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To extinguish burnout, bring back physician autonomy

June 17, 2021

In his article, “Medical education needs to stop burning out students — now,” Augustine Choi suggests the culture of medical education is responsible for increasing numbers of depression and burnout among medical students, and suggests that more programs are needed to address self-care and wellness in order to build resilience.

While I agree that mental health treatment should be readily available and easily accessible to those in need, I’d argue that medical students and physicians are already some of the most resilient individuals alive today. I submit the real cause of “burnout” or “moral injury” can be linked to the correlating rise of “health care” over the past 20 years.

The loss of physician autonomy plays a huge role in feelings of hopelessness and frustration that many of us experience. And I believe that health care — intrusion of third parties into the practice of medicine — is to blame for much of the distress, unhappiness, and frustration we see among physicians and those aspiring to practice medicine. Instead of adding more programs about wellness and resiliency to the medical school curricula, let’s recognize the root causes of systemic burnout — those which exist across the entire profession of medicine today — and empower both students and physicians with the skills necessary to advocate for and bring about needed change.

Factors playing a role in the loss of physician autonomy:

1. Insurance companies dictating and questioning our orders for treatment of our patients, including but not limited to: prior authorizations for prescriptions, diagnostic tests, therapies — in short scientifically evidence-based medicine proven to help our patients — is being limited, impeded, or outright denied, all in the name of profit. Legislators tout the need for universal single-payer insurance, the hypocrisy of which is that having insurance does not equate to access to or the receiving of actual medical care, nor does it help reduce the underlying causes of skyrocketing health care costs.

2. Middlemen PBMs and GPOs are driving up the cost of prescription medication and supplies, corralling physicians into prescribing what is on their formularies, and directly causing shortages of basic medicines in hospitals throughout the country. Our hands are tied into treatments decided by these third-party middlemen, creators of contracts with ever-increasing partnering monopolies limiting choice and the free market and receiving legalized kickbacks (aka rebates) for doing so — the only instance in which these kickbacks are legalized due to the Safe Harbor Act of 1987, which exempted PBMs and GPOs. Such kickbacks are illegal in all other businesses. Coupled with government interference/restraint of the free market and inability to pass legislation that would actually lower health care costs, both physicians and patients remain chained, unable to break free in order to create real needed change.

3. EHRs the mandated integration of the electronic health record was highlighted and pitched as the ability to integrate & share needed health information across systems for the benefit of our patients and those caring for them. No longer were we going to have to search for charts or transfer information between offices/hospitals/clinics. All important patient health records would be easily and immediately accessible for those physicians caring for the said patient — a universal system of access when we needed it most. Instead, EHRs became the bane of our livelihood: time-consuming never-ending clicks, without interoperability, degrading patient interactions and exorbitantly expensive. EHRs are neither for the patient nor the physician; they are a data source for coding and billing for insurance companies, to the detriment of patient care.

4. Government-mandated reporting and pay for performance instituted as a way of improving public health, has instead become unnecessary busywork with no proven benefit in improving health outcomes. In fact, the Minnesota Medical Association has recently withdrawn from the board of MN Community Measurement due to Minnesotans’ health actually declining since its inception.

5. Physician replacement by lesser trained/qualified/experienced individuals — this trend is happening across the country and patients are being harmed. Don a white coat, call yourself a doctor — and the public is none the wiser. Physicians spend years and countless hours earning the privilege to be allowed to care for patients.

We are competitive, driven, resilient individuals that overcome countless obstacles, excessive testing, and years of supervised training, prior to being allowed to care for patients independently. We are assessed, tested, questioned, and made to complete multiple steps prior to being licensed to practice medicine and surgery.

In fact, once obtaining our doctorate of medicine or osteopathy and our state medical license, we must continue our supervised training for a minimum of three to seven years depending on specialty. And that’s before being allowed to independently practice medicine and care for patients.

Yet, these standards are not required for other non-physician caregivers who have managed to bypass the years of education and supervised training by convincing Congress to pass legislation that allows them to independently care for patients.

The term “provider” began being used by administrators to lump us all together, obscuring our training and confusing our patients & the public. It is deceitful and done in the name of profit, increasing revenue for hospital/business entities at the expense of patient safety. Billed as “cost-saving and increasing access” for patients, this trend of physician replacement is causing undue harm, morbidity, and mortality. The ability to safely practice the science and art of medicine is earned through education, not legislation. When placed in charge of life or death decisions, above all else, training matters.

Maintenance of certification (MOC) was created by medical boards, starting with the ABFM in the 1960s>, with all 24 American Board of Medical Specialties participating by 1990, as a means to increase revenue.

Over the past 20 years, there has yet to be a study linking participation in MOC to improving patient outcomes, yet there are multiple instances of cause of harm and duress to both physicians and patients. Physicians are lifelong learners by default. We are constantly reading, learning, and participating in CME in order to do the best for our patients. We attend conferences, consult with colleagues, and seek out new and proven evidence-based medical treatments. Our years of required training have instilled this drive in us. Initially billed as voluntary, MOC morphed into being required for hospital credentialing and insurance reimbursement. Fail to pay the ever-increasing costs of MOC, and you will no longer be allowed to care for your hospitalized or clinic patients, nor receive payment for your services from their insurance carriers. MOC takes an earned lifetime doctorate degree and turns it into a time-limited certificate. It is ludicrous to think a physician’s knowledge base disintegrates because they refuse to pay for MOC: one day certified, the next not? Physicians are finally standing together to put an end to the extortion and racketeering of MOC, and one brave physician has won the battle against MOC in the state of Michigan.

Administrators who are non-physicians turning medicine from a learned profession into a for-profit business, usurping control from physicians at the expense of our patients. Dictating how and what we physicians may or may not do within a hospital system – all in the name of cutting costs, often to the detriment of our patients. We now spend more time worrying about how many patients we need to see in designated time slots, checking boxes, running behind, doing never-ending non-physician required tasks than we do on patient outcomes, discussing interesting cases, learning from one another, sharing, teaching, and inspiring each other to hone our skills in the art and practice of medicine. Collaboration, connection, teaching, individual physician expertise and spending time with our patients developing relationships, is now deemed less important than productivity and following the dictated — and often nonsensical — rules. And if we dare disagree, speak up or suggest an alternative method, we are labeled as disruptive, troublesome, threatened with dismissal/termination and often replaced, leaving our patients without their trusted caregiver.

Patient satisfaction scores being tied to promotion/advancement. My job as a physician is to diagnose and treat my patients, often with an illness or treatment that they may very well not want to hear. We try our best to partner with our patients, run on time, provide acceptable options/treatment plans, but medicine is not an exact science, nor are patients one size fits all. There is an art to medicine. Schedules are imperfect. Patients may be scheduled for one thing, yet have another more pressing matter that needs to be addressed. Emergencies happen. Babies need to be delivered. A physician may not be readily available at the exact time the patient desires. Life happens. As physicians, we are not providing a service for customers; we are caring and treating our patients as we know best, in hopes of bettering their health and wellness. This practice may lead to less satisfaction at times by some, but in no way means we are less deserving of being promoted, paid, advanced, or treated with respect. We try our best to do the best we can for our patients, and we put our patients first, always.

If we wish to bring back our learned profession of medicine, inspire others to become physicians and help guide, mentor and encourage them along the way, I argue we must change the system, not the individuals. We must activate, value, and put physicians back in control of medicine rather than the above mentioned third-party contributors that over the past 20 some years have created for-profit health care. We must bring back and respect physician autonomy. We, as physicians, have the power to do so, and standing together we can, and we must bring back medicine.

Christina Dewey is a pediatrician.

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