September 3, 2014

'Collective malaise': Why doctors are growing tired of medicine

Daily Briefing

    In an essay adapted from his latest book, Doctored: The Disillusionment of an American Physician, Long Island Jewish Medical Center physician Sandeep Jauhar explains the "collective malaise" of doctors and why it is hurting patients.

    'Collective malaise'

    "Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented, and anxious about the future," Jauhar writes. This is in stark contrast to previous decades, when there was "nothing nobler or more rewarding" than medicine.

    In a 2008 survey of 12,000 doctors, only 6% said their morale was positive. Most physicians say they don't have enough time to see their patients because of paperwork, and many plan to stop practicing or reduce their workloads.

    Writing on Sermo, an online community for more than 270,000 doctors, one physician said, "I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients."

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    How the malaise set in

    Jauhar identifies the introduction of Medicare as a turning point for physicians.

    Doctors generally profited when Medicare became law. In 1940, a doctor's mean income (in inflation-adjusted 2010 dollars) was $50,000. By 1970, that average rose to $250,000. "But as doctors profited, they were increasingly perceived as bilking the system," Jauhar writes.

    Reports identified unnecessary procedures and care as an issue, and health maintenance organizations (HMOs) were introduced in 1970 to rein in spending and eliminate unneeded services. Through the HMOs, doctors were responsible for excess spending.

    By 1981, half of doctors said they would not recommend their profession as highly as they would have 10 years earlier. At the same time, public opinion of physicians shifted. "Doctors were no longer unquestioningly exalted," he writes.

    Jauhar acknowledges, "There are many reasons for this disillusionment besides managed care." For instance, medical advancements have made once-terminal illnesses into complicated chronic conditions that require decades of treatment. Meanwhile, doctors say they don't have enough time to spend with patients. 

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    There's also the "labyrinthine payer bureaucracy." Doctors in the United States spend nearly one hour per day on paperwork for insurance companies.

    And although health costs have soared, "less of that money is actually going to the people who provide the care." A 2002 study in Academic Medicine found that the education investment for a primary care doctor is just $6 per hour of work, compared with $11 for attorneys.

    How it hurts patients

    The "growing discontent" affects patients in many ways, including through the looming shortage of primary care doctors and diminished doctor-patient interactions. "Insensitivity in patient-doctor interactions has become almost normal," Jauhar writes.

    Jauhar examines ways to address the issue. He suggests creating new incentive schemes for doctors that highlight and reward good doctoring. He also recommends eliminating the existing fee-for-service system for systems that incent doctors to efficiently manage patients' care with rewards for good outcomes.

    Moreover, "American doctors need an internal compass to navigate the changing landscape of our profession. For most doctors, this compass begins and ends with their patients," Jauhar writes. He explains that "the key to coping with the stresses of contemporary medicine" is "identifying what is important to you, what you believe in, and what you will fight for" (Jauhar, Wall Street Journal, 8/29).

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    Organizations face a number of daunting changes in the near future, including reimbursement changes, mergers and acquisitions, facility expansions, IT adoption, and more.

    As these changes collide, hospital and health system staff are increasingly at risk of "change fatigue."

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