Of the articles I’ve read to dissect and rip over the past few years, this one has left me sadder, more hopeless than most. Author Peter Ubel asks, “Have Reimbursement Rules Taken The Joy Out Of Being A Physician?”
Of course the knee-jerk answer is a resounding “Duh!” Ubel, a physician and behavioral scientist at Duke, leads off with an example of an urgent care doc treating a woman for a sprained ankle, and then getting financially dinged for not addressing her mammogram status or initiating diabetes screening. Such an occurrence is an insulting rip off of the physician, but not a surprise to any of us.
The author has embarked on a research project to investigate for physicians “what can be done to help them thrive at work even though an increasing number of outside parties are looking over their shoulder, assessing the quality of the care they provide.” That’s all well and good I suppose – Dr. Ubel notes, “physicians have gone from being independent decision-makers to being bureaucrats forced to check boxes.” As an academician, I hope Ubel bucked the trend and opposed mandatory EHR’s, the whole P4P, fashionable “quality” payment model, and pretty much everything in the ACA. His bio includes “I am currently exploring controversial issues about the role of values and preferences in health care decision making, from decisions at the bedside to policy decisions. I use the tools of decision psychology and behavioral economics to explore topics like informed consent, shared decision making and health care spending.” Again, that’s fine. I haven’t read the man’s books, so I won’t make assumptions (even if in my experience, stereotypes exist for a reason.) Of course he is a physician making inquiries “to better understand why many clinicians are miserable in their careers.” It isn’t a mystery to non-academic, seeing-patients-every-day-in-order-to-make-a-living physicians.
Physicians, most of whom are still very well-paid relative to the rest of the world, are working harder fulfilling busy-work requirements that are strictly negative reinforcements: do this or you won’t get paid. Or the legal fears: order this test, or you’ll be sued; code this just so, this week, until it changes, or you’ll be penalized, and maybe charged with fraud. That, and the anger patients have at the system, their rising health premiums or simple lack of access, the consequences of their own lifestyle choices, and the generally collapsing turmoil that is health care, will be directed at you, the doc. To that one can add the negative satisfaction – if one is truly self-honest – that in playing all these games, one is not working for the patient, and claiming to the contrary is naked self-justification. I state to Dr. Ubel: beyond millions of individual examples of excellence and compassion, medicine in general is no longer an honorable profession.
Do you think I’m being a little harsh? My blood ran cold reading the author’s statement: “In part, these external accountability measures have been put in to place because people paying for medical care – insurance companies, Medicare administrators, and even patients – realized that the quality of medical care wasn’t always as high as it ought to be.” According to whom exactly wasn’t quality up to snuff? Ubel’s source for this was the damned Institute Of Medicine, the same clown car that covered us all with MOC vomit.
And then the author piled on: “And since the profession wasn’t doing everything it could to promote high quality, they recognized that somebody from the outside needed to hold physicians accountable for their practice.”
What the hell ever happened to the patient and the physician being accountable to each other? That admittedly naive question is so far removed from the future of medicine as to be irrelevant (Direct Primary Care being of course, the obvious exception). What behavioral scientist Ubel seems to be missing in his musings are the permanently corrosive effects of generations of oversight by Big Insurance, lawyers, Big Government, and yes, academicians prodding the previous three. Line up all these noble sources who constantly imply, or state outright that doctors are not to be trusted, and guess what? It works. Any inquiry into the mysteries of physician dissatisfaction that does not point the finger of blame at these culprits is just another lie.
Incredibly, hilariously, Ubel quotes an anecdote from some Yale research about a hospital custodian that “found great satisfaction in her work by going beyond her required “to dos” to find ways to improve patients’ hospital experiences,” like pictures in their rooms. The obvious inference is that whenever the government gives you another quality measure to chart, whistle a happy tune for the sundowning gomer who still needs his foot exam to be documented. For the author to take this tack as a kind of salve for the miserable clinician is arrogant, and disconnected.
For a behavioral scientist, I am surprised that the author seems to have missed this point: physicians have egos generally larger than the average person. It’s not whining to note that we have also invested a hell of a lot more in our careers than the average person, and expect to be rewarded for it. We did not get into this work to be ordered around by furtive little rodents masquerading as coders, Medicare auditors, and JCAHO inspectors. Most of us began this trip seeking rewards not just monetary, but the thrill of discovery and the pride from excellent work. Those goals could only be pursued with independent judgment, by individuals making their own best decisions. Take that away with nonsensical quality requirements, along the myriad other shackles, tethers, and threats that have nothing to do with being a physician, and you take away the pride. You take away the fun. All that will be left to feed the ego is the dwindling paycheck, which will come with an increasing amount of resentment, and hopes of finding different, more honest work.