Money is only a microcosm of physician burnout

The medical director of my clinic once gave me a book on burnout. I never read it. Didn’t have the time or energy.

Because a young reader considering a career in surgery referred to stories he’s heard of depressed and disappointed surgeons and asked for my thoughts, I’ll try to address it. Parenthetically, I’ve heard from more than a few readers that my blog and/or book has inspired them to consider surgery as a career. Don’t know whether to smile proudly, or shoot myself.

I quit my practice much younger than I’d have predicted when I went into it. In thinking about the reasons, not all of which can I distill, I can’t make the claim that one ought to generalize: I speak only for myself. In some things, the themes are universal; in others, maybe more particular to me than my colleagues. As with many others, it’s true that my love for my work diminished over the course of my career: yet at its core, the rewards and pleasures remained. It’s just that it was harder and harder to access them, as the layers of bullshit of all sorts increasingly hid it all from view. Maybe it’s like this: early in my career a day of work had ten pounds of pleasure in it. By the end, it was still ten pounds (heck, maybe even twelve), but I had to wade through fifty pounds of crap to find it. Thirty years ago, it was only five.

Surgeons my age are transitional characters. When we first dipped our toes in the pool we were touched by ripples of the good old days: regulations were minimal, the default presumption was that we knew what we were doing, most of our time was taken up with actual patient care. The occasional meeting. Serving on a committee once in a while. And we could charge what we thought was a fair price for what we did. Let’s get that last concept out of the way first. (Reality check: not everything about the good old days was good, especially for the consumer. I admit it enthusiastically. It’s not necessarily better now; just different.)

I’ve yet to meet a medical doctor of any sort who went into the profession first and foremost for the money. (For some, that came later.) Nor would I claim that doctors deserve to be the highest paid of professionals. In fact, at the time I took up the scalpel, I thought many docs — surgeons especially (general surgeons less so!) — made way too much money. The public health would be much more adversely affected were garbage collectors to cease to exist than if doctors did.

Yet there’s a truism: most people willing to work very hard, who have an ethic of excellence, who take great and justifiable pride in what they do, expect some sort of reward commensurate with and in some way proportionate to the quality of their product. And money, for better or worse, is one of the vehicles for providing that reward. Not the only one; not, maybe, the most important one. But a very tangible one. Measurable. Whereas I recognize that speaking about it at the outset risks losing any sympathy (in fact, I’m not asking for sympathy: I’m just trying to explain, and to answer an honest question), I think it’s central, symbolically, to understanding the unhappiness that I and many of my cohorts came to feel.

My brother is an attorney. A very successful one; a senior partner in one of the US’s bigger international firms. I gather he’s really good at what he does: the accolades he’s received within his profession attest to it, as do (to the extent that I can understand them) the extremely complex cases he’s guided to favorable outcomes. He charges by the hour, a hefty sum which has risen steadily over the course of his career. More, I gather, than many of his peers. And, I’d wager, his clients are happy to pay it: for their top dollar, they get a top echelon lawyer who can be counted on to work his ass off and most likely prevail in their cause. To them, he’s worth it. (Makes four times more than I ever did, and is probably four times better at what he does than I was at what I did — I’m thinking there may be greater divergence among good attorneys than among good doctors.) As in virtually every other profession, you get what you pay for. Not so, any more, with medicine.

Two things have happened to physician reimbursement, and both have had a perverse and adverse effect on professional morale. First, payments have steadily declined, to about a third of where they were when I started out. Second, fees have become standardized, meaning doctor A gets exactly the same amount to take out a colon as doctor B, no matter how much better at it one is than the other. By law and/or contract, doctors have no ability to establish their own charges or to collect the difference.

In the first instance, the effect is that doctors have to work harder and harder every year just to stay even financially; in the second, it means there’s no incentive — financially anyway — toward excellence. If money is a surrogate for acknowledgment of a job well done, the current system says “we don’t give the slightest shit about whether you are doing your job better than the next guy or girl.” Take it, and shut the f@*k up. Or so it seems. You may or may not believe this: doctors are, for the most part, altruists. The real rewards come from doing right by the patient.

I love the relationship I have, as a surgeon – especially and particularly as a surgeon — with my patients. I love (except when all hell breaks loose) being in the operating room. (Heck, sometimes even then: as long as I can bail myself and my patient out, able to tell myself I did good, and seeing the instant proof.) But (or is it “so?”) it’s enormously deflating every year to get the latest announcement from Medicare, or Blue Cross, or for-profit Joe the insurer and its multimillionly paid exec, of the latest cut in what they’ll pay me.

Similarly, the notion that they’ll be paying the same amount to some guy who I KNOW is not getting the results I am (or saving them the amount of money I am, by virtue of a passion for cost-effective care and willingness to work extra hard to achieve it.) Like I said, it’s perverse. And my claim is that it’s having an effect on who chooses to go to medical school, and who chooses to go into the most demanding specialties. My friends in academic medicine seem to agree. It’s elsewhere that hard work and excellence are valued more.

Every year I was in practice I made more than in the previous year, despite the fact that in virtually every year, reimbursement declined. The reason is obvious: I simply kept working harder and harder. Partly it’s because that’s who I am: I never took as much time off as I was allowed, I always took call on my own patients, rounded whether I was on or off. So here’s an instance in which my behavior contributed particularly to my burnout. But the milieu was the same for everyone. And it compounds itself: as you work harder and harder to stay even, you’d like to hire some help.

But anticipating further cuts, you feel you really can’t afford to. As I got older I came to think I’d be happy to trade time for money; but my younger partners — with young kids and longer futures — didn’t want to take the financial hit. And whereas they were taking the same amount of call as I was, they (perhaps wisely!) kept fewer office hours, saw fewer patients, and took more vacation. And why shouldn’t they? Coming along in the new era, maybe they saw that hard work wasn’t recognized and rightly concluded it wasn’t worth it. Yep, you get what you pay for.

Sid Schwab is a retired surgeon who blogs at Surgeonsblog and is the author of Cutting Remarks: Insights and Recollections of a Surgeon.

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  • Shane Irving

    I have heard similar sentiments from other surgeons. Hopefully in 10 years or we’ll be able to look back on some positive improvements. (Starting Monday with the glass half full)…

  • DoubtfulGuest

    Thanks for the explanation, Dr. Schwab. I don’t have a problem taking physicians’ money concerns seriously. In addition to the excellent points you make, I imagine it’s a pretty strange feeling after a long day to meet a neighbor or acquaintance who wants to chat, and hear them insist you make X amount of money for reasonable hours when you know darn well you don’t. It’s a huge disconnect with reality and a failure of empathy not to consider what you all are going through.

    • rbthe4th2

      It depends on the specialty I think. Cardiology is going to require a lot more keeping up, probably ob/gyn for surgery, any of the surgical specialties, would require more hours. The ROAD ones, I’m not sure on. At least for allergists, they are 9-5 types. There aren’t a lot of them I see on staff at hospitals nor do I envision they are on a call list. With radiology, there is the fact that they can ship that out, one of the reasons why the specialty is now getting some residencies that are leaving.
      We have director levels where I work making at least $25-30K less than FP’s but they put in 50+ hour weeks. Plus they travel more than any doctor I know, and I’ve got a director/director couple who end up missing each other a lot for work travel.
      I’d also suggest that you review their time off. The doctors in hospitals, those on call, they do get paid pretty well for being on call and they can get time out of the office on Friday before weekend call and they get 4-6 weeks of vacation. There are some nurses I know getting 6 weeks. That is more than the 2 weeks most of us get.
      I also understand that they can get food free in the cafe’s – at least in our area, they bring them food. The nurses, all the rest of the staff pay for it.
      You need to factor in that when the loans are paid off (30% of med school students are in a “medical family” and I’m sure get help for paying for school) the salary is really good.
      Hospitals/groups may pay for the recert board exams too.
      I saw a publication of someone who broke things down and posted a bunch of questions that they didn’t take into the equation. One of which was that the salary remained constant. It didn’t take into account that I know a good deal of doctor/doctor couples, and I don’t think it accounted for the fact of at least 20-30 or more years of $300 to $600 or more thousand a year without loans. Another item is that it doesn’t take into account what I would term “combat pay”. FP’s and the like are all in the front line of patient care. Why should they get paid LESS than radiologists or academic medicine that doesn’t have daily patient care contact?
      Also, doctors should be well acquainted with the pay and hours before medical school. If they didn’t like it, why go into medicine? I was recently asked by my doctor about my job, and I immediately replied I LOVE IT. There are problems and I have my complaints, but I knew what I was getting into in my field.

      • DoubtfulGuest

        I see what you’re saying. By “you all”, I just mean the ones who are actually struggling financially, or working themselves into the ground to stay afloat, despite public perception. I’d like to get a better sense of numbers here, like how many physicians have had to close their practices due to an unsustainable situation and how many project they may have to close up shop in the next few years. Obviously some doctors are still doing really well. But it must be weird (as in “cognitive dissonance”) for those who are not, to be told they are and just need to shut up about money. I can’t think of any other professionals that happens to. As for why go into medicine, I think most of these problems are recent and beyond what anyone expected. If anyone had the time, which they probably don’t, the public might benefit from some snazzy graphics to counter the one in the NYT recently on specialists’ salaries. I would like to understand the timeline and different factors that have led to the current state of affairs.

        • rbthe4th2

          Seriously? I don’t know of any one of them like that. Most around here are groups of physicians affiliated to a hospital. I would have 2 questions: 1) are you trying to live above your means, 2) what is your financial budget and are you laying it out? My parents wouldn’t let me have a checking account until I knew how to manage it. They didn’t care that I didn’t take accounting, they figured any one who could make an A in physics and pass trig and calculus should be able to create a spreadsheet and do finances.
          Just how many physicians like this are we talking about, as in percentage? I’m not doubting that there are people like what you’re talking about DG, but if its just a few, what kind of advantages are they taking and sacrifices are they making at the beginning of careers? If the working couples I know make less than the PCP’s I know and get upper middle class houses or homes built for them, then someone isn’t doing some right with the finances.
          I’m not saying they should shut up, they should be speaking up and getting financial help. Those loans go from 10 to 20 years, after that the salaries go well above what middle class here can live with.
          As for single or concierge practices, there is information and groups out there to help someone set that up on the business/financial end.
          IT shops around here, many closed down, the small Mom and Pop stores because they didn’t make enough and they had to pay overhead, etc. just like a doctor would. So its not just doctors, its others too.

          • DoubtfulGuest

            I’m honestly not sure what the deal is. I know Medicare/Medicaid cuts are a big part of it. I don’t want to add more information because I’m trying to maintain anonymity for the doctors I’m speaking of, and myself. I would like more information about this problem. It’s obviously a concern for many physicians here and I think we should believe them. I understand your point of view. It’s just that if we blow off what they’re saying, it’s kind of like when they say to us: “My other patients with your symptoms pretty much never turn out to have anything serious”.

  • buzzkillersmith

    General surgery is dying, primary care with a scalpel. The surgeons around these parts are all clinically depressed.

    • DoubtfulGuest

      I’m sorry to hear that. Can you tell us patients a bit more to help us understand why this is happening? Please and thank you.

  • sparklingsoul

    Dr. Schwab, I am sorry that you weren’t able to see the forest for the trees. The vast amount of Americans work very hard at a job they don’t like and make enough to pay for just the basics. You were lucky enough to work very hard AND make a very good living.

    I’m a marriage and family therapist who put in five post-grad years only to enter a career where I have people’s lives in my hands every day yet only get reimbursed by insurance $50 for a therapy hour. Now I work in a different career that I don’t love but pays the bills and not a lot more. I also work very hard.

    It’s too bad you made yourself unhappy comparing what you had to what you used to have rather than realize you had it better than 99% of people.

    • Sid Schwab

      Of course I expected at least one comment like this. I never suggested that I wasn’t better off than most people. It’s not an insignificant point, but an irrelevant one to what I was explaining, as honestly as possible. It was less about money, per se, as you might have noted had you approached it differently, than about the fact that hard work and excellent results are not valued. Nor did I ever suggest that such factors were exclusive to surgery, or to medicine in general.

      Yet, at the risk of sounding predictable, I regularly put in 70 or 80 hour weeks, got calls pretty much every night in the middle of the night. Worked all night many nights followed by full days. As I wrote, the public health might well be more adversely affected were garbage collection to disappear than if doctors did; but surgeons do, in fact, work harder than most people. It’s hard not to get tired at some point.

  • Sid Schwab

    It all depends on the circumstances. All I can say is that when I quit, my clinic hired three more surgeons in the next two years, because wait times to see a surgeon became intolerable. In other words, I was working as hard as at least two surgeons. Why? I think I explained it: my younger partners didn’t want to work that hard, voted against hiring another surgeon, and I felt obliged to see the patients that needed seeing. They were okay telling women to wait two or three weeks to be seen for a scary mammogram. I wasn’t, and worked them in on the same day as their doc called, or, at worst, the next day. By coming in early, staying late, working through lunch, etc. Other types of patients, too, of course.

    Plus, I was never comfortable seeing sick patient in the hospital only once a day. I saw them two, three, four times a day. Why? Because it made for better care. Find me a young surgeon who does that, and good luck trying.

    Once again — and it’s obvious that the point will be lost on those who see my article as the whining of a rich guy, which, who knows, maybe that’s all it is — is that for a person committed to hard work and to providing excellence, medicine is becoming less and less attractive. Not because of money, but because it was never about excellence: it was about who was willing to sign on for the latest cut.

    I’m out of the game (I still assist a young surgeon on complex cancer cases); my plan is to not get sick. Or, if I do, and surgery is required, to let nature take its course. If I could find a surgeon like I was, I’d let him or her operate on me. Maybe. Anyhow, I’ve said what I’ve said. If it’s just something to brush off as whining, so be it. If it’s something that deserves thought by the next generation of patients and doctors, so be that, too.

    • sparklingsoul

      Thanks for sharing that, Sid. Now I get it–office politics forced you to pick up the slack for your colleagues, plus you went the extra mile with your patients. My friend complains about picking up the slack for her colleagues, too.
      I guess no one escapes death or office politics. Sigh.
      Hopefully you never need surgery, but if you do, I found an awesome general surgeon in my area who changed my life. I did notice that he got $1,500 for my 3.5-hour surgery and three follow-up visits, while my ENT got $500 for a two-minute procedure to scope my throat in the office. There is definitely something out of whack with how surgery is reimbursed at a much lower rate than a quick in-office procedure.

      • Sid Schwab

        There’s a difference, of course, between what one “charges” for a procedure, and what one gets. It may or may not be the case that the surgeon was actually paid $1500; in fact, the only people –sadly — who pay what the “official” charges are, are those with no insurance, people who can’t afford but are a little too well-off to qualify for medicaid. That’s being fixed by “obamacare,” except, of course, in those red states where their governors refused to expand medicaid because Obama. By law, you can’t discount a fee for such people, because that’s “Medicare fraud;” if you charge someone less than you charge medicare.

        Nevertheless, I could say my fee is $1000 for something or other, but insurance will pay about a third of that nowadays, and you can’t collect the difference.

        Again, though, it’s not the money per se. And I’d not characterize my situation as “office politics” as much as the realities of the effects of trying to control health care costs only by cutting reimbursement to docs and hospitals. At some point, there are perverse consequences.

        I have no idea what’s a fair price to pay or what sort of income is appropriate for docs. But if you want people willing to work as hard as I did, and who are as committed to excellent care and as empathetic to patients as I was, it’ll have to be at a level that doesn’t say to such people, you can do a heck of a lot better and be appreciated more if you design widgets or work for Google. And you’ll have to do what Silly Sarah the Moose-killer called “death panels:” look at what works and what’s cost-effective (hint: what I was so compulsive about doing).

        • sparklingsoul

          My surgeon did get paid $1,500 (between my co-insurance and what Cigna paid), and my ENT got $500 (which I paid in full, due to having a deductible). I believe that my surgeon was underpaid for the type of work he does and total amount of time he spent with me during and after surgery.
          However, I think my ENT was WAY overpaid; $500 for a two-minute scoping and 15-minute office visit. If he sees four patients like me in one hour, that means he is making $2,000 an hour. If I was a surgeon, this is what would really get me mad.

  • Sid Schwab

    See my above comment regarding a couple of good things about the ACA. As to “unnecessary” surgeries: I don’t really disagree with you, although when it gets to trying to fit an individual situation into a general rule, it gets tricky. There are times, for example (in my case, way fewer than what’s considered “acceptable”) when someone gets operated for presumed appendicitis and the appendix is normal. It happens, for several reasons. If the indications were there, was it, in retrospect, unnecessary?

    I’m no expert about hysterectomies, and I don’t entirely doubt your claims. I suspect (hope, anyway) that the cases where women are talked into it by unscrupulous money-grubbers are rare; and, at least based on how the hospitals I know have worked, such practice would be uncovered pretty quickly and dealt with. The “castration” thing is complicated: once the uterus is gone, of course, you can’t have kids. Leaving ovaries in retains the risk of ovarian cancer which is very hard to detect until it’s past the curable stage. So there’s an argument to be made to remove them at the time and replace their function, easily, with hormone supplements for some period of time. I’m no expert, though, so I’m probably over simplifying.

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