How Being a Doctor Became the

Most Miserable Profession

Ni ne of 10 doctors di scourage others from j oi ni ng the professi on, and 300 physi ci ans commi t sui ci de every
year. When di d i t get thi s bad?
By the end of this year, its estimated that 300 physicians will commit suicide. While depression
amongst physicians is not newa few years back, it was named the second-most suicidal
occupationthe level of sheer unhappiness amongst physicians is on the rise.
Simply put, being a doctor has become amiserable and humiliating undertaking. Indeed, many
doctors feel that America has declared war on physiciansand both physicians and patients are
the losers.
Not surprisingly, many doctors want out. Medical students opt for high-paying specialties so they
can retire as quickly as possible. Physician MBA programsthat promise doctors a way into
managementare flourishing. The website known as the Drop-Out-Clubwhich hooks doctors
up with jobs at hedge funds and venture capital firmshas a solid following. In fact, physicians
are so bummed out that 9 out of 10 doctors would discourage anyone from entering the
profession.
Its hard for anyone outside the profession to understand just how rotten the job has become
and what bad news that is for Americas health care system. Perhaps thats why author Malcolm
Gladwell recently implied that to fix the healthcare crisis, the public needs to understand what
its like to be a physician. Imagine, for things to get better for patients, they need to empathize
withphysiciansthats a tall order in our noxious and decidedly un-empathetic times.
After all, the public sees ophthalmologists and radiologists making out like bandits and wonder
why they should feel anything but scorn for such doctorsespecially when Americans havent
gotten a raise in decades. But being a primary care physician is not like being, say, a plastic
surgeona profession that garners both respect and retirement savings. Given that primary care
doctors do the work that no one else is willing to do, being a primary care physician is more like
being a janitorbut without the social status or union protections.
Unfortunately, things are only getting worse for most doctors, especially those who still accept
health insurance. Just processing the insurance forms costs $58 for every patient encounter,
according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland
Medical Center who is writing a book about the crisis in primary care. To make ends meet,
physicians have had to increase the number of patients they see. The end result is that the average
face-to-face clinic visit lasts about 12 minutes.
Neither patients nor doctors are happy about that. What worries many doctors, however, is that
the Affordable Care Act has codified this broken system into law. While forcing everyone to buy
health insurance, ACA might have mandated a uniform or streamlined claims procedure that
would have gone a long way to improving access to care. As Malcolm Gladwell noted, You
dont train someone for all of those years in [medicine] and then have them run a claims
processing operation for insurance companies.
To make ends meet, physicians have had to increase the number of
patients they see. The end result is that the average face -to-face
clinic visit lasts about 12 minutes.
In fact, difficulty dealing with insurers has caused many physicians to close their practices and
become employees. But for patients, seeing an employed doctor doesnt give them more time
with the doctorsince employed physicians also have high patient loads. A panel size of 2,000
to 2,500 patients is too many, says Dr. Schimpff. Thats the number of patients primary care
doctors typically are forced to carryand that means seeing 24 or more patients a day, and often
these patients have 10 or more medical problems. As any seasoned physician knows, this is do-
able, but its certainly not optimal.
Most patients have experienced the rushed clinic visitand thats where the breakdown in good
medical care starts. Doctors who are in a rush, dont have the time to listen, says Dr. Schimpff.
Often, patients get referred to specialists when the problem can be solved in the office visit. Its
true that specialist referrals are on the rise, but the time crunch also causes doctors to rely on
guidelines instead of personally tailoring medical care. Unfortunately, mindlessly following
guidelines can result in bad outcomes.
Yet physicians have to go along, constantly trying to improve their productivity and patient
satisfaction scoresor risk losing their jobs. Industry leaders are fixated on patient satisfaction,
despite the fact that high scores are correlated with worse outcomes and higher costs. Indeed,
trying to please whatever patient comes along destroys the integrity of our work. Its a fact that
doctors acquiesce to patient demandsfor narcotics, X-rays, doctors notesdespite what
survey advocates claim. And now that Medicare payments will be tied to patient satisfaction
this problem will get worse. Doctors need to have the ability to say no. If not, when patients go to
see the doctor, they wont actually have a physiciantheyll have a hostage.
But the primary care doctor doesnt have the political power to say no to anythingso the to-
do list continues to lengthen. A stunning and unmanageable number of formsoften illegible
show up daily on a physicians desk needing to be signed. Reams of lab results, refill requests,
emails, and callbacks pop up continually on the computer screen. Calls to plead with insurance
companies are peppered throughout the day. Every decision carries with it an implied threat of
malpractice litigation. Failing to attend to these things brings prompt disciplining or patient
complaint. And mercilessly, all of these tasks have to be done on the exhausted doctors personal
time.
Almost comically, the response of medical leadershiptheir solution is to call
for more physician testing. In fact, the American Board of Internal Medicine(ABIM)in its own
act of hostage-takinghas decided that in addition to being tested every ten years, doctors must
comply with new, costly, "two year milestones." For many physicians, if they don't comply be
the end of this month, the ABIM will advertise the doctor's "lack of compliance" on their
website.
In an era when nurse practitioners and physician assistants have shown that they can
provide excellent primary care, its nonsensical to raise the barriers for physicians to participate.
In an era when you can call up guidelines on your smartphone, demanding more physician testing
is a ludicrous and self-serving response.
It is tone deaf. It is punitive. It is wrong. And practicing doctors cant do a damn thing about it.
No wonder doctors are suicidal. No wonder young doctors want nothing to do with primary care.
But what is a bit of a wonder is how things got this bad.
Certainly, the relentlessly negative press coverage of physicians sets the tone. Theres a media
narrative that blames physicians for things the doctor has no control over, says Kevin Pho, MD,
an internist with a popular blog where physicians often vent their frustrations. Indeed, in the
popular press recently doctors have been held responsible for everything from the wheelchair-
unfriendly furniture to lab fees for pap smears.
The meme is that doctors are getting away with something and need constant training, watching
and regulating. With this in mind, its almost a reflex for policy makers to pile on the regulations.
Regulating the physician is an easy sell because it is a fantasya Freudian fever dreamthe
wish to diminish, punish and control a disappointing parent, give him a report card, and tell him
to wash his hands.
To be sure many people with good intentions are working toward solving the healthcare crisis.
But the answers theyve come up with are driving up costs and driving out doctors. Maybe its
too much to ask for empathy, and maybe physician lives dont matter to most people.
But for Americas health to be safeguarded, the wellbeing of Americas caretakers is going to
have to start mattering to someone.