An Occasionally Pleasant Minimum Security Prison

What three things do the following occupations have in common: teacher, nurse, secretary (now called administrative assistant), and information technologist?

First, I would classify them all as helping professions. Second, based both on surveys and my own experience as a physician, they all work under conditions of stress, suffer a lot of anxiety and depression, report increased job dissatisfaction, and experience high burnout rates. And third, someone, somewhere (likely in a brief moment of guilt) established for each of these professions an “Appreciation Day.” So instead of devising a means to reduce the burnout that looms on the horizon, the people in charge figured everything would be hunky-dory with a box of candy, some flowers, and a yip and a yay.

In light of all this, I should have been less surprised when I opened the New York Times on Saturday and discovered, despite having practiced medicine for decades, the existence of Doctor Appreciation Day. Wow! I could now officially join the ranks of other depressed and burned-out professions. I learned of my special day through a full-page ad signed by the CEO of New York-Presbyterian Hospital. This fortunate man, according to information readily available online, enjoys a salary of $7 million a year, a largesse approved by the board of directors of his not-for-profit hospital. Hazarding a guess that the average primary care physician there earns about $200,000 a year, the CEO rakes in nearly 35 times what he’s paying his medical staff members.

No wonder he appreciates doctors.

Let’s move on to physician burnout

A survey last year in JAMA Internal Medicine reported that nearly half (45.6%) of primary care physicians (family medicine, internal medicine, ob-gyn) experience professional burnout of a degree sufficient to impair the quality of their lives. This number, by the way, is higher than for any other profession, though separate surveys show teachers are perilously close. Much less burnout occurs among physician specialists, the real winners those in non-surgical specialties such as allergists, dermatologists, radiologists, anesthesiologists, and pathologists.

I personally feel blessed that I’m well within the unscorched 54.4% and attribute this success to being surrounded by WholeHealth Chicago practitioners and staff. Our alternative practitioners, freed from many of the daily hassles of primary care medicine and able to concentrate on the well-being of you, their patients, have an enviably low (low!) rate of professional burnout.

Determining the reasons behind primary care burnout isn’t rocket science. A typical family practitioner, internist, or ob-gyn is overworked, seriously underpaid (especially when compared to other physicians), and watching her income slide steadily downward every year. She’s lost her autonomy as an independent thinker, compelled to make decisions often not in the best interests of her patient, but rather geared at increasing the bottom line of a health insurance company. She’s arriving home late every night after hours of relentless paperwork and is seeing less and less of her family. Years after finishing her training, she’s still paying off medical school loans, the average doctor leaving medical school with $150,000 in debt. (Don’t be too thrilled if your kid gets into Harvard Medical School, where tuition is currently $1,000 a week for four uninterrupted years.)

Added to this debt, her malpractice insurance is steadily rising: $45,000 a year for an internist, $120,000 a year for ob-gyn. But at least it will help shield against the inevitable ambush of a malpractice suit. Most doctors have at least one in their careers and, guilty or not, it’s usually accompanied by two or more years of clinical depression.

Stressors mount

If the appearance of a process server in her waiting room delivering a malpractice suit isn’t anxiety-inducing enough, at any time she can be raided by auditors from any of the dozen or so insurance companies she’s contracted with. If an insurer believes she’s overbilled for services, it can stop all reimbursement to her practice until the debt is repaid (this, by the way, is called “clawback” by doctors. Nice image, eh?). Overbilling errors are virtually always technical misunderstandings rather than deliberate fraud. Medical billing is a rat’s nest, complicated enough to bill honestly and openly. Most doctors have neither the time nor the cleverness to deliberately perpetrate billing fraud. Ironically, these random but stressful insurance audits never reveal inadvertent underbilling (“Oh, Dr. Jones, you’ve undercharged all these years. Here’s a big check for what we owe you!”).

Added to this, her practice is endlessly monitored by various self-styled bureaucratic and insurance watchdogs. She’ll get notifications if she prescribes too many brand-name medications (versus generics), orders too many lab tests, or makes too many referrals to specialists. She’ll even get a scolding if she spends too much time with patients.

Hasta la vista, physician autonomy.

As a result of all this stress, she’d like to exit her profession years earlier than she’d originally planned, but expenses have been too high and she’s not been able to save enough for retirement. Like most doctors, she actively discourages her children from becoming physicians themselves. This is a sharp contrast to my medical school years, when many of my classmates were grooming themselves to take over their father’s practice.

All this dissatisfaction is generally mystifying to the general public

In most any town, the doctor has a beautiful house and a couple of nice cars, with kids who are well dressed and go off to good schools. Unemployment among physicians is virtually zero. But if you return to the data on physician burnout, it’s the town surgeon, orthopedist, or neurologist who has the five-star life, not the GP in his Kia.

And yet primary care doctors do hang in there, expressing over and over again that they really like helping people, are genuinely fond of their patients, and enjoy the prestige and intellectual stimulation of being a physician.

Of course I noted that two days after Doctor Appreciation Day was April Fools Day. The coincidence of this briefly crossed my mind, especially given that on April 2 the government’s directive to cut Medicare reimbursement by 2% to all physicians nationwide goes into effect.

I was exchanging emails about burnout and the Medicare cuts with a physician friend. “Let’s face reality,” he wrote. “We’re really stuck. Doctors are too inept to do anything but be doctors. We can’t change a tire, repair a faucet, or arrange flowers. You I wouldn’t  trust to make a sandwich if you owned a 7-11 franchise. I’ve come to realize that practicing medicine these days is like living in a reasonably pleasant minimum security prison. Pleasant…but still a prison.”

Be well,

David Edelberg, MD