作为一个医生，为什么现在是美国历史上最坏的时期？

Last week, Dr. Pearl kicked off a three-part series on the physician experience. His first installment revealed Why This Is The Best Of Times To Be A Physician In America.

With apologies to Charles Dickens, just as now is the best of times to practice medicine, it is also the worst of times to do so.

In their twenties, most physicians choose health care as a career for altruistic reasons. They dedicate years to arduous training, making personal and financial sacrifices to serve, heal and otherwise help others. They looked forward to being rewarded accordingly, and feel privileged to be able to build long-lasting relationships with patients and experience a level of trust and respect that, among human interactions, remains unique.

Throughout much of history, this was the social contract that attracted doctors to the profession. But increasingly all that training and hard work offer no protection from a growing number of day-to-day difficulties that leave physicians feeling increasingly frustrated and even powerless. Today’s blog focuses on three of these current “facts of life” that, for many physicians, compromise and undermine the joys and fulfillment of the practice of medicine.

Physicians are not naive. When they applied to medical school, they knew full well that the practice of medicine entails hard work. They also understood when they opened their offices, that they would be responsible for managing the business of a medical practice. But few imagined the level of pressure, frustration and exhaustion they would feel most days. And certainly none who began their career a couple of decades ago expected that one day, despite working harder and harder, their income would decline year after year.

It’s no surprise then, that in many parts of the country, professional satisfaction among physicians has sunk to an all-time low. Indeed, half of all practicing physicians report discouraging their children from following in their professional footsteps.

The Fee-For-Service System Corrupts Medical Practice 

A majority of practicing physicians today get paid based only on the number and complexity of services delivered, through a fee-for-service reimbursement scheme that fails to recognize the whole of what they do for their patients. And it is this reimbursement approach and the associated administrative burden that accounts for much of the frustration and dissatisfaction so many doctors feel today.

This payment model originated in the time of Hippocrates and has continued essentially unchanged across the 20th century. Only a few decades ago, the types of problems patients experienced were relatively straightforward, and the number of therapeutic interventions fewer and less complex. And until 50 years ago, a large percentage of medical care was paid directly by the patient, without a third-party intermediary.

In the past, clinical care was provided mainly for urgent problems with relatively inexpensive solutions. A child broke his arm, and the doctor put on a cast. A woman developed an infection, and went home with an antibiotic. A teenager had appendicitis, and the surgeon took him to the operating room for a straightforward procedure. The prices of these treatments were reasonable and reflected the time and training required to do an excellent job.

But today medicine is vastly more complex, often requiring teams of physicians and very expensive drugs and technology. With our population now so much older, a growing number of patients have major chronic illnesses that require on-going treatment for decades. And with some drug companies charging over $1,000 a pill for medications and device manufacturers offering multi-million dollar machines, the cost of providing medical care to a single patient can be tens of thousands of dollars, if not hundreds of thousands. And as a result, the total expense for American health care continues to rise rapidly, much faster than the Gross National Product. Although doctors bear some accountability for this upward spiral in health care expenses, many now feel like victims of a system gone haywire.

Third-party payers could have chosen to work with physicians and hospitals to transform health care practice, but few have. Instead they continue to use the traditional fee-for-service approach, preferring to leverage their size and bargaining power and focusing on unit, rather than total, costs. And given the recently announced mergers of the largest insurance companies into three mega-giants, we can expect this process to continue. Increasingly, we are seeing this approach take an adverse effect on patient care and physician satisfaction. And when doctors complain that these payments fail to cover even their office expenses, insurers threaten to exclude them from their company’s increasingly narrow networks. Already insurance companies prohibit about one-third of providers from participating in the state health care exchanges.

The results are predictable. As reimbursement per patient declines, particularly for so-called “cognitive” specialties like adult and family medicine and pediatrics, doctors find themselves with no choice but to work longer hours, see more patients every day, and devote less time to each one. The result is that the doctor’s relationship with patients, previously so strong and mutually rewarding, has deteriorated.

But in many cases, reducing unit prices is not the only approach used. For many of the more expensive tests and procedures, physicians are required to obtain permission from the insurance company, which makes doctors feel they are being second-guessed by clerks. The result is daily frustration, delays in getting medical care and an increasing administrative burden.

And even when the care is finally authorized, the process to get paid for the service is complex and can take months. Today, doctors find it necessary to employ a large number of “back office” people to file claims and do billing. Indeed, the size of this clerical staff in many physician offices outnumbers the people involved in direct patient care.

And treating patients insured through government programs is no less an obstacle in itself. As the Federal government and most States face budget challenges, they look to health care as an area to cut costs. For physicians that means reimbursement for many health conditions and procedures remain flat at best. As the cost of office staff, equipment and medical supplies continues to jump, payments from Medicare and Medicaid are often barely enough to keep the lights on for some doctors, particularly primary care physicians, who are paid significantly less than specialists. As a result, newly trained physicians, who often begin practice with medical debt averaging as much as $200,000, might need more than a decade to get their heads above water.

Growing Costs To Consumers Affect Doctors, Too

Health insurance no longer covers what it did in the past. Increasingly, patients must pay thousands of dollars out of pocket before their insurance plan kicks in. For many families, this is unaffordable and physicians are affected by their patients in need of medical care who face these economic hardships.
Often doctors find themselves squarely in the middle of the equation, with patient on one side and insurer on the other.

As a consequence, physicians and their staffs can spend most of a visit discussing how much each treatment option will cost the patient, rather than the benefits and risks of various treatment options. And when the patient is unable to afford, say, $5,000 for a surgical procedure or complex course of therapy, all the physician can do is try to figure out a viable alternative.

And being prevented from providing the right therapeutic option is frustrating and exhausting for physicians, particularly when they read that the insurance company used 15% or 20% of the patient’s premium for administrative expenses and return to shareholders.

How The Electronic Health Record Can Thwart Physician Performance

As I noted in part one of this series, when physicians need to obtain information immediately, the electronic health record (EHR) is a godsend. But for many doctors, particularly those in individual and small offices, the EHR all too often is more hindrance than help.

The problems begin with the design. Early EHRs were programmed primarily for billing purposes and data storage, rather than as tools to improve the physician’s clinical workflow. And the newer systems are built to follow the designs of the past.

Also frequently, doctors are frustrated by the cost of installation, the time required getting the staff up to speed and the incompatibility of the EHR they use with those in other physician offices and the hospitals where they have privileges to practice.

The underlying computer architecture leads to another major problem. Entering and retrieving information via EHR can take a physician inordinate time compared to entering the information in a paper medical record. And the high number of clicks required, even for relatively simple problems makes many physicians feel like data-entry clerks. Combining the added time to document with the need to see more patients a day, physicians are acutely aware of how much less time they now have with their families and each of their patients.

Most problematic, the EHR often proves to be a distraction for physician and patient alike during the clinical encounter itself. The doctor, instead of making and maintaining eye contact while taking a history, faces the computer, sacrificing the personal connection between doctor and patient so valued by both. The presence of the computer and the time data entry decreases communication, both verbal and non-verbal. Physicians don’t want to diminish their interaction with their patients, but most feel trapped.
Spend a day practicing like this, and the result is a doctor who goes home tired, dissatisfied and, increasingly discouraged about the future.

What’s The Solution?

Fixing these problems, and others beleaguering aspects of medical practice today, won’t be easy. Some of the solutions being bandied around would most likely make the situation worse. Were the government to run our health care system through a single payer, the inevitable red tape and politicization would be disastrous. And selling your practice to a hospital or insurance system, which many doctors have embraced. proves even more frustrating for most as the demands imposed by these institutions once the deal is done more than offset the short-term advantages.

And of course, doing nothing is going to cause serious problems.

So what can be done? Already there are organizations like the Mayo Clinic, Kaiser Permanente and Geisenger Clinic that have overcome many of these problems and improved the lives of both patients and physicians as a result. But much more needs to happen at the national level This will be the focus of part 3 of this series. Without question, the proposals won’t be easy to implement. And various health care system stakeholders will reject and try to block many of the recommendations. But if the physicians caring for patients and families are to provide the best health care possible, we need to be willing to keep all options on the table. 

Dr. Robert Pearl is the CEO of The Permanente Medical Group, a certified plastic and reconstructive surgeon, and Stanford University professor. Follow him on Twitter: @RobertPearlMD.