Dr. Sandeep Jauhar, a cardiologist, believes with good reason that many physicians have become “like everybody else: insecure, discontented and anxious about the future.” In a recent, widely-circulated column in the Wall Street Journal, “Why Doctors Are Sick of Their Profession,” he explains how medicine has become simply a job, not a calling, for many physicians; how their pay has declined, how the majority now say they wouldn’t advise their children to enter the medical profession, and how this malaise can’t be good for patients.
Dr. Jauhar gets it right in many ways, but the solutions he recommends miss their mark completely.
I was 100% in accord with Dr. Jauhar when he argued that “there are many measures of success in medicine: income, of course, but also creating attachments with patients, making a difference in their lives and providing good care while responsibly managing limited resources.”
The next paragraph, though, I read with astonishment. Does Dr. Jauhar really believe that publicizing surgeons’ mortality rates or physicians’ readmission rates can be “incentive schemes” that will reduce physician burnout? Does he seriously think that “giving rewards for patient satisfaction” will put the joy back into practicing medicine?
If so, I’m afraid he doesn’t understand the problem that he set out to solve.
The truth behind “quality” metrics
There is no question that some physicians are inherently more talented, more dedicated, and more skilled than others. In every hospital, if you speak to staff members privately, they’ll tell you which surgeon to see for a slipped disk, a kidney transplant, or breast cancer. They’ll tell you which of the anesthesiologists they trust most, and which cardiologist they would recommend to someone with chest pain. But none of these recommendations are based on simplistic metrics like readmission rates or even mortality rates. They are based on observations over time of the physicians’ ability, integrity, and conscientiousness–all of which are tough to quantify.
Let’s take, for example, a common operation such as laparoscopic cholecystectomy: removal of the gallbladder using cameras and instruments inserted through small incisions in the abdomen. This is a procedure which most general surgeons perform often, with few complications.
When complications occur, there are almost always factors involved other than surgical error. Patients with diabetes are more likely to develop wound infections, for instance. Surgery on patients who have had prior abdominal operations may take longer and could cause bleeding or damage to other internal organs because of scar tissue. Morbid obesity and advanced age are risk factors too.
The surgeon whose mortality rates are higher, or whose patients are more likely to be readmitted to the hospital, may be dealing with a much different patient population from the surgeon with the lowest rates. An inner-city hospital may admit more patients as emergency cases, in more advanced stages of disease.
It’s difficult for statistics to reflect accurately the dramatic differences among patients that affect surgical outcome. A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon. Trying to distinguish among surgeons with “outcomes data” will only result in more surgeons refusing to operate on high-risk patients.
Emphasizing 30-day readmission rates as a quality measure puts pressure on hospitals too. CMS now plans to link hospital payment to readmission rates and hospital-acquired complication rates. Community hospitals inevitably will feel pressure to funnel complicated, frail, or high-risk patients to the nearest major medical center which can’t bar them from the ER.
In my own line of work, anesthesiology, I often take care of patients who need chest surgery. They have serious illnesses such as lung cancer, emphysema, and ALS–the bucket-challenge disease. These high-risk patients don’t all have good outcomes, though I like to think that my management of their anesthesia care helps most of them return safely home.
My scores are fine on the meaningless “quality” metrics that the Joint Commission and CMS use to rate anesthesiology performance, despite their scant relation to clinical excellence. (I’ve written before on how many of these metrics are flawed–see “The Dark Side of Quality“.)
But the best measure of whether or not I’m a good anesthesiologist isn’t either my outcomes data or my “quality” scores. It’s the fact that surgeons and OR staff members at my hospital, who watch me work every day, often request me when they or their family members need anesthesia. That’s a measure you won’t find in any report.
I can’t think of a worse way to address physician burnout than to publicize flawed “quality” or outcomes data that would unfairly pit physicians against one another. Dr. Jauhar’s further recommendation to link doctors’ pay to health outcomes (“pay for performance“) would only make matters worse.
The perils of patient satisfaction scores
Dr. Jauhar writes that his hospital sends quarterly reports to physicians, telling them how their patients rate them on different points such as communications skills and time spent with them. I’m guessing that his reports must be good, or he wouldn’t consider patient satisfaction scores to be an incentive that could reduce physician malaise.
I’m also guessing that Dr. Jauhar’s colleagues in emergency medicine and primary care might feel differently. Those physicians are under daily pressure to give narcotics to any patient who complains of pain, to prescribe antibiotics to patients who don’t need them, and to order expensive tests like CT scans at the slightest indication. To do otherwise is to risk poor patient satisfaction scores.
The Atlantic published a recent article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.” It highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.” Patients often visit multiple emergency rooms and doctors’ offices asking for narcotics, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.” They’ll be angry if their narcotic requests are denied. Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.
Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A recent study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs.
A prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality. I can easily see how that could happen in the treatment of pain after surgery. If you gave every patient enough morphine or Demerol, you wouldn’t hear complaints of pain. But the patients would be sleepy, wouldn’t want to get out of bed, and would run a higher risk of breathing problems and blood clots due to inactivity.
A recent Forbes article, “Why Rating Your Doctor Is Bad For Your Health,” concluded that “giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.” Many doctors would agree.
“Managing hopes”
Dr. Jauhar concludes that the solution to satisfaction as a physician is to settle for less. He looks to medical students, who are “not so weighed down by great expectations”, to be the physicians of the future who won’t mind less money and prestige.
But here is where Dr. Jauhar misses the heart of the issue. Most physicians didn’t go into medicine thinking to make a fortune–we leave that to the entrepreneurs and investment bankers. Most of us never expected to be treated like gods, with the possible (tongue-in-cheek) exception of our colleagues in cardiac surgery and neurosurgery.
We did expect, though, to have a certain amount of autonomy in our daily working lives. We expected to want to come to work every day and take the best possible care of our patients. We expected to have our education and opinions valued and respected, not second-guessed at every step by bureaucrats with clipboards.
Here is what I see as the downhill slide of 21st century medicine:
1. The surge of uncritical belief in “evidence-based medicine” has led to rigid algorithms–cookbook recipes, really–for patient care. Experienced physicians know these algorithms are often a poor fit for patients with multiple medical problems, and must be ignored or subverted for the good of the patient. At the same time, the physician may face criticism or sanctions for not following protocol.
2. Bureaucrats and regulators seem convinced that if only we can produce enough care protocols, we can cut out physicians altogether and save money by having advanced practice nurses take care of everyone. They encourage the devaluation of physician education and expertise. This seems to be the philosophy behind the proposed new VA rules which would eliminate physician supervision of veterans’ health care. (I’ll be curious to see if physician-free care will be considered good enough for the President and the Congress.)
3. The unchecked power of regulatory agencies–including CMS and the Joint Commission–is growing, while their reason for being is the constant creation of new rules that get pettier by the day. These proliferating rules have become a dangerous distraction to physicians and nurses, and take time away from their patients.
Where to go from here?
The way forward out of this mess won’t be easy, but a good place to start is this set of policy recommendations: “The 2014 Physician’s Prescription for Health Care Reform.“
In the meantime, it’s helpful to keep a few basic principles in mind.
Fee-for-service pay isn’t the chief culprit. The best physicians stay busy because they have respect and referrals from their peers. As they develop a base of satisfied patients and colleagues who recognize clinical excellence, they achieve financial success and have no wish to perform unnecessary procedures. Price-fixing of physician services by third-party payers is the root cause of financial pressure to increase the number of services provided.
Limited provider networks benefit only insurers and the government. They destroy long-standing patient-physician relationships, and prevent physicians from referring patients to other physicians whose work they know and trust.
Encouraging the medical students of today to settle for less isn’t the way to get the best and brightest to become the physicians of tomorrow. As a society, we need to push back hard against today’s flawed rules, laws, algorithms and metrics that promote mediocrity and standardization, and provide all the wrong incentives in healthcare. That’s the only way that all of us–physicians and patients–will be able to enjoy the experience of individualized, personal patient care.
After all, the “human moments”, as Dr. Jauhar rightly points out, are the best part of medicine.
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Tough to go cash when you’re in a hospital-based specialty like mine (anesthesiology), and have to accept any patient that the hospital lets in the door. Especially when you have a trauma center! In our group, we pool everything so the non-pay, Medicare, Medical pts at least get averaged in and we even out the losses.
Physicians want to have their guild and eat it.
Until they are willing to compete with all level providers including MDs from other countries openly in the market place there is little moral basis for objecting to enroachment by the state.
There is, of course, an empirical basis: i.e. such enroachment is useless, which it is.
Sorry MD, I forgot this blog is the doctor whining blog.
Can you never stick to the subject?
Teachers were screwed by government take-over of “education” long before physicians were screwed by the same John. Both groups thought it was a partnership….
Wrong.
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“Doctors have been left totally responsible for outcomes with less and less control over the situation and less to show for it.”
Substitute “teachers” for doctors in that sentence MD and you can really see an oppressed profession – at far less pay.
MD as HELL, you sound like my kind of doc. You may enjoy my blog:
https://kapsacare.com/blog/
Being in your sixties can do that to one’s memory.
Don’t let it bother you.
I am in my sixties and I remember when being a doctor was fun. Maybe being in one’s sixties can do lots of things to a memory.
Doctors have been left totally responsible for outcomes with less and less control over the situation and less to show for it.
Not complaining…I will be at work in an hour(11PM). I am still pushing care in the direction for the patient, despite the fearful leadership in the system.
People need to know their health is not at the heart of healthcare.
Fantastic. Your words should be required reading for anyone who cares about the future of medicine. Perfectly stated.
Glad to oblige Perry with the truth. If docs want a better professional life it seems going to a cash basis practice is the answer. But it takes guts.
For complaining docs either get involved, go cash, or suck it up.
Ha, I knew it.
Thanks for not disappointing, Peter.
I’m in my sixties and I can’t remember a time when docs were not “sick of their profession”.
They’re just a naturally a complainer bunch. Seems to be in the DNA.
You will always be a nurse, and that’s ALL you will ever be. I want a REAL doctor to treat me, not some pretend wannabe who got their doctorate out of a cracker jack box.
Besides, my insurance company requires a $30 copay regardless of whether I see an NP or a doctor. Why would I want to spend that money on an NP when I can get a REAL DOCTOR for the same price?
Agree Joni! Thanks for standing up for NP practice! Our outcomes are the same if not better and in most cases we want to work as a team to improve patient care and access to care! NP practice is one way to do this!
I believe you have been misinformed about beta blockers. You only need to document that you have addressed the issue. If the patient has clinical reasons for not giving them (Hypotension as well as bradycardia), you note them and do not give them. Yes, the glucose control issue was wrong, and it was quickly corrected.
What you fail to acknowledge, and I know you weren’t trying to write War and Peace, is that absent such measures people really don’t always provide this kind of care, even when it has level 1B indications like we have for continuing Beta blockers (new ACC/AHA guidelines). Look at the central line guidelines. The literature on that was very strong. However, it was not adopted at many hospitals until it was required. At my primary institution, we adopted it before it was mandatory. When we were asked to help out at another facility which had some problems, we were actively harassed and berated for insisting on following it. (How could a sheet over them help?)
AFAICT, the ACA doesn’t much address physician vs mid level practice. That is largely regulated at the state level. While I haven’t read all of the particulars of the VA plan, I would reiterate that the maximalists positions of the AANA and the ASA are, I believe, wrong. It is unfortunate that with our insurance structure you (often) get paid more for the care given to a healthy ASA 1 pt with private insurance having a knee arthroscopy than you do a sick ASA 4 pt having a VATS or fem-pop. (My thoracic guys are fast.) It is a shame that our payment structure drives a lot of this disagreement.
Anyway, you seem like a decent sincere person. I wish there were easy answers. If we don’t give physicians the right incentives they wont work. If we give them the wrong incentives, they will do too much. It would be nice if physicians would take an active role in solving these problems. Most don’t.
William,
That comment seems a bit harsh “So why do we not hold patients more accountable for outcomes especially those that pay little or nothing for healthcare but demand so much?”
Your attitude/perspective is representative of why the future of healthcare is radical change.
Wow!
I recently left the health care industry. And I have no desire to go back. Too many MBAs and MHAs trying to top-down manage something they’ll never put the effort out to even understand. Health care will keep getting more expensive until the cancerous administrative side of health care is eliminated.
Evidence-informed medicine is what we all strive to practice. But that’s not at all what the Joint Commission and CMS are pushing. Just look at the beta-blocker and glucose control measures. If a patient’s heart rate is less than 60, we’re still supposed to make sure the patient gets a beta blocker according to rigid time marks. That’s inherently ridiculous, and forces clinicians into a corner. And it has the unfortunate additional consequence of turning people against ALL quality measurement.
You’re correct about unnecessary testing, and that’s definitely one of the payment reforms that needs to happen. But bundled payments have a host of their own problems–how do you rationally divide the payments? Incentivize harder work, more productivity, and innovation? Account for the outliers–the high-risk patients who really do consume more of everyone’s tie and the system’s resources?
I have no problem working with NPs, PAs, and CRNAs. But you and I both know that the ACA acknowledges no difference in education and expertise, and I do have a problem with that. Team–based care? Yes. Physician-free care? That’s the Walmart version.
There is a difficulty comparing medicine to law, architecture or even dentistry. People or organizations pay for those services on their own dimes. I don’t know what specialty Dr. Palmer practices, but likely he is paid by third-party insurers for his care.
Without insurance, few Americans could afford care of any sort, so we would all be unemployed. With insurance, there is a chance to get treatment. But, as my father never tired of reminding me, those who pay the piper, call the tune. Insurers want proof they’re buying a quality product. Hence the “rating, grading and evaluation”.
It’s an awful, soulless system. But it isn’t going away soon.
Great truths in this fine article. Thanks.
Can you imagine any other profession that allows all this measuring and rating, grading and evaluation? Law? Dentistry?Architecture? These people would all quit.
Again, we need more pushback testosterone and standing up for our patients and our profession. You want us to follow that algorithm? Well then, tell us how to do this when you have co-morbidities of diabetes, hypertension, and a recent TIA? Tell us please what to do with antibiotics in our hospice patient who has Parkinson’s and now has a bronchopneumonia? We’re waiting.
Excellent piece Dr. Sibert! So many smart people trying to push systemic solutions that all have unintended consequences that make the medical system worse….and degrade the profession of Medicine.
I am also an anesthesiologist. I run a medium sized group. I am an old cardiac guy. While you are correct that this guy doesn’t know how to solve our problems, your solutions are also bad.
1) You are wrong about evidence based medicine. First, if you understand it well, it is not rigid and not cookbook. For weak and/or poorly trained physicians they might be, but then they are always a problem. A well trained, wlel read doc should be comfortable departing from guidelines when merited. My guys do. What we try to track is to see if there are patterns in people who do so. Many people want to default to do what they learned in training. When it is always the same 2 or 3 people departing, you probably have a problem.
2) We need to learn to use mid-levels wisely. They are capable of doing much more than many physicians want to admit. In our own specialty, both the ASA and the AANA are wrong in many ways. We are finding better ways to use our people. You should do the same.
3) Fee for service is not the only problem, but it can create problems. One of my partners did an extensive paper on how we could save money by reducing testing. (I hope you are aware that most of our studies show we do way too much.) The hospital had zero interest as they were getting paid (well) to do those unnecessary tests. Now that we are become a cost based facility rather than a revenue based one, they are very interested.
Last of all, metrics on docs can be hard. That doesn’t mean you get to do without them. We need them. One anecdote. At a recent conference the topic of promotion to partnership arose. Several groups, including some very large ones you would probably have heard of, said they had never not made a new hire into a partner. They fired no one. What are the odds that they recruit so well that they never get a dud? I would say zero. Yes, Press-Gainey is mostly dumb. So are some other metrics, but if you aren’t working on measuring your people you don’t know what you think you know.
Steve
It’s a very good book. Painfully honest. I have cited it at length, along with Dr. Ofri’s “What Doctors Feel”.
Now there is talk about radiologists monitoring patients to make sure they get followed-up for the defunct incidental finding!
Will Sapiens ever learn?
Tough problems. I have cited Sandeep’s book on my blog, as I write about healthcare workforce issues. Blog.KHIT.org
I have read the first three chapters of his book, and I do intend to finish the rest.
Already I find Jauhar an intellectually honest writer, a trait I have boundless admiration for.
I agree that his prescription to the problem is part of the problem not the solution.
There are no solutions. There are, were and always will be bad doctors. Any attempt to monitor them will inevitably lower the morale of the good doctors.
I agree about the quality metrics. As a nurse practitioner, I need to enlighten you about care protocols. I do not have to use them. I work in a state where I am as independent as you. Physicians have asked my advice and I have presented at grand rounds and conferences. Just last week an ETC doc asked if I would present to the state medical society. We NPs , and PAs as well, can be just as good, or bad, as MDs. You are doing a disservice to patients when you malign us.
“A noncompliant patient who doesn’t fill prescriptions and follow instructions is more likely to have problems, independent of the experience and skill of the surgeon. ”
So why do we not hold patients more accountable for outcomes especially those that pay little or nothing for healthcare but demand so much?
Stop criticizing and follow our fearless Thought Leaders!
I think most hospitals kill more people than they help
My twin sister went into the hospital for a Breast biosey ,,,
From the x rays it looked like she might of had cancer in one of her breast ,
From the reports I read they didn’t find any cancer ,,
But one of the surgeons ,,, decided to do a double Breast mysectmy ,,
From the reports … It looks like she developing a blood clot in her right leg prior to the breast surgery ,,,
After the breast surgery the blood clot got worst ,,,, so they cut her leg off below the knee cap ,,, a week later ,,, I guess the surgeon didn’t do a very good job ,, because he had to go back in and cut her leg off above the knee cap ,,,they then put a feeding tube down her throwt but while they were doing that they put a whole in her stomach ,,, so another surgeon had to go in and fix that ,,,,she got a fever ,,, they said she had Mersa and several other types of infections , all this time for 3 weeks I asked to see or speak to her doctors
I was told they were too busy to see me ,,,so I went home ,,,
The next day a doctor called me to tell me she had gone back into surgery and ask if I would give him permission to take her off life support ,,
He seemed like a nice doctor ,,, I said I wish I had spoken with him several weeks ago ,, but I said yes . I said in nam I was use to guys dieing around me all the time ,,, but I didn’t think something like this would happen in one of the best west coast (Scripps) hospitals and most expensive in America … He was a nice doctor tho
I got all the medical records and thought about suiting them ,,, but I decided no
I am very lucky and have made a lot of money ,,, I could easily do it ,, but it would take 3 or 4 years of my life ..( I thought about it for a while and if I won the lawsuit I was going to give all the money to an animal shelter ,, she loved cats ) but I thought . My sister would not want me to wast my time and life ..
the doctors knew what they did ,,, I ‘m glad I was not one of the surgeons ,,,
My uncle was a surgeon ,,, he said he refused a lot of surgeries ,,didn’t think a lot of people needed them,,,, , he was one of the best ,,,, few all over the world helping people on his vacations ,,,
Too bad he died years before my sister went to the hospital ,,,
Well put.
As a Radiologist I spend a lot of my time following up things that don’t really need to be followed (very small pulmonary nodules, small thyroid nodules, uterine fibroids, etc.) It is soul killing to know that what you are doing is of little good and being driven mostly by fear of lawsuits and unreasonable expectations. And of course you are being blamed for increased costs caused by tests you didn’t order.
Recently, I had to train in a hospital’s new EMR (a system I will never use). The EMR is badly designed software which seems designed to maximize billing revenue and compliance with various mandates by making sure every useless piece of information is “documented”.
In real dollars, my income has declined over the past 20 years and the workload is up.
Time for me to retire and let the young-uns take over. I hope they find more satisfaction in what they are doing than I do.
“Price-fixing of physician services by third-party payers is the root cause of financial pressure to increase the number of services provided.”
INDEED!
Not unlike the wage and price freeze of the 70’s that wrought one of the worst inflations in US history, with 18% long bond rates.
And corners are being cut more aggressively as professional time is being wasted while clicking in orders and documentation in order for the suits to make their measurments of quality.
Thank you. You are spot on.
Excellent post. I bet most physicians would agree with you on almost all of this. There is not an easy way to define quality medical care. So let’s stop pretending we can do it.
Please keep writing.
Very good points Dr. Sibert. I am sure some commenters will chime in with “whiny, money grubbing docs, who cares?
I would encourage any non-physician to read “One Doctor” by Dr Brendan Reilly. This book gives excellent insight into a doctor’s life and thoughts, and is a good example of the dedication and caring most of us have about what we do. The current situation in Medical care today is a culminaton of many problems, including some greedy doctors and hospitals, greedy lawyers, inane regulations, exclusion of patients from direct medical costs, and unreasonable patient expectations.