A few weeks ago, The Health Care Blog published a truly outstanding commentary by Jeff Goldsmith, on why practice redesign isn’t going to solve the primary care shortage. In the post, Goldsmith explains why a proposed model of high-volume primary care practice — having docs see even more patients per day, and grouping them in pods — is unlikely to be accepted by either tomorrow’s doctors or tomorrow’s boomer patients. He points out that we are replacing a generation of workaholic boomer PCPs with “Gen Y physicians with a revealed preference for 35-hour work weeks.” (Guilty as charged.) Goldsmith ends by predicting a “horrendous shortfall” of front-line clinicians in the next decade.
Now, not everyone believes that a shortfall of PCPs is a serious problem.
However, if you believe, as I do, that the most pressing health services problems to solve pertain to Medicare, then a shortfall of PCPs is a very serious problem indeed.
So serious that maybe it’s time to consider the unthinkable: encouraging clinicians to become Medicare PCPs by aligning the job with a 35 hour work week.
I can already hear all clinicians and readers older than myself harrumphing, but bear with me and let’s see if I can make a persuasive case for this.
A little over a year ago, I found myself burning out and realized that my worklife was unsustainable.
I’d been working at an FQHC clinic, and had become the site’s medical director a few months before. I was practicing as a primary care doc, trying to improve our clinical workflows, problem-solving around the new e-prescribing system, helping plan the agency’s transition from paper charts to electronic charts, and working on our housecalls and geriatrics programs.
All of this was supposed to be a 50% position — plus 5% paid time for follow-up — because I had two young children that I wanted to have some time for, and was also working one day/week for a caregiving website (Caring.com).
Needless to say, this job was taking far more than 55% of my time, and seemed to be consuming 110% of my psyche. I very much liked my boss and colleagues, was learning a lot, and felt I was improving care for older adults.
But I was also irritable, stressed out, and had developed chronic insomnia. And clinic sessions were leaving me drained and feeling miserable: try as I might, I couldn’t find a way to provide care to my (and my patients’) satisfaction with the time and resources I had available.
One evening my 3 year old daughter looked at me and asked “Why are you always getting mad and saying no?”
Good question, kiddo.
A few weeks later, I told my boss that I’d be resigning my position in 5 months. And I started trying to reimagine how I might practice geriatrics.
My current clinical practice, which I launched last October, is the result of that reimagining.
Being a doctor isn’t a happy profession in 2012: 3 in 5 doctors say that, if they could, they’d retire this year. Over three-fourths of physicians are pessimistic about the future of their profession. 84% of doctors feel that the medical profession is in decline. And, over 1 in 3 doctors would choose a different professional if they had it all to do over again.
The Physicians Foundation, a nonprofit organization that represents the interests of doctors, sent a survey to 630,000 physicians — every physician in the U.S. that’s registered with the AMA’s Physician Master File — in March-June 2012. The Foundation received over 13,000 completed surveys back. Findings from these data are summarized in the Foundations report, A Survey of America’s Physicians, published in September 2012.
Morale among physicians is much lower than it was in 2008, as shown in the first chart. Five years ago, less than 1 in 2 doctors would opt to retire; that’s up by over one-third. What’s driving doctors toward pessimism are the least satisfying aspects of practicing medicine in 2012, including:
Concerns about liability, 40%
The hassle of dealing with Medicare, Medicaid and government regulations, 27%. Over 52% of doctors said they’ve limited access to Medicare patients to their practices, or they’re planning to do so.
Lack of work/life balance, 25%
Uncertainty about health reform, 22%
Paperwork, 18%. The survey found that physicians spend over 22% of their time on non-clinical paperwork, resulting in a huge clinical productivity loss.
EMR implementation as a “least satisfying” aspect of work is quite low on the roster of concerns, with only 9% of doctors noting that as a prime concern in 2012.
As a result of uncertainty due to health reform, regulation and finance/reimbursement, the percent of physicians who remain independent will drop to 33% in 2013, Accenture forecasts, from 57% in 2000, 49% in 2005, and 43% in 2009. Aligning with a health system/hospital gives doctors more economic security and fewer administrative hassles.
I cleaned out my office yesterday. I gathered up the outdated pictures of my family, handwritten notes from my children when they were much younger, pictures of patients, notes from patients, and the knick knacks that accumulate over 18 years of being in one place. Most of them were dusty or worn with the tarnish of time; things that sit in the office unnoticed until a moment like this.
I also went through the files of old information – information I seldom if ever used – detailing the financial struggles it took to build a successful practice. Here’s what we collected in 1998. Here are the notes from an office administration meeting in 2002. Here are handwritten flow diagrams I made to figure out a way to improve workflow. Here’s a list of patients from 2000 who were eligible flu shots with a sticky note affixed to the folder saying: “give to Angie.” I’m not sure I ever gave it to her.
The majority of paper, however, was spent on spreadsheets. There are spreadsheets of productivity, of income, of expenses, projected income, effects of adding new partners, of quality measures and of the ever ominous accounts receivable. These are numbers my distractible brain always had difficulty wrapping around, yet they stand as a testament to the myriad of details that work in the background of life. They mean even less to me now than they once did, like the dates on gravestones for people long forgotten, yet their existence reminds me that these days were not the dusty pictures sitting on the shelves of my memory; they were days of many small details and struggles. Life looks like a movie from the outside, but its reality is found in the spreadsheets it leaves behind.
It happened again. I was talking to a particularly sick patient recently who related another bad experience with a specialist.
“He came in and started spouting that he was busy saving someone’s life in the ER, and then he didn’t listen to what I had to say,” she told me. ”I know that he’s a good doctor and all, but he was a real jerk!”
This was a specialist that I hold in particular high esteem for his medical skill, so I was a little surprised and told her so.
“I think he holds himself in pretty high esteem, if you ask me,” she replied, still angry.
“Yes,” I agreed, “he probably does. It’s kind of hard to find a doctor who doesn’t.”
She laughed and we went on to figure out her plan.
This encounter made me wonder: was this behavior typical of this physician (something I’ve never heard about from him), or was there something else going on? I thought about the recent study which showed doctors are significantly more likely than people of other professions to suffer from burn-out.
Compared with a probability-based sample of 3442 working US adults, physicians were more likely to have symptoms of burnout (37.9% vs 27.8%) and to be dissatisfied with work-life balance (40.2% vs 23.2%) (P < .001 for both).
This is consistent with other data I’ve seen indicating higher rates of depression, alcoholism, and suicide for physicians compared to the general public. On first glance it would seem that physicians would have lower rates of problems associated with self-esteem, as the medical profession is still held in high esteem by the public, is full of opportunities to “do good” for others, and (in my experience) is one in which people are quick to express their appreciation for simply doing the job as it should be done. Yet this study not only showed burn-out, but a feeling of self-doubt few would associate with my profession.