THCB

Why Doctors Quit (And What to Do About It)

John Haughom MD white

I got an e-mail from out of the blue the other day.

The e-mail informed me that a colleague, a man I respected greatly, had tendered his resignation at the hospital.  That coming Friday would be his last day. There would be an informal gathering for staff at the hospital cafeteria and that would be that.

I was shocked. The physician in question was an institution at our hospital. As far as I knew he was happy, his patients loved him, he was respected by his peers.   I could think of no earthly reason for him to go.  This did not did not sound like the old friend I knew.

I did what any friend would do: I picked up the phone and called him.

“I just got the e-mail. What’s going on?” I asked “Is something up at home? Is everything ok with Sarah and the kids?”

“Nothing’s wrong. I’ve just been doing a lot of thinking. I’ve decided I want to spend time with the kids and explore some outside projects.

Outside projects? What sort of outside projects?

My friend was the not kind of guy who you thought of as spontaneously quitting his job. I pressed him. He finally broke down and confessed. He was miserable at work.

“It’s the bean counters. They’re everywhere. Every day I get an e-mail that says I’m underperforming on this metric or that metric. It’s making me crazy. My self-esteem can’t take it. Last week, I got an e-mail that told me I need to do a better job of answering patient e-mails. I didn’t even know they were allowed to e-mail us. How long has this been going on? I tell you, I love my patients, but I just can’t take it anymore.”

We talked for a solid forty-five minutes.

He told me about his troubles. He had been keeping longer and longer hours at work, spending an ever increasing number of hours on administrative tasks. His patient care was deteriorating as a result. He was putting on weight. He was testy. Relations with colleagues and support staff had eroded dramatically as a result.

As we talked, it became clear that the hospital’s electronic medical record was the culprit.  My friend had been driving himself crazy trying to keep up.  But try as he might, it just wasn’t working. His brain was simply not wired for the task. And his perfectionist nature — a valuable asset in the operating room – did not give him the room to work with the new system.  Try as he might, he simply could not make the adjustments needed to make the practice medicine the old way.

“You’re sure there isn’t anything I can do to make you change your mind?” I asked.

There wasn’t.  I was sorry to see him go, but I understood why the decision was the right one for him. The changes that he was asking himself to make were just too much for him. The sacrifice just wasn’t worth it.  He was doing the right thing.

Change can be a painful thing.  In the heat of the moment, it’s easy to forget that we’re going through a period of unprecedented change, unlike anything in the history of Medicine. Not everybody is going to make it.

The new science of medicine is going to require a new kind of physician. One that is at least as comfortable using technology and data as they are reviewing test results and examining patients. That change is going to take time. And it is going to take patience. Some people, like my friend, are not going to make the transition.

That’s not to say there won’t be bumps along the way.

For example, at this point, it’s clear to almost everybody that the complaints we’re hearing about the early generation of electronic medical records have at least some validity. Many systems are clunky, and that’s putting it nicely. “A medieval torture device with a mouse” was how one colleague described his system.

He wasn’t far from the mark.  And the companies involved have done a pretty awful job of responding to criticism (I say this as a physician speaking to my colleagues, not as a representative of my employer). It’s almost never a good idea to ignore your customer’s complaints or to blame problems on “ignorant users.”

I don’t blame people for being frustrated.

The good news is that the market is responding. New solutions are appearing every day. And a lot of very smart people are working on the problem.

I can confidently predict that within a few years the problems we are talking about today will be a thing of the past. The next generation of EHR systems will be lightweight, customizable and allow doctors to practice medicine without getting in the way.

The day is not far off when any resident will be able open up their laptop and crunch his or her patient data in the same way I can open up Excel spreadsheet on my home computer and look at my spending habits. They’ll be able to compare the effectiveness of the medications they prescribe themselves, look for suspicious patterns, compare their numbers against CMS benchmarks and do a hundred other things that sound like the stuff of science fiction today.

The Millennials are Coming!

By definition, the younger generation of physicians is far more open to technology, more comfortable with managing a large volume of information and used to quickly adapting to new technologies. After all, they’re trying out new apps and new programs every day. What’s new to my generation is old news to them. Millennials are more comfortable than the generations before them. From what I’ve seen, Generation-Y is even more adept.

That’s encouraging to me and should be for you too.  This makes them the perfect candidates to practice medicine in the new era where technology and data will be as important as instincts and classical training once were.

I’m absolutely convinced that coming generations of healthcare providers will not only be comfortable using these new technologies but will demand access to them. Data-driven medicine will become not only widely accepted but the new standard of care. The idea of practicing medicine without digital tools and without data will be unthinkable, like going back to the days before vaccines and antibiotics!

I can confidently predict that one day, we’ll look back and say “remember how we used to have to do this?” And laugh.

My friend who quit medicine?

I understand why he left and I wish him the best, but I have to admit that I wish he’d stuck around. The younger generation may get technology and may be more comfortable with rapid and disruptive system change, but there is much for them to learn about our craft.   My friend was — and remains — a good doctor. There is much that he had to share.

I think back to the kind and generous mentors who guided me through my medical school years and through my early years in practice. It is no exaggeration to say that I would not be the doctor I am today without their generous support and encouragement.

If you’re of my generation and feeling frustrated or confused by the changes that are playing out in our field today, I hope you’ll consider staying staying around just a bit longer.

These new guys? They may have their iPhones and their patient e-mails down, but that doesn’t mean they don’t have a world of learning to do. And this is where we can help.

It remains my personal operating principle that it is each and every physician’s duty to leave medicine better than on the day we found it.

And my friend? Well, let’s just say I have a sneaking suspicion he’ll be back.

John Haughom, MD is a senior advisor to Health Catalyst.

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21 replies »

  1. I’m glad someone else feels there’s hope. As somebody new to the healthcare world, this is blatantly obvious. In most industries, nobody would even consider bringing to market a software that has over 100 clickable options on any given screen.

    I met a couple doctors who decided the problem was bad enough (many colleagues wanted to stop practicing, too) to pick up programming and do something about it because nobody else was going to. They started developing software that automates the manual and repetitive processes within their EMR – specifically EPIC. After 3 years, they’ve been saving those in their clinic ~40 minutes a day and couldn’t be more excited to share it with the world.

    Full disclosure and fast forward a bit, it’s my responsibility to carry this creation of two passionate doctors into the world of software. What they’ve shared to me about how their practice has changed since the introduction of the EMR reflects much of what I read here. And what’s working for them, could work for others…http://fluent.systems/

    We’re still building and would love some feedback from doctors/nurses who care enough about the problem to have found themselves here on THCB.

  2. Dude,

    your retarded. you are what’s wrong with medicine. Its ok to think critically I know medicine beat that out of your mind during training.

  3. you hit it on the nail. I was thinking the same as reading it. Is he trying to turn this into a feel good story. Medicine is getting less and less humanistic and more bout data mining blah blah checks and balances. The author is the worst kind of clueless.

  4. And by the way, I envy your friend for having the courage to get out. If he does come back, have his mental status evaluated.

  5. I AM a younger doctor who loves technology and EMRs are epic fails! They are absolutely terrible and I wish I had stuck to paper. Being a doctor now is a miserable endeavor. When I hear statistics like 400 doctors per year commit suicide, I am NOT surprised! This career has gone straight to hell. In the U.S., you are better off trying to be a YouTube star. You’ll be loved and well-compensated if successful. As a physician, you are drowning in school debt, drowning in overhead, drowning in regulations and everyone wants to take advantage of you! I am seriously considering emigrating to another country.

  6. Mr Findlay and his organization have been making important contributions. But their attempts to empower consumers are missing the forest for the trees and the EHR mantra is defoliating the forest. Science is most powerful when it is refuting some hypothesis. Hence, an organization such as Mr Findlay’s is a match for overdiagnosis and overtreatment. But these are the soft underbelly of the clinical encounter. The reason for the patient-doctor relationship is to parse the values of both when contending with the clinical science that is yet to be refuted. This is a very human, idiosyncratic event that leaves the patient vulnerable and places a great deal of responsibility on the shoulders of the physician. No digitization, not even the ICF-10, can capture this most human of interactions. And all attempts to reduce it to serve a binary data set denigrate its humanity. I wish wonderful heath for Mr. Findlay, but should he suffer some clinical misadventarue, I wish him the advantages of a trusting relationship with the last surviving wise physician.
    Nortin M Hadler MD MACP MACR FACOEM

  7. Very good dialogue. My take: there will ALWAYS be tension between the doc-as-decider/professional/wise-and-well-trained-eminence with only his/her patients’ interest at heart AND the “system”—bureaucracy/regulation/budget/$$$/oversight/public health. This tension exists in other fields of human endeavor as well, of course. But we all know it’s pretty heavy duty in medicine/healthcare. There are many good reasons for that. To name one: it’s a life and death business every single day. EHRs are one of the latest bureaucratic/regulatory/tech approaches. As Dr. Haughom’s thoughtful blog notes, we are in the midst of a large-scale transition… from a crappy clinical record keeping system to a (hopefully better) electronic one, and from a passive and lax quality monitoring system to one that holds clinicians properly and fairly accountable. Both were always destined to occur once the world of information went digital, and research on the magnitude of poor and unnecessary care mounted steadily. The pain and creative disruption around these changes were predicted years ago. Bottom line: this transition/disruption will and must continue, and there will be casualties. Older physicians leaving medicine because it’s evolving are among those casualties. None of which is to suggest that a dedicated good doctor who quits prematurely out of frustration is a nice or necessary thing. Hospitals and health systems should mitigate that pain where possible, and finding ways to do that should become a priority.

  8. I think I’ll probably take “leave the world a better place than when I found it” as a philosophy

  9. “It remains my personal operating principle that it is each and every physician’s duty to leave medicine better than on the day we found it.”

    Does this principle also apply to amputating the scope, reach and klutziness of EHRs? I thought not.

    The fundamental dissonance I find in articles such as this is a failure to acknowledge that “better” is also “worse.”

    The piece can be summarized as “Say you’re all right Jack. Say it, dammit.”

  10. Based on the info we’re given here, it seems like the doctor quit very specifically because of the mind-numbingly pointless chores the bean-counters required him to do. But this hits a little too close to home for the author, who choses to frame the story as yet another variant on “old fart physician is too stupid to learn how to use the EHR.”

    Clueless.

  11. Yes, this scenario has become too common but I disagree with laying most, if not all of the blame on the EMR. Certainly it plays a role that varies in each individual’s circumstance. As I toy with the idea of walking away after 35 years if you count internship and residency the primary frustration is being an accomplice in the corrupt health care financial system in which we waste thousands of hours, dollars and skilled labor on the tower of babel of admission, observation, day surgery etc. No one has acknowledged one of the primary drivers of obscene health care expenditures without improving care is administrative costs which continue to grow with the ABSURD “reform”. The triple aim is absolute BS. The emperor has no clothes and I wait for the day when all physicians and nurses simply refuse to participate in this charade and insist that they we allow to do what we are trained to do, take care of patients.

  12. This anecdote is fairly familiar. And the perception by the physician who “had enough” and is leaving the practice is that the problem is the administrative burden put on physicians and the onerous nature of the EHR tools he is being asked to use. But, is this really the underlying issue? I would argue that the root of the problem is deeper.

    How we deliver healthcare is undergoing a profound change, from a fee-for-service basis to a value-based one. None of us are experienced in knowing how “value” is to be measured – neither those who make e-tools, nor those who organize medical practices. Much of the problem that physicians are facing are from trying to fit an old modus operandi into a new environment.

    Population health measurement, workflow efficiency, clinical quality measures, care coordination – these are the things that are becoming a bigger part of the practice of medicine. Speaking as an “old school” physician trained in the 70s, I was trained to see patients, deliver an independent assessment of the situation based on review of the evidence at hand, and move to the next case. If there is a problem, my reaction is to fix it. That is a physician approach. An administrative approach is to develop a process to fix the problem, and when the problem is not fixed, then re-work the process. Physicians don’t think that way, as a rule.

    In the world of care coordination and population management, the things required are elements done by the system, not the doctors at the front line seeing patients. Doctors don’t do care coordination – organizations do. In a traditional setting, doctors did their work, which generated the revenue for the organization (hospital, medical practice), and therefore doctors were in leadership about governance and structure of those organizations. In a value-based environment, the work is different, the organization is different, and the tools are different.

    It will take us time to re-tool the way we organize healthcare. As physicians, we should do what we are best at doing – taking care of patients, developing a connection with our patients, and interpreting the data we have at our hands. Administrative and care-coordination tasks need to be done by those best suited to do that, which is not the doctor. And the tools need to be a whole new generation of products that build and utilize universal patient-centered data – something we have yet to see emerge. (I’ve written more about this new paradigm and what it means for technology here: http://blog.flowhealth.com/the-operating-system-for-value-based-care/)

  13. So sad. It’s not as if we don’t know how to build interfaces that actually work for the customer. They are all around us. Just not (mostly) in healthcare.

    The core of the problem is that from the start, the vendors who created most of the EHRs, and the executives who bought most of them, never thought of the physician as the customer. They thought of the system, and the executives who run it, as the customer. They thought of the physician as part of the product value stream to be measured, tracked, and controlled.

    This is a fundamentally backward way of looking at the systemic problem. In any imaginable system of healthcare, the physician is the core. If you want to create more value in the system, you have to create more time and space for the physician by making everything you want them to do vastly easier, faster, more intuitive.

    This absolutely can be done. Any hopeful future for better cheaper healthcare critically depends on getting this right.

  14. Dr. Haughom,

    Don’t blame the doctor. Dr. Hadler is absolutely correct. This is a moral issue. No longer are physicians taking care of individuals with unique visions, needs and illnesses, but physicians are being forced to take care of patients as a population data point. I am retired, I am about your age, and I mastered the EMR in my office for the last 7 years of my practice. I did not use templates, since patients do not fit them. I also used CPOE at the hospital, and was a superuser who was on committees to help the hospital best implement the use of other computer programs as well. I successfully attested to Meaningful Use. Technology is not what made me finally decide to retire.

    Despite all of my expertise I refused to be caught in the trap of treating to a “quality measure” that was inappropriate for the individual. One of the most important points that I learned in my training was that approximately 50% of what we believe to be true today in medicine will be proven false in 10 years. Data can tell you about averages, but will never tell you about the patient in front of you.

    Now you blame the doctor for having a conscience and knowing that following the dictates of some “expert” group could cause his patient harm. Too bad the younger physicians will not develop the necessary skepticism to practice medicine properly, and challenge “traditional wisdom.” Their true mentors, such as you colleague, will not be there, nor will they be allowed to give divergent views.

    I think it will be more like we look back and remember how we took care of patients, real people, and cry, not laugh.

  15. Dear Dr. Haughom
    I see where you’re coming from and where you’re going. Soon you will be scheduling patients (“units of care”) who will be processed to satisfy the requirements of record keeping and billing by people who work for your institution. They will be interviewed by means of questionnaires so that you won’t lose time having to focus on other than the presumptive reason they turned to you as a “provider.” In keeping with notions of efficiency and “meaningful usage”, you will ask the critical question while your scribe enters the reflexive answers into your EHR. Of course you will have a template into which you can enter the bits of information particular to this unit of care. As an orthopedist, no doubt you’ll have a “shoulder template”, for example, with a blank space for you to enter “right” or left.”
    You will then schedule the individual, if you deem it appropriate, for whatever intervention you deem indicated, allowing whatever time you deem appropriate for discussing options. “Summary” in hand, your unit of care will enter into the algorithm of your inpatient facility to emerge “cured.” It’s the same six-sigma mindset that rendered many industries less “labor intensive” and more productive. It’s like making cigarettes or fast food or…. Clearly you have bought into this sophistry hook line and whatever else you mean by “Health Catalyst.”

    I view your “respected, beloved” colleague who retired before his time as I view many a colleague of mine and many a former student. These physicians are heroic. They would not and cannot countenance a system that causes/forces them to practice in a fashion that is not according to their conscience. They are paying a terrible personal price for their moral stand.

    You see, we physicians never see templates. We physicians know that a history is the secret to trust as much as it is the entry to rational health care. We physicians cannot tolerate degrading the patients we wish to serve as “units of care.” And I for one refuse to let anyone call my colleagues “providers.”

    Furthermore, in addition to the flawed business model, your prediction of institutions of medicine populated by “Stepford Wives” speaks to the fact that the health care institution you championed is perverse, unethical and unsustainable. It promotes self-service instead of a community dedicated to serving. And it has unbridled greed.

    I have written several THCB posts that expand on my arguments (and a great deal elsewhere):

    https://thehealthcareblog.com/blog/2014/01/30/how-clinical-guidelines-can-fail-both-doctors-and-patients/comment-page-1/

    https://thehealthcareblog.com/blog/2014/01/15/fee-for-service-vs-fee-for-serving/

    https://thehealthcareblog.com/blog/2014/03/21/mcnutt-hadler-credo-for-value-laden-medical-decision-making/

    https://thehealthcareblog.com/blog/2014/07/11/missing-the-forest-for-the-granularity/

    and recently

    https://thehealthcareblog.com/blog/2015/05/18/forks-in-the-road/

    Nortin M Hadler MD MACP MACR FACOEM

  16. my sense is that it is not the EHR per se — but the EHR is the poster child for the increasingly over-regulated, bureaucratic nature of US health care delivery.

    We all – -especially our patients– have benefitted immensely from the advances in technology from pharma, to devices, to communication, to imaging… etc…

    Those are innovation driven —

    EHR is regulatory driven — and it has caused perhaps the most perverse misallocation of capital in US history.

    Many will say this is a partisan political statement– but its roots are wholly bipartisan.

    To advance from here, a massive deregulation ought to occur… even ACA champion and ‘die at 75’ advocate Ezekiel Emmanuel just admitted in the WSJ yesterday that the holy grail of the last 10 years of academic/regulatory advocacy– ACOs — are effectively an abject failure. (of course his solution is to consider other centrally controlled regulatory schemes).

    TCHB regular contributor Dr. Lamberts appears to have the very scary to current doctors pathway to higher quality care and improvement of the profession — leave the government-lobbyist driven system that is now in hyperdrive– and engage patients with technology as a tool, rather than the other way around.

    (note that I am an orthopedic surgeon who takes most insurances and participates in medicare and who is part of a group participating in a medicare bundled care payment initiative– disclaimer)

  17. I’ve heard a lot of stories like this.

    If you were trying to persuade your friend to stay on what would you tell him?

    I think this is an ongoing conversation a lot of places ..

    / j

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