This also makes physicians a target for every spending adjustment measure. Physicians are not the primary driver of cost growth in america: new procedures and changes in drug prices are (when was the last time an internist raised his prices 5000%? Never, because his reimbursement is set by Medicare). But they do write the prescriptions and orders and referrals. This means that the entire system converges on controlling physician activity.
This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.
So why are physicians burning out? Why are fewer and fewer "best and brightest" applying to medical school?
- Increased accountability with decreased authority. As the centerpoint for changes in documentation and prescription patterns, everyone is twisting physicians' arms to act in very precise ways, whether or not those ways are what the physician believe is good for the patient. Physicians get the scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!" "why are doctors doing Y?!" - and none of the power to actually decide any of this.
- Decreased authority in the hospital. Hospitals are suffering the invasion of the MBAs (and MPHs, and MHAs), and have more and more people with zero clinical knowledge setting policy. The big trend has been in nurses getting MBAs (and MHAs and MPHs) and going into administration, combining "I saw what doctors do from the side, I must totally know what's going on in their heads, right?" with MBA acumen. It's deeply problematic. "This patient has depression, and you didn't give them an SSRI! Malpractice! What's wrong with you?"
"This patient has multiple comorbidities that are more serious than their depression. I have them on medications for those comorbidities, and those drugs are all second-line therapies for depression. Time has shown that this combination has been effective for controlling their depression, and as a bonus, I avoided risking the side-effects of putting this patient on a third medication."
You cannot imagine the absolute pleasure of being regularly second-guessed by someone with a tiny fraction of your training. I imagine it's rather like a senior engineer having their code regularly criticized by someone that just finished "learn python in one week!". And they will then go to the EMR folks and have them add an alert, so that I can never place an order w/o SSRIs for a patient w/ depression without going through a whole Alert! rigamarole. There are so, so many alerts that alert fatigue is ubiquitous.
Additionally, in (fair) response to bad behavior of physicians in the past, nursing and other auxiliary services have moved into parallel reporting structures.
So, when patients are mad at something that has happened in the hospital, they call the doctor and yell at them! How could the hospital have done such a thing! I have no authority over the nurses that did it, or the nurse MBAs that made the policy, but I will get to take the scolding, the risk of malpractice suit (because patients don't sue over errors - they don't know enough medicine to identify errors - they sue over breakdowns in relationships with physicians), have zero authority to change or fix anything, and if I say a word, it's outside of my operational stovepipe and I will be both ignored and ultimately ignored by nurses. The latter means that my future care orders will be ignored or given low priority, and I can rely on that ultimately affecting my patients. So I have to keep my mouth shut over anything less than egregious problems.
- Increased time doing things unrelated to patient care. There's a myth that somehow all this new documentation is meant to improve patient care. It does not. The three major reasons have absolutely nothing to do with patient care:
---Many of the increases in documentation have to do with increasing specificity that strictly increases opportunities for error, and thus reimbursement denials.
---CMS wants increasing information on practice patterns, and wants to extract this from EMRs. Because they can't spend any money to collect this information (as I said above, they are required to be budget neutral), they shift this cost onto hospitals, which shift it onto physicians (it's worthwhile for hospitals to comply, because otherwise CMS brings out the reimbursement stick.)
---EMRs make billing more reliable, and reporting data to CMS more easy, and are required now as part of the ACA. EMRs are slow as fuck, because the end-user is not the customer. Their UIs are just fucking atrocious. There aren't words enough to relate how bad they are. Most can't even present lab results in a decent way.
The result is more documentation, done more slowly, for reasons unrelated to taking care of the patient in front of me - but that none the less take time away from seeing the patient in front of me.
And there is a constant media barrage about how terrible physicians are, which studiously ignores that 99% of the things they are describing and criticizing are systems-level issues physicians have no control over.
On top of all this, I have only rarely met a physician without a real sense of professional pride. That we are ordering tests we don't want to order, creating delays we don't want to create, hiring shitty front desk staff we don't want to hire, creating massively packed waiting rooms we'd rather not have, while patients are being bled dry by their pharmaceutical companies, all while working our asses off, getting scolded for it, and having trouble paying off our ever-growing student loans is... it's fucking heart-breaking.
It's heart breaking.
You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career." If anyone was willing to pay me my current salary to see a dozen patients a day rather than thirty, to give every single one of them the extended visit to collect a rigorous history and give them the scrutiny they deserve, I'd take it in a heartbeat.
You want me to be that doctor. I want to be that doctor. The delta between that, and what the system allows me to be, hurts us both.
In my first year of college I wanted to be a doctor and landed an absurd position - in hindsight - over my freshman summer where I was in the operating room with my surgeon nearly everyday (he led the residents). I tagged along through all the rounds, operations, and (of course) the tedious paperwork and billings.
By the end of the summer I was entirely jaded and switched programs. I still often think about whether or not I should have stuck it out.
However, what I ultimately saw (as you mentioned) were residents at this top, well-funded hospital who deeply loved medicine when they began medical school fall into a deeply jaded, pessimistic state. They made no money (while living in a high CoL city), were consistently overworked, and riddled with anxiety about where they would actually get a job post-residency.
Becoming a doctor - a surgeon in particular - struck me as a dozen year journey of constant make-or-break tests, quasi-lotteries with regards to residencies/fellowships, and then complete ambiguity as to where you would actually work when it was all done and you hit your mid-thirties. It also seemed increasingly devoid of any kind of professional autonomy and, most surprising to me, was how ungrateful and mean-spirited many patients were. Their lives would be saved, but they would yell at the surgeons over cosmetic concerns about the scars.
I often wonder whether my experience was not representative or simply too much to absorb as an 18-year-old at the time. However, the only folks I've talked to who seem to be truly satisfied and content with their careers are family doctors operating (largely) on their own terms and making 200-300k a year.
EDIT: I should say, I wish you the best moving forward and hope you find a level of contentment and happiness in a bruising - to put it mildly - system.
Everything you described is concordant with what I saw on my surgery rotations in medical school, and everything I've seen of surgeons in the hospital since then. Especially the mean-spirited and ungrateful patients. The ones that hurt, though, are the ones that come into the hospital hostile and confrontational from the outset.
"I know exactly what I need, and exactly what you need to do, and you're going to do it, or I'm going to have your balls!" I mean, that might be true. Sometimes it is. Sometimes it isn't. But nothing about talking to me like a rabid dog is going to make the process any better. And honestly, if you know your health, that's great - that will be very helpful. But ignoring other things it can be that masquerade as what you've got would be tragically irresponsible, so please don't bite my head off when I address the other conditions on my differential. I'm not ignoring you, I'm just trying not to be negligent.
Some patients will understand that, if we're given time to talk to them like human beings. But we basically never are, which makes things terrible for everyone.
The constant make-or-break tests and quasi-lotteries are a particularly apt description of medical school, and why - IIRC - the most recent stats put medical student rates of anxiety disorders at almost 50% of med students, and depression at approximately 30%. We absolutely destroy young physicians right at the outset. Studies of physician compassion have found that med students' compassion drives into the ground somewhere in third year - not with their first "your entire career relies on this" exam, but with their first exposure of what medicine has become, and how patients will be treating them.
Are you me and my MD friends?
I'd add, from the clinic setting, that the amount of micromanaging of care and the amount of cost shifting back onto the patient by insurers is appalling. Want to prescribe an inhaler? good luck trying to figure out which one the patient's insurance will cover, and once you do they'll change it to a different one in 6 months without warning you or the patient. Want your patient to take insulin? good luck trying to find anything for less than $100/month, often much more. I hear about "copays" of $3-400/month for patients for insulin. This is with insurance. Its a joke. And yet the insurers, and my employer, would like to grade me on the % of patients with diabetes under 'good control'.
I fantasize about various alternate careers on my commute home.
What I'd recommend is that she get in touch with a healthcare professional. So, so many docs I know are afraid of getting help for the (fucking inevitable) depression because they're afraid of the stigma, despite it being so common in our field. I was one of them. Keeping a good, discrete psychiatrist in your corner can be incredibly valuable for getting through that time in one's life.
In Germany - once you finish medical school (6 years) you can practice medicine and be paid for it but you're not yet specialized. Specialization is achieved via a 5-year hospital residency. During that time you're considered an "Assistenzarzt" (assistant doctor), which is hilarious. She was handed her own station 2 months into her residency - a station with a capacity of 15 patients that's very often at 20, with extra beds crammed into what used to be 3 person rooms. That residency rewards you with a lower middle class salary for days that consist of 8 hours of frantic clinical work and 4 hours of clerical work. There's a serious overall doctor shortage, especially of senior doctors, so on-the-job training and guidance is very thin. Never enough time and always too much responsibility is the name of the game.
My girlfriend has a therapist who supports her and isn't afraid of any stigma. That part is easier here because the system is so desperate for doctors that no one has reason to fear for their job. But, I just don't understand what any therapist can do to help anyone survive 60-80 hour underpaid weeks with occasional night duty, in a context where serious medical mistakes are simply inevitable. She knows she's doing her best and she knows she's being set up to fail, but in her mind, understandably, none of that negates that in the end, it was her that made that mistake.
Where did you land? Did you find a sustainable way to practice?
My interest is in chronic pain management, by way of psychiatry. I have very strong feelings about the way chronic pain is handled, or mishandled. The american approach to pain is incredibly ... uncomfortable with pain. There's an underlying guilt and discomfort that makes physicians very, very uncomfortable, in a way I think very few are willing to honestly admit or engage with. They turn their brains off when it comes to pain, the better to salve their hearts. When the drug companies pushed hard to market "pain as a vital sign," it gave physicians permission to just throw painkillers at patients to shut them up. Now the addiction crisis gives physicians license to just not throw painkillers at anyone. Either way, it's mindless, and patients suffer for it. Heck, even when physicians are thinking about it, the question is always about addiction, malingering, etc. This isn't helped by the fact that addiction and malingering are common, and addicts and malingerers also get sick and also have pain that requires training.
I don't have a good answer for that one. It's just another survival thing. We aren't robots; we can only do so much to retain our sanity in the face of pain. But I am more bothered by pain treated poorly than I am by the mere existence of pain itself. It helps that I'm chronically ill myself, have been in shoes few patients have ever been in, and can meet them heart-to-heart on the topic.
Psychiatry residency in the states is pretty merciful compared to others, either because psychiatrists better appreciate psychological distress in general, or because we're the ones our colleagues come to for help and we're loathe to inflict the same suffering on our trainees. It comes with a decent hit to your bottom line - you give up a fair chunk of income in exchange for retaining your sanity - but I am happy to be able to see my loved ones and remain a human being. I used to think I'd want to do critical care, but seeing how critcare fellowships ate alive people far more resilient than I am... thank goodness I didn't do that.
I think the concept of burnout in medicine is not something unique to medicine. Everyone I know, whether they are family members or friends in computer science, architecture, law (big time), or even being a stay at home parent exhibits burnout to the same degree I see in my colleagues. I think doctors are just more likely to talk about it and publish it because (cynic in me), it's a way to write papers and pad the resume, career advancement.
> This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.
If I understand your first comment correctly, you're saying that the effect of increasing residency slots will be to employ more doctors working fewer hours, but since expenditures for services are more a function of # doctors than # services performed, this will increase medical expenditures overall, which is a non-starter for CMS due to its budget-neutral requirement?
There's more demand than supply for physician services.
The result of increasing residency training spots has two phases:
Phase 1, which I skipped discussing:
A given hospital, in the short term, has only so much infrastructure - i.e., 6 ORs. Adding residents does not address those bottle-necks. Or, if we're looking at internal medicine, I only have so many internal medicine beds to host patients, and only so much faculty to supervise those residents. This won't directly rack up medical costs, because the bottleneck on services provided isn't the number of residents. There are other knock-on effects, of course: if I have a surgical residency staffed such that my ratio of residents to current surgeries is approximately 1:1, that's solid training. If I go to 1.5:1, I now have an inadequate number of surgeries for training my residents, and I produce worse docs. Also, the american council on graduate medical education has requirements for how many procedures my surgical residents do, and if I can't meet those requirements they don't get to become surgeons. So, in this phase, if Medicare funds more spots, what we get is more Medicare expenditures without increasing supply of medical care.
But the primary issue is phase 2, which is what I discussed in my original post:
Those residents complete their training, and enter a market where demand >> supply. They go work for hospitals with under-utilized infrastructure, or they open their own clinics. Now they'll soon be working at capacity. Rather than diminishing the average workload across all physicians, they've simply shortened the backlog of unmet medical need somewhat. That's not a bad thing, but it's an increase in healthcare expenditures.
I can see why hospital administration would drive doctors with that inelastic preference to work long hours. But if there is a sizable pool of doctors who’d rather get paid less to work less, that suggests some firm can come along, make such a hospital, hire those people and do ok, maybe even better since their doctors are not as overworked.
What prevents that?
Try telling that person "you know, you could have a reasonable middle class life if you just give up on the idea that all that work and sacrifice should have had any ROI."
Administration also prefers docs to work those hours for the fact that the entire hospital is built around these shifts, operationally, and a good deal rides on a doc carrying all his patients in his head for their entire course of stay. Hand-overs are disruptive and inefficient. If you offer a hospital "I don't want to work 10 on and 10 off, how about I work 10 days on, 20 days off, and you prorate my salary accordingly?" the hospital might agree, but they'll get rid of you in favor of a full-timer as quickly as they can.
When I went to school, a few people had wealthy parents that made the debt issue disappear. Most were about 300k in debt when they graduated. I had a cheap undergraduate, but a private master's, so I came out of school at about 350k, with my interest rates ranging from low-6's to high-6's, with one "small" loan (~80k) at 7.8%.
By the time you hit residency, some folks are still single, but most have at least a serious partner, or are married, plus or minus a kid. When I hit residency I had a wife and a kid; my buddies were all married, getting ready to have a kid. They'd all have one by their second year of residency.
So, at this point, you're making about 50k a year, your spouse is probably making something similar or less, while effectively being a single parent. They probably still have school loans of their own, never mind carrying the cost of supporting the entire household. They are not servicing your debt. Kids are expensive, and the childcare you have to pay for as effectively-a-single-parent is even more expensive.
If you're single, depending on cost of living in your area, you're either putting off all your repayments (taking income-based repayment schedule) and living with a few roommates, or you're actually taking more loans to make it through.
Your training program will pay for your licensing exams in residency, and cover a decent portion of the cost of attending academic conferences. You won't spend a lot in this category unless you're aggressively academic.
It is not uncommon at this point to finish your residency training with more debt than you started - if you went in with 350k, it would not at all be surprising to be >500k at this point.
Now you go into practice. Fresh out of residency, general internal medicine, depending on your region, expect to make 180-220k. You're also at this point in your 30s, you've got a kid or two, your debt, likely a good chunk of your spouse's debt. Most available jobs are in reasonably high CoL areas, or they're out in the middle of nowhere. CoL isn't entirely up to you - most residencies are in high population density, high CoL areas. Residency is where you form all your professional connections; it's very hard to land a job outside of the zone of your residency, unless you're willing to go to an extremely poor backwater that just can't attract a physician at all.
Some docs at this point are willing to continue living like they're paupers, keep their family penned up inside a tiny apartment, driving their old beater. If that's the case, you take your 220+60 = 280k/yr household income, call it 200k after taxes, and devote 100k of it to debt servicing. You can pay off your loans in six years.
The truth is, though, that after you've lived like a pauper for your entire twenties and into your early thirties, and you've got kids, and a spouse that has supported you through all this garbage, and all of your non-medical friends have long ago vastly outpaced you, and you haven't had a decent vacation in ages...
Some new docs go overboard and start spending like mad.
Most don't. All the folks I went to school with came out and got reasonably nice apartments, so that at least their kids could each have a bedroom, got a slightly-better-than-entry level sedan (Nissan Sentra or Nissan Altima was de rigeur), bought a few suits so that patients would stop confusing them for students, took their spouse on vacation, and started servicing their debt - most taking a 30-year plan, and adding pre-payments. Some folk could pay it off by the time they were 50. Most couldn't - once they realized they also had to start putting money into their kid's college funds, and hopefully build something like a retirement fund, well...
I entered residency with 380k of loans (I paid off undergrad by attending a cheap public institution and working it off, but I got a Master's in a private school, though they gave me a solid merit scholarship, and then... med school.) My wife had about 80k of her own loans remaining; luckily, her parents paid off her private undergraduate debt, but she had grad loans to pay. We had one child, and were planning on two - financially timing a kid is hard, because the counterpoint is the rapidly increasing chance of birth defects with maternal age. I was 32. (I worked for a bit between Master's and Med school). We lived in a 2br as far from our intensely-high CoL area as we could tolerate commuting to. Want to picture commuting an hour in each direction when you need to be in by 5:30a and (hopefully) leave by 6:30pm? Fuck. We drove a Nissan Altima, because the area we lived in (that far from the city center) was not public transport friendly. I was lucky, though, because my wife was a high-earner. We still managed to burn through her income on a monthly basis, but it meant that she was able to service her debt on a 10-year repayment plan, and when she got bonuses from work they were put towards my loans.
We were moderately disciplined. I wasn't a martyr; we bought organic fancy groceries for our kid (not for ourselves; we had "organic strawberries for baby and whatever random berry was reasonably cheap this week for mom and dad"), we went on a cheap vacation once a year; we went out once a month.
I got into residency commuting distance from a low-compared-to-where-we-were-before CoL area. We rented a 3br apartment for less than we were paying for our 2br before. My wife had to switch to a lower paying job, because she couldn't keep her old one remotely. Much lower. Our QoL went into the shit, and by the time I graduated, our collective debt had barely budged. Childcare expenses reigned.
I expect I'll be paid off by 45. Hopefully in time to start a retirement fund for my wife and I, and a college fund for the kid. In exchange, we will continue living in a cramped apartment and driving the same car I see college undergraduates driving. Or I could lease a nicer car, and mortgage a house, and I'll be paying off my loans well into my 50s or 60s. And of course this assumes I work crazy hours. If I work half as much, I don't pay off my loans in twice as much time - interest will be compounding. If I work half-time, I'll never pay off my loans, never mind put anything away for retirement.
There are four major groups of physicians:
-Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it."
--Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh?
-Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+.
-Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc.
-"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore.
Key to Understanding Medical Reimbursement:
This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service.
That's it; that's your cap.
Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.