“Get the suits out of medicine.”
This refrain has become commonplace among physicians, who worry that patient care, the essence of medicine, is increasingly taking a backseat to bureaucratic demands on safety metrics and electronics health records as well as corporate measures of efficiency. Without physicians, after all, there is no health care system for administrators to administrate, they say. Not only do top-down regulations make patient care more cumbersome, they significantly distract from the joy and meaning that so many seek when they choose a career in medicine.
As a medical student, I have heard these words all too often from many types of physicians, ranging from primary care providers to anesthesiologists. Research, moreover, seems to back this up. A 2013 study from Johns Hopkins showed that interns spend 40% of their time in front of a computer screen compared to just 12% with patients. A 2010 meta-analysis on the distribution of physicians’ time in the hospital setting showed that, across 13 different studies, physicians consistently spent significantly more time on activities related to indirect patient care compared to direct patient care. And a 2006 study showed that the same reality to be true for emergency physicians.
Even more worrisome is that these day-to-day frustrations seem to be changing physician behavior on a larger scale. According to a 2013 report, Jackson Healthcare, a major physician staffing company, anticipates an increasing void in the healthcare field because “physicians are preparing to leave medicine early either through retirement or a change in their career field” due to “feeling disconnected from their patients because of increasing regulatory and reimbursement restraints.” Anecdotally, my conversations with fellow medical students and physicians echo this report as more and more are choosing to forego patient care for consulting, industry, entrepreneurship, and other “alternative careers in medicine,” as they’re often called.
The problem with the perspective of “leave us alone,” however, is that physicians, like many groups, have been notoriously ineffective at self-policing. The good old days yielded unsustainable growth of health care costs to 18% of GDP as well as the now infamous report from the Institute of Medicine, “To Err is Human,” which shed light on preventable medical errors that led to between 44,000 to 98,000 deaths in hospital per year. Meanwhile, the growth of insurance, technology, and larger health care systems in the second half of the 20th century only made the problems more complicated.
The “suits,” in a way, were a response to the increasing complexity, cost, and questionable quality of care. In the 10 years following the IOM report, we appeared to be making some, albeit slow, progress on patient safety according to a 2009 paper in Health Affairs due to increasing pressures, standards, and requirements on hospitals and providers. More recently, the quality initiatives in the ACA seem to have led to decreased hospital readmission rates and incidents of patient harm (though some argue these trends preceded the law).
Moreover, the increased focus on cost in the ACA has led to a slowing of U.S. health care expenditures to record lows over the last three years, a trend that has persisted even after the economy started to recover from the recession. Although there is some evidence that this slower growth of national health care expenditures really began a decade ago due to a decline in real income and shift of patients from private to public insurance, the provisions for new insurance structures, payment policies, and models of care delivery and payment in the ACA will be crucial towards sustaining this trend, which would allow us to spend more of our country’s resources on education, infrastructure, defense, and anything-not-health care.
Doctors, as the ones who actually deliver the basic unit of health care, must be involved in the development and implementation of these administrative and national policies. Unlike other stakeholders in this complex system, physicians are in the unique position of understanding the “reality on the ground,” of what it means to actually deliver patient care in different settings. Provider input, for example, is critical in determining which quality metrics are useful vs. simply easy to measure or what kind of electronic health record is beneficial vs. merely burdensome.
At a time when physicians are increasingly feeling slighted and retreating from the spotlight, wishing administration would just let them be, disengaging from public policy (AMA membership is at an all-time low and continues to decrease), and hoping “Obamacare” would simply disappear, we need their insight more than ever. Hospital systems, insurance companies, and certainly the U.S. health care system are incredibly complex entities, whose effective and cost-sensitive management requires a variety of disparate skills and training that only different professionals, whether physicians, policymakers, or administrators, can provide. The question should not be who is in charge but how can we work together.
So is medicine for the suits or the white coats? For the system to work at its best, it has to be for both.
Simon Basseyn is a medical student.