Help people understand what it is really like to be a physician

In a recent article, Malcolm Gladwell dissected and diagnosed American health care.

Throughout our interview, he tackled controversial topics from the Affordable Care Act and medical malpractice to the contrasting Canadian health care system and much more. I expected him to dive deep below the surface and provide new and intriguing perspectives. He didn’t disappoint.

But it was his closing comment that caught me off guard. When I asked Gladwell what topics he thought I should cover in future Forbes blogs, he said, “Help people understand what it is really like to be a physician.”

I did not see that coming. I figured he’d request an expose on Big Pharma, an in-depth examination of various medical conditions or a portrait of preventive care. But explaining what it’s really like to be doctor is a much more personal request and, as it turned out, much more challenging.

The duality of being a doctor

Most physicians go into medicine with a mission-driven spirit, committed to helping people. They are grateful for the opportunity to care for others, proud of their ability to diagnosis and treat, and inspired by the trust their patients put in them.

But those experiences contrast vividly with the economic side of being a physician. Each day, mundane financial tasks distance doctors from the reasons they chose medicine as a career in the first place.

That’s the duality of being a doctor. There’s the fulfilling personal side and the frustrating impersonal side. The personal side reminds doctors why they love practicing medicine. The impersonal side poses a significant threat to the future of medicine. Let me begin by explaining the personal side.

Awe and terror: The clinic side of practicing medicine  

For academically outstanding students with a desire to improve the lives of others, becoming a physician is a great career choice. They work hard in their training to master both the science and art of modern clinical practice.

This hardworking and altruistic spirit is necessary for aspiring doctors to endure the physically, emotionally and financially taxing aspects of medical school and residency training. And that’s where future physicians experience both awe and humility as they navigate the complex journey of becoming a doctor.

They spend their days exploring the mysteries of the human body. They learn to decipher medical secrets by looking into the eye, listening to the heart and palpating the abdominal organs. They gain the competence and confidence needed to cut open a body with a scalpel, insert scopes into the different orifices and cavities, and remove damaged tissue to eradicate disease and restore health.

Out of context, these practices would constitute assault and battery. In medicine, these activities are essential. Being entrusted to perform them is a privilege afforded only to those who earn the title of “doctor.” It is an awesome responsibility.

Physicians are permitted and often required to ask deeply personal questions. Patients answer willingly. The intense and intimate nature of the doctor-patient relationship represents a unique bond, a trust forged in just a matter of minutes during a standard clinical encounter.

The majesty of the human body, the importance of health, and the personal fulfillment that comes from healing define the physician’s world and the clinical practice of medicine.

But along with the awe and pride comes an underlying terror.

As physicians treat patients, they are afraid of making a mistake or harming someone. Physicians worry about missing a life-threatening diagnosis, unintentionally spreading infection or committing a technical error. This fear isn’t just the self-protective paranoia of being sued for malpractice. It stems from a profound anxiety of violating the deeply embedded, core principle of the profession: Primum non nocere or “first, do no harm.”

Most nights, physicians go to sleep fulfilled and grateful for the honor of becoming a part of their patients’ lives. And overall, the opportunity to make a difference is fulfilling and satisfying.

But when something goes wrong, the agony runs deep. There are sleepless nights filled with tossing, turning and painful reflection.

Claims and pains: The clerical side of practicing medicine

As fulfilling as patient care is, most doctors (particularly those in individual and small practices) lament the other side of the job: the business of health care.

As much as half of each day can be consumed with clerical and administrative tasks: completing insurance claims forms, navigating complex coding requirements, and negotiating with insurance companies over prior approvals and payment rates. And this affects not only physicians, but also their patients – further complicating medical practice and increasing the level of frustration.

In my conversation with Gladwell, he spoke about a doctor’s office he’d recently visited. He described interacting with four support staff: three doing paperwork and only one assisting the physician with medical care.

“That’s insane,” he said. “The only other industry in America that has a higher ratio of back-office to front-office is financial services, which also is a massively crazy business. It’s just wrong. It’s a misuse of resources.”

He also expressed concerns about the economics of medical practice and the consequences for physicians:

“I don’t understand, given the constraints physicians have in doing their job and the paperwork demanded of them, why people want to be physicians. I think we’ve made it very, very difficult for them to perform their job. I think that’s a shame. My principal concern is the amount of time and attention spent worrying about the business side. You don’t train someone for all of those years of medical school and residency, particularly people who want to help others optimize their physical and psychological health, and then have them run a claims-processing operation for insurance companies.”

It’s this side of medical practice that wears down even the best physicians.

Yet it’s the reality for many American doctors, particularly those in small offices, who are reimbursed on a fee-for-service basis. Filling out claims forms and managing thousands of billing codes are frustrating and exhausting tasks. No wonder multiple surveys over the past two decades show a progressive decline in doctor satisfaction among those in community practices.

It’s not the long hours or the demands of patient care that have eroded their satisfaction. It’s the insurance side of health care.

And in 2012, a study found that 9 out of 10 physicians across the country areunwilling to recommend the profession to others.

Where does that leave the future of medical practice?

The life of a practicing physician can be incredibly rewarding. Making challenging diagnoses, helping patients deal with and overcome devastating illness and comforting families after the loss of a loved one — these are powerful emotional experiences. Across history, they have provided physicians with a profound sense of fulfillment.

But the insurance system can erode the professional and personal satisfaction of even the most dedicated physicians. That’s why it has to change.

The solution is not a government-run program with the inevitable red tape and endless regulations. This will only make matters worse. Instead, improving the situation will require a systematic shift — one that moves away from doctors being paid for volume to one that rewards value in a predictable, prepaid way.

It will require helping doctors transition their practices from individual and small office settings to working in integrated, physician-led medical groups. The organizations that have done this have seen higher quality outcomes and increased physician satisfaction.

Malcolm Gladwell: A much-needed catalyst for change

I left Gladwell’s New York residence hoping that he would apply his powerful and paradigm-shifting insights to the health care world. I’m optimistic he can help create a new language and lens through which our nation can discuss the health care challenges we face.

If he decides to write a book about American health care, I predict the opening chapters of his book will contrast the past five millennia of clinical practice (ones filled with dedication, commitment and fulfillment) against the harsh reality and financial challenges the profession faces today. And maybe, just maybe, his words will serve as a catalyst for system-wide change. Let’s hope so.

Robert Pearl is a physician and CEO, The Permanente Medical Group. This article originally appeared on Forbes.com

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  • Dr. Drake Ramoray

    If by transition, he means force. Sure that’s a good description of what is happening.

    • Deceased MD

      Sounds like some form of torture. Pts are mandated to have insurance and now doctors are “mandated” to hospital employment. I think their is a term for that– “hostile dependency”.

      • Dr. Drake Ramoray
        • Deceased MD

          As crazy things are i doubt this will ever get passed. thanks for the info.

        • NewMexicoRam

          I just saw on one of the physician news reports (AMA?) that Medicare is considering a new rule that any Medicare Part D prescription would need to be written by a participating Medicare provider or Medicare won’t pay for the rx.
          There go the concierge practices.

          • Dr. Drake Ramoray

            I haven’t heard that one before. Massachussetts at one time was looking to make taking Medicare /Medicaid a requirement. Not sure if they still are but at one time there were discussions about sampling the community in which a doctor practiced and insuring through the EMR that the doc saw a “proportionate” amount of Medicare/Medicaid that reprented the community in which they practiced.

            Med studs are insane to go into primary care right now, and practicing docs need a plan B if not a plan C and maybe D too.

            I have an academic job lined up if needed, a direct pay plan that I will try and implement, and connections overseas. Got to have options.

          • http://onhealthtech.blogspot.com Margalit Gur-Arie

            Not exactly. You either enroll or specifically opt out, one or the other.
            It’s the same as what they did with labs, imaging, and other orders back in 2009, and finally kicked in this year. The problem is that for Part D, they want to get it all done in less than a year and the AMA says that this may cause problems for patients at the pharmacy and such…

          • Dub

            Why would a concierge doc refuse to take Medicare and other insurance?

  • DoubtfulGuest

    I was reading along and thinking, “Nice article…yes…yes…very interesting and…” then the sound of brakes squealing…

  • NPPCP

    I thought exactly the same thing….kind of squeezed it in there. Never a discussion of free market or other alternatives. The drumbeat is incredible. It won’t happen in the end. We have already wasted hundreds of millions on PCMH. And stating the obvious – “physician-led.” Well, no kidding! You are a physician! who else would you recommend leading these new fantastic enlarged bloated works of art Mr. Pearl? And concerning the daily drudgery – I don’t think medical professionals will ever learn that we are not special. People do not care about billing issues or the intricacies of our private businesses. They most definitely think “I have the same problems you do – why do I have to think more or less of you?” I just don’t get it…….the “I’m special” mentality.

    • rbthe4th2

      YAY!!! Wish I could like this 20 times. Once you’ve been bitten by blackballing, messed up medical records, ego physicians who threaten you, and the constant hits of medical paper retractions for faking data or people like Charles Cullen, you tend to have a different slant on who (and a bunch of other specifics) does the controlling.
      Especially when we can’t get anything done about missed or delayed dx’s, changes in medical care to go for the cheaper solutions.
      And when you see MD/MD (insert DO too) couples who’s kids can afford the best schools and are going on to medical school since they’re a “medical family” (30% of kids from the last study I saw were), why would an independent businessperson who struggles to pay all this work and his 10 to 15 workers care about their problems?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Well, yes, this argument has been made “across history” in other contexts where the harshness of independence was unfavorably compared to the predictability and relative comfort of lack thereof…
    The only think I don’t understand is why are Kaiser premiums as high, and often higher, than the alternatives, and why are prices at all these integrated havens for doctors higher than their respective alternatives…. because I thought our problem was that health care costs too much, or maybe this is a solution for a different “problem”?

  • pmanner

    You mean, an integrated, physician-led medical group like Kaiser Permanente?

    Who’da thunk?

  • Patient Kit

    Doctors will never be free of the growing business side of medicine as long as our healthcare system in the US is, at it’s core, a big business — one of our biggest businesses, in fact, and getting bigger all the time. At least with a single payer system, imperfect as that surely would be, you’d be dealing with one government entity whose sole reason for existing isn’t the profit motive instead of hundreds of different profit-driven insurance companies and plans

  • Dr. Drake Ramoray

    Well, I certainly didn’t do a fellowship in Endocrinology to make money, neither did the peds, and family practice guys and gals. Interestingly enough the lowest paid docs also spend the most time on administrative hassles. Plastics, ortho, GI, cardiology, radiology, anesthesia, and urology are the high payers and have the least administrative burden. This is why docs gravitate to these specialties.

    • Patient Kit

      Where does oncology fall in that money/admin hassles spreadsheet? I don’t imagine most docs choose to spend their life treating cancer patients mostly to make money.

      • Dr. Drake Ramoray

        Oncology used to be a real money maker. The GWB era cut down on reimbursement for outpatient chemotherapy which has diminished there income some. That wouldn’t necessarily be bad except this was the same time that the facility fee was introduced.

        • guest

          Oncology pay is decreasing. For a recent graduate in a large metro area working 60 to 80 hrs/week the pay is around $60 to $80 per hour. Subtract taxes and various other expenses… More than 50% of what I do is not face to face patient interaction. Not to mention student debt of close to 300K. If I see each patient in 5 min maybe my week would be closer to 40 to 50 hrs/week.

          • Dr. Drake Ramoray

            I hadn’t realized it had gotten that bad. Not terribly surprised. Unless you cut something out (as a specialist) or burn something with X-rays the overhead and non-reimbursed care really cuts into the hourly pay.

          • chaplaindl

            $60 an hour? Really?
            Therapists $20.10 http://www.salarylist.com/jobs/Therapist-Salary.htm
            Plumbers $23.27 http://www.salarylist.com/jobs/Plumbers-Salary.htm
            Hairstylists $35.61 http://www.salarylist.com/jobs/Hair-Stylist-Salary.htm
            Family practitioner physician $57.45 http://www.salarylist.com/jobs/Family-Practitioner-Physician-Salary.htm
            By the way, most professionals work more than 40 hours a week, often many more hours than that, whether they are salaried or they bill by the hour. Therapists, plumbers and hair stylists have overhead costs to pay as well.
            It’s a good thing that physicians earn a good living for all the responsibility they take, for all they know and for all that they had to do to be in the position to do so much good. However, It would be good for a physician to have an accurate view of the world in which most patients live.

          • Nk

            Salarylist.com isn’t the most reliable source… the AAFP claims that the average salary for a 1st year Family Practice Doctor is $170,000. When you take into account that many Family Practice doctors work 40 hour weeks and don’t have to take ER call… that’s a pretty nice gig.

          • guest

            You are right. Money should not be a primary reason for practicing medicine, it is a secondary consideration. It is a learned profession. We should make as much as teachers. We have lost our perspective a bit. Here is my plan, make as much as possible while there is money to be made. $60 per hour is not so bad. Ten years ago it was close to double. Make as much as possible to make up for the years of training and pay down debt and then save a little in order to make my transition out of medicine easier. With the stress associated with it it is just not worth it. I am dreaming of having a small business, living on the edge of poverty but having a little more autonomy, time for a bathroom break, no one checking off if I washed my hands before each patient as if they assume I am some a criminal in waiting. Be respected, that is what I would like, not money.

  • guest

    “A ton of money?”

    The typical hourly wage for a PCP is about $60. Your average hair stylist, plumber, massage therapist and psychotherapist make more than this, with far less educational debt, risk and stress, not to mention governmental intrusion into their work. In my opinion, anyone doing what a PCP does for the amount they do it for, is completely entitled to complain about increased administrative time. It is not “disingenuous” at all.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      I’m glad you pointed that out, because Medicare is planning on publishing how much it pays doctors, and that is going to be a lot more than $60 per hour, and the headlines in the media are going to be spectacular.

      By then it will be an uphill battle to clarify that:
      a) more than half the money goes to paying for overhead, including payroll and
      b) nobody is working 40 hours per week (well, almost nobody and certainly the higher paid ones don’t).

      So now would be a good time for some docs out there to take control of the story and preemptively start writing about this stuff….

      • Dr. Drake Ramoray

        So few doctors realize that Third party payers see them as the enemy. Rich prima donnas who order too many tests and make healthcare too expensive. The powers that be in Medicare included.

        Docs have to be taken down a notch if/so the NPs and PAs can swoop in and assume the mantle of physician, at least for some in the public eye. The NPs want to work on their own, and also reject the PCMH concept as physician led. Docs have no allies, but still believe they are driving healthcare. Buzz said it best earlier. Primary care docs are being herded like cattle into the arms of corp med. The bolt gun looms.

        • Deceased MD

          Very good point. No allies. Including the medical societies who work against us. (Endo as the exception).

        • querywoman

          Some doctors do order too many tests. There are ways to tell when they do, like if they don’t accept other doc’s tests.
          My mother’s doctors were always calling each other for test.
          Insurance and government programs usually pay for another doctor to rerun tests, but nongreedy docs don’t do it unless the tests were questionable.
          My endo team and my general internist share blood work all the time.

  • buzzkillerjsmith

    I worked for Kaiser for 6.5 years. Physician-led? What a joke. The docs at the the top had dedifferentiated into suits and they and the natural-born suits then used all the rest of us as factors of production, human coal.

    A choice bit was when they made a single advice nurse center for the entire Northern Cal. Region. Pts would call in and ask for an appointment and one of the nurses in the massive panic room/call center in Lodi or some other godforsook place would set the pt up for an appt. The nurses did not know the pt, did not know us, were overwhelmed and were totally unaccountable for any of the numerous mis-triages that resulted. How could they be accountable? The job was impossible to do. This decision to create this thing was made with zero input from rank-and-file docs.

    This kind of stuff happened all the time. The system was disorganized and chaotic and just too damned big. If you liked working at the VA, check it out. But for me working there was a horrible, horrible job. And now you also get to be an EHR clerk.

    But I will admit that working for a hospital-based system was even worse.

    • querywoman

      Thanks for the insider’s view of Quackzer Permanente. This bull hockey system suffered a quick extinction in Texas.
      On the upside, I do think Kaiser’s Texas misdeeds have led to better regulation of HMOs. Governor Bush passed the strongest HMO regulating laws ever in Texas, and other states followed suit.
      Texas is not a welfare state. Perhaps Texas realized that the public had to pay for HMO misconduct.

  • Bill Viner

    I would call you a “fool” but I think you are just ignorant. Maybe in the glory days of medicine (70s to 80s) docs made a “ton” of money. I can tell you that my colleagues are making half of what they once made in the mid 90′s with a lot more stress as well. I’ve seen their tax returns. One of my closest friends works for a medical supply company and does better than I do. As the article states, we are being forced to become business minded just to survive. Go pick on a pro athlete, rap star or CEO on one of their web sites if you don’t like it.

  • Bill Viner

    Overall I liked the article. Not sure about the physician led group thing in a rural area though.

  • Mengles

    It isn’t salary, it’s administrative burden. Certain specialties have great administrative bs to deal with. For example, General Internal Med vs. GI.

  • Fred Olin

    When I was a senior medical student in 1973, I was having coffee with a faculty member in the hospital cafeteria. He said something I (obviously) have never forgotten. “Medical school disassembles you and puts you back together as a physician.” He was right.