This year was no different. Throughout the 2021 MLB playoffs, and amid an exciting World Series between the Houston Astros and Atlanta Braves, I’ve been glued to the action. But I have also observed troubling similarities between baseball’s hurlers (the pitchers) and medicine’s healers (the doctors).
Borrowing lessons from America’s pastime, here are three sets of issues facing primary care physicians today. These troubling trends must be addressed quickly to avoid irreparable harm being done to both doctors and patients.
The problems of pay and prestige
If you want to know who matters within a profession or organization, look at the salaries. It’s true in sports and medicine.
Based on pay, two of baseball’s rarest jewels are (1) the “ace” pitcher who can dominate the opening innings of a game and (2) a “closer” who can reliably secure victory in the final inning of a tight contest. Starting pitchers account for 7 of the 10 highest-paid players in baseball, earning up to 18 times the league’s $2.1 million average salary. Closers, also highly valued, earn 33 percent above the MLB average—making them the third-highest-paid position group on the field.
If starting and closing pitchers were doctors, they’d be high-status specialists: cardiac surgeons, neurosurgeons, and orthopedists. They are the heroes. Everyone knows their names and sings their praises. And because of their professional prestige, these physicians take home big money.
Then, by contrast, there are the primary care doctors. If they played baseball, they’d be the lowly relief pitchers. Disparagingly referred to as “failed starters,” the reliever’s job is to quietly pitch the middle innings of a game, between the starters and closers.
In baseball, as in medicine, reputation often matters more than reality. In reality, relievers are among the most important players in the majors. They outnumber every other position on a typical 26-man roster. They’re increasingly relied upon as “openers” (relievers who actually begin the game in place of a starter). In this era of high-strategy baseball, relievers are increasingly accountable for a team’s wins and losses. But despite their essential contributions, relief pitchers are still seen as “faceless” and nameless—interchangeable parts of the major-league machinery. Few fans know their names, sing their praises or pay them much respect. As a result, they also don’t get paid as much as their colleagues: relief pitchers earn 65 percent below the league average, the lowest salary of any position in baseball.
Dave Dombrowski, Boston Red Sox president of baseball operations, accurately summed up the problem for not only relievers, but also primary care doctors: “The more you rely on guys and the more they get used, the bigger the chance they won’t bounce back and (perform) as well the next year.” Sure enough, when a reliever’s arm wears out from overuse or injury, he’s tossed aside and replaced, usually by young hard-throwing pitcher from the minor leagues. Few people notice or lament the loss.
As a medical specialty, primary care doctors can relate to these indignities. Like relievers, they outnumber their colleagues and yet their work is rarely recognized or adequately compensated. In fact, the three lowest-paid specialties in medicine are pediatrics ($221,000), family medicine ($236,000), and preventive medicine ($237,000)—all of which fall under the category of primary care. Combined, they earn only 65 percent as much as their specialist colleagues.
The problems of overwork and abuse
It used to be that both physicians and pitchers worked reliable schedules, got sufficient rest and, as a result, enjoyed sustainable careers.
But in baseball, as in medicine, the job isn’t so simple (or easily defined) anymore. The demands are ever-increasing and the scope of responsibility ever-expanding. And because of the unpredictability and stress, everyone is paying the price.
Let me give you a recent baseball example: Max Scherzer of the LA Dodgers, arguably baseball’s best pitcher on the league’s best team, had a strange experience in this year’s playoffs. During a pivotal Game 5 in the division series against the SF Giants, Scherzer’s role on the team changed suddenly and without warning. The famed starter—whose job is to pitch the opening four to six innings of a game—was brought in as a relief pitcher to secure the final three outs, something he’d never done in his career.
Just three days later, he was back in his starting role against the Atlanta Braves without enough time to rest or recover. He didn’t do well. The Dodgers lost and, after the game, Scherzer admitted his “arm was dead.” Worse, the ace pitcher was too exhausted to make his next scheduled start against Atlanta, which forced fellow starter Walter Buehler to replace him on short rest. That didn’t go well either and the team was ousted from the playoffs. Ultimately, bad management decisions and unreasonable demands kept the talented Dodgers out of the World Series—and kept their pitchers from performing their best.
A similar sequence is happening in primary care. Each year, these doctors are asked to do more and more. Many in solo practices find they must see 20 to 25 patients each day just to pay their staff and make overhead. And just when they’ve figured out how to meet the dozen or so metrics imposed on them by insurance companies, new ones are added. It’s no surprise that nearly half of all primary care physicians report being dissatisfied, unfilled, and fatigued—the classic symptoms of burnout.
Like sore-armed pitchers having to throw their hardest day after day, primary care doctors find themselves in constant pain. Burnout is becoming endemic in the specialty as doctors are now exiting the profession at an alarming rate.
The problems of conformity and low-effort thinking
Baseball managers, like health-insurance executives, are ruthless competitors. They’ll do almost anything to get a leg up on their opponents. Everything, it seems, except something unconventional. Though they’re ruthless and ambitious, these leaders are also morbidly afraid of failure and criticism; fears that lead to a lot of missed opportunities.
Professional baseball, for example, is so famously conformist that a single, rare exception to the norm became the basis of a bestselling book and, later, a blockbuster movie called Moneyball. For decades, MLB teams relied on scouts to evaluate players and build their rosters. But in the early 2000s, Oakland Athletics manager Billy Beane decided to take a different tack. He knew his small-market team could never compete with the likes of the New York Yankees—at least not on the basis of salary. So, he used data analytics to build a roster of players who, according to his spreadsheets, were grossly undervalued. This number-crunching approach took the A’s all the way to the playoffs in 2002 and 2003. Now, almost every team in the major uses an identical strategy.
A decade ago, the idea of planning a “bullpen game” with as many as nine pitchers coming in—one after another—would have been ridiculed. Today, it’s a commonly used strategy, not only during the regular season but in the playoffs, as well.
Overusing and abusing relievers has become the norm in baseball, just as demanding too much of primary care doctors has become standard practice in health care. Insurers, trying to lower costs, force primary care doctors to see more and more patients each year, fill out ever-more paperwork in order to receive authorization for testing and referral, and be subject to endless performance evaluations based on 20 or more metrics. This is the approach almost every insurance company now takes. But it contradicts the data on achieving superior clinical outcomes.
Research has shown that adding ten primary care physicians to a community increases the longevity of patients by 250 percent compared to adding ten specialists.
Thus, rather than squeezing every dollar out primary care physicians—who account for only 6 cents of every health care dollar spent—insurers should give these doctors more resources, augment the support staff, reduce their patient panels and reimburse the purchase of useful information technologies. Doing so would allow primary care physicians to more consistently prevent disease and more effectively help patients avoid complications from chronic illnesses.
As a nation, we must train more primary care physicians and ensure they’re compensated fairly. We should reward those who practice in under-resourced communities by forgiving their medical school debts, which today exceed $215,000 on average, in order to make their careers more sustainable.
And rather than compensating primary care on a fee-for-service basis, which rewards doctors for doing more rather than doing better, insurers would be better off paying them an annual salary, commensurate with the positive impact they have on the health of their patients. Phrased differently, insurers, payers, and governmental programs would all benefit if they embraced a long-term strategy for primary care, rather than the short-term approaches that stifle progress. In medicine, success can’t be determined by the quarterly earnings of insurance companies. It must be measured by the health of people over many years.
Americans can and will continue to debate the best use of a pitching staff for decades to come. But in medicine, we already know the recipe for better care and more satisfying careers: give primary care doctors more respect, resources, and relief. There’s no need to debate it. What we need now is action.
Robert Pearl is a plastic surgeon and author of Uncaring: How the Culture of Medicine Kills Doctors and Patients. He can be reached on Twitter @RobertPearlMD. This article originally appeared in Forbes.
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