Why Doctors Are Sick of Their Profession
What happens when doctors are unhappy? They have unhappy patients. A new memoir, 'Doctored,' presents one cardiologist's take on the challenges facing American medicine and the real impact on patient care. Dr. Sandeep Jauhar discusses his book on Lunch Break with Tanya Rivero. Photo: Getty
All too often these days, I find myself fidgeting by the doorway to my exam room, trying to conclude an office visit with one of my patients. When I look at my career at midlife, I realize that in many ways I have become the kind of doctor I never thought I'd be: impatient, occasionally indifferent, at times dismissive or paternalistic. Many of my colleagues are similarly struggling with the loss of their professional ideals.
It could be just a midlife crisis, but it occurs to me that my profession is in a sort of midlife crisis of its own. In the past four decades, American doctors have lost the status they used to enjoy. In the mid-20th century, physicians were the pillars of any community. If you were smart and sincere and ambitious, at the top of your class, there was nothing nobler or more rewarding that you could aspire to become.
Today medicine is just another profession, and doctors have become like everybody else: insecure, discontented and anxious about the future. In surveys, a majority of doctors express diminished enthusiasm for medicine and say they would discourage a friend or family member from entering the profession. In a 2008 survey of 12,000 physicians, only 6% described their morale as positive. Eighty-four percent said that their incomes were constant or decreasing. Most said they didn't have enough time to spend with patients because of paperwork, and nearly half said they planned to reduce the number of patients they would see in the next three years or stop practicing altogether.
American doctors are suffering from a collective malaise. We strove, made sacrifices—and for what? For many of us, the job has become only that—a job.
That attitude isn't just a problem for doctors. It hurts patients too.
Consider what one doctor had to say on Sermo, the online community of more than 270,000 physicians:
"I wouldn't do it again, and it has nothing to do with the money. I get too little respect from patients, physician colleagues, and administrators, despite good clinical judgment, hard work, and compassion for my patients. Working up patients in the ER these days involves shotguning multiple unnecessary tests (everybody gets a CT!) despite the fact that we know they don't need them, and being aware of the wastefulness of it all really sucks the love out of what you do. I feel like a pawn in a moneymaking game for hospital administrators. There are so many other ways I could have made my living and been more fulfilled. The sad part is we chose medicine because we thought it was worthwhile and noble, but from what I have seen in my short career, it is a charade."
The discontent is alarming, but how did we get to this point? To some degree, doctors themselves are at fault.
Health Law Has Caveat on Renewal of Coverage
Conservative Experiment Faces Revolt in Reliably Red Kansas
HUTCHINSON, Kan. — In his 40 years living in Kansas, Konrad Hastings cannot remember voting for a Democrat. He is the type who agonizes over big purchases, trying to save as much money as possible. He is against stricter gun laws, opposes abortion in most cases and prefers less government involvement in his life.
But when he casts his ballot for governor in November, he plans to shun the leader of this state’s conservative movement, the Republican incumbent, Sam Brownback, and vote for the Democratic challenger.
“He’s leading Kansas down,” said Mr. Hastings, 68, who said he voted for Mr. Brownback four years ago, when he easily won his first term. “We’re going to be bankrupt in two or three years if we keep going his way.”
Voters like Mr. Hastings are at the heart of Mr. Brownback’s surprising fight for political survival.
Although every statewide elected official in Kansas is a Republican and President Obama lost the state by more than 20 points in the last election, Mr. Brownback’s proudly conservative policies have turned out to be so divisive and his tax cuts have generated such a drop in state revenue that they have caused even many Republicans to revolt. Projections put state budget shortfalls in the hundreds of millions of dollars annually, raising questions of whether the state can adequately fund education in particular.
This has boosted the hopes of the Democratic candidate, Paul Davis, the State House minority leader, who has shot up in the polls even though he has offered few specifics about how he would run the state. Many disaffected Republicans might give Mr. Davis their vote because, if nothing else, he is not Mr. Brownback.
“There’s just a lot of negative momentum behind Brownback, and Davis has been hammering that home,” said Chapman Rackaway, a political-science professor at Fort Hays State University.
The governor’s campaign has appeared so worried about his weak poll numbers that it took the unusual step last month of releasing an internal poll that showed the race to be essentially tied, hardly something that would usually be showcased.
Limiting Choice to Control Health Spending: A Caution
Insurers selling plans in the exchanges are offering fewer choices of doctors and hospitals. According to a
2013 survey by Mercer of employers who sponsor work-based health plans, over one-quarter of employers with more than 20,000 employees and 15 percent of those with over 500 employees offer plans with limited networks of providers selected for quality, as well as cost, considerations.
Narrow networks, as they are known, save plans and employers money because they tend to exclude doctors and hospitals that demand higher prices. Some of the savings is passed on to consumers through lower premiums.
A recent study by
McKinsey & Company found that plans that covered care at more than 70 percent of hospitals in their area charged 13 to 17 percent higher premiums than plans with more narrow networks. It’s a trade-off: lower premiums for less choice. However, the restrictions in choice may not be detrimental to patients, as suggested by
a recent study of narrow network plans in Massachusetts, which found that such plans were associated with a 36 percent reduction in health care spending for consumers who joined them and their employers.
We’ve seen this before. Seeking to end the rapid rise in health care costs, in the 1990s employers embraced managed care plans — plans, like health maintenance organizations, that restricted consumers’ choices with narrow networks, as well as requirements for preapproval for some forms of treatment. Though such plans were promoted nationally by the
Health Maintenance Organization Act, signed by President Nixon in 1973, they did not achieve prominence until the 1990s. By 1993, 51 percent of private plan enrollees were covered by managed care; a mere two years later,
that figure rose to 70 percent.
About this rush toward managed care,
Robert Winters, head of the Business Roundtable’s Health Care Task Force from 1988 to 1994, explained: “What happened in the late 1980s and in the early 1990s was that health care costs became such a significant part of corporate budgets that they attracted the very significant scrutiny of C.E.O.'s,” and more and more C.E.O.’s were "saying, ‘Goddammit, this has to stop!’ "
What stopped it, at least temporarily, was greater restrictions on choice of doctors, hospitals and treatments and a greater willingness of employers and consumers to accept them. Health care spending growth moderated. After many years of rapid growth,
premiums held steady in the mid-1990s. The success didn’t last.
To keep the lid on premium growth, and in an attempt to maintain profitability,
over the years plans further tightened networks, imposed more frequent and stringent preapproval rules, and offered less coverage for more cost sharing.
These cost-saving measures became increasingly unpopular. The backlash was swift and severe. Consumers
filed class-action lawsuitsagainst insurers, alleging that H.M.O.'s misrepresented the level of coverage and service they delivered. Stories of patients denied coverage for specific treatments circulated, whether factual — a
denial of a wheelchair to a paraplegic patient — or fictional — Helen Hunt’s
famous dissatisfaction with her H.M.O. in the 1997 movie “As Good As It Gets.”
How transparent should doctors be with their patients?
Dr. Leana Wen wants her patients to know she was born in Shanghai, China, that she has no kids but would love them someday, and drinks the occasional glass of wine. She believes such transparency — along with a full disclosure about how she earns her paycheck — is a must for keeping doctors honest and helping patients get a sense as to how their doctor’s personal views and financial interests factor into the care they receive.
On a new website Wen launched in the spring called
Who’s My Doctor,Wen wrote in
her profile that she receives 55 percent of her annual income from her clinical practice at the George Washington University Emergency Department in Washington and doesn’t get paid based on how many tests she orders or procedures she performs. She also disclosed the sources of her research funding and which hospitals and patient advocacy groups have paid her to give speeches.
“I think patients want to know if their doctor is salaried at a hospital or is fee-for-service, meaning that the doctor gains financially every time a procedure or test is performed in the office,” said Wen, who recently left Boston where she was an emergency medicine resident at Brigham and Women’s Hospital. They may also want to know their doctor’s position on abortion or comfort level in treating transgender patients, she added.
Massachusetts state law prohibits drug and device manufacturers from providing expensive gifts — like free trips to golf resorts — to doctors who prescribe their products, and a new state law requires doctors to disclose the cost of treatments when asked. Wen, however, would like to see even more transparency practiced by doctors.
How much, though, do patients really need to know? Johns Hopkins internist Dr. Zackary Berger revealed on
his profile that he’s Jewish and a Democrat.
Dr. Tanner Caverly, a Unitarian, also described his work philosophy: to strive to practice in a way that meets the demands he places on physicians who treat his own family members.
“Disclosure about financial conflicts is one thing, but trying to put into words a physician’s philosophy on medical care is more complicated,” said Dr. Joshua Kosowsky, vice chair and clinical director of Brigham and Women’s Hospital’s emergency department, who co-authored the book
When Doctor’s Don’t Listen with Wen.
“Feelings about rational care to curb unnecessary medical costs and end of life issues are important principles that doctors should be discussing with their patients,” Kosowsky said, but it should go beyond the few sentences written on a Web profile.
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