June 17, 2019

Physician burnout has been in the news for many years. (I wrote about it eleven years ago.) In the last two decades the practice of medicine has become more difficult and less rewarding for many doctors. Though I know that physician burnout is increasing, I still find it shocking. We’re paid better than most. We’re generally held in high esteem. Why don’t more of us love what we do?

This month Dr. Danielle Ofri, an internist at Bellevue Hospital in New York penned a New York Times opinion piece that sounds the alarm about physician discontent. Her accusation is summarized well by the piece’s headline – “The Business of Health Care Depends on Exploiting Doctors and Nurses”. (The rest of my post is a reaction to her article. You might want to read it first and then come back here. I’ll wait.)

I find her charges entirely credible, as I’ve heard them corroborated by many colleagues and friends who work for large medical groups. The consequences are deeply disturbing. Physicians and nurses – who would be expected to be most aware of mental illness warning signs and of mental health resources– commit suicide at higher rates than most other professions.

I think good luck much more than wisdom led me to escape the sources of stress and frustration listed by Dr. Ofri. Like most doctors in training, I looked forward to the practice of medicine and had no interest in (and no training in) running a business. I took my first job at the UCLA Medical Group thinking that if I left the hiring and firing of office staff, the billing, all the details of running the business to someone else, I could concentrate on doctoring.

But I quickly learned that running the business is integral to patient care. Hiring excellent staff, deciding on which insurance contracts to accept, making sure the appointments are long enough, and myriad other administrative details directly determine the care I deliver in the exam room. I became an employee under the assumption that these details would be executed well, and that the administrators’, doctors’ and patients’ interests all aligned. I quit my job and went into private practice when I saw that this wasn’t so. Administrators have a strong interest to maximize volume. Doctors and patients have an interest in maximizing the quality of each encounter. Administrators have an interest in enrolling their group in as many insurance contracts as possible. Doctors have an interest in limiting their patient panel so that they can deliver excellent care and availability to each patient.

Dr. Ofri bemoans the enormous increase of administrators per doctor. But that simply reflects the exploding complexity of medical billing and insurance contracts. Dr. Ofri is right that these administrators are not creating value for the patient, but they are clearly creating value for the large medical systems which employ them. “If we converted even half of those salary lines to additional nurses and doctors,” she suggests, “we might have enough clinical staff members to handle the work.” Who is “we”? Dr. Ofri is not hiring the administrators. Her bosses are. Sadly, she does not have the authority to convert anyone, and there are no incentives for her bosses to act against their interests and instead follow the advice of an excellent NYT Opinion piece.

Dr. Ofri offers no solutions for physicians, and instead looks to the administrators for help. “Those at the top need to think about the ramifications of their decisions. Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine.” I hope administrators heed her plea, but I suspect they won’t.

My suggestion is much simpler. Unhappy doctors and new trainees should go where the happy doctors are – into private practice. Our practice has three physicians, two employees and zero administrators. We three have chosen an EMR that we actually enjoy using (appropriately named Elation). We are in control of our own schedules. We balance our work and our lives. We are directly responsible to our patients.

If we want happy doctors, medical training should teach the rudiments of business management – how to hire and manage employees, how to select and lease office space, how to lead a team. As it is now, everything about medical education prepares physicians to be dedicated, brilliant, unhappy employees.

For a generation doctors have fled private practice and entered jobs as employees. They gave up risk and autonomy for job security and a steady paycheck. They gave up the responsibility and burden of running a business to focus on patient care. Now it turns out that the administrators to whom doctors ceded their authority are making decisions that doctors don’t like. Doctors shouldn’t be surprised by that.

Doctor’s owe their patients excellent care, and they owe themselves a life outside of medicine and reasonable compensation. If we have failed to keep that balance, we have no one to blame but ourselves. We should look to no one but ourselves for solutions.

Learn more:

The Business of Health Care Depends on Exploiting Doctors and Nurses (New York Times, Opinion)
What’s Doctor Burnout Costing America? (Shots, NPR health news)
Beyond the Economics of Burnout (Annals of Internal Medicine, Editorial)

My post in 2008 on the shortage and discontent of primary care doctors:
On Being Doc And Being Happy