The practice of medicine in America is undergoing a major upheaval. As a patient and a physician, I have watched how the practice of medicine has been taken away from clinicians and placed into the hands of politicians and business administrators, at the expense of the doctor-patient relationship. From my perspective, it is clear that the commodification of medicine is destroying this ancient art and critically important profession.
Commodification, as described by Douglas Rushkoff, happens when market values replace social values. For example, a patient came to me with a burning sensation when she urinated and said, “Give me that purple antibiotic that I only take for five days.” The patient approached the situation as a business transaction: she has burning, I give her antibiotics in exchange for money.
But as a physician, it is my responsibility to understand more about the symptoms before I prescribe antibiotics, and I may determine that antibiotics would do more harm than good. I provide a service based on my education and training. I have taken an oath to do no harm.
In modern medical practice, however, it has become routine and acceptable for patients to lodge online complaints when their physician doesn’t provide a specific treatment the patient deems necessary. There is an inherent threat in this market shift, when public opinion, no matter how ill-informed, trumps medical professionalism. I am seen as a dispenser for antibiotics rather than a trained professional, and my livelihood depends how many stars I have next to my name in an online search.
But the fact remains that the practice of medicine is not a business, and patients are not just customers. In an excellent article on the blog site, KevinMD.com, Shirie Leng points out that patients cannot demand positive outcomes. The outcome of my care for a patient may mean that the patient dies, but that doesn’t mean the service provided to the patient and family was poor.
Patient satisfaction, then, does not necessarily correlate with the quality of the product. In fact, it may do more harm than good.
The link between patient-driven medical care and poor outcomes is supported by research. In a large study published in the Annals of Internal Medicine in 2012, higher death rates were associated with higher patient satisfaction. More aggressive care to improve patient satisfaction can create instability in a couple of ways: patients perceive they are receiving better care, physicians make more money, get better ratings and face fewer lawsuits. All while delivering potentially harmful services. If I were running a business, I would be thrilled. But as a physician, the fact that providing more care to make everyone happy misses the point that we are causing harm.
I’ve discussed the potential harm that is caused by the assumption that medical expertise is a commodity. In following section, I will discuss how regulation of medicine as a business is leading to increasing administrative burden and burnout. Lastly, I will present some thoughts on how to restore the profession of medicine.
Even before graduation from medical school, young doctors-to-be are bound by a professional code of ethics. Once they graduate and begin medical practice, the regulation of almost everything they do piles on: there are federal, state, and practice-based rules and regulations, as well as guidelines proposed by each subspecialty professional group. And every one of these requirements and guidelines adds administrative burden, reduce doctor-patient time and doctor job satisfaction.
For example, I may spend 30 minutes in a difficult conversation with my patient about end-of-life issues. As a cardiologist, many of my patients’ illnesses will significantly reduce their lifespan, and I need to make sure they understand the impact of their heart disease and what we can do about it. But, in order to get full compensation for those 30 minutes, I first have to do a complete assessment, including asking about their eyes, ears, joints, skin and so much more, just to comply with the Centers for Medicare and Medicaid Services guidelines.
While I do care very much about all of these things, how do those questions improve my patients’ health care in this particular visit? I went to school to be able to learn when I need to ask about hair loss or skin changes. I should not be required to check a box at every visit to prove that I am providing excellent care.
What started, no doubt, as a good idea, has morphed into a misery-inducing, time-wasting task. One way doctors have gotten around this is to hire more nurses and mid-level healthcare providers to check the boxes. But this also further bloats our current healthcare system.
If I owned my own practice, I might choose to forego this time-wasting practice and find a different way to support my patients and their health. But more and more small practices are being bought by hospital systems and must now comply with their rules and regulations as well.
In fact, hospitals own more of the medical delivery pie than ever before. Many physicians were happy to sell their practices, hoping that this would mitigate the costly overhead and bureaucracy of running a practice. But the reality is the opposite.
Physicians’ income today must pay more than their own salaries and overhead. It also contributes to hospital administrators and CEOs. In a May 2014 piece for the New York Times, Elizabeth Rosenthal summarized a Compdata Survey which showed that an average insurance CEO earned $584,000, a hospital CEO $386,000, and a hospital administrator $237,000. Note that these jobs may or may not require a four-year college degree. Compare that to $306,000 for a surgeon and $185,000 for a general medical doctor, both of whom are required to have at minimum seven years of education after a four-year college degree.
Particularly egregious salaries include Mark T. Bertolini, the CEO of Aetna, who earned $977,000 in 2012 but had a total compensation package of $36 million. And hold on to your hats, fellow MDs – the U. S. Department of Labor website says that the employment of hospital administrators is expected to grow 23 percent from 2012 to 2022, “much faster than the average for all occupations.”
We are told that we need high-dollar administrative leaders because running a hospital is complex, that it requires business as well as relational acumen. If we don’t pay them high salaries, we are told, we will lose the high-quality healthcare to which we are now accustomed.
But despite these dire warnings, a systematic review of the literature published in 2014 showed no correlation between hospital CEO income and variables such as financial performance, organization size, job difficulty and nonfinancial performance.
So why were hospital CEOs being paid such outlandish sums of money? The authors concluded that “the question of what factors determine health care executive compensation remains unsettled according to the extant empirical literature.” In short, they are earning millions of dollars because they can, not because it provides Americans with better health care.
As a physician trying to deliver excellent and timely care, I feel I am no longer working for my patients, but rather to provide income for hospital and insurance company CEOs. Not only does this haunt me in my cynical moments, but it intrudes on my peaceful moments, too.
All this sounds like whining, you may say. To do a complete review of systems may take only 10 minutes. But 10 minutes may be all I have to spend with my patient. And those are 10 minutes I would rather spend helping my patient understand their medications, finding out about the impact of their health problems on their family and work life or answering their questions. After all, that is what I was trained to do.
On a larger scale, all of these minutes add up. A recent study by Woolhandler and Himmelstein showed that U. S. physicians spend on average one-sixth of their work week on administrative duties, and the more the administrative effort, the less satisfaction experienced by that physician.
They found that the presence of electronic medical record systems increases administrative hours, and that hospitals rather than small practices come with a greater administrative burden. And doctors are burning out in record numbers.
In a Medscape survey, burnout rates increased from 40 percent in 2013 to 46 percent in 2015, the highest rates in younger (35 or younger) physicians in small specialties (urology – 63 percent, infectious disease – 61 percent), but also in docs on the front lines: young ob/gyns and internists (53 percent), and pediatricians (47 percent). The top causes for burnout were “too many bureaucratic tasks” and “too many hours at work.”
Many medical professional societies hold legislative conferences where we can speak to legislators directly and tell them how legislation may improve our ability to provide excellent medical care.
I have been to these conferences, and they really do mean well. Physicians are given a list of topics considered important to the professional society. We practice our speeches in groups and then meet our legislators.
In the past, this process was how our legislators learned about problems among their constituents, and it felt good to be part of it.
But physicians who attend have to pay for their own travel, accommodations and food. We often have to attend on our own time since we are not generally given time off for these kinds of events – the meetings are neither educational nor academic, and they can’t be considered sick time. So when we are not working and catching up with the endless stream of paperwork, we are out trying to defend our lives at legislative conferences that may or may not have impact, at a cost to our families, our personal time and our finances.
I discouraged my children from becoming physicians years ago, but not because of the administrative burden. I didn’t want my children to have to experience the long years of grueling, often cruel and expensive training. Now I wouldn’t want my grandchildren to become physicians because we are being forced into a business model of health care delivery that is less and less satisfying for the physician, but more importantly, less effective in actually providing care.
How can we re-create the profession of medicine in a way that improves the doctor-patient relationship and patient health, but also acknowledges the high cost of complex delivery and regulation? We can start with addressing the cost of creating physicians, reframing the incentives that drive our practices and reducing the administrative burdens that diminish our time and experience with patients.
If we remember that the practice of medicine has social value, then training to become a medical practitioner is a societal responsibility. The average medical school debt in 2014 was $176,000.
If we decide that medical school should be tuition-free, graduates would be less pressured to seek high-paying specialties in order to pay back loans, and it would be more likely that graduates could practice in underserved areas of medicine, or follow their dream of going into research. Tuition-free medical school has been offered at the Cleveland Clinic for about 7 years now, paid for through general hospital funds. Most students are still in residencies, but they appear to be favoring research or rural medical practices as predicted. Having more physicians in primary care will assist with prevention of major health problems, and having more physician-scientists will create an efficient pathway for investigating our current treatments and creating new ones.
We also need to asses the value of high-level administrators in complex healthcare systems. Do their high salaries result in better outcomes for our nation or not? This has to be addressed systematically and in an evidence-based way, since there is a great pressure on individual hospital systems to have “the best” leadership.
Regulations on physicians are oppressive, yet regulations are necessary to prevent destabilization of our complex healthcare system. Physicians are bound by a professional code of conduct, but also by federal regulations, state laws, rules within their own practice, and limitations imposed by each individual insurance company.
The most administratively burdensome regulations are those imposed by our third-party insurance system, those required for reimbursement. We must abolish the third-party insurance bureaucracy, eliminate the need for preauthorization of testing and unify prescription guidelines, to name a few. This will be the most difficult to accomplish since there is great financial benefit for those at the top of these bloated systems.
We must collectively decide whether we believe good health is a right or a privilege. If we decide that good health benefits everyone – rich and poor – then good health is a right. It is easily forgotten that we pay as a country no matter which path we take – either we pay for the catastrophic strokes and heart attacks that happen when we fail to prevent them, or we pay for the preventative care up front. If good health is a right available to all Americans, we must invest in a system that provides the same excellent care to the poor as well as the wealthy. It won’t be free, and it won’t be cheap.
We will have to accept this and manage it together. The Affordable Care Act, regardless of the emotions it inspires, is designed to provide healthcare to those who cannot afford it. It is not yet clear how the Affordable Care Act has impacted the profession of medicine. The main goal – to reduce the number of the uninsured – is certainly being achieved. Whether it is a burden or boon to the practice of medicine remains unknown.
Ultimately, we must return the dignity of the profession to the practice of medicine. As physicians, we enthusiastically and willingly take an oath to do what we can to heal and restore the health and well-being of our patients. Of course, the physician needs to be reimbursed for his or her time so that he or she can care for themselves and their families, to maintain and restore their own health and well-being. But this does not make medicine a commodity. When we forget that, we run the risk of discouraging outstanding people from choosing and staying in this truly one-of-a-kind profession.