But he or she does need your understanding.

In the course of my career I’ve seen many changes. The most alarming is physician morale. In my new, semi-retired capacity I’ve had a bit more time to spend on various medical sites that solicit physician comments on various topics, and it’s hard to miss the more pervasive mood of dissatisfaction.

I was in clinical practice for almost 40 years. Six years ago I went part-time and limited my practice to outpatient, spending the other half of my time in a capacity as a consultant/medical records reviewer for a company that provides services for hospitals and case managers helping to accurately assess the individual acuity of care that affects reimbursement. A little over a year ago I left clinical practice and continued in my part-time position. When I attended a training course for this latter vocation 6 years ago, what surprised me was the number of relatively young, “in their prime,” docs looking to join the ranks of medical reviewers, either half- or full-time. They were clearly in an advanced stage of clinical “burn-out.” Much is currently being written about this phenomenon. This, along with with my personal experiences, suggests that burn-out may be reaching epidemic proportions.

Medicine, some segments of it more than others, has always been a high-stress profession. For doctors “worth their salt,” caring for the weak and infirm carries a heavy burden of responsibility. In a bygone era, although the hours were long and the consequences of mistakes no less dire, the knowledge base and tools of the trade were less complex and dramatically inferior. Beyond certain surgeries and a limited number of marginally effective medications, much of the physician’s business was diagnosis (also more limited) and hand-holding. Today, doctors are tasked with deciding when to use, or harder still, withhold, a myriad of new, advanced techniques and therapies that are changing at an accelerating pace, in an ever older and sicker patient population. And this in the setting of an ever-changing series of guidelines intended to provide more cost-effective care. Failure, or perceived failure, is met with a much greater potential for litigation or loss of license to practice. And the government and medical boards are watching. Closely.

Doctors now have to not just certify, but continually re-certify. The process involves an ever-increasing battery of tests and requirements that many physicians feel, judging by comments I’ve seen repeated time and again, are less for the purpose of ensuring up-to-date clinical competence than generating revenue for a progressively burdensome bureaucracy.

The upshot of all this is fewer people entering primary care medicine, a looming physician shortage, and a loss of sense of medicine as a profession. This is a perfect storm at a time when Medicine has become just competent enough to manage chronic illness well enough to “squeeze every last ounce of life out of us” at great expense, in an era of burgeoning debt and aging baby-boomers.

Mid-level practitioners (nurse practitioners and physician assistants) have evolved to help fill the gap and reduce costs. While there are clearly many arenas in which this kind of help is beneficial, many specialty-based physicians (myself included) have experienced an increase in referrals from mid-levels, raising questions of just how much $$ we’re saving. It’s not unreasonable to assume that, in some circumstances, cost savings may be undercut by over- or under-diagnosis, since by necessity mid-levels have less intensive training and fewer academic requirements for entry (occasional overlap notwithstanding). I’ve worked over the years with many skilled, competent mid-levels and appreciated their help, but don’t see expanding this sector of the medical community at the expense of the physician pool as an ultimate solution.

What can we do?

In the intermediate to long term (20-40 years) many of the current problems will be solved by an evolving knowledge base and artificial intelligence. In the short term, I’m convinced we could streamline the training of physicians without compromising quality. Much of the initial 2 years of medical training could be completed in the undergraduate years (there’s been a trend toward increasing clinical exposure earlier, but not nearly as aggressively as I’d like to see). More clinical slots for interns, residents and fellows are needed. A thorough review of the government-mandated and medical board oversight and re-certification processes is in order, from the ground up. To accommodate ever-changing regulatory requirements for reporting, our EMRs (electronic medical records) have become monsters (perhaps you’ve noticed during an office visit your physician’s red, bleary eyes hardly ever meet yours any more). This will eventually be conquered by AI, but at present may be as much a problem as a solution.

Lastly, give your doctor a kindly pat on his or her back (perhaps, in this supercharged environment, a friendly smile will suffice). It will say, “I understand.”


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