A framework for physician malaise

There is abundant evidence for malaise in the physician workforce, but little agreement about etiology, treatment options, or prognosis.  As a senior physician who still has a lot of involvement with physicians of all ages, I want to propose an etiologic framework. Perhaps if we agree on etiology, we can look at treatment options.

There are three ways to look at what doctors do: the artisanal, the economic, and the scientific. The artisanal approach sees practice as a series of encounters of n=1, where one’s duty is to do the best you can for that one patient. The economic viewpoint sees the physician as the engine of production driving the prosperity of the health care system.  Here it is the number of procedures, office visits, admissions, and so forth, that matter. The payer, of course, sees the physician as the driver of the medical loss ratio, and tries to find ways to limit these same things. The scientific viewpoint sees the physician as the technologist who applies “evidence” to treatment decisions for individual patients.

The artisanal perspective is scorned by those who take the other two views, but likely reflects the mindset of many physicians. Furthermore, it is certainly the perspective patients expect of their doctors. Proponents of value-based purchasing see the economic mindset as the evil consequence of the fee for service payment system, but I suggest it is the ever present reality in doctors’ lives. Proponents of the scientific approach scorn individual experience, but sometimes overlook the lack of evidence for a lot of the problems patients want us to address.

Of course, most physicians experience these viewpoints in combination. There are now required surveys of patient experience, which tend to reinforce the artisanal perspective. There is no doubt that physicians are under economic pressures to produce medically necessary services, despite countervailing pressure from the payers, and there is no question that those services are being measured by various quality metrics. But is our malaise a result of an imperfect blend of forces, the conflicts that these perspectives have with each other, or a mismatch between present reality and the expectations of those who have gone into medical practice?

I think we went to medical school for a mix of three reasons: psychic satisfaction, financial reward, and intellectual stimulation. These three motives line up rather well with the three different mindsets, all of which have been present for a very long time. Is the current malaise based upon changing reality or changing expectations. If you are satisfied, can you say why? If you are not, can you articulate which aims are being frustrated? If we can agree on the most common issues, perhaps we could frame treatment options that would re-balance the work of physicians and thereby lead to better health care.

Lucius F. Wright is a physician and can be reached at Clinical Leadership for Practicing Physicians.

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