Can American doctors get off the hamster wheel?

What follows are not complaints. These are just the facts.

Here’s a recent exchange from an enlightened physician leader, one who has yet to give up: “My colleagues are discouraged and frustrated every day, leaving the office defeated and fatigued. There are other ways to practice.”

High health care costs get most of the attention, but there’s a more important crisis coming your way.

First a review, then to the looming crisis.

When Americans travel to Belgium or India on their own dime to get cheaper medical care, you know things are bad. The same atrial fibrillation (AF) ablation costs ten times more here than in Europe. This is crazy.

Excessively disruptive, ineffective and downright inhumane care of the elderly is also a major driver of rising costs. This is tragic.

Fee-for-service rewards doing more work units, whether or not such units are grounded in science or aligned with a patient’s goals for care.

Listen to this one: A couple of years ago, after my trip to Germany, I learned to do AF ablation without an expensive ultrasound catheter. That saved the health care system a lot of money. Alas, using an ultrasound catheter is well compensated — there is a code for that. Doing the procedure more cost-effectively, therefore, saved the system money; but hurt the bottom line for the hospital and me. This too is nuts. It should be the opposite.

If I was piling on, I could add the costs of defensive medicine. Ask any ER doctor about that. How in the world can any human do ER medicine? These folks have my admiration.

You get the point. President Clinton, in his plenary speech at the Heart Rhythm Society this year, said it well: “We can’t keep going on like we are.”

No one disagrees. Things must change.

The issue is how it’s being done.

The default, and I can see why, is that payment for services must be cut. Doctors and hospitals must get less. The caregivers are the problem. And oh my, if it was only that. On top of lower compensation has come onerous regulations. These oppressively burdensome intrusions take caregivers away from delivering care.

Doctors went into medicine to use their hard-won skills to help people. We desperately want to deliver care. Our self-esteem turns on how well we do it. And this is the problem.

Skillful, compassionate and well-aligned care takes time. It goes slowly. It requires face-time, not computer time. We have to listen to the fellow human in our midst, examine her, go over both relative and absolute risks and benefits of treatment options, and then be clear about expectations. You don’t really think an EMR is capable of removing fear and ignorance from medical decisions, do you? And the 6-page office note…this helps align care with a patient’s goals?

There were two important essays recently on the state of doctoring in the United States. Dr. John Schumann writes poignantly about how doctors are looking for a way off the hamster wheel. I liked it because it contained a shred of optimism:

When I was a medical student, I held the naive and idealistic belief that if I just did good work, the business side of things would somehow take care of itself.

How wrong I was.

Dr. Danielle Ofri captures the problem perfectly:

For the average practicing physician, the major goal of any given day is simply to stay afloat. The typical 15-minute office visit is rarely enough time to fully address the clinical needs of patients with multiple chronic illnesses, and the onerous documentation demands of electronic medical records ensure that doctors spend most of that visit interacting with the computer rather than with the patient.

United States health care is mired in an epidemic of over-treatment. One way out is with better decision quality.

It is fantasy to think our current model of delivery will foster decision quality. You can’t see more patients, sign more forms, click more boxes, do more corporate safety modules and also expect high quality shared decision-making.

For me, I have decided to run slower on the hamster wheel. I will see fewer patients, not more. Decision quality is just too important. I need for my patients to make informed decisions. They must know what an ICD can and cannot do; they must not be surprised when AF recurs after a single ablation procedure, and they must understand that taking an anticoagulant means trading an increase in bleeding risk for prevention of stroke — and that decision is up to them. I have it easy — specialists focus on one organ system.

You can’t have shared-decision making and patient-centric care when the hamster wheel turns that fast. It’s not possible.

But few doctors have the luxury of going slower. Most will simply keep trying to run faster on the wheel. But you know what happens when athletes run too much and rest too little.You don’t think caregivers are immune to inflammation and joylessness, do you?

A cycling reference fits. Etched into a wooden bench at the top of a nearby mountain bike trail is a recommendation: “Hey racers: stop racing around so fast, you are missing all the good stuff.”

Why is this stuff so important?

It’s not when you are well.

John Mandrola is a cardiologist who blogs at Dr John M.

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  • pbat

    I wonder if the next generation of physicians (which I am in) will help evoke this change? It could go either way with us owing much more in loans but more demanding of better lifestyle than any generation of docs before us. I know for me at least at this point in my life I would not take a job requiring 15-20min med checks but who knows….

    • Mengles

      Sorry, but tons of medical students have tried to “evoke” change. Your generation won’t be the first (something med students on KevinMD refuse to understand) nor last. In considering specialties, the ROAD is the way to go. You’re much safer there.

      • pbat

        Thanks, but I am actually freshly out of residency–not in a ROAD but I do feel like a make very good money for the hours and work I put in my job and there is a massive shortage in my field. I’m doing locums and making money while I can, and paying down debt as fast as possible. If the future is great and we were all just unnecessarily stressing over Obamacare, then I’ll make out ahead. If things do get as bad as some are saying, I have a plan to work 2-2.5 days a week, live frugally as I already am, and enjoy life OFF of the hamster wheel….

        • T H

          Good luck with that. Sincerely, good luck. Mission creep occurs in all aspects of life, plus ‘living frugally’ means something different when a real paycheck is coming in.

        • macbook

          Hi pbat,

          How do you like doing locums?

    • Adolfo E. Teran

      I agree with pbat, I take my time to talk and listen to my patients. I’m a solo doc, no administrators stabbing me in my back. The walking suits don’t even check my TDAp status before stab you in the back.

  • Anthony D

    When the 3 big three (Pharma, Government, and Insurance Co.) running the show nowadays. Its almost impossible to get off the hamster wheel!

    Welcome to Dictator Medicine!

    • SarahJ89

      I wish we (doctors and patients) were at least on the same wheel. Alas, we’re not.

      • Anthony D

        Sorry I got my own hamster wheel. (*_-)v

  • Adolfo E. Teran

    Interesting article, I like the idea of getting of the hamster wheel.
    It is the way to my Santiago de Compostela ( dream goal). I strongly believe that in Order to achieve it, we need to bring back things to a simple. We need to bring back the payment between the doctor and the patient, we need to kick out the middle rich man.

  • buzzkillerjsmith

    The wheel will continue to turn for a while yet. The turning benefits our masters.

    I’ve always been on the wheel, but the crucial differences between now and 1989 are the pt population and the administrative sea anchor.

    Long ago we saw pts with complex chronic illness, but numbers were manageable. We also saw young healthies with acute but minor problems. These were catch-up patients, requiring minimal time to see and even less to scribble about in the chart.

    These pts are few and far between for most of us now. These pts often see folks in the urgent care, and there are a lot more old sickies, which is fine. It’s usually better to be old and (somewhat) sick than it is to be dead. But the workforce to take care of these old sickies is not there for the reasons we go over ad nauseam at this website.

    The paperwork/computer work/phone work/FAX work associated with old sickies is simply unimaginable to those not in the field. And this work is not paid for. Moreover, another determinative factor is that medical students do not have to do this “challenging” job for a living.

    So we are now starting to see articles in the mainstream about the general physician shortage. Curiously, most of the articles end with a hopeful message. Have you notice. I shake my head.

    • buzzkillerjsmith

      Nice little article from 9-9 at Nerdwallet Health on relative attractiveness of different specialties. It sheds some light on the FM and IM hamster wheels.

      • NewMexicoRam

        Link?

        • buzzkillerjsmith

          I can’t seem to link it, but if you go to Nerdwallet Health you can find it.

  • SarahJ89

    I miss having a doctor. Corporate medicine rules in my area. I’d much rather have a doctor instead of a set of policies.

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