OP-ED

The Doctor Crisis

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 replies »

  1. There is no “I” in team.

    There is also no “U” in deposition.

    Teams in healthcare are a complete joke as long as the doc’s name is alone on the signature line. When things go wrong, the so-called team vanishes and the doc is left by himself at the deposition table.

    No doc who has ever been through it (or even known anyone who has) will ever trust his fate to a “team” again.

    Fix that, and maybe teams can work as intended. Until then teams are just a way to get the use of the license while getting a sucker to draw all the incoming fire.

  2. This concern should gradually diminish as doctors get used to electronic records and come down the learning curve in how to work with them.
    I note that in East Germany, the drivers of the Wartburgs and the Trabants, good (East) German vehicles complained endlessly about them and did NOT get used to them. They are rotten little cars that did not survive reunification, to the cheers of the Eastern Germans.
    The free market is handling the doctors, if you look carefully. The “free market” is stating that there is a vast oversupply of physicians, and there is a flow away from the profession in retirement and taking on non-clinical jobs. If the “free market” were truly the free market, this would be proper. However, it seems to be a distortion of market forces consistent with a controlled economy. East Germans wanted cheaper cars for the proletariat – and they made them. The little two-cylinder Wartburg is famous for its awfulness. The Party Leaders, however, drove BMW’s and Mercedes….

  3. Your comment speaks to the complexity of the crisis and the need for a comprehensive system that supports doctors as healers, leaders, and partners so that together with our teams, we can deliver quality care that is accessible and affordable for our patients.

    Health care is a team sport. It requires great working relationships and collaboration – a balance between leading and sharing responsibility – between doctors, nurses, technicians, pharmacists, and others. Fostering support for medical team members to perform at their highest level of skill at the top of their license means that all members of the team have the capacity to address patient needs. This also enables doctors to focus on what they want to do most…care and heal.

    Alleviating the administrative burden, regulation, bureaucracy, are an important part of solution. You mention payment. Payment model reform is needed to ensure that we pay for value, quality, and outcomes, and reward the best clinical care and delivery. This changes our questions from, ““How often should you see a patient?” to “What’s the best way to monitor a condition?” And it allows us to deliver the right care, by the right person, at the right time, in the right setting.

    See “Complete Care At Kaiser Permanente: Transforming Chronic and Preventive Care,” an article by Kanter et al in the November 2013 issue of The Joint Commission Journal on Quality and Patient Safety. It provides an excellent overview of how comprehensive system redesign, integrated clinical information systems, decision support and workflows, and culture change support a collaborative approach to meeting patient needs and improving outcomes.

    Building in a way to measure how we do by looking at process and outcomes so that we can do better next time helps to evolve the culture. And, if we can spread the best learning, we can turn the best work anywhere into the standard everywhere.

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

  5. “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.

  6. 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.

  7. 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.

  8. @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.

  9. 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.

  10. 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.

  11. 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.

  12. 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.

  13. @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.

  14. 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.

  15. 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?

  16. 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.

  17. @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.

  18. @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.

  19. 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.

  20. 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?

  21. 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.

  22. 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.

  23. 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.

  24. 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?

  25. ” 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.

  26. 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?

  27. “However, there will always be unethical people looking to game or cheat the system so some documentation will always be necessary and it’s likely to be more onerous than the majority of honest doctors think is needed.”

    And this is the problem, the majority pay for the minority of bad apples. The problem is, it takes away valuable time from doing what docs are supposed to be doing in the first place.

  28. 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.

  29. 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.

  30. 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”.

  31. Can validate what Rob has said. I’ve spent spent the last three years listening to physicians about the possible alternative futures for their profession, and the overwhelming desire was exactly as Rob said- an overwhelming impulse to flee. There are probably more docs that want to be in a cash-only, no Medicare, no private insurance billing type practice than there are patients that can afford it.

    I think a big piece is generational. Almost 40% of practicing docs are over the age of 55, and another 30% between 45-55. A lot of that 70% were burnt to a crisp by the time they were fifty, burnt by a caustic mixture of mistrust, practice “friction” from the revenue cycle, and a numbing sense that their patients, despite their best efforts, continue killing themselves, and keep showing up in hospital and their offices for preventable reasons.

    Younger docs have attempted to escape burnout by seeking employment in hospitals or other places, shifting a lot of the logistical burden and financial risk to the institution that employs them. It isn’t going very well. If hospitals don’t do a better job of managing their practices than they did the last time they tried this (in the 1990’s), many of the newly employed docs will be irritated enough to look for alternatives in a few years, if they are not laid off before then.

    In the work I did for the Physicians Foundation in 2011-12, I urged physicians to create new practice models and new, risk-bearing structures that can create a safe zone for innovation and caring. I also urged an all-out assault on the wave of box checking and “core measures” that are drowning professionals in minutiae (see my blog below on Charting Day)
    through Commission on Administrative Simplification for Medicine.

    If leadership is going to emerge, it’s going to have to come from Gen X and Gen Y docs, in most cases, because I think a lot of their elders have given up and either retired, or fled into direct-pay as Rob did.

    It isn’t a pretty picture. . .

  32. 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.

  33. 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.

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

  35. Perry,

    Thanks for your response. I always appreciate comments and feedback from doctors who can provide a real world perspective.

    Regarding the NP’s, as a general principle, I think it’s best when care can be delivered as cost-effectively as possible in terms of both providers and settings. If NP’s can handle the easy cases, that’s fine. Hopefully, they also recognize the cases that need a doctor’s attention and don’t try to handle those themselves. Doctors should, of course, be paid appropriately and well. The salary plus bonus model may work better for them in the future than the current fee for service system. In more rural areas, where it’s harder to attract doctors due mainly to lifestyle issues, NP’s may be the only care available.

    On hospital consolidation, increased market power can indeed drive up prices per service, test, procedure, device, etc. I think there are ways for private insurers to create countervailing power, however, including tiered networks and reference pricing. Suppose, for example, that an insurer told patients that it would pay X for a specific procedure which equates to 115% of the regional Medicare rate. Let the doctors explain to patients why they expect to be paid 200% or 300% of Medicare when they already accept 100% of Medicare as full payment from a significant percentage of their patients.

    To the extent that documentation requirements can be identified as genuinely necessary as opposed to busy work, we should work to eliminate the busy work. However, there will always be unethical people looking to game or cheat the system so some documentation will always be necessary and it’s likely to be more onerous than the majority of honest doctors think is needed.

  36. @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.

  37. 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.

  38. “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.

  39. 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.

  40. “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?

  41. I agree, but many states are expanding regs for them to practice fully without physician supervision.

  42. the first line in the conclusion to that article:

    “Now is the time to eliminate the outdated regulations and organizational and cultural barriers that limit the ability of nurses to practice to the full extent of their education, training, and competence.”

    that is fine let them practice to full extent of there license, that is a far cry from practicing to full extent of a physician license.

  43. there are a couple of other issues noted, one being about hiring the team to help out with patient care. The problem is the more team members i hire, the more i am being asked to increase productivity because most of those team members dont bring in any revenue. so then you get a nurse practionier to take care of the “easy things” “low hanging fruit like uti, uri and mild rashs” so now that leaves me, internist, with the job of handling the more critical and complex patients. THAT BY THE WAY DONT PAY ANY MORE THEN THE ROUTINE SIMPLE PATIENTS DO. We also always talk about having our staff work to the maximum of there license yet as the physician i am being saddling with task well be low my license like having to place the orders, place referrals, do the precerts and peer to peer reviews for imaging etc. thats what is frustrating

  44. Barry,

    I agree with some of what you say, but a few comments:

    Regarding Nurse Practitioners, I have nothing against them and feel they can and do play a big part in the healthcare scheme. However, what is the point of going through med school, 3 years of residency, and constant re-certification of boards, if an NP can practice freely with half the education? It would be like a very experienced paralegal being able to open her own law practice. Maybe this is where we are headed to help curb costs, but you can hardly blame doctors for wanting to protect a little of their turf.

    I agree docs have not had to think too much about costs until recently, but then again, neither have patients. I think too many parties have not had to deal with the cost issues directly, so now we are reaping the consequences. I believe we see now that all parties, patients, providers, insurance companies and employers are going to be much more vigilant.
    Many of the Medical Societies and Boards are coming out with recommendations about tests or treatments that are not necessary.
    There are some studies coming out that indicate practices aligned with hospitals can improve care, but costs also go up. I do think it’s unrealistic to expect doctors to adhere to guidelines without some sort of malpractice reform.

    As far as documentation, well, I think we really need to determine what is appropriate and necessary for good patient care and what is just busy work.

  45. I will give you that physicians have been part of the problem, as a primary care doc of a hospital owned practice who sits on the finance committee and compensation committee i have seen how it works from the management side. The problem is that when making changes to payment for value the physician takes the bigger financial risk then does the system. In order to show the value required I have to to reduce productivity, take the financial hit and then hope i get rewarded in the years to come from some shared savings. As a primary care guy who lived thru the gatekeeper model we never seem to reap the reward.

  46. I think fear of litigation is a legitimate physician concern and I believe safe harbor protection from lawsuits for doctors who follow evidence based guidelines and protocols where they exist would be very helpful. Aggravation around documentation requirements is partly related to the spread of electronic records which I hear doctors complain about all the time. This concern should gradually diminish as doctors get used to electronic records and come down the learning curve in how to work with them. Hopefully, non-physician employees can take on more of that work over time. As for payment rates and business related hassles, more and more doctors are opting to be paid on a salary plus bonus basis as an employee of a hospital system, large physician group or integrated delivery system.

    From a total system cost perspective, though, I think doctors have always been a core part of the problem. They have a long history of trying to stifle competition at every turn, most recently, the opening of primary care clinics in retail stores and state level legislation to allow nurse practitioners to practice at the top of their license. Until very recently, they didn’t see it as part of their job to know or to care about healthcare costs unless the patient brought it up as an issue. They didn’t have any interest in trying to save money for insurers, taxpayers or society at large. That has to change as their medical decisions drive almost all healthcare spending. They could also embrace price and quality transparency so both patients and referring doctors can more easily identify the most cost-effective high quality providers in real time and direct our business to them. As Brian noted, none of these reforms can happen without physician buy-in.

    Sometimes my perception of what doctors want boils down to protect us from lawsuits, pay our bills without question or significant documentation requirements and leave us alone to practice medicine as we see fit. That won’t cut it.

  47. Rob,
    Very powerful thoughts and very moving as well. Dr. Cochran and I thank you for sharing your views. Your conclusion goes to the heart of a point we try and make in our book. You write: “I’ve lived in the hell that is American health care and ended up leaving, despite the fact that doing so really hurt me personally.’’

    This is so disturbing. Undoubtedly, Rob, you started out with a sense of mission and wonder as so many young doctors do. You endured the rigors of medical school and training with a mission to care for patients. And yet, something happened along the way. As you write: “… docs mostly feel like piñatas, with swings being taken by CMS with threatened audits and publishing payments to docs, insurance companies with increased work for less pay, patient advocates who rightly decry the bad care given but don’t look beyond the doc for the reasons, and the press/internet who again demonize docs as being selfish and ungrateful.’’

    So many physicians feel as you do and if this level of frustration doesn’t speak to the existence of a doctor crisis I am not sure what does.

    While change is neither rapid nor widespread enough, things are changing. Increasingly, physicians are stepping up as leaders to fix the way care is delivered. We write about numerous examples in our book including the “In Search of Joy in Practice’’ work done by Drs. Christine Sinsky, Tom Bodeneheimer and their colleagues (Annals of Family Medicine May-June 2013).

  48. Brian thank you for your response. We agree that physicians share some of the blame for the dysfunctional nature of so much of our delivery system.

    But we also think the blame game toward physicians has gone too far. Let’s stipulate what you suggest – that physicians share some of the blame – and let’s move on to finding solutions. Moving on demands that we acknowledge the challenges and pressures on physicians that mount every day.

    The research indicating burnout and lack of satisfaction among physicians is alarming. When credible research firms such as Harris Interactive describes the practice of medicine as a “minefield’’ where physicians feel “under assault’’ we need to recognize the seriousness of the problem. How can we improve access, quality and affordability when we have a physician population so deeply stressed and so often unhappy?

    We argue that the physicians of this country have never needed our help more than they do today. They need us – and by us we mean patients, health plans, administrators, policy makers and other health care stakeholders – to acknowledge the crisis and help find with solutions.
    We get into this in greater depth in our new book THE DOCTOR CRISIS, published last week (PublicAffairs Books, New York). In the book we cite many examples of work that is reducing the unnecessary burden of work on physicians thus freeing them to focus on value-added work that improves individual patient care and population care.

    We also call on physicians to step up and recognize that the evolution of the physician role demands that doctors go beyond being great healers to also becoming strong leaders and reliable partners. Our bottom line is that working to solve the doctor crisis is one of the most patient-centered steps we can take in health care today.

  49. I am somewhere between agreement and disagreement here. In a certain sense, individual doctors ARE victims of a system that rewards over-consumption, ridiculous documentation, attention to codes over people, and bureaucracy over partnership. The most important relationship a physician has in our current system is with the payors, since they are entirely responsible for keeping docs in business. The patient is a raw material with which the healthcare transaction is built, with the end point being documentation, not care. These enormous flaws are things that individual docs have no power over, and are the cause of the rise of burn-out and cynicism.

    On the other side, physicians as a group have been complicit in building this system, and so should bear a lot of the blame. We were wooed by the money thrown at us for bad care and didn’t raise the objection that we were being paid to do the wrong thing.

    The importance of this subject can’t be overstated, though, as docs control most of the costs of health care and must be the lynch pin of any attempts at reform. But docs mostly feel like piñatas, with swings being taken by CMS with threatened audits and publishing payments to docs, insurance companies with increased work for less pay, patient advocates who rightly decry the bad care given but don’t look beyond the doc for the reasons, and the press/internet who again demonize docs as being selfish and ungrateful. The worst thing that could happen would be for doctors to go through with the common fantasy most docs have: to leave medicine. I left the “system” last year (doing a DPC practice), and I am about as emotionally committed to doing the right thing for my patients and society as any doc I’ve met. My goal is to be part of the process that helps fix the system, not to escape it, but I suspect many/most of the docs that leave won’t be so ambitious and will give the system the finger as they walk out the door.

    This is far more likely than most seem to realize. I’ve lived in the hell that is American health care and ended up leaving, despite the fact that doing so really hurt me personally.

  50. You’ll excuse me, but I find the opening of this piece to be quite remarkable.

    How did we get to this place? There is wide consensus that doctors are part of the problem? This explains everything.

    I think what you meant to say was there is a wide consensus in management circles in healthcare and government that doctors are part of the problem. The way that you frame your statement suggests how badly relations have deteriorated.

    I’ll ask you a follow-up question if I’m allowed to do so:

    To what extent can management help walk us through this crisis? I’m very interested in your reply.

    I hear everyday about initiatives that are being imposed from the top down followed by more initiatives followed by memos.

    Is it possible that doctors aren’t the only ones who need to do some soul searching?

  51. Thanks for a thoughtful article and deeply well-intentioned article.

    But I’m concerned that you have framed your argument as though physicians are victims of the system rather than partial drivers of its characteristics. Talk with ACO managers who are trying to transition away from excess to appropriate care and you’ll hear first hand about the pushback from doctors who are infuriated about their diminished incomes. Anyone aware of the influence of the AMA’s RBRVS Update Committee – see http://www.replacetheruc.net – on the overvaluation of specialty services and undervaluing of primary care is also able to trace some of the dysfunction back to the physician community itself. Or look at the evidence on physicians’ open reception to the favors of the drug and device sector, and there’s additional reason for skepticism.

    Now its important to recognize that rank-and-file physicians are different than those driving mechanisms like the RUC and the continuation of FFS reimbursement, but there’s no question that all doctors are complicit in their mainstream professional behaviors.

    There is also no question that any serious change will require physician buy-in, but at the same time it is easily arguable that, as a group, physicians have traded a great deal of professionalism for self-interest, often putting their own rewards above those of patients and purchasers, and refusing to meaningfully self-regulate.

    To get back to rights, there must be at least some acknowledgment by the physician community of their own participation in our crisis, as well as genuine steps toward remediation of the practices within their spheres that have played a role.

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