A recurring theme expressed by many contributors and commentators to KevinMD is physician burnout.
It is generally accepted that chaos causes burnout. There is no shortage of chaos in the practice of medicine: emotional, physical, personal, professional, and political stresses, not to mention the threat of lawsuits and the cost of liability insurance. This is just the shortlist. There is also no shortage of adjustments that doctors make in response.
It is not intended for doctors to burn out. Increasing chaos increases burnout. In fact, doctors are bound to the Hippocratic Oath. There is even a modern Hippocratic Oath based on the notion that doctors serve society. They serve at the pleasure of a health care system, and the health care system serves at the pleasure of society.
Make no mistake about it, burnout is a catalyst for socialized medicine. Doctors suffer from the chaos in the health care system by adjusting, and so do patients. The health care system, however, serves at the pleasure of other interests, who advocate for the right to health care, specifically, socialized medicine. Maybe health care is a right, maybe it isn’t. However, asserting that it is causes more chaos.
Nevertheless, adjustments to chaos are the slow progression to socialized medicine. By adjusting, today, many doctors are participating providers. Health insurance has been around for over 100 years and Medicare for 60. Yet, Medicare rules are adopted by most private insurances as their own. Medicare is a government program. Hence, whether they know it or not, participating providers are governed according to rules established by the government.
Doctors also adjust to chaos by forming integrated health systems, which are joint ventures between their practices and a hospital. Health systems are modeled on a medical home. The medical home is an innovation of the Agency for Healthcare Research and Quality (AHRQ). AHRQ is a governmental agency.
Medical homes adhere to best practices, which are also innovations of AHRQ. Best practices typically underutilize resources to control health care costs. Hence, employed doctors live by rules established by the government, whether they know it or not.
Adding to this chaos, the Affordable Care Act codifies rules for participating providers, health systems, best practices, and medical homes.
Some doctors adjust to chaos by joining concierge practices so that they can live by their own rules. This is a myth. They still participate with health insurance and Medicare. Rather than practicing by best practices established by AHRQ, they practice by rules established by a franchise, like MDIPA or SignatureMD. They prosper by overutilizing resources. It is just a matter of time when they, too, will be regulated.
Adjustments increase liability risk. Complications are inevitable. Because of best practices, patients in health systems may not connect a complication with an underutilized resource; however, their malpractice attorneys will.
Even concierge physicians get sued. Patients may not connect a complication with an overutilized resource; however, their malpractice attorneys will.
Furthermore, physicians become employees in health systems or choose concierge medicine because of the chaos caused by malpractice insurance premiums. By joining a health system, doctors are covered under the malpractice insurance of the organization. In concierge medicine, physicians pass the cost of premiums on to patients by the yearly retainer. Finally, the ACA does nothing to address the chaos caused by the threat of malpractice lawsuits.
All this brings socialized medicine a step closer. The final step is accepting the proposition that, as federal employees in socialized medicine, doctors cannot be sued. When this is accepted, the game is over.
It is no accident that the Agency for Healthcare Research and Quality researches physician burnout. AHRQ’s MEMO (Minimizing Error Maximizing Outcome) Study reviews medical records from 119 ambulatory care centers. There are 1,795 patients and 422 general practitioners.
At the very least, this study ignores that there are 1 million doctors in the country, not 422. There are many other specialties, not just GPs, and there is an enormous patient pool, not just 1,795. Nevertheless, this study is considered a landmark.
AHRQ enumerates five causes of physician burnout: 1) family pressures, 2) time considerations, 3) electronic health records, 4) lack of control, and 5) chaos.
Undoubtedly these are causes, and chaos is included.
AHRQ performs another study, “Minimizing Stress by Maximizing Success of the EHR, the MS Squared Study.” It enumerates five strategies: 1) flexible schedules, 2) staff surveys, 3) a better work/home balance, 4) more time off, and 5) improvements to electronic health records. The last strategy is the most important. The patient portal is one improvement to the electronic health record.
Next comes the Mini Z Burnout Survey, prepared by the medical director of a medical home in Minneapolis but financed by AHRQ. It shows that physician burnout is less problematic in a patient-centered medical home.
If I only had known, I would have joined a medical home, taken more time off, enjoyed my family, gained control by responding to staff surveys, and used a better electronic health record with a patient portal. Things might be better. Perhaps not. AHRQ has no designated strategy for chaos.
To that point, if chaos is a generic factor, it is where medical liability resides, and one would expect medical liability to be at least as important as staff surveys and electronic health records, which are singled out.
Anyone who believes that socialized medicine is good because doctors cannot be sued is living a myth. The Federal Tort Claims Act holds federal employees accountable for injuries that arise in the course of their employment. It does not matter if the federal employee is a doctor. Complications are inevitable; so, without a doubt, there will be malpractice lawsuits with socialized medicine. Of course, it is conceivable that doctors are granted immunity for liability, in which case, patients have no recourse when they are victims of a medical error.
Assuming burnout leads to socialized medicine recalls the mantra, “We are from the government, and we have come to help.”
Howard Smith is an obstetrics-gynecology physician.