Posts Tagged ‘Physician burnout’

Is it time to unionize?

Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

Are you an employee?

You may be eligible to unionize if you are an employee without the power to “hire, fire, or make managerial decisions.” According to one estimate, more anesthesiologists are employed (55%) today than ever before, and this trend is accelerating as private practices are absorbed by large healthcare systems in mergers and acquisitions.

Hospitalists in Oregon elected in 2015 to form a union affiliated with the American Federation of Teachers. Primary care physicians employed by clinics in Washington State voted to be represented by the United Salaried Physicians and Dentists Union. Their vote to unionize was challenged by their employer on the grounds that some of their work was “supervisory”, but the National Labor Relations Board (NLRB) upheld the physicians’ argument that their clinical supervision duties did not constitute managerial decisions.

The important distinction here is that within the ASA, some members would meet the NLRB’s definition of employees – even if they direct the clinical work of anesthesiologist assistants or nurse anesthetists – because they are directly employed by hospitals, health centers, or foundations. They could vote to unionize.

Other ASA members, whether they work within a group partnership or on a 1099 basis, would be classified as self-employed or as independent contractors, depending on exactly how their contracts are written. A third group – those in leadership and managerial roles, such as department chairs – would be considered supervisors or managers. All these are excluded from collective bargaining as a central provision of the National Labor Relations Act.

The ASA can advocate for fair physician payment, but an ASA attempt to negotiate payment rates on behalf of all its members would constitute “a horizontal agreement among competitors to fix payment” and would violate antitrust law.

Could we strike without a union?

Anesthesiologists and other physicians can act collectively without any union affiliation, and they have done so before. If no union is involved, it doesn’t matter whether or not they are employees.

In California during the 1960s and 70s, jury awards for pain and suffering in medical malpractice cases rose exponentially, and malpractice insurance premiums rose too. By 1975, insurance companies either withdrew from the California market or raised anesthesia malpractice premiums by as much as 350%. (These events have been described in detail in an excellent column by Drs. Jane Moon and Mark Singleton, published on the website of the California Society of Anesthesiologists on May 13.)

Some anesthesiologists left the state or retired, and others decided to practice without coverage. In desperation, California anesthesiology leaders headed for Sacramento to demand legislative change. Anesthesiologists and surgeons in northern California began a dramatic protest by refusing for weeks to perform elective surgeries. Finally, on September 23, 1975, Gov. Jerry Brown signed the landmark Medical Injury Compensation Reform Act (MICRA), which capped “pain and suffering” awards at $250,000. Despite repeated challenges, MICRA still stands.

At first MICRA was vilified as unconstitutional until the California Supreme Court ruled to uphold it. While the court deliberated, anesthesiologists and surgeons in Los Angeles began their own month-long work slowdown in January 1976, again refusing to perform elective operations. This strike was studied extensively to determine if patients were harmed as a consequence. Though an estimated 25% to 50% of physicians participated, patient mortality decreased overall, and surveys by UCLA and the LA Times showed no significant negative effect on access to care.

Yes, but is it ethical?

Physicians today in many specialties are deeply unhappy about working conditions, production pressure, and how powerless they feel. The electronic health record is associated with burnout and disconnection from direct patient care. Could unionization be the best way forward, now that more and more physicians are employees of large healthcare systems?

According to Dr. Eric Topol, cardiologist and author, the answer to that question is yes. He believes it’s high time for a “new organization of doctors that has nothing to do with the business of medicine and everything to do with promoting the health of patients.” In his article titled “Why Doctors Should Organize”, published in the New Yorker last year, Dr. Topol asked, “Who will be in charge of our health as we move forward – doctors or their managers?”

The trouble with the word “union” is that it evokes the image of strikers picketing for better pay. The public will never sympathize with physicians if payment is our only cause. But patients and physicians might get behind “industrial action” in support of more time spent with patients, more and better PPE, fewer hours wasted with poorly designed electronic records – as long as patients are guaranteed that emergency coverage is always available.

Maybe it’s time to try a different approach. The right to organize and strike is supported by the United Nations and international law. Physician work stoppages or slowdowns can be conducted ethically, without patient harm.

Here’s one appealing idea for collective action. Take full care of the patients but document only the clinical care. Don’t waste your time ticking all the irrelevant boxes in the electronic record, which is a tool for billing and compliance-checking, not for patient care.

This kind of collective action could get some real attention from health systems and large employers because it would affect their billing and revenue. They are the ones with the size and clout to negotiate better contracts with third-party payers, to demand better electronic health records, and to push back against regulation creep. We love to blame insurers, but employers share responsibility for physician exploitation and demoralization. As the AMA Journal of Ethics has stated, “It is morally acceptable for physicians to unionize and employ collective action, including striking, as long as patients’ best interests are their reason for doing so.”

Where do I sign?

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This article originally appeared in the December 2020 edition of the ASA Monitor

If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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“Each man or woman is ill in his or her own way,” Dr. Abraham Verghese told the audience at the opening session of ANESTHESIOLOGY 2019, the annual meeting of the American Society of Anesthesiologists. In his address, titled “Humanistic Care in a Technological Age,” Dr. Verghese said, “What patients want is recognition from us that their illness is at least somewhat unique.”

Though we in anesthesiology have only limited time to see patients before the start of surgery, Dr. Verghese reassured listeners that this time has profound and immense value. He pointed out that there is “heightened drama around each patient” in the preoperative setting. “Everything you do matters so much,” he said. What patients look for are signs of good intentions and competence, and the key elements are simple: “the tone of voice, warmth, putting a hand on the patient.”

Dr. Verghese, a professor of internal medicine at Stanford University and the acclaimed author of novels including the best-selling Cutting for Stone, believes that patient dissatisfaction and physician burnout are the inevitable consequences of today’s data-driven healthcare system, where physicians seldom connect with patients on a personal level or perform a thoughtful, unhurried physical examination. “Our residents average 60 percent of their time on the medical record,” he said.

“It’s the ‘4000 clicks’ problem,” Dr. Verghese said, citing a study in which emergency room physicians averaged 4000 mouse clicks over a 10-hour shift, and spent 43 percent of their time on data entry but only 28 percent in direct patient contact.

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For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

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Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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