Is Health Care Reform Possible Without Caring For The Providers?

There is much talk about health care reform. Insurance for all. Better care for everyone. More available care. Cost control. The ideals on the agenda should make any American proud. Yet, there is an underlying erosion of the spirit of doctors that is not being noticed, and it should be. Because if it is not, then the "ideal" reform program will be provided by burned out doctors and algorithm slaves who have to cave to time and money pressures to provide "evidence-based" solutions that have little applicability to real-life situations. Everyone wants doctors to bear the economic and social brunt of the health care disaster that currently exists, but I would caution against that. There are conversations that are too controversial to be currently aired that will likely lead to a brain drain and an influx of "yes-men" who are corporate America's dream, and health care's nightmares. Here are some of these conversations.

Firstly, most people do not ask relevant questions when it comes to "evidence-based medicine." In principle, and in general, this is a great start to explore how people should be medically treated, but it is rarely the best solution for any given person. "Evidence-based practices" are derived at their "best" from double-blind placebo controlled trials that usually relate to a specific kind of person. For example, people who are excluded from the trial may not represent the general population. In fact, one study found that less than half of the patients undergoing treatment in a general practice would have been included in the hypertension trials. So when Joe Schmo enters your office, you often have little "actual" evidence and have to "overlook" this to think of his particular case. Add to this the time pressures of doctors and nurses -- being paid less, being regulated more -- and no matter how angry you are about doctors needing to care more and think more carefully about a case, it will simply not be possible. I have found this to be the case in many of my referrals to standard medical practices, and many of my colleagues would concur.

Another conversation that idealists like to have about socialized medicine is that doctors should feel obligated to provide great care. And I concur that this is the best ideal and one we should all strive toward. But what happens when we lower the bar for great care? What happens when we ignore physician and nurse burnout and expect health care workers to "suck it up?" What you're left with is a less than competent doctor who is a psychological victim of burnout. A recent article in the Archives of Surgery reported that as many as 38 percent of surgeons are burned out. When will it be time to pay attention to statistics like this? And why does reform not address rewarding doctors more explicitly? "Delayed gratification" is one of the most prominent reasons for burnout. Simply cutting costs and payment to doctors is shortsighted, idealistic, ignoring a real problem, and not going to actually improve the health care crisis we are in. Those doctors who are willing to "suck it up" may themselves be burned out, so that is who will be caring for you. In addition, they may not actually see other solutions for they what to do for a career and settle for what they can get. Trust me: you do not want a person who feels this way treating you, let alone cutting into you. But if we continue to ignore the value and needs of doctors, this is the person you will meet as your doctor.

Doctors are expected to care less about finances than many other professionals. Somehow lawyers, hedge-fund managers, and most other professions face less of a wagging finger when they care about the amount of money they make. Doctors, on the other hand, are expected to be philanthropic and caring and by inference, less concerned about their bank accounts. I can tell you that there are a significant number of extremely well-trained doctors who care a lot about their bank accounts, and they are also very caring and good about what they offer. But I can also tell you that there are an increasing number of doctors who have an eye out for any exit that will get them out of what often feels like an unfair trade-off for the number of years of education, emotional drain, intensity and amount of time spent on any given day at work. Not everybody feels this way. But the current mentality of socialized medicine will usher in a new kind of doctor and usher out many talented, gifted and important physicians who could have made amazing contributions to health care. You simply cannot treat health care staff as "manpower" without recognizing the kind of talent and thinking that we need to grow. Blind health care reform without considering physician financial needs is therefore very shortsighted.

If these burnout facts seem inconsequential to you, then consider the following: "The overall physician suicide rate cited by most studies has been between 28 and 40 per 100,000, compared with the overall rate in the general population of 12.3 per 100,000 Overall, then, physicians are more than twice as likely as the general population to kill themselves. Each year, it would take the equivalent of 1 to 2 average-sized graduating classes of medical school to replace the number of physicians who kill themselves. This rate appears higher than among other professionals... Female physicians appear to be especially vulnerable. Suicide rates for women physicians are approximately four times that of women in the general population..." (http://www.medscape.com/viewarticle/410643_2)

We do need a better health care system. And the ideals for which we strive are very worthwhile. Still, I think that striving for these ideals without considering the humanity of health care workers and their need for rewards is short-sighted and will lead to less innovative "yes-men" who suffer from a lack of drive and motivation to care about the people under their medical care, in large part, because they will be unable to care for themselves.

Follow Srinivasan Pillay on Twitter: www.twitter.com/srinipillay

Comments

[csavage]

Yes, physicians suffer burnout and substance abuse and die from their own hands at a higher rate than the average person. I read your post, as a physician with 20 years experience, in the military as a provider in a single payer system, a solo practitioner, in a small group, and employed by HCA, and I found your post to be incredibly naive and reflecting of a small amount of experience. I look back on my days as a military physician, with no worries about paying staff, myself, the electric bill, and my malpractice insurance and I get downright wistful. I also disagree with your misinterpretation of "evidence based medicine". I am a general internist. I practice evidence based medicine where there is evidence to practice it. I deliver it with the compassion that my 20 years of dealing with people have provided me. I manage see 25-35 people daily, answer all questions, pull up all weblinks I like to use for education. Yes, not every condition has evidence to support the latest technology, but, you'd be surprised, your patients can understand the limitations of your recommendations if you tell them you gained a particular method of treating based on a previous patient, or a conversation with a trusted mentor or even with a simple "Call if this doesn't work and we'll figure out what next to do"

[BenNC]

Quite to the contrary,
A results-centric health care system would not devalue any of those people who have expertise in this important area. By the far the most disrupted group would be the insurance specialists, who have a keen statistical knowledge of the heuristic links between symptoms, tests, treatments, and outcomes; However, instead of using their computing power to increase profits by rationing insurance (hint: exclusion for pre-existings IS RATIONING), the insurance companies should be tasked with providing doctors with the expert information systems that can save costs while improving outcomes. Helping doctors make the best choices quickly will save time and allow the doctors to see more patients - which is really what is needed - simple access to primary care for more people - without spending more money.

[Srinivasan Pillay - Huffpost Blogger]

thank you for your comment. i think this is an interesting perspective and i would like to clarify a few things:
1. i am in favor of research forming an important part of treatment recommendations, but i have seen research being misused clinically on many, many occasions. in that sense, i think that medicine is both an art and a science.
2. i think we are similarly disposed with regard to insurance companies, but here again, there is no easy solution. one phenomenon that i have wondered about is research that is specifically done to justify insurance perspectives or to justify a treatment approach that is less than optimal from the viewpoint of cost savings. algorithm driven treatment is great as a skeleton and necessary for defensive medicine, but it often compromises the quality of care.
3. what the "best choices" are is quite controversial. choices that are statistically better are important to know but the choice does not end with this when treating someone.
4. simple access to primary care is a noble goal and one we would all probably support. however, the point of this article is focusing on caregiver burnout and the impact on treatment. i don't think that doctors should be seeing more patients in their current given units of time. that would be unfair to them and their patients regardless of the research associated with their choices.

[BenNC]

1. Art v. Science. This is simple, Taxpayers should not subsidize one seeing a doctor because one is bored, lonely, scared, or addicted to pain medications (ie the non-outcom­e-oriented "artistic" side of medicine). Public health policy should be reserved for the rigorous application of FDA-Approved procedures and drugs for indicated symptoms.

The public should not pay for statistically unhelpful procedures. I suspect that a great deal of medicine today is the over-prescription of antibiotics, painkillers, and SSRIs. In my business, I design systems which allow professionals to serve more customers in less time. The medical industry should be doing the same thing.

[BenNC]

2-3. You're suggesting that premium care is over-and-beyond the cost-optimal indicated procedure track. That is imperialistically false at the macro level, as it invariably robs medical resources from Peter in order to provide super-optimal resources to Paul. There is no getting around the fact that the medical field is resource-limited. There is no shortage of potential customers; consequentially, the over-indulgence of some is balanced by the under-utilization by others. Arguably this redistribution of medical resources is a modern day caste system in which some deserve super-optimal care, while others deserve suboptimal care. The only distribution which optimizes outcomes is the cost/benefit optimized scenario.
4. I would broaden the caregiver bench by permitting nurses and pharmacists to provide more convenient care. (in most of the world, I can still walk into an Apothecary or Apteka and walk out with an antibiotic, and I know firsthand that our prominent drugstore chains have better tools than doctors for prescribing basic drugs while avoiding drug interactions and over-medic­ation.) US pharmacy-chains should be able to take blood, get results, and prescribe the computer-indicated cost-optimal prescription.

Doctor burnout is a symptom of a non-distributed workload. If Nurses and pharmacists could also practice, under the protection of a computed best-practices diagnosis, we would need far fewer PhD's to diagnose and treat the statistically rare cases.

[CanadianBeef]

What a shockingly biased and selfish article this is!
"(T)he current mentality of socialized medicine" that he sees in America is a right-wing fantasy. What most Americans support is single-payer. But judging by the action in the Senate, they are very unlikely to get even a shadow of a public option, let alone single-payer, let alone "socialized medicine," which is a Red Scare phrase anyway. Anyone who used that phrase has just displayed so much bias that nothing they say afterward can be taken seriously.
Americans have great respect and concern for their doctors. That may change if more of them write articles like this one. It is unworthy of HuffPo.

[Srinivasan Pillay - Huffpost Blogger]

frankly, there is no underlying political thrust that informs my concern about physician burnout. your objection to the overuse of "socialized medicine" is fair. however, i think that physician burnout is becoming more and more of an issue and ignoring this feeds an erroneous fantasy that doctors are beyond needing care themselves. this i think, is selfish.

[bellaliso]

would a single payer system relieve the burden? Granted, upon introduction, there would be some serious difficulties of transition. But wouldn't having the shackles of insurance company requirements be a relief?

[mythster]

Just using the term "Socialized medicine" demonstrates a serious lack of objectivity and political naivete or serious bias. Can you, or anyone you know actually define socialized medicine? Have you ever lived for an extended period in a country with a single payer system? E.g. the U.K., France, the Scandinavian countries etc.? Do you think that the system as it now stands, is "the best of all possible worlds?"
What are the factors contributing to the high rate of suicide among medical practitioners in this country and what are the suicide rates for MD's in Europe and elsewhere>
Finally, did you do any research at all before writing this article or is it all just a "pipe dream"?

[queeninjun]

My dad is a doctor and I've seen the issues that Srinivasan speaks of firsthand. He has some valid points and I don't think he needs to be shamed out of making them Canadian Beef.

[ReedYoung]

[
Everyone wants doctors to bear the economic and social brunt of the health care disaster that currently exists, but I would caution against that.
]
Who wants that? Everybody blames insurance corporations, and rightly so. It's all their fault. Many states have more than 42% of medical care in their state controlled by a single corporation, fitting the normal but waived definition of "highly concentrated" for purposes of antitrust law. This seems to be a fundamental assumption of your essay, and I don't believe it's a common one. It at least requires more explanation.

[
"Evidence-based practices" are derived at their "best" from double-blind placebo controlled trials that usually relate to a specific kind of person.
]
It stands to reason that standard scientific research methodology, controlling for a single variable, will not map directly onto any individual patient having multiple "variables" (symptoms, pathologies). "Evidence-based practices" indeed looks like a problem waiting to happen.

[Chaimirija]

no...evide­nce based practices will help lower all of the unneccessary care and testing going on right now...and if he is afraid of burnout (which most nurses already suffer from) than they ought to get rid of the the AMA imposed limit on physicians. Many highly qualified individuals are turned away from medical schools all of the time

[Srinivasan Pillay - Huffpost Blogger]

one thing is for sure-we are going to need more doctors and nurses.

[Srinivasan Pillay - Huffpost Blogger]

thank you for your comments. on the bright side, the us has played such a major role in advancing medical research and treatments in the world. however, i am simply stating what my experience has been in dealing with physician burnout: doctors are feeling burnt out. the statistics support my perception. i think that insurance companies do contribute significantly to the current problems. i am merely pointing to a neglected part of the equation: that is the assumption in this article...­that doctors are burning out and someone needs to pay attention to this. regardless of whether the structure of health care is single-payer, socialized, insurance based-we will have fewer and fewer functioning doctors if this does not rise as a priority.

[ReedYoung]

Thanks for clarifying. What I thought you were saying is that doctors are generally being _blamed_ for lack of health insurance. It makes much more sense to say that an effective health care reform bill should address the problems of health care workers, not just health care customers. I'd be surprised if this year's bill is ideal for either party, but I'm hopeful that the worst dysfunctions will at least be ameliorated significantly.

Do you accept the premise that a single payer plan, and to a lesser extent any strong public option, are likely to be easier for doctors to work with, at least once billing protocols are established, than the average private insurer is now?

[leorising]

It seems to me that doctors now operate under onerous conditions, having to keep a large staff to keep up with all the different medical plans, options, etc. Doctors also spend an inordinate amount of time calling insurance companies, running unnecessary tests to satisfy their bean counters' requirements, trying to get care for patients who HAVE insurance but are denied for bureaucratic reasons. Rather than being overregulated, doctors are forced to deal with profit-seeking, unregulated pencil pushers who are causing the reimbursement system to be overly complicated.

Single-payer insurance would solve these problems and relieve the onerous burden of working with dozens of insurance companies. Doctors could get back to providing quality care to their patients, and could in turn pocket some of the profit that the insurance companies have sapped from them for years.

It is the insurance companies, not regulation or malpractice, that are burning out doctors, and the health of all Americans suffers for it.

[Srinivasan Pillay - Huffpost Blogger]

thanks for your articulate and thoughtful comments. the proper attention to physician burnout is very necessary.

[Romulus]

The trouble with articles like this is that they point out a problem but don't seem to offer a solution.

[Srinivasan Pillay - Huffpost Blogger]

i think that you are correct in assuming that i do not have a solution. however, this article is aimed at pointing out a neglected problem. to start moving toward a solution, i would suggest the following:
1. i hope that patients will consider whether their doctors are burned out or not.
2. a physician burnout focus should be developed by relevant societies that monitor the stages of burnout and detect burnout early before it gets too difficult to work with.
3. i think that we need to get the idea of "physician as god needing no financial rewards" out of the closet and into conversation.

especially the second point above could be helpful to physicians who are burning out.

[plaidsportcoat]

trouble thinking for yourself?