In recent months, there has been a lot of talk on social media and in the press about how miserable many doctors are. These conversations have also brought inspiring alternatives to the forefront. For example, Zubin Damania, MD, founder of Turntable Health, and Pamela Wible, MD, a leader in the Ideal Practice movement, have notably and smartly encouraged doctors practicing on the front lines to take matters into their own hands, creating new practice environments that bring the humanity back to the doctor-patient relationship.
Concurrent to fresh approaches like Dr. Damania’s and Dr. Wible’s, I think that there are institutional and systemic changes that can be made, and need to be made, if we are to see more happy, fulfilled, and empowered physicians delivering excellent, cutting-edge, and holistic patient care.
There are a number of macro-level issues to address, but here I will take on three: fixing training, applying big data to the problem, and rewarding the innovators.
At present, doctors training in internal medicine, family medicine, pediatrics, and OB/GYN spend a minimum of three years in residency. Though most of these physicians will go on to work with outpatients, residents in these fields don’t spend significant time developing skills relevant to that. Instead, the majority of their training hours are devoted to working in the hospital, becoming proficient at managing acutely ill inpatients.
The tradeoff is that these doctors have far fewer opportunities to learn innovative team-based practice management strategies, techniques that can reduce costs and improve outcomes. They have fewer chances to learn about low-cost, good risk-profile, non-pharmaceutical based therapies, such as diet programs and stress management tools for chronic disease. They have less time to learn how to best manage patients in the much less reliable, harder-to-control outpatient setting, where lifestyle and economic factors often determine outcomes far more than fixed protocols do.
In a recent article in the New England Journal of Medicine, Amitabh Chandra pointed out that residents generate “substantial revenues for their hospitals, particularly after the first year of training” — revenues that more than cover residents’ average $50,000 annual salaries. The authors point out that if the government funding’s purpose is to relieve indebtedness, to encourage more doctors to go into primary care, or to prepare residents to employ team-based strategies to improve outcomes, this money would be more effectively spent directly on these activities.
So how do you fix training to create happier doctors who are also better prepared for the realities of outpatient practice in a changing healthcare landscape?
First, make salaries competitive with those of other professionals straight out of graduate school. MBAs entering financial institutions and first year legal associates at law firms typically start their postgraduate careers with salaries in the low six figures. Given Chandra’s observation, why not raise compensation to be even a little closer to market rates? Compared to the costs-of-care problems brought forth through expensive tests, drugs, and hospital-based care, the cost of this shift seems minimal, and has the potential to dramatically lower care costs by fostering a large and talented workforce grounded in prevention and community-based care.
Second, cap hospital-based training at two years for primary care fields like internal medicine, pediatrics, and family medicine. If physicians in these fields plan to specialize, they will get more inpatient training in their fellowships. If they don’t, they will be working as outpatient physicians and need more experience doing exactly that. Then, reserve the third year of residency for practicing in a mix of both community clinic and private practice settings. This training year should also include direct experience learning innovative practice design and management tools for better outcomes, something all community physicians will be rewarded for in the new healthcare system.
Applying big data
It’s already possible for hospital systems and large provider groups to use big data to identify their doctors’ practice patterns, working to maximize the referral process by better matching patients to appropriate doctors.
Another use for this kind of granular data on physician practice patterns could be to correlate behavior with happiness. The same way the healthcare industry has turned a spotlight on patient satisfaction, it would do well to simultaneously measure physician satisfaction in an effort to discover which practice structures result in both optimal physician happiness and optimal patient outcomes, with emphasis on practice redesign at the intersection of these points.
I would be willing to bet that the outcome data seen in innovative primary care practice models like Iora Health and Turntable Health, or in functional medicine practices like mine (where initial visits are an hour to 90 minutes and more holistic approaches to chronic disease management are employed systematically), will tell the story of what happens when both patients and doctors are happy.
Rewarding the innovators
System-wide, the culture of medicine can often be its own Achilles heel, rewarding inflexibility over innovation. The revolution in digital technology is being powered by young people. Those building the most creative solutions in digital health are often physicians who have left practice in order to express and find reward for their innovative spirit.
I recently spoke to a friend who graduated from a prestigious residency program last year. He observed that his hospital still felt like an “old boys’ club” culture, where doctors (male and female alike) either conform orleave.