The Doctor is Out

9th June, 2012

We’ve come to a sorry pass in American medicine when physicians are willing to spend a lot of money to attend conferences—not to learn how to become better physicians, but to find a way out of the pit of clinical practice.

Few of us have the charisma (or chutzpah) to make a living in medical show business, like Sanjay Gupta or Mehmet Oz.  But apparently any physician today can be clever enough to secure a comfortable nonclinical niche where the specter of The Joint Commission never lurks.

I came home recently to find a glossy brochure in my mailbox, inviting me (for a mere $1,295) to attend a two-day meeting with the principal aim to help me stop taking care of patients.  This conference promised contact with recruiters and employers who would put me out of my misery as a clinical physician.  In case I didn’t know I was miserable, the brochure pointed out that switching to a non-clinical career has “more financial potential” than clinical medicine.  It suggested sympathetically that I might be among the many physicians who don’t enjoy going to work any more, and want to eliminate the “stress and time commitments” of patient care.

People in Washington DC would do well to take a good look at this brochure, just in case they were wondering why Medicare patients have trouble finding doctors. The panel of experts speaking at the conference includes a host of former internists and family physicians, all happy to explain how they fled the tiresome business of seeing patients for their new careers as consultants, entrepreneurs, business executives, motivational speakers, and expert witnesses. One emergency physician on the expert panel left the ER to become a “Master Sherpa Coach”, whatever that is.

It’s no wonder why so many physicians are getting progressively unhappier. In the past ten years, inflation-adjusted physician fees have declined by 25%, and at present aren’t even keeping pace with inflation. The non-elected Independent Payment Advisory Board, created by the Affordable Care Act, has the sweeping power to mandate even more pay cuts to physicians, and doesn’t even include a practicing doctor among its members.  The overhead costs of running a medical practice continue to rise, and there is no relief in sight to reduce the crippling cost of malpractice insurance in many states.  Documentation requirements (thanks to the Centers for Medicare and Medicaid Services and The Joint Commission) and penalties for noncompliance grow more threatening every year.

Why wouldn’t an enterprising physician look for a way out of this trap?

A few minutes browsing the Internet will convince you that many physicians are looking for a lucrative exit from clinical medicine via social media.  Some—like Kevin Pho, the proprietor of the KevinMD website—keep at least a foot in the door of clinical practice.  Other physicians leave patient care entirely to give social media their undivided attention.  Pam Yoder, an ob-gyn physician, now works full time for HealthTap, a recently launched website that relies on the uncompensated time and good will of other physicians to answer patients’ questions on line.  Daniel Palestrant quit surgical residency in Boston after three years to found Sermo, an online forum for physician-only chat and opinion exchange.

Many physicians are going back to school for MBA degrees, hoping to land better jobs as pharmaceutical executives, department chairs, or government regulators.  Business schools have been quick to establish weekend programs and online courses geared toward the MD market.  Even medical students are flocking to nonclinical careers. The number of joint MD/MBA programs has mushroomed from 33 in 2001 to over 60 today, and they graduate at least 500 students each year.  Many medical schools are offering dual programs in medical informatics, biomedical engineering, or public health, appealing to the many medical students who are losing confidence in patient care as a promising future.

If you’re a graduating resident in anesthesiology and don’t have an MBA already, the University of Washington’s anesthesiology department will be happy to help you.  Their new “faculty fellowships” will allow you to work part-time as a clinical attending while you pursue that MBA, or perhaps a certificate in “Quality and Safety”.  The department’s avowed goal is for a trainee to become “both a content expert and a thought leader”.

A “thought leader”?  That’s just what we need:  more people with scant experience outside the academic bubble, telling the rest of us what to do and how to do it.  Even the term “thought leader” sounds as though it originated in a propaganda bureau whose purpose is to tell a docile (or downtrodden) public what to think.

I’m quite sure that the new “thought leaders” will be well versed in the jargon of accountable care organizations, SCIP guidelines, evidence-based medicine, and the rest of the buzzwords that dominate the conversation about health care.  But while they’re sitting around talking about health care and figuring out where to lead our thoughts next, who’s going to be left to take care of the patients?

Someone has to ask the question:  If you didn’t want to take care of sick people, why did you become a physician?  Health care can’t be an abstract idea.  Certainly health care delivery is a “macro” concept, but health care is delivered one patient at a time.  By all accounts, the shortage of physicians in the U.S. is growing more severe as the population ages.  Midlevel practitioners play an essential part in health care delivery, but patients want to see a doctor–not a “doctor of nursing”–when critical decisions must be made.  Does anyone seriously think patients care about the musings of a “thought leader” when what they need is ready access to clinically experienced physicians?

There’s another question, too.  Is medical education a public good or a private possession?  When physicians incur $200,000 or more in debt acquiring a medical education, it’s easy to see how they would feel that the education is theirs to do with as they please.  Yet the American taxpayer contributes to the education of physicians by funding state universities and medical schools, and by funding resident training with Medicare dollars.  Aren’t American citizens entitled to service in return for the billions that they spend each year on medical training? How would they react if they knew that so many of the doctors they paid to train are abandoning clinical practice if they possibly can?

It’s easy to see how nonclinical careers can be tempting.  If someone offered me a decent salary tomorrow to become a columnist, or a substantial advance to write a book, would I keep on practicing anesthesiology?   Would I continue to risk malpractice litigation from a poor outcome on a high-risk patient?  Would any of us choose to face exposure to VRE, MRSA, tuberculosis, and HIV?  Or deal with the payment denials from Medicare and insurance companies?  Or read the memos from administrators and bureaucrats who create senseless new rules all the time?

If there is a sure indicator that American health care is heading down the wrong track, it’s the fact that current policies are driving physicians out of patient care.  When physicians are willing to pay good money to attend seminars on how to land nonclinical jobs,  then I think we can all agree that Washington’s health care policies are incentivizing physicians in exactly the wrong way—to abandon patient care.  I seriously doubt that’s what Americans really want, and I’m certain that when children dream of becoming doctors they’re not imagining a desk job, even in a corner office.

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