical home and medical management communities. It is not just an insurance/health plan view, but a clinician perspective.

Guest
Allan
May 14, 2014

@Brian: “I am an owner an Principal in a primary care/medical management company”

As an owner you look at things differently than what a medical practitioner should be looking at. That is what you are supposed to do and I appreciate your efforts.

The physician, however, is supposed to look at the patient at the bedside and only the patient at the bedside. Anything else infringes on the doctor/patient relationship where trust is a major issue. When the patient sees divided loyalties his trust is reduced and that can even elevate healthcare bills in the long run.

“care of the patient and management of the population – are complementary ”

Yes, they are somewhat complementary, but not at the patient’s bedside. Those two items that you call complementary represent a big conflict of interest. What the physician chooses to do with that conflict is up to him and his ethical standards.

“Mission-driven professionals and organizations that are focused on obtaining better health outcomes at lower cost must be able to attend to both the individual patient and the group in the course of their work.”

The above is another conflict of interest waiting to happen and it does all the time. I’ll add another one of many problems, economic credentialing.

You claim your view “within the patient-centered medical home and medical management communities.” is a clinician perspective. It becomes that only after the physician recognizes that his actions at the bedside need to meet commercial needs rather than the needs of the patient.

Guest
Granpappy Yokum
May 14, 2014

Believe it or not, lawyers have a much clearer code of professional ethics: the ABA makes it clear that they are representing ONLY their client. Yet the posters here are telling doctors they they have to juggle the various interests of the patient, the other members of the “panel,” the insurer, the ACO, the doc’s for-profit employer, the good of society, and . . . Impossible.

Guest
May 14, 2014

Actually, Allen and Granpappy, you have it exactly backwards. In companies like mine, we do not pay incentives for physicians to practice in any way except according to what the science says is best for the patient. Mainstream medicine departed from that long ago, pursuing what was best for the professional and the organization, putting the patient and purchaser last. There is a new crop of health care organization that is far more mission-driven and is focused on disrupting the institutionalized mechanisms of excess while driving appropriate care and cost.

When I refer to “managing a population,” what I’m really referring to is clinicians tending to all her patients on an ongoing basis. Sure, sometimes that’s “at the bedside,” but more often it is making sure that they get the right care at the right time in the right venue.

There is a lot written about how to do care better, and a lot of data showing what happens when you do. I’m not sure what kind of conflict of interest you think occurs when physicians tend to both the individual patients in front of them and those will be in front of them soon. But in a health care system overflowing with conflicts of interest, this is one situation where, in my experience, it is most unlikely.

Guest
Allan
May 14, 2014

@Brian: “Actually, Allen and Granpappy, you have it exactly backwards. In companies like mine, we do not pay incentives for physicians to practice in any way except according to what the science says is best for the patient.”

You can say that if you wish, but then you wouldn’t be engaged in managed care to any extent. One might think direct incentives are the only incentives around, but indirect incentives can be just as powerful. By the way who determines “what the science says is best for the patient”? Your company or the physician? There is a lot of dispute over what the science says and considering the fact that the science is generally dealing with one age group and one disease amongst numerous other things and the generalist might be working with patients from another age group with multiple diseases there is frequently no clear cut scientific guideline. Therefore, I ask again who makes that determination? If it is your company then surely incentives are involved.

You say “Mainstream medicine departed from that long ago, pursuing what was best for the professional and the organization, putting the patient and purchaser last.”, but physicians had many incentives aligned with the patient. Now insurers wish to put themselves first and the patient and physician last, but their incentives are not aligned with the patient.

This new crop you talk about comes around every decade or two until the warts become apparent and then we move onto another new crop. Understand I am not against insurers because I believe we need them and I find them very valuable, but let us not pretend in this environment that the insurers are trying to protect the patient. In this environment the patient needs an agent and the physician that is not held captive is one of the best agents the patient has. If the patient actually pulled the strings and chose the insurer or anyone else as an agent I would have no problem with that scenario. The problem is the patient is merely a pawn, a money machine, for all involved, but I believe a physician chosen by the patient makes a better agent than an insurer whose primary concern should be to their stockholders.

“I’m not sure what kind of conflict of interest you think occurs when physicians tend to both the individual patients in front of them and those will be in front of them soon. ”

That is not a conflict of interest until a third party becomes involved and starts to pull the strings. Then the physician has to choose between the economic benefactor (the insurer) or the one he is supposed to treat (the patient). Dollars are very strong incentives and it is the insurers that own the dollars.

Guest
May 14, 2014

Sorry Granpappy, but you’ve described an outdated view of the primary care physician’s role. Of course the doctor should focus on the patient on the table, but one of the widely acknowledged principals of an advanced medical home is that the team, including the physician, is thinking about the well-being and needs of all their patients, whether or not they’re standing in front of them. This is the best way to track, safeguard and help facilitate every patient’s optimal health.

Guest
Allan
May 14, 2014

@Brian Klepper”
What you are claiming to be outdated is not outdated. You might be confusing the “new” physician ethics with the old as seen in some HMO’s where the ‘pool’ becomes what the physician is treating at the bedside. As we have already seen that poses considerable danger and the suits against HMO’s and other medical institutions have proven that to be true.

Guest
Charles Kenney
May 14, 2014

Granpappy Yokum, What do you mean by “the herd?” Other patients? Do you believe that a physician and her team has a responsibility to work to make sure all patients in the panel are up to date on recommended tests and screenings? That patients with diabetes, for example, are managing well — perhaps with the help of a nurse and/or clinical pharmacist? Of course a physician has a responsibility to treat the patient in front of her in the exam room. But is that where her job ends?

Guest
Allan
May 14, 2014

@Charles Kenney:
The ‘panel’ involves a business mechanism and is not really a part of the actual ‘care’ provided though it might directly impact care so let us not confuse individual ‘care’ with ‘panels’. Of course the patient at the bedside should have adequate follow-up when he vacates the bedside, but that doesn’t mean that all members of the ‘panel’ require the same care.

Guest
Charles Kenney
May 13, 2014

Allan. Agree re: physician at bedside. But isn’t the doctor in a primary care practice responsible for a population of patients? Say, those with multiple chronic conditions, for example? And isn’t that doc responsible for working with his/her team to make sure all patients are up to date on all recommended tests/screenings?

Guest
Granpappy Yokum
May 14, 2014

That’s the thought-du-jour that is being forced down own throats, but it’s not true. The physician’s ethical responsibility is to the patient that she is treating at that time, and not to the herd. That’s public health, and to imply that it is the responsibility of the primary care physician is demean the value of the work done by those who specialize in that field.

Guest
Allan
May 13, 2014

At the bedside means active treatment of one patient at a time. (*non* judgmental in many respects i.e.: is the patient worth the cost?

I don’t get what you are trying to say. We recognize that physicians are not always at the bedside so other activities take place at other times. A doctor works with a patient first and with others if that is what is needed for the patient.

Guest
Allan
May 13, 2014

” physicians take responsibility not just for individual patients ”

I fear the good doctor has forgotten the understanding that a physician at the bedside is responsible to that individual patient and not the group.

Guest
SouthernDoc
May 12, 2014

You question “How could there be a “crisis’’ afflicting such highly educated, well-compensated members of our society?” As a primary care physician I can agree with the educated part. The highly compensated part is not so obvious when teachers often earn more per hour than physicians over a lifetime. More at http://www.bestmedicaldegrees.com/salary-of-doctors

Getting to valid conclusions requires beginning with valid assumptions.

Guest
Charles Kenney
May 13, 2014

SouthernDoc — Your point seems to be that doctors aren’t all that well paid after all. The document you cite suggests that doctors are paid 3 cents less per hour over their careers than teachers. Just so I understand: You contend that teachers earn higher pay than doctors, correct?

Guest
SouthernDoc
May 13, 2014

Doctor deserve a minimum wage!

http://www.thedailybeast.com/articles/2014/05/13/why-primary-care-physicians-need-a-minimum-wage.html

A few docs do very well if their family paid for their education, scholarship picked up the tab or made it into highly profitable niches. What confuses the public and many docs with minimal financial skills is the belief that upon their first big pay check they are rich and subsequently pick up a luxury car, a McMansion or other toys. What many miss is that unless they are beneficiaries of generation wealth transfer they will most likely be playing catch up a very long time.

Guest
Peter
May 12, 2014

@Peter1,

From your comments over the years one could make the
conclusion that you really dislike doctors and their income.
Making money doesn’t stop someone from wanting better working
Conditions. In addition, we all are on the hook for teachers outrageous pensions and bennies for the rest of their lives.

Guest
Peter1
May 12, 2014

So Peter, we all have to agree or we hate doctors? From your comments you hate teachers.

Guest
bird
May 12, 2014

docs did not create this crisis, nor do they feel they are the only group that is being abused, but since this is the health care blog it would only make sense to have more articles on the doctor crisis. but there is a crisis and it was created by unnecessary insurance regulation and government interference to gain control of a large part of the gdp. the more they try to fix it the worse it gets. the doctor portion of the cost or medicine is not the issue, most docs pay around 60% overhead so we really only account for about 25% of the cost of health care and the rest is related to a bunch of parasites trying to gain some control.

Guest
Peter1
May 12, 2014

bird, don’t like the money that comes from insurance and its government regulations – go cash only. There, fixed.

When you take income from large institutions they want accountability. Get off the grid and free yourself.

Guest
Peter1
May 12, 2014

“More and more practices are liberating their physicians by having other well-qualified personnel take over duties that help reduce the burden of work on physicians. And increasing numbers of physicians are stepping up as not only healers, but as leaders and strong partners/teammates, as well. More and more doctors recognize that they must be the leaders to solve the doctor crisis.”

Then this “crisis” is self solvable and within the power of docs to fix? If that is so where is the crisis? As far back as I can remember docs have been the complaining profession. They are never happy – maybe they need professional mental help from other docs.

As for teachers my point was that docs speak as if theirs is the only abused profession – but teachers aren’t in a position to make the fix within teaching and don’t make the income to compensate. I guess the short of it is docs come across as whiners.

Guest
May 12, 2014

I agree that docs come across as whiners, and that does always bother me with this situation. Some patients come across as whiners as well, and I have to put my emotional response to their delivery and assess what they are actually saying. I think docs trying to sound like martyrs is a very hard sell to the general public. But as a PCP, I’ve seen the morale in my area, and I see a major crisis coming if the complaints are ignored. PCP’s are very likely to follow my lead and leave the system, and unlike me they are simply going to look to escape and make their money in peace (I am trying to build something that, if replicated, won’t tear the system apart like straight concierge care would do if widely embraced).

Peter, do not dismiss someone’s sentiment just because it comes across as whining. I honestly think meeting this true crisis with a dismissive, “just suck it up, you earn plenty” is like ignoring the anxious person having true cardiac angina.

Guest
Peter1
May 12, 2014

Rob, I’m with you on PCPs, under paid and appreciated. That’s why I question the use of the all inclusive “doctors” when describing a “crisis”.

Guest
May 12, 2014

Well, good on ya then. My dream (be it vague and distant) is that we make primary care so attractive that specialists consider going back to their initial training and do primary care. I’ve been contacted by a large number of medical students and residents who see DPC (working for patients, not payors) as a way to do the medicine they hope they can do. PCP’s truly do control the cost of care, given that specialists require our referrals for much of what they do and the remainder would be eliminated if we can keep our patients out of the hospital.

Guest
Charles Kenney
May 12, 2014

Peter1. Thx for your comment. We make a point above noting that “On the surface the notion of a doctor crisis seems altogether counterintuitive. How could there be a “crisis’’ afflicting such highly educated, well-compensated members of our society?”

When one listens to doctors — individually, collectively, via surveys — there is little doubt that there is a crisis in the profession. Yes, you are right, many doctors have nice, homes, cars, etc. They make more than people in many other professions — all true. Physicians also go through many years of medical school and training. Many physicians complete medical school owing hundreds of thousands of dollars in loans. Then, during their years of training they are not paid well to say the least.

Should doctors have to work in conditions where the practice structure is dysfunctional? Where they spend significant chunks of their time on administrative and other matters demanded by the bureaucracy? More and more practices are liberating their physicians by having other well-qualified personnel take over duties that help reduce the burden of work on physicians. And increasing numbers of physicians are stepping up as not only healers, but as leaders and strong partners/teammates, as well. More and more doctors recognize that they must be the leaders to solve the doctor crisis.

Re: your point about teachers. Certainly huge numbers of teachers work very hard and do magnificent work. And they are not paid as well as doctors that is true. But I don’t think that has anything much to do with the doctor crisis.

Guest
Peter1
May 12, 2014

“a profession Harris describes as “a minefield’’ where physicians feel burned out and “under assault on all fronts.’’”

All doctors – there are many types in different practices? The docs around here who work for large groups and hospitals make excellent incomes, live in big houses , drive luxury cars and can afford to send their kids to the best colleges.

Could we say teachers, “feel burned out and under assault from all fronts” but who make a pittance of what docs make?