Physicians are Their Own Worst Enemy

The profession of medicine is under attack and physicians are as much to blame as the enemies that are strategically breaking down our profession.  Physicians sold out to large hospital organizations and venture capitalists and now 2 out of 3 physicians are employed. Employed physicians are in a triangulated position being required to satisfy the needs of their employers (usually corporate conglomerates), insurers and most importantly their patients.  Patients are no longer the sole focus and physicians are faced with loss of autonomy, lack of professional respect, perverse incentives for productivity and mounds of useless paperwork and electronic box checking.

Both physicians and patients wind up as the losers in this broken system.  Physicians train for a minimum of 12 years and many times longer. They are the experts in their field.  They spent a substantial part of their lifetime away from family and friends and spent significant amounts of money for their education, upwards of 100’s of thousands of dollars to become masters in their fields; only to be second guessed by lesser trained individuals whose primary motives are greed at the cost of safe and quality care.  

Once upon a time, physicians owned their own practices and were in control of their destiny.  In the past, physicians took care of patients the way they were trained and were not influenced by these disrupters.  Today, large hospital based systems and private investors have stolen control from physicians and we let it happen. We are now manipulated to see more and more patients to pay for unnecessary and unsubstantiated overhead costs that we have no control over.  We are made to sacrifice patient care by shortened visits times, use of lesser trained midlevels and constant interruptions to the patient-physician relationship primarily the use of electronic medical systems necessitating physicians to now provide all the data entry in the room which steals away critical time from the patient.  These tasks were once relegated to non-clinical staff, but somehow once EMRs were implemented it became the physicians responsibility and we let it happen. Yes, there are some ways to alleviate these burdens with the use of scribes, but this adds another person into the equation adding more costs and another disruption in the room.

Physicians continue to perpetrate the problem by being silently complicit and allowing themselves to be manipulated.  How did this happen? It happened because we were too focused on our patients. While we were working long hours with our heads buried in paperwork and computers, beat down by a system that no longer values our expertise.  We were taken off committees and other non-clinical face to face, non-revenue generating duties to become more productive. When this happened, we lost a say in our profession and allowed people who have no business to decide what we should and should not be doing to call the shots.  We allowed midlevel providers to work outside of their scope and replace more highly trained physicians. We allowed the medical profession to become watered down because we were too busy or too tired to see it happening. Some of our colleagues succumbed to greed. They sold out their practices for a big payday.  They supervised midlevels and allowed them more freedom than their training allowed and now we are faced with a dichotomy of care. Midlevel providers are also being manipulated in a multitude of ways. Their national organizations and teaching institutions are promoting that they have equal training to physicians when this could not be farther from the truth.  They graduate with this inflated sense of entitlement and a false sense of knowledge. Corporate medicine, large insurers and even our lawmakers perpetuate this falsehood to save money at the sake of patient safety. They manipulate data and false titles and training to further confuse the public.

Both patients and physicians suffer.  Physicians suffer by burnout and loss of autonomy.  Our organizations such as the AMA, ACP and AAFP have deserted us.  We don’t seem to have the numbers or the national support to collectively regain our profession.  We are so busy trying to be altruistic and take care of people that we are not taking care of ourselves or preserving our profession.  

Jaclyn Nadler MD

Jaclyn S. Nadler, MD, MBA, FACP is a practicing internal medicine physician in Southwest FL. She received her medical degree from the University of Miami and undergraduate (BSN) and graduate (MSN/ARNP) training from the University of Florida in Gainesville. She attended residency at Wake Forest Baptist Medical Center in Winston-Salem, NC and completed her MBA degree with a concentration in medical management from UMass, Amherst. Dr. Nadler recently joined the Direct Primary Care/DPC movement when she became disillusioned with the current state of healthcare including physician abuse, corporate medicine’s focus on quantity of care over quality and the loss of physician autonomy. She started her own DPC clinic, CoastalMED DPC in January 2019 where she can practice medicine on her own terms and provide her patients with the time and superior care they have grown the expect. She is passionate about physicians regaining their rightful place at the helm of healthcare and physicians reverting back to independent practice and regaining autonomy. She is a member of the Florida Medical Association and Direct Primary Care Alliance, she is a Fellow in the American College of Physicians and received her certification as a physician executive (CPE) through the American Association of Physician Leaders. You can learn more about Dr. Nadler and view her blog at www.JaclynNadlerMD.com 

  15 comments for “Physicians are Their Own Worst Enemy

  1. Tim Blain, MD
    June 20, 2019 at 10:36 pm

    I am Dr. Nadler’s partner from the practice she left to go into a Direct Primary Care Practice. When Dr. Nadler applied for a job with the corporation I work for I recommended to our administrator that we not even interview her for a job with the group. Why did I recommend against interviewing her? When I looked at her resume I saw a physician who was having a hard time accepting the brutal reality by which an employed physician must practice. This usually means they care a lot. I knew that our group would pretty much chew her up and spit her out which they did within 2 years. When she left it had a profound effect on me because I really respected her based on the breadth of her professional experience and a genuinely caring person that her patients loved.
    I have been in practice for 19 years (9 years with current company) and had been one of those doctors at 95% MGMA production mark that had a very hard time saying no to accepting new patients. The thing I have been spending the past 19 years trying to find out is how to get more time with my patients doing all kinds of crazy things. Humans are funny that way in that many times if you subject them to unbearable conditions long enough they start to think it normal. That was me.
    When she left I took a hard look at the brutal facts of my current situation and realized I was not doing nearly as much as I could for my patients. So I decided to do a little experiment, sample size=1.
    Over the past 4-5 months I decided to put “First Things First” which of course is the patient. I wanted to find out what type of impact I could have on patients care if I spent the amount of time and fully applied my clinical knowledge/intellectual skills into formulating a diagnosis and treatment for my patients. I can tell you without hesitation that it is nothing short of amazing on a personal level, patient satisfaction level, and ultimately financial cost expenditure level. When you really focus 100% on a patients problems while utilizing your clinical experience and your clinical knowledge (on tip of your tongue-your brain and the tip of your fingertips-UpToDate/Dynamed), you start to solve patients problems and not just treat their symptoms. You also start to form cause and effect connections that ultimately lead to improvements in their mostly self inflicted conditions that are not contingent on a medication (that will very frequently lead to further secondary problems). The cause and effect connections frequently come through just casual conversations that to the untrained observer seem trivial and wasted time in the room preventing the clinician from getting into the next room.

    Take the case of the 74 y/o gentleman who I saw for low thoracic pain who I took a fairly detailed clinical history which included asking about history of prior back injury which he denied but as I was having him get onto the exam table I asked him where he typically rode his bicycle because during the course of taking his clinical history he noted that he rode his bike a lot without symptoms of pain. He proceeded to tell me that he had been struck by a vehicle not once but twice with the last incident being 1 year ago which based on his description he obviously was injured but chose not to seek medical treatment. Had I not shown an interest in his bicycling, which I did not ask with the intent of gaining vital information, that information would have never been revealed by the patient.
    I have had multiple patients who have had surgeries for problems that did not need to be fixed only to have the same original complaint after the surgery simply because they fixed the wrong problem due to not taking a good history and basic physical examination on the patient. Instead they depended to heavily on a test result without taking into account the patient history and physical.

    I am now starting to be able to prevent the surgeries from being performed. I had a patient with chronic back pain and multiple back surgeries who had increased radiating pain down his left leg to the calf for which his pain management physician recommended implantation of spinal stimulator. The patient had come to see me for my opinion on whether I thought that would be appropriate and casually asked me whether the pain he was experiencing could be a circulation problem. I proceeded to describe the difference between vascular and neurogenic claudication which no surprise he was having classic vascular claudication for which he had known disease and already sees a vascular surgeon yearly (who probably also spends no time with him). When I asked the patient whether the physician asked many questions prior to recommending a costly and potentially harmful procedure, no surprise almost no history.

    The most sobering thing is the patients whom I have been seeing for 9 years that had been complaining to me about some problem for years that with a little more time and focus in the room I either was able to solve the mystery or more importantly convince the patient to get treatment for a problem in my gut I always knew they had but never took the time and effort to get them to see it. A lot of your supposed problem patients, your missing something.

    Patients really believe that the reason doctors/hospitals order all of these costly procedures and tests is because they have “good insurance” and are just bilking the system. What I see over and over since spending more time with my patients is in the majority of cases doctors are just not spending the time needed to make a diagnosis and instead hope a medication will just make the problem go away even though they don’t really know what might be causing it or depending on a test to make the diagnosis. The problem is if you have the wrong working diagnosis because of inadequate history/physical then many times you will order the wrong test or refer to the wrong specialist only to drop the patient down a rabbit hole to fix a problem that really did not need to be fixed.

    • Pat
      June 21, 2019 at 9:26 am

      I’m confused. Are you saying you just ignored the corporate constraints that would’ve confounded Dr. Nadler? Did you just stop wasting so much time clicking boxes? And if so, were their repercussions?

      • Tim Blain, MD
        June 30, 2019 at 2:21 pm

        Short answer: Yes, No, none. Will I eventually jump on the DPC train because the current healthcare system is beyond repair? Almost certainly.

        The corporate constraints are for the most part imaginary up to a point. They are usually cloak and dagger about where that point is reminiscent of a car salesman. However when you go from 50% MGMA to around 75-95% MGMA production that is when most doctors that care about their patients burnout. Healthcare is not unique in an employers desire to increase the productivity of their employees to increase the profitability of the company so you can’t really fault them from trying. Crazy thing is we just let it happen for various reasons. Employers easiest way of controlling productivity of physicians is by controlling the scheduling of patients which was the straw that broke Dr. Nadler’s back. You can try to make lots of noise which sometimes works but ultimately does not so you are left with one option if you are not ready to make the jump to DPC or start over with zero patients every 5-10 years with a new employer.
        You steadfastly focus on the patient and not the clock no mater how far behind you are in the day (within reason). You regulary engage your office staff on the changes that will occur to the patient flow in the office. It is very painful at first (i.e. no lunch, patient complaints) but what happens is things start to gradually bend in your direction due to the typical limitations that are put on staff hours. You also get very far behind on your charting as well which thanks to EHR’s we can’t get paid until the physician closes the encounters which tends to get the administrations attention from top to bottom . Then when you can’t take it anymore that is when you have a conversation with your employer to cut your patient panel back if it is overloaded with patients.

  2. NN
    June 18, 2019 at 8:47 pm

    Great article!

  3. Bill Ameen MD
    June 17, 2019 at 4:36 pm

    Thank you, Dr. Nadler! One of the best posts i’ve ever read. Should be a full page in major newspapers. ( However, the vast majority of patients really don’t care what their doctors are going through, as long as they can be seen by a corporate PA or nurse practitioner! ) It perfectly sums up the arc of medical history from the beginning of my studies in 1969 (when Dr. Felix Marti-Ibanez published that beautiful magazine MD celebrating the honored life of Physicians) to my retirement in 2014 (after 4 years in corporate medicine after selling my practice), now that we’re called “providers” and are being replaced by NPs and PAs to save the big hospitals money so the CEOs can make more millions.

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  4. Terry Nugent
    June 17, 2019 at 4:13 pm

    I empathize with all your sentiments but the flip side of the coin is that it is arguable that physician deserted their professional organizations as well.

    I spent the 1980s trying to persuade physicians to join the AMA, which was
    my most depressing job amongst stiff competition. As a result I have heard every lucid, brilliant argument against membership.

    However, the AMA was endeavoring to preserve the physician-patient relationship back then as it is now. Had
    It had more active participation perhaps a better fight could have been fought.

    However the profession needs
    to look forward rather than back. Today there is an association offering FREE membership that is dedicated to fight for physicians and their patients: The Practicing Physicians of America (PPA). Orthopods will likely concur that they are giving medicine a much needed spine transplant.

    • Jaclyn S Nadler
      June 17, 2019 at 4:29 pm

      Thanks for your comments. I agree, too many times physicians don’t support their respective organizations. This can be multifactorial in that student debt is at an all time high, physician salaries are going down, there are just too many organizations so we have to prioritize. I currently participate in those supporting DPC and my state association with plans to join my local medical society. The costs really do add up and we as a profession need to unite to have one solidified message.

    • RSW
      June 18, 2019 at 10:40 am

      As I said before: it would have been beyond Stockholm Syndrome for me to give any support to the AMA during the past quarter century while they were promoting intra-professional warfare and encouraging the proceduralists to cannibalize the other specialties. The RUC has been the single most damaging force in the destruction of primary care in this country.

  5. Dana
    June 17, 2019 at 2:50 pm

    As a wise man once said, “I agree but instead of just complaining, what are you going to do about it or what are you willing to do about it?”. Posts to a blog won’t change anything as I don’t think your thoughts on this are new or not already widely accepted as fact. Every workday I see physicians not stand up for what is right for themselves, not stand up for their practice and even more sadly, in some cases not fight the fight for their patients.
    DPC, I believe is noble way of trying to take some of this back but as an overall doesn’t help your profession fight back. It places you in a separate category/fight from your colleagues who are having trouble for one reason or another trying to fight the fight.

    It will take nothing short of standing together and saying enough is enough to (CMS) Medicare, there is no other way to change this current path of minimizing physician control of healthcare and doing so in the interest of the entire profession and not just ones preferred method of delivering their care. This platform is one of many great ways to start getting everyone together but seems to be focused on just promoting DPC, a DPC EMR and telling everyone else their style of practice is wrong and DPC is right. I promise that the things you enjoy about DPC will all change if you do not stand together.

    • Jaclyn S Nadler
      June 17, 2019 at 4:37 pm

      I agree. Although we as physicians to some degree are persecuted by society and don’t seem to have any media sympathy or support. Physicians are fired for standing their ground for both themselves and for their patients. DPC allows those of us to do the best we can with the resources we have, but you are correct in that it doesn’t fix the problem. The system is broken and it will require a major overhaul to make things right. At this point, what I try to do is support those organizations that support independent practice and patient safety. I don’t see things changing until something drastic happens and the intent of the blog was more to spread awareness since I feel so many physicians are being complacent.

    • Pat
      June 17, 2019 at 6:24 pm

      Thoughtful response, Dana. My argument with the recent NYT op-Ed by Dr. Orif was exactly that she defined the problem, but took a dive on solutions, and therefore, on the core problem.

      I hope Doug will address the pros-/cons with your assessment of the blog. I am not a DPC doc, but will continue to state that it is the only genuinely honest medicine left, and society should support and promote it. The rest of us to some degree are corrupted, and I HOPE someone will try to argue the point, just for the fun of it.
      The column, and it’s responses, are depressing, because we are so far gone. We are encouraged to fight for patients who have helped put us where we are, because like voters and their governments, patients largely determine the medical care they deserve. This is not to excuse our profession, which self-betrayed a half-century ago and will not admit it.
      The author said we have been too busy being altruistic, and yes indeed, we have. The choice of altruism over philanthropy defines all the difference between a mob and the individual, and it is deadly. By refusing to demand and defend their own worth, physicians became a commodity, and beaten down pawns to enforce corporate and government subjugation of whatever drinkers, smokers, porkers, gun-owners, heteronormative non-vegan, gluten-promoting non-conformists, or statin non-believers that may be bucking the dogma of now. And anyone gullible enough to have gotten through medical training now sees the monsters of futility and death reinforced with a serpent of deferred gratification; they just want a break, and to have a little fun outside of a job that for a great many, isn’t.
      The answer, a solution?? I have read a great many colleagues proclaiming their goodness by whatever arbitrary, fanciful Oath they took to care for all comers, so far removed from the Classical Hippocratic as to be printed and recited for the convenience of Big Pharma and CMS (with which we may include the Vichy AMA et al).
      I HOPE we one day see a strike, a painful one that rewards the consequences sought by so many to them in their need, but we’ll need some heads up on the date, so we can save and stockpile against that lean time the way union workers might. But of course we won’t have a union, and will further the self-harm while blathering about nobler obligations, which always seem to include shooting another toe off.
      The smart ones, if they go into medicine at all, will have a backup plan, or better, not even rely on actually seeing patients as their primary income. Standing on a hilltop, punching smoke, trying to fight against MIPS, MACRA, coding, EMR’s, quality measures, satisfaction scores, and the AAFP morons who think they can streamline the abuse, is too obviously a waste of shortening years. Many of us – like me – will just try to muddle along and survive, until hopefully one day we can quit.
      How’s that for a solution?

      • Kurt
        June 19, 2019 at 1:52 pm

        Ditto, “Muddle along and survive until one day one quits”. 28 months and I see the light at the end of the
        tunnel. The only happy FP is a retired one (Or one that has an established DPC and doesn’t take call or do
        hospital work anymore.)

  6. John
    June 17, 2019 at 12:38 pm

    I’m a solo doc here in MI. I recently had a conversation with a hospital exec. He told me days of solo practice are dead. I should see the writing on the wall and enlist with the big hospital group.

    Not today.

    • Douglas Farrago MD
      June 18, 2019 at 6:15 am

      “What do you say to the god of death?”

    • PW
      June 18, 2019 at 8:53 am

      Quit before you join a hospital group.

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