Are physicians really valued, or merely problems to be solved?

I wonder, sometimes, are physicians valued professionals, or merely problems to be solved?  Are we skilled clinicians vital to the well-being of our patients?  Or are we merely assetts to be managed?  It occurs to me as I walk around hospitals these days, and see the overgrowth of people with clip-boards, people with undue authority over our lives and practices, people trained in business and management but untrained in either the science or art of medical practice.

I ask because I see the struggles of many good clinicians, who are beset by administrators (who are themselves beset by rules and threats from federal and state overseers as well as various groups like the Joint Commission).  Granted, there will always be a few docs who need re-direction.  But we should be doing it, instead of leaving it to those who really don’t understand. Ultimately, however, the things done in the name of corporate compliance or patient satisfaction or any of the dozens of other new catch-phrases are done in a manner that seems to see physicians as wayward children, or at the as worst felons just looking for a chance to commit their great crimes.  We are often treated as if we are on some preemptive parole.

In some instances, the problems stem from patient complaints and customer satisfaction issues.  The problem, as I’ve stated before, is that the customer satisfaction model does not move easily from retail America to medical America. When applied in our hospital emergency departments the “customer” is often unreasonable, rude, profane, threatening or has inappropriate expectations.   But this is then transformed into a scenario in which the physician (or nurse) who cared for the customer must have been the problem.  It is interesting to see the clip-boarded staff desperately trying to make excuses for the drunk, the addicted or the simply rude people who slow down care and thereby make life unpleasant for the medical and nursing ‘commodities’ in our departments across the land.  They always seem a little confused when we explain that these customers never pay anything into the hospital. They have one paradigm and shifting from it is simply impossible … unless the entire industry shifts.

I even saw this at work after our facility had a an event in which a mentally ill patient assaulted, and very nearly killed, a nurse and injured several others.  The committee meetings that followed were sometimes comical, as administrators sat wringing their hands over whether we needed cameras or more security; and over whether or not police officer should be allowed to have weapons in the ED.  (We can’t have a dangerous customer being shot, it appears.)

In addition to being “problematic” and “disposeable,” physicians are now viewed with significant suspicion.  The amount of oversight and regulation of our profession is staggering.  Hospitals have multiple employees and committees, multiple “watchers,” to track credentialling, complaints, compliance with regulations and quality of care.  They are forever keeping data, keeping charts, logging the time till the patient was seen, the time till the patient was discharged, the time till the CT scan was done or read, the time till the ECG was ordered and interpreted.  They bring us forms and show us files and remind us over and over that we are under scrutiny.  They check the charts and take us aside.  “I need to discuss this with you …,” sometimes in the midst of our busy shifts.  I realize that some of this is driven by the Joint Commission or by the feds via CMS.  But that doesn’t mean hospitals and their administrations shouldn’t make compliance as easy as possible. And it doesn’t mean that they can’t give feedback to the higher powers about the utility or difficulty of these measures.

Not only so, we have enormous higher oversight.  We have assorted board exams in medical school and residency, then specialty boards which reasonably ensure our competence.  We have background checks and state licenses and state and federal narcotics permits.  We have background checks and fingerprinting to obtain those licenses.  When applying to new hospitals or states we need references and more background checks. We have to demonstrate that we have been continuously employeed and give the dates and contacts.  They tsk, tsk over even one lawsuit, even if it had been years before, as if any error were an indicator of a higher character flaw.  It all may seem fairly benign to those outside of medicine. But from where I sit, it all feels onorous.  It all feels as if I’ve done something bad, and need to be watched carefully by teams of trustworthy, diligent nurses and managers.

But what bad thing have I, have you, done?  In emergency medicine especially, we have worked long and hard to be trained, and we have spent days, evenings and nights frequently treating the poor and destitute, the drunk and addicted in addition to the gravely ill.  Much of our care has been given for free.  We have been available holidays and weekends.  And we have done it all while trying to please the customers and respect our managers.

Our efforts, our struggles, our life and death, day and night lives sometimes make it a little difficult to be endlessly monitored and judged, evaluated and vetted by those who are unavailable after hours, or in the midst of violent assault and terrible tragedy.  Evaluated by those whose days move from meeting to meeting, punctuated by lunch and paperwork at the desk, and upon whom no one is imposing rules that say:  “You know, you had ten minutes to finish that form. You went beyond ten minutes and I’m going to have to start documenting your progress. If you can’t do better, we may need to consider hiring someone else.”

Our collectively well-demonstrated dedication to the practice of emergency medicine, and medicine in general for our colleagues in other specialties, makes it galling and demoralizing to know that from every angle, from every organization, at all hours of the day and night, we receive more oversight than the average criminal.  In fact, I have cared for any number of patients who were injured while driving under the influence, only to find that they had multiple previous convictions pled down to first offense. For us, it feels as if there is no plea-bargain.  Only another file kept in another office.

Increasingly, as in much of regulation driven America, our crimes, our errors, will seem small to us, but enormous to the “machine” that is the modern hospital.  They will have to do with things already mentioned.  Time to EKG, time to PCI, time to CT, time to documentation.  They will be issues of documentation, and screening and of doing all the things that eventually roll down to emergency physicians and nurses from the rest of the world, but with time-limits attached.  They’ll will be issues of patient satisfaction, which will be tied to reimbursement.  They will all happen in what will continue to be the endlessly chaotic world of the ED, where there is never a limit on who can come in, or how many can come in and never a limit on what we are asked to do, for patients, consultants and administrators.

I understand.  There are rules and regulations.  And someone has to implement them.  But there are too many of them, and clinicians need help and support more than increased distrust and oversight. There are bad doctors; I get it. But most are good and need to be treated and valued as such.

I don’t want to spend my career feeling like a criminal, or like a form to be filled-out, a problem to be managed. I want to spend it doing the job I love and do so well, which is caring for the genuinely sick and injured.

Dear administrators and politicians, regulators and all the rest.  In the words of my surgery resident during medical school:  “Help me, don’t hurt me.”

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test. This article originally appeared in Emergency Medicine News.

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  • Ellan

    It is my experience that when administrators try to get the MD’s to come up with processes to make compliance easier, the MD’s don’t have time to deal with it. As a result, the hospital hires compliance police to chase down each individual physician. Unfortunately, these compliance officers don’t understand the workflow from a physician’s perspective and frustration ensues. Physician’s need to be part of the solution either by working with administration or putting pressure on Joint Commission and other regulators, but I guess they can’t bill for that.

    • rtpinfla

      That last comment about not wanting to be part of the solution because “we can’t bill for that” pretty much tells me you haven’t the slightest idea what you are talking about when it comes to how physicians spend their time. Either that or you do and your obvious disdain keeps any physician from wanting to deal with you. I know I wouldn’t want to deal with somebody with that attitude about what I do.
      Here’s a novel idea How some administrators and/or compliance officers trying to be part of “solution” by getting out of your offices and actually spend some time in the trenches and see what the direct patient care providers (doctors, nurses, techs) actually entails. And I don’t mean one of the meaningless 5 minute PR opportunities in the middle of a shift. How about spending a few 10 hour shifts actually shadowing a physician or two to help understand what’s going on? Maybe then these “compliance officers” will better understand the physicians perspective and y’all administrators might even get even be able get some insight into your product(it’s patient care, remember?) beyond the spreadsheets.

      • Ellan

        My experience is as a staff nurse working within ad hoc committees trying to develop order sets and protocols, mostly when we switched to CPOE. I volunteered, thinking that if those of us providing the care had input, it would save everybody time and be better and safer for the patient. I have worked on multiple order sets and protocols for ICU (for both intensivists and surgeons) and it is very frustrating to get physicians to come to the table and provide input. And yes, their argument is that they don’t get paid for that and it is the job of administration. The only way to get it done is for me to do all the research, write it up and then chase down each individual surgeon to review it, so that I can make edits and start the process over again. It often takes over 6 months to get it to the department for formal approval. It is time consuming to say the least and I do much of it on my own time. I used to enjoy it, I love doing the research and despite what you may think, I like working with the physicians and they are appreciative of all my efforts on their behalf.
        I don’t think shadowing a surgeon for 10 hours is going to help the process. What I need is their insight from years of education and experience. When I can get the physician group to sit down together for 30 minutes and discuss an issue, we have been able to get so much done, but the last year or so, the physicians are increasingly burned out and unwilling to do that. I have an enormous amount of respect for physicians, but I can’t abide by anyone sitting around complaining about their lot in life, but not willing to do the work to improve it.
        It is true that my experience with the issue that Dr. Leap raises is limited, but his message that physicians should just be able to take care of the patient and everyone else is there to make it easy for him is a little naive in this age of regulatory bureaucracy. Believe me, as a nurse, would love to just be able to take care of the patient and not deal with the endless charting and paperwork but I don’t see that being a reality, so I try and do what I can to improve the process, for myself and for the patient.

        • guest

          The fact is that if the healthcare organization truly wants physician input into processes, it needs to free up physician time in order to participate, because the administrative process is so very inefficient and time consuming that it is really not possible for a physician to participate meaningfully in it and also carry a full-time clinical caseload.

          I find it fascinating, that in a time when physicians are expected to “efficiently” manage increasing patient caseloads and also to have 100% compliance with all work deadlines, that administrators are apparently under no pressure at all to perform to the same standard.

          This was brought home to me when I foolishly agreed to write an order set for opiate withdrawal for my hospital, which had no standardized way to deal with new patients who were withdrawing from opiates. In my innocence, I thought I would write the order set, turn it in, and the EPIC team would turn it into EPIC-ese, or whatever.

          ONE YEAR LATER, I have been involved in innumerable email exchanges, answered dozens of questions, sat in meetings, and complied with ridiculous requests such as the one to track down the doctor who created the Clinical Opiate Withdrawal Scale (an emeritus professor at UCLA) and get him to give me written confirmation that the COWS is in the public domain. All of that, and the order set is still not loaded into EPIC and I would say that about 80% of my occasional reminder emails asking about any progress go unanswered.

          Doctors are busy, but they are not too busy to notice that administrators are holding them to a level of efficiency and accountability that the administrators themselves are not expected to attain. And believe me, we are very reluctant to get involved with an activity involving people who sit in meetings all day and have zero sense of urgency about what they accomplish.

  • JR

    Is there a possibility that your hospital could implement some kind of rotation, where each physician spends 3 months every few years in an administrative role (maybe part time, they don’t take on new clients during that time but can continue with clients under their care? I’m assuming most ER doctors at least could do this, and considering the stress ER docs are under, it might provide a mental health break for them too?).

    It might of course require hiring more physicians, instead of non-physicians, but would this give physicians a chance to be involved in their hospital, give feedback to each other, be responsible to each other, etc?

  • ninguem

    Edwin, I’ve read your columns in EM News for a long time.

    The stuff I’m reading lately seems more bleak. Maybe it’s selection bias, I don’t know. Are things getting worse in your corner of the world?

  • edwinleap

    Ninguem, thanks for asking! Actually, I’ve made a career change and I’m rather happy. But I feel obliged to speak about the many disheartening things happening in my specialty and in medicine in general. In the end, care will be worse and physicians miserable if things don’t change. ‘A voice, crying in the wilderness?’ A little presumptuous, but sometimes that’s how I feel. I have more humor and happy stories inside; I’ll unleash them as well, so thanks for the reminder.

    • ninguem

      I don’t know how to characterize it, maybe you seemed “above it all” because of your faith, character, whatever, not that I’ve ever met you, just from your writing.

      Seemed like it was getting to you. I was really getting a feeling of “if it’s getting Dr. Leap down, I’m doomed”.

      I couldn’t do emergency medicine at all, I swear I’d leave medicine if that were my only choice. Admirable that someone can do it, and I’m sure most EM’s would leave medicine if their only choice were primary care like me. Vive la difference.

      So if you don’t mind my nosiness, what’s the career change? Out of emergency medicine, or just in a different setting but in the same line of work?

      Not that I dispute a single thing you’ve written lately, mind you…..

      • edwinleap

        I appreciate the reminder; I need to write upbeat as well as about troubling issues, so thanks! Actually, doing full-time locums and really enjoying the change of venue. I have more control over my life this way, but also have an opportunity to see medicine around the country. Expect writing about that over time. I told someone I’m roaming the medical world like Kwai Chang Kane on Kung Fu! May take the wife and kids overseas at some point. Have a great day!

        • ninguem

          Have you considered any international locums?

          Most of the people coming back from the Australian and New Zealand gigs seem to have enjoyed themselves.

  • NPPCP

    Hi mingles, aside from the above, wouldn’t know what to do without you guys in my practice. Yes I am independent. Yes there are no physicians in my clinic. But that has nothing to do with how valuable you are. Physicians are way under rated – some deserve it some don’t – like NPs. But the time and effort you took are greatly discounted. It’s not right. Just ain’t.

  • betsynicoletti

    I’d be interested in hearing everyone’s opinion/experience with when a physician is the CEO, not the CMO of health care organizations. Does it change the work environment for physicians?

    • guest

      Having a physician-led organization, in my experience, is vastly superior to the alternative. My one experience with a hospital system that was exclusively non-MD led was that administrators had no clue about physician or nurse workflow and quite frankly didn’t care. It was the most efficient, disorganized place I had ever worked and almost every time I interacted with an administrator I had the sense that they were just playing “fake it till you make it,” since they had no idea what they were doing.

      The bottom line is that in healthcare, you can’t competently administrate something you have never done yourself. It just can’t be done.

      Also, there was a nasty, anti-physician vibe throughout the entire organization, very similar to what is described above. I was never sure where that came from, but I wondered if it had something to do with the preponderance of ex-nurses in leadership positions in the organization. However, since there was also an anti-nurse vibe, maybe that wasn’t it.

  • Martha55

    In corporate America, employees are liabilities, not assets. If doctors are still considered assets, they should feel lucky.

  • Ellan

    I was thinking that the AMA did have the muscle to put pressure on The Joint Commission and The American Hospital Association to try and reduce the ever increasing amount of regulation that physicians are working under. And I don’t have a desk job and am not part of administration, nor would I want to be.

    • goonerdoc

      That would imply that the AMA represents physicians’ best interests, which it absolutely does not. Nice try, though.

      • Dr. Drake Ramoray

        Or that administrators want less beuracracy

        • goonerdoc

          Touche

  • Deceased MD

    I think the way I view it, is doctors are objects to be both manipulated and exploited by corporate America, just like a commodity in the stock market. It is hard to be upbeat with this POV.
    And it is a well known fact that psych pts don’t do well in ER’s. It is not surprising that violence can occur with the acute stimulation, for a psychotic pt with staff overwhelmed with the other pts. The answer there is clearly getting psych beds and a really novel notion: a psych hospital. But this does not fit into corporate America. So let the chips fall where they will.

  • buzzkillerjsmith

    You have some spelling errors here, doc. And you have a doctoral degree. Just sayin’.

    That said, your point is that medical care is now in hands of non-physicians, and that is a bad thing. Bad for docs and for pts. Yep.

  • Politiwars

    After having had numerous horrific experiences with multiple doctors on both a personal and family level, I find very few of them to be of any value at all. You can only lower the bar on patient-centered care so many times before you have third-world health care. It doesn’t take rocket science to see the statistics of where the U.S. system ranks among oecd countries, and it’s extremely poor, especially when the cost is factored in.