In the not-to-distant past, American health care was the gold standard. It offered job satisfaction and autonomy, was financially rewarding and was considered by many to be the most honorable profession. But as we all know, over the last two decades, increasing health care costs and demands and increasing competition for insurance contracts have changed the face of medicine. Metrics ranging from quality and safety (which are needed and were not a priority) to patient satisfaction, wait times, access, EMRs, decreased ancillary staff and revenue have changed the face of medicine. Long gone are the days of seeing one’s physician and making eye contact and getting to know the patient as a whole rather than a symptom.
While most physicians started out with the idealism to change the world one patient at a time, the pressures outlined above have made it impossible. The value of educating young medical students and residents and mentoring junior faculty has been eliminated. The bottom line is the bottom line.
Today, it’s all about money. But who is making it? Doctors are now no more than employees of large corporations. However, unlike big business that promotes quality and gives appropriate compensation, medicine is now driven by volume only.
Medicine once deeply valued experience, but the meritocracy has vanished. Junior faculty can make more in salary than their own mentor by sheer volume alone. What we physicians thought would be a good idea — hiring MHAs and MBAs to run our business side, in order to focus on patient care — has insidiously become our downfall.
While we weren’t looking, administrators decided that we work for them. They don’t seem to get it, and to our detriment, we have not bonded and collectively reminded them that they work for us. They don’t create. They don’t build. They do not provide the care that actually brings the revenue. They do not heal. Yet, they own us. If we raise our voices, we are threatened with replacement. We are dispensable. There are people waiting in the wings to take our place.
For those institutions that have adopted the RVU model — an acronym for relative value unit — a value is placed for each type of patient interaction. We are placing a numeric value that is completely inconsistent with what we actually do. Who decided that a particular interaction was worth a particular value? A
Additionally, RVUs were initially introduced to level the playing field across specialties, but some institutions pay different dollars per RVU depending on the specialty. We are talking about human beings often at one of their most vulnerable times and have put a value to that interaction as if all are equal.
We have allowed administrators to be our bosses rather than out facilitators, and they have often created nothing more than glorified sweatshops. We are told what our RVU targets are, if we want a lunch break we need to make up the 30 minutes or hour we take, not realizing we are always an hour or more behind anyway. Soon, we will clock in and out for bathroom breaks. Yet, we push forward because that’s who we are. We are determined, conscientious, honorable individuals. We strive for perfection. We want to provide the best care possible. We want to look patients in the eye and learn more about them as individuals and not just their diagnosis code. We don’t want to be stressed about whether we are meeting an administrator’s assessment of what our revenue goal should be (after all, RVU targets are just a discrete way of saying how much money we need to bring in).
Medical students and residents are innocent bystanders in this new system. No value is being placed on training students and residents. In fact, many physicians shy away because it requires time and would delay our days in the office if we need to teach students who are shadowing or if we have to leave the office in order to lecture. Personally, this is has been a highlight of my career sharing my wisdom and learning from my students. Keep in mind that the very people telling us this have never shadowed us. They have no idea what we do all day and into the evenings and weekends, calling patients with results, answering queries since we are now accessible 24/7 with EMR access and being honorable because patients come first. Patient-centric care. A beautiful, honorable goal. But at what cost?
“Physician burnout” has been attributed to many physicians who retire early if they can amidst these changes. However, as Pamela Wible so aptly wrote in her article delineating the seven shaming words, we should never say-physician burnout amongst them, it is not burnout, but physician abuse. Burnout implicates the physician as the cause rather than the victim. It lays blame on the person.
The pool of physicians willing to teach will dwindle as the demands increase and the support and value continue to be secondary. When did this happen? Physicians have to band together and take back medicine. It is our job. We do the work. We should be in control. Not some administrators in their ivory towers who stand to make big bonuses off our sweat and threaten to easily replace us if we don’t adhere to their rules. No one is indispensable, that is clear, but in health care, if the doctors aren’t doing the work, then who is? How will the institutions make their money? And more importantly, who will care for the patients? We need to take back the profession only we know how to run. Ultimately the patients and the future doctors will benefit.
The author is an anonymous physician.
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