How Do Physicians Effectively Respond to the Pressures We Face?

I finally ran across the eloquent essay by Dr. Jeffrey Singer; see “How Government Killed the Medical Profession” in the tweet below.

As you can see, I called this required reading for resident physicians and medical students, although it could be enlightening and possibly career-saving for high school students and college undergraduates as well.

Learners are guaranteed to get the party line that Dr. Singer decries. Geezer teachers like me give a less articulate version of his perspective (littered with curse words as needed) almost every day–when we’re not galloping on the treadmill our hospitals and clinics have installed for us.

Dr. Singer is one of a vanishing breed, a doctor who has a wealth of institutional memory wherein is stored a timeline on the  economic and political evolution of our health care delivery system in America.

Doctors are beleaguered, burdened with increasing regulatory pressures, and on the precipice of losing our identity as professionals. The most recent indicator for the latter is the historic formation of a union by doctors in Oregon, something I never thought any group of physicians would do:

This evolution of the view of the practice of medicine as a profession to a trade, or as Dr. George Dawson has pointed out, of doctors being treated as production workers rather than knowledge workers, has been coming for a long time.

I rattle on about this to residents and medical students, who understandably don’t have time to focus on it because they have piled up a huge load of student loan debt which they have to repay.

Financially and psychologically, they can’t afford to think too much about Singer’s perspective. The question I can read on their faces is “What can I do about it now?”

Hey, the student loan debt crisis has been in the news a lot these days.

The CNN special on the high cost of college was enough to make many students question its value in today’s world. In this kind of environment, how do your persuade them to embark on a career in medicine, especially if doctors are increasingly being treated like widget workers?

Sometimes I feel like those of us who are trying to call attention to where the practice of medicine is going are a lot like the Cooper Union students protesting the college’s decision to charge tuition for the first time in its 150 year existence. They occupied the President’s offices for months but were unable to turn back the tide.

Debates, petitions, protest marches, sign-carrying, sit-ins (and now “die-ins” in response to recent controversial grand jury decisions regarding police killing unarmed African American males) are the American way. But geezers can’t persuade young folks to speak up. Organizations like Change Board Recertification and Physicians for Certification Change can’t get doctors united in great enough numbers to influence powerful certification boards.

Do they have us where they want us (and who are “they” anyhow?) and is there a more effective way to respond to change, rather than simply reacting?shooting-fish-in-a-barrel

 

 

I think that may be what my trainees are waiting to hear from me.

 

 

 

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Comments

  1. Jim,

    About 15 years ago I sent some poetry I had written to my old college English professor. He was interested in why. I think many English professors would make good psychiatrists. I told him my usual complaints about the beating I was taking at the time and he said:

    “You should never really doubt your profession. With the time and energy you have put in so far it would be a mistake to think about doing something else.”

    At the time, I was shocked. He was a very liberal bright guy telling me to stay on the conservative path. No chasing dreams here. No doing what feels right. In retrospect he was right of course.

    Your thoughts about engineering are interesting. I am a member of the IEEE, not because I am an engineer but because I worked with electrical engineers on EEG projects back in the 1990s. I noticed right away that I have the personality of an engineer. I had to read their literature and still read it from time to time. I am currently fantasizing about getting an engineering degree in retirement. If young people ask me, I often recommend they consider engineering rather than medicine. If they are girls or women, I add the argument that in all of the engineering and science literature I read there is a movement to get more women in both fields and I add an additional recommendation on that basis.

    At the level of people already in another field of medicine, it is a different matter. I have not seen it studied, but if I had to guess I would say that psychiatry attracts more MDs who have been specialists in other fields than any other specialty. Some of my mentors started out as internists and cardiologists. I can recall having a patient with severe bipolar disorder who had a QTc of 520 msec. I located an author in the literature who also co-authored a large study on post-MI depression and sent him an e-mail. He called me with the recommendation of what atypical to use. In that call I learned that he started out as a Cardiologist. I have also talked with many colleagues in the physicians’ dining area who were fascinated by our field but also repelled by various aspects like trying to figure out who was suicidal or dealing with agitated, angry and demanding people. Even more interesting, I have talked with some specialists who think, talk, and act like psychiatrists even though they are highly skilled in their own specialties.

    If our field is that secretly attractive to other MDs, it makes me think that we may have made the right decision. We are focused on the most fascinating organ in the human body. So when other MDs ask me, I tell them I know many highly accomplished psychiatrists who started out in another specialty. I also tell them it is a much harder job than most people think and not to expect any breaks from the press.

    George

    Liked by 1 person

  2. Jim,

    They definitely have us where they want us. Only a miracle of physician cooperation (or possibly a union) will save us now. Dr. Singer’s article is interesting because it contains all of the themes that I complain about on my blog. I actually remember a mandatory coding seminar (is there any other kind?) where we were all basically threatened with federal prison if our documentation did not match the billing codes. We learned that if any of the resulting bills were mailed we would be subject to racketeering charges through the RICO Act. Just a few years earlier we had FBI agents raiding doctors offices with the same intent. Rather than learn a lesson about there being better things for FBI agents to do, this activity is still going on at this time and is being documented by a physician blogger who has been subjected to these tactics. The real telling piece of information is that the only reference that I could ever find that looked at the reliability of coding showed that professional coders could agree on documents with the same frequency as a coin toss.

    This coding problem illustrates the main problem with physician response. There is none. Even our professional organizations have done nothing but sell us down the river. Their big tent philosophy allows any faction to come in and create initiatives that compromise our integrity. I would never have imagined that at some early point in my career that it would be ethical for a physician employee of an insurance company to be sitting in an office many states away telling me how to treat a patient that they have never personally seen or assessed. When I was trained as a physician that was the standard ethical approach.

    When you let businesses and the government compromise a standard ethical approach to your profession what else is left to be compromised?

    That by the way is who “they” are.

    George

    Liked by 1 person

    • Thank you so much, George, you’re right on target. I have never understood coding and I suspect many of my colleagues think the same way. Coders have apparently recently found a way to make doctors force fit a diagnosis by offering a select group of diagnostic “choices” in the charge capture field of the electronic health record. I’ve been pretty frustrated by it, although there seems to be a way to get around it and do the right thing. Doctors should be doing the diagnosing, not coders.

      What would you say to a resident or a medical student about how to navigate this system? Would you encourage high school students and college undergraduates to go to medical school?

      George might come back with a reply, but I guess I thought I should be giving an answer to this question too.

      I’m reminded of what I said to a resident who wanted to switch from his current training program to a psychiatry residency. As he expressed this, before I could stop myself, I said “I don’t know why anyone would want to do that nowadays,” or something to that effect.

      So maybe that was too much honesty, but I’ve commiserated with another colleague about the state of psychiatry and our sense is that there may be too much enthusiasm for the field today by some who tend to gloss over the flaws and overemphasize the so-called reforms which thousands of doctors hate.

      So what about the other half of the glass? Is there a reason to consider the practice of medicine and particularly psychiatry as a career?

      In another life, I worked for consulting engineers. In a way, they saved my life. That led me initially to target engineering in college. Gratitude got me just so far down that road, mainly because I liked the idea of helping people more than trying to solve mathematical problems.

      Fast forward to today, there is still nothing like bearing witness to another human being’s suffering, listening and validating, learning from patients what healing means to them and the lesson in humility always comes first.

      There is always some nuance in empathy I detect I must learn nearly every day I’m at the hospital, moving from crisis to crisis. It’s a spiritual journey and humanism is the path.

      So I’m a consulting psychiatrist rather than a consulting engineer. There is no single experience or person which led to my choosing medicine. It’s just that there is nothing like sharing another’s pain, helping when I can, even if it’s just sitting and listening.

      Those are my reasons for staying on the path.

      I sometimes use a zombie apocalypse metaphor as a way of conceptualizing today’s medicine. The bureaucrats and politicians and CEOs (that’s who “they” are as George Dawson said) are the walking dead and some of those who teach young doctors-to-be walk in that crowd. As a young trainee, it’s easy to be “bitten” by them and walk like a zombie too—because they don’t know what it was like before the apocalypse. This just feels normal to them. They’ll adapt to it—and then the world will change, just as it did for me. It won’t change when they expect it or want it, but depend on it, the world will change.

      And it could change for the better. Zombies need love too.

      Liked by 1 person

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