June 4th, 2014

My Fellow Doctors, Are You Miserable?

A few weeks ago, I read a Daily Beast article, titled “How Being a Doctor Became the Most Miserable Profession,” by Daniela Drake. The teaser at the top declares, “Nine of 10 doctors discourage others from joining the profession…” That is an unsettling fact. Are the leaders in our profession burned out, and are most of us too tired to care anymore?

As far as I can tell, we have taken many steps to enhance the quality of our profession, but almost every idea has been either hijacked or twisted. We develop guidelines to improve our practice, but now lawyers and insurance companies use them to justify suing us and denying payments to our patients. We decided to develop electronic health records in good faith, and now they want us to spend a lot of time filling in useless information and limiting our time to interact with patients. Also, many hospitals use practice guidelines for the unintended purpose of measuring physicians’ productivity. Many doctors now accept less compensation for their work, but the insurance companies, hospitals, and even the government don’t pass these savings on to patients.

The worst thing is that, for many different reasons, we doctors no longer have good standing in society. I always wonder why everybody is so worried about fraud, overspending, overtesting, and excessive referrals. Any profession can have a few bad apples, but to my eye ours isn’t particularly plagued by this wasteful behavior. Meanwhile, the system asks for perfection from members of our profession: no mistakes, long working hours, continuous availability, permanent training, and often inadequate compensation. These expectations, in the aggregate, are a fantasy. I don’t know of any other profession that has to accept such unrealistic terms.

Many people think that the new horizon for us will be “corporatization” and business consolidation, recognizing all the while that these features are fundamental to the problem. Shouldn’t we be concerned about the possibility of actually limiting free and true competition? We know what happens after that: Quality declines and prices rise. Remember, once you eliminate competition, it’s gone for good — so I think it is crucial to preserve competition at any cost.

A new analysis from Stanford University found that prices were most likely to increase when hospitals bought physician practices, rather than forming looser contractual relationships with physicians. Hospitals have increasingly bought physician practices during the past decade, arguing that it helps them to coordinate care and control costs. However, insurers and many economists say that the hospitals’ primary motivation is to negotiate higher prices with insurers and build referrals to increase admissions.

Excellent arguments abound on all sides, but the reality is that the system is not working overall. Sometimes people do the right thing for the wrong reasons and sometimes the wrong thing for the right reasons. What are we doing in this case? Is choosing the least of many evils our only option? If being a doctor has become a bad idea, what kind of talent is the profession is going to recruit? I see a very cloudy future ahead.

Do you think being a doctor is now the most miserable profession? What can we do to change the path we’re on?

7 Responses to “My Fellow Doctors, Are You Miserable?”

  1. Regina Druz, MD says:

    A brave post, Enrique,
    Tellingly, there appear to be no comments!
    I could not agree with you more. All of your points are well-taken, and reflect the ongoing reality of cardiology practice. I do believe, though, that despite a rather pessimistic outlook, we have am opportunity for change. Medicine as a profession has long ignored any opportunity offered by more traditional businesses structures: fiscal transparency and accountability, market valuation and COMPETITION and INNOVATION. As a matter of fact, how many of the older generation physicians ( with all due respect they deserve) continue to manage departments, divisions or groups the same way now as they did 20 or 30 years ago? A stale, hierarchical nature of these arrangements interferes with progress and marginalizes physicians at the time when they should be developing innovative and entrepreneurial approaches to practice. But, as the famous saying goes- there is an app for that! Expansion in mobile health, epi genetics and social networking will revolutionize medicine, foster more competition and innovation, and bring about the much needed changes .

    • Enrique Guadiana, Cardiology says:

      Thank you very much for your comment, you are very kind.

      I am a strong believer that free competition is the only way to obtain quality and price. I don’t have a pessimistic outlook for the medicine, all the contrary. My intention was to open the discussion. We are living times of change and we need to participate, but for some inexplicable reason nobody talks about this.

      The post has very few comments, but at this moment it is the second most read in the blog. It was shared many times in the social media so this means that many are interested but not many want to comment.

      Do we have to be brave to talk about this?

  2. Jose Gros-Aymerich, MD says:

    The first thing to be remarked is that, even when the word: ‘Miserable’ is written the same way in several languages, its meaning is far from being identical.
    A question in a SCID-P, for screening mental disorders, was asked to patients, in a say if do you feel this way or not, it was: ‘Often, I feel I’m miserable, and worth dying’, well, the meaning of: ‘Miserable’ in this frame may be: ‘I lack any value’, but in Spanish, the word: ‘Miserable’ refers not to those who are in a condition of misery, those being in need, but: ‘Miserable’ has the main correlate to somebody that is mean, bastard, vile, fel; asking this to an Spanish speaking person would add nothing but a reinforcement of the guilt feelings linked to depressed mood.
    Some would ask you: Doctors are lacking any value, aren’t they? just to spread the new among other professionals that you despise colleagues and obtain that you’re chased out of medical social life.

    Some kind of qestions hardly if ever admit a constructive or positive answer, and you better stay away, run away immediately from those asking it. Salud †

    An anecdote. In a similar line of remark of: ‘missed in translation’ events, the S Kubrick’s movie: ‘Full metal jacket’, was translated into Spanish as: ‘La chaqueta metálica’-‘The metal blazer’. ‘Full metal jacket’ is a military term, related to the bullets that have a hard metal sheat over the lead core, preventing it from exploding when entering targets, and making a big hole, the so called ‘Dum-Dum’ effect. The intention of the title was 100% lost in this translation.

    • Enrique Guadiana, Cardiology says:

      Thank you very much for your comment.

      The title was a suggestion from the editors of CardioExchange. I like it! The post was no meant to be translated to Spanish. The meaning of miserable is the same in Spanish and English, in this case is used to refer unhappy or sad as an adjective like Daniela Drake used in her article.

      I am not asking if my collages are bastard, vile or fel.

      My translation to Spanish is ¿Colegas médicos, están tristes?

      I agree this is a ‘missed in translation’ events.

  3. The issue of physician burnout should be prominent in every medical center in the country. How can a physician with burnout possibly practice the highest quality of care. And central to this discussion is how our practice environments and workflows and payment structures have evolved to wring out the pleasure of practice. The time with patients has shrunk, the time chasing RVUs and documenting in frustrating EHRs has risen. We all see that bitterness has increased. What can we do to make practice better – patient-centeredness is important – but the work environment should also be one that makes it enjoyable to provide the care.

    See http://www.ncbi.nlm.nih.gov/pubmed/22911330

    In this article almost half of the surveyed doctors exhibited as least one symptom of burnout. And yet little has happened since this article was published a couple of years ago.

    It is time that we faced this problem!

  4. Karen Politis, MD says:

    I practice in a very different environment, but some of the points brought up by Dr. Guadiana seem to apply to many physicians of developed countries.

    The demand for perfection and infallibility, which we impose on ourselves as born perfectionists with massive superegos, but also comes across loud and clear from policy makers, the legal system and lately social media seems to be getting worse in spite of efforts to not blame the lonely practitioner, but to search for the systemic hazards. We live with a huge burden of responsibily and in the fear of being destroyed by a mistake. Even if we are not punished, the guilt will haunt us for the rest of our lives.

    The overwhelming work load in a chaotic atmosphere, with interruptions, sudden emergencies and in many places, less staff than “in the good old days” to lend a helping hand. The EMR’s are far from perfect, and many of us spend a lot of time glaring at the icon of the hourglass on the computer screen, time that could me spent caring for patients. In the end, we go home after hours of unpaid overtime efforts, with a sinking feeling that we have forgotten to do something but haven’t a clue what it might be.

    I would like to add that the gap between the ever expanding boundaries of medicine and the resources we have to dispense is widening. On the other hand, often we have feelings of medical futility and overtreating patients who have little to gain from out efforts, just to justify to ourselves that “everything possible has been done”. Sometimes I envy the physicians of old who had very little to offer, but had time to compensate by offering words of comfort to the patient and his family.

    In short, although medicine is often a rewarding profession and an excellent vantage point to see humanity in all its richness, I often feel frustrated and miserable, and tell young people to not choose this profession unless they really love people, have a good sense of humour and have a healthy dose of humility.

  5. The laws of unintended consequences hits hard with medicine.

    As an internist, I am delighted that none of my children have followed in my footsteps. They see the time commitment, paired with the lack of compensation, making medicine unattractive on the surface. Peel back a few layers and you see the irrational requirements for documentation, offensively judgemental payor and Federal scrutiny and I ask myself why do I remain in this profession.

    The answer lies in the fact that despite all the issues that are destroying the profession, the opportunity to work with individuals and make their lives better is a gift that I get every day.