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Physician burnout widespread, especially among those midcareer, report says

227 points by eplanit 7y ago

_sbrk 7y ago
Paywall-free URL?
- foopdoopfoop 7y ago
  https://github.com/iamadamdev/bypass-paywalls-firefox https://github.com/iamadamdev/bypass-paywalls-firefox https://github.com/iamadamdev/bypass-paywalls-chrome https://github.com/iamadamdev/bypass-paywalls-chrome
Psyladine 7y ago
Anecdotal but my gen prac warned me on this 10 years ago, that obgyns were being driven out by high malpractice insurance. He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability. Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.
- Ididntdothis 7y ago
  “cheaper prices for consumers” Has this ever materialized? I thought it was the other way.
- bachmeier 7y ago
  The article is paywalled, so maybe the title doesn't provide a good description, but what does malpractice insurance have to do with burnout?
  - ksdale 7y ago
    I'm an attorney, not a doctor, but from my perspective, rising malpractice rates are connected to burnout because they indicate a working environment that feels hostile. Doctors generally become doctors because they want to help people, and they do all of their work in good faith, and it creates a lot of anxiety to constantly worry about being sued, and it creates even more when your take home pay is materially impacted by malpractice insurance. For competent doctors, this may be misplaced anxiety, but it exists nonetheless. This anxiety might cause the doctors to seek a work set up that limits their personal liability to relieve their own anxiety, but it creates other anxieties, like those that come with working for a giant company and lead to burnout. Lawyers, it may surprise some people to hear, also enter the legal profession wanting to help people, and the same mechanisms are at work. I may want to be a solo-practitioner for the flexibility and the ability to charge lower rates to help a broader part of the community, but feel pressured into joining a much larger firm just to protect myself from some crazy, one-off, life-destroying legal event. Like I said, it may be an irrational fear, but that, combined with a giant amount of student loan debt and an already rather stressful profession is a recipe for burnout.
    - RHSeeger 7y ago
      > protect myself from some crazy, one-off, life-destroying legal event It's funny, it's this exact type of thing that the recommendation "don't talk to the police" comes from. Most cops are wonderful people that do want to help. Then there's the one bad apple that ruins your life. I guess "don't talk to the police" isn't exactly solid career advice for a lawyer ;)
      - ksdale 7y ago
        Haha yeah exactly. I think this dynamic exists in a lot of places. I feel like there should be a phrase that communicates something like "I know you're acting in good faith, but I'm just trying to be cautious." Because it's easy to misinterpret that reticence to talk as some sort of hostility or distrust (though the best cops won't interpret it that way). I have a similar experience when someone is trying to sell me something, I don't bear them any ill will for doing their job, but also it's a waste of both our time for them to continue with the sales pitch. But it's hard to communicate that without implying that I think they're doing something untrustworthy. And from what I've read, there are a lot of cons that rely on people not wanting to be rude and not questioning something they don't think is right.
- danans 7y ago
  > He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability. That's not necessarily a bad thing. Safety in herds and shared risk pools work to limit individual risk for physicians. This can take the form of larger private practice groups like Kaiser Permanente's physician group (a distinct entity contracted with the Kaiser Permanente hospital/managed care corporation). It can also take the form of NHS in the UK which employs the vast majority of physicians there and represents them in malpractice cases. The risk inherent in medicine is real and has to be borne somewhere. Better by shared risk pools, however they are organized, than by individual patients or doctors.
- hanniabu 7y ago
  I've seen this with my own doctor. They said another reason besides the insurance was the increased demand for paperwork and electronic backups or something like that. So it's much easier and cheaper to have a single team manage the digital side for 20 doctors instead of just 1 or 2 doctors. From the consumer end I like this more because their new group has a wide variety of specialties so you don't need to keep filling out the same paperwork and they also can afford to maintain an electronic system so you receive text notifications for appointments and can make appointments online and such.
  - mumblemumble 7y ago
    As a consumer, I'm coming to dislike it. In theory, that consolidation of redundant efforts should improve my care and reduce my costs. In practice, I've seen the opposite happen. My local health care market has consolidated down into a single large corporate entity that, like any good monopoly, has every reason to reduce quality of service while increasing prices. I guess I fill out less paperwork, but that isn't saving me enough time to justify all the little routine visits that used to cost me $50 out of pocket suddenly costing $300 out of pocket.
husarcik 7y ago
I can see the burnout starting in medical school and I would not be surprised if this trend continues to get worse.
- kxyvr 7y ago
  The physicians that I know talk about this a lot. From what I gather, part of the problem is that medical school is really expensive, so they take these really massive loans to get through school, which is generally on top of their debt from their bachelors and masters. Then, many of them discover that they're not in love with the field as much as they originally thought. The problem is that it's very difficult to back out at this point; they're hundreds of thousands of dollars in debt and dropping out leaves many of them with a degree that will not allow them to pay this debt down. As such, they power through. Then, they enter a profession were the hours are truly and utterly terrible. People don't get sick on a 9-5 schedule and unless you're working in something like dermatology, you're going to work nights and you're probably going to work shifts that range from 14-24 hours even as an attending. Yes, this depends on specialty, but hospitalists, emergency medicine, any surgical specialty, and most people doing procedures will end up with long night shifts at least a few times a month. And, this must be done for several years even after residency in order to clear the debt even if you just want to quit the profession entirely. Every physician I know of talks about an exit plan as soon as they enter the profession, which is generally not a good sign. Though, probably a smart one. Now, does this differ from any other profession where we take on debt to get a degree in a profession that we don't like just to work that profession to pay off the loan? For the most part, no. I think the distinguishing feature for physicians is the debt is higher and it takes more years to get into a position to pay off that debt, so the exit point is farther away. I do think physician hours suck far more than most professions. I also think the profession is far more abusive than most white collar professions, but that's debatable.
yayajacky 7y ago
Does this indicate that more physicians are needed in the market, or that current system/workflow is unsustainable?
- nerdponx 7y ago
  I'd guess both.
- DiabloD3 7y ago
  Yes.
- dantheman 7y ago
  Remember the AMA successfully lobbied to reduce the number of residencies and thus the number of doctors in the 90s. We need to open up the medical profession to competition and allow the # of doctors to meet the demand.
  - neaden 7y ago
    I think this is the key, so much of of the problems physicians face were created by physician and their own lobbying. American Physicians are paid more then other countries by a lot [1] in large part because of high educational requirements that were supported by physicians. Resident burn out is awful, but the people pushing them to work insane hours aren't the hospital administrators, but older physicians who have the attitude that they went through it too. It's really hard for a physician from another country to immigrate to the US and practice, restrictions supported by, you guessed it, physicians! If you really want to lower physician burn out and decrease health costs we need to increase the supply of physicians in this country, and you'll have to fight the existing physicians to do it. [1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0204 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....
    - naveen99 7y ago
      American software developers also get paid multiples of their non-us counterparts. Same with many other professions.
tempsy 7y ago
hasn't this always been widely known? same with big law lawyers
6gvONxR4sf7o 7y ago
I think specialization is making labor markets more exploitative. If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.
assblaster 7y ago
Physician practices get absorbed by large national corporations and patient care gets reduced to metrics that administrators can tweak to extract more revenue and profit. The benefits get paid to administrators as bonuses, while physicians see their salaries stagnate. The corporitization of physician practices is destroying the profession.
- lotsofpulp 7y ago
  The country also wants more supply of healthcare, at lower prices, while the supply of doctors remains constrained via the restriction on number of residency training spots each year. This is the root cause, insufficient supply in the face of demand, and it is manifesting itself in these various side effects.
  - assblaster 7y ago
    This is incorrect. There is no supply/demand relationship for pricing services. Doubling the number of trained physicians will not decrease healthcare costs, it will simply drive down physician annual income. The main driver of inflated healthcare costs is administrative waste: hospital management, insurance management, government management.
- commandlinefan 7y ago
  > patient care gets reduced to metrics that administrators can tweak So they’re applying “agile project management” then?
- rohitb91 7y ago
  The takeover of real jobs by bullshit jobs
chkaloon 7y ago
I would like to see the data sliced by employed vs independent physicians. Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it. Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient. Would be good to see if there is a correlation there.
- ses1984 7y ago
  >Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient. "Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.
  - conro1108 7y ago
    Wouldn't the profit motive be stronger for an independent physician since they actually directly profit, rather than facing indirect pressure based on your employer's profit motive?
    - ses1984 7y ago
      Independent physicians are free to act as they see fit, some are very profit motivated, some aren't. Employed physicians are pushed to be as profit motivated as their employer wants them to be, or they get canned.
- pasttense01 7y ago
  On the other hand employed physicians in an integrated health system have to deal with their bosses and lack control over their working conditions.
  - chkaloon 7y ago
conanbatt 7y ago
Almost all burnout in the medical profession stems from state intervention and the extremely complex lobby relationships between different actors in the market. Classical liberal policies would change everything in the market. In particular, there are a few things that crush doctors: Problem: Cost of education: You require licenses per-state, and a license can be gotten only after a very grueling and expensive educational process in the half a million dollars range or more in student debt. Solution: Make it legal to practice medicine with foreign education licenses. Doctors can study in countries where the education is free or nearly-free. ---- Problem: Too few people go into the medical profession per-capita in the US. Currently a 20-year in practice specialist doctor from any other country has to go through a lowly paid residency in the US to be able to exercise, plus compete in the very narrow H1B visa space. Solution: Make a special purpose visa for medical professionals (Nurses & Doctors) and allow them to practice medicine. ---- Problem: Malpractice insurance is extremely expensive due to the high levels of litigation in the medical profession, that far outstrip the typical responsibility of a professional. Some specializations require insurance of thousands of dollars a month! Solution: Allow for malpractice waivers that let doctors practice at a cheaper rate, and let patients decide what kind of risk they are willing to get or not. ---- Problem: US has the lowest level of Primary Care doctors per capita of developed nations in great part because they are the least protected specialization by the AMA which is mostly compromised by specialty doctors. One rule made here is that PCP's cannot collect 'kickbacks' or revenue by referring patients to a speciality doctor, and thus the PCP works for free to provide referrals to specialists. Solution: Allow for transparent processes of verticalization and monetization, which will bring PCP's to a more natural rate count. ---- Problem: The government subsidizes medical insurance by making it tax exempt. This makes it so everyone gets insurance through their employer which in turn makes it impossible for a doctor to compete with the insurance model that is tax exempt by being all-cash. The tax benefit allows insurance companies an oligopoly against small practices. Solution: Eliminate insurance through employer and/or get rid of the tax exemption. ---- Problem: The government pays a higher revenue rate if the medical practice is digitalized. This has pushed the entire industry into using electronic records to get that revenue boost long before its time, producing terrible technical solutions. (The biggest player in the space, Epic, collections millions of dollars a year per hospital and its made in Visual Basic) Solution: Get rid of all electronic record requirement laws, subsidies, programs, etc. ---- I can keep going. In the health industry market literally every single player has a legal advantage over every single other. Its everyone screwing everyone.
hhs 7y ago
Here's the full report: https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460?faf=1 https://www.medscape.com/slideshow/2020-lifestyle-burnout-60... Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out? I wish the WSJ asked these types of questions.
adamc 7y ago
We need doctors. This is a serious problem. I wonder how this compares to countries with nationalized healthcare.
- tempsy 7y ago
  maybe we shouldn't saddle new grads with $1M in debt if we want to incentivize more people to go into the field
- lend000 7y ago
  It seems reported healthcare quality is highly correlated with physicians per capita, in developed countries. Notable exceptions are Japan and Singapore, but these countries tend to have more efficient infrastructure and populations with predilections toward above average health. Socialized healthcare countries like the UK and Canada, known for their absurd wait times, have comparable physicians per capita to the US [0]. Most of the other European countries with touted healthcare systems also tend to have significantly more doctors than the US. [0] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS https://data.worldbank.org/indicator/SH.MED.PHYS.ZS
milofeynman 7y ago
It's even worse in Pediatric ICU. They're one of the lowest paid doctors due to ICU not being profitable. They have the mental/emotional stress of really sick and dead kids. They have to work 24+ hour calls with little to no sleep. I know one who worked 36 hours last weekend and got 2 hours of sleep. That can't be good for outcomes, but they can't hire more because again, the ICU loses money. They don't get big salaries from drugs like anesthesiologists. It's almost like healthcare shouldn't be run like a normal capitalistic business. I imagine burnout is much lower around the world and would love to see the data on that.
- lotsofpulp 7y ago
  The root cause is the people receiving the healthcare in a pediatric ICU don't have the ability to pay for it, and based on the lack of votes for taxpayer funded healthcare, voters also don't want to pay for it. Notice how people 65 and over have no issues getting their healthcare paid for. That group of voters has a very high voter participation rate.
- rhinoceraptor 7y ago
  IMO medicine is currently in a pre-germ theory of disease state when it comes to sleep. The importance of sleep is completely disregarded for residents, as well as for patients. There really isn't much that's more important than sleep. And it's a well known fact that the extreme residency model was pioneered by a cocaine addict [1], but yet no progress has been made. It's fucking absurd. 1: https://en.wikipedia.org/wiki/William_Stewart_Halsted https://en.wikipedia.org/wiki/William_Stewart_Halsted
xzel 7y ago
Both of my parents are doctors. In high school I had real thoughts of going into medicine. They strongly discouraged me towards going into that field. In college I was pushed towards a MD/PhD program by my lab's PI. I thought about graduating at 28-30 and decided against it. Jr year I interned at Amazon after that experience I knew I made the right decision. It is a really, really hard sell for this current generation to do another 5 years of school with residency and then specialization when you can quickly make 100k+ at a tech company. All of my friends who went into medical school are working hours like 6am-6pm or 8pm-8am. They get like two days off every two weeks. I think there are a bunch of possible solutions but the easiest one is making 5 year medical programs (2 years undergrad, 3 graduate) more common in the US.
- mbbutler 7y ago
  It's not that tough of a sell when you consider that many/most medical students are math-phobic and would most likely be unable to obtain a high-paying SWE gig in lieu of becoming a doctor. There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).
  - NotSammyHagar 7y ago
    That doesn't seem right to me. They have to get through chemistry and physics. They have to memorize a giant decision tree that they employee when evaluating people, questions to ask. They have to adjust that over time, then they get a speciality and they learn new things. There's a difference in skill set that is developed over time, but doctors have to be able to have mental models of how bodies work, how things work in the body, "just like us".
- pkaye 7y ago
  Another solution is allow more doctors to be licensed so they don't need to be as overworked.
  - sodosopa 7y ago
    Is that from lowering educational requirements or from lowering standards?
kingkawn 7y ago
Medicine burned me to the ground
univalent 7y ago
Please lobby the AMA to not artificially limit the supply of doctors by creating regulations around residency. I personally know of many people with MDs from India who don't work here as physicians because they could not get a residency 'slot' in the Bay Area where their family lives. Relevant thread with links on StackExchange: https://skeptics.stackexchange.com/questions/4561/does-the-ama-limit-the-number-of-doctors-to-increase-current-doctors-salaries https://skeptics.stackexchange.com/questions/4561/does-the-a...
- tmh79 7y ago
  to be fair, there are very few residency spots in the bay area in any specialty anyway. My wife went through the residency match program last year and the bay area programs are ultra competitive because it is a desireable place to live. Adding more residency slots is a good idea, but they're going to be spread across the US.
- neonate 7y ago
  Dean Baker has been arguing against this medical protectionism for years. Also as a factor why costs are so high.
- nradov 7y ago
  The AMA isn't limiting the supply of doctors. The actual limit is in the number of residency program slots funded by the US Federal government. If you actually want to increase the supply of doctors then lobby Congress for higher residency funding. https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages https://www.ama-assn.org/press-center/press-releases/ama-fun...
  - benjohnson 7y ago
    The AMA backs the residency requirement. In my opinion it potentially gives doctors bad habits: Tolerating a miserable sleep schedule, placing too much value on quick diagnosis, equating long hours with effectiveness, and perhaps not placing enough value on teamwork with nurses.
code4tee 7y ago
I was interested in medicine in high school. I was able to shadow a few physicians and talk about career options. At the time I was shocked that most of the physicians I talked to said they would take a different career path if they could do it over again. The common theme was that they felt it used to be a respected profession but now they’re broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork. I ultimately didn’t pursue medicine.
boyadjian 7y ago
Well well, I think most people have financial problems nowadays, it's not a secret that the human world is on the descending slope.
drewr 7y ago
I'm sure this isn't the case for every doctor, but what I've observed is that scale seems to be killing everything. When you have 10 minutes with a patient, have no long-term relationship, ship them off to a specialist that has even less context of their overall health, and ultimately just prescribe them meds to treat a symptom, that person does not get healthier. Over thousands of patients that starts to challenge any sense of moral obligation you originally had when entering the field. Then you become disillusioned and burn out. The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.
- wincy 7y ago
  There’s a few doctors in my city who charge a $50 a month fee for a 30-39 year old and you can call and see them whenever. Insurance doesn’t cover it at all. I’d also imagine if you tried to really abuse the relationship and show up constantly for no reason the doctor might fire you. I feel like it’d encourage a relationship of respect both ways. I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.
  - wise0wl 7y ago
    My parents have a concierge medicine relationship with their physician. It's fantastic. He is a complete professional who cares deeply about all of his patients (he works nights and weekends, does research outside of business hours, works around insurance and exploits every legal loophole possible to help them) but holy crap is it expensive. They are paying for their normal insurance plus this service ($3000 annually). This is what it's come to in the US---to be able to have a semblance of a relationship with your physician you need to pay a premium on top of the gouging that your "insurance" already charges you. Note: My parents are not* rich, they scrape by on social security and my dads part time work fixing sprinkler systems.
wavepruner 7y ago
I have seen this happen as a chronically ill patient for the past 30 years. There is a wave of poorly understood chronic illness and doctors are powerless to treat it. It must be exhausting to tell so many people that there is nothing they can do. I say this with 100% sincerity. It must be a nightmare to work so hard without the reward and satisfaction of significantly improving people's lives.
neonate 7y ago
http://archive.md/HZOmv http://archive.md/HZOmv
overlyLogical 7y ago
Physicians spend hundreds of millions of dollars making competing with them illegal. Now they can't handle the demand. But hey physicians make 300k/yr...
overlyLogical 7y ago
Nice job marrying someone in medical. I too married a doctor. Should be set for life.
- teej 7y ago
  In my partner’s speciality, a job in SF or Oakland pays less than a starting software eng at Google or Facebook. A medical degree costs easily 5x an undergrad CS degree.
- pc86 7y ago
  What a gross way to frame it. I hope your spouse doesn't see this.
beerandt 7y ago
Mandated electronic medical records is the problem, not some constrained supply of doctors. (Not the concept of electronic records, but the implementation. Scanned paper records probably would have been fine. Epic and competing software solutions are not.) It means the same supply of doctors has less time for the same (or increased) demand. Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate. Also results in doctors focusing on the computer instead of the patient. You didn't see burnout levels increase until electronic charts were forced.
jshaqaw 7y ago
What is the baseline of burnout for all mid-career professionals? I'm a mid-career guy and most of my friends/peers are a little burnt out no matter what they are doing. Balancing any serious career with kids on one side and aging parents on the other is tough.
arkades 7y ago
There are a lot of misconceptions and misinformation coming out in this thread. I'm going to try and shed some light on them. (HN says my post is too big, so I'll have to split up a bit). There are four major groups of physicians: -Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it." --Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh? -Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+. -Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc. -"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore. Key to Understanding Medical Reimbursement: This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service. That's it; that's your cap. Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.
SkyPuncher 7y ago
My wife just graduated medical school and started residency. The burn-out affected both of us and we're just starting to get over it. * Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years. * We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings. * Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations. * Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially. * Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low. * That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position. * Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency. * Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate. * Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for. * Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives. I could rant for hours about all of the bullshit my wife went through (and, lesser myself). If you're thinking of becoming a doctor, do yourself a favor and do something else. If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.
- throwaway5752 7y ago
  Thank you so much for posting this. If you rant on about this for hours in this thread, I for one would be interested. I have a feeling that your observation that, "Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives." is dead on. Further I think the technology side really has to start servicing the physician. A GP's office doesn't have to be the place to get an ECG, and a GP doesn't even necessarily have to see the readout barring some kind of change over time. So much of that should be automated and/or done in specialized clinics. I know how it's complicated by data format standardization, privacy, security, and regulation but it's a shame that we can help doctors be more efficient. I will spare the rant about slightly (and slighty justified if I'm being fair) Luddite tendencies among physicians.
zyang 7y ago
It's not so much the profession itself, but not finding one's true "Ikigai". Too many smart people getting medicine for the money and prestige. Unless you truely enjoy helping sick people, you will get burned out at some point..
trey-jones 7y ago
While I was having a vasectomy late last year I had a conversation with the doctor performing the surgery. It started with a quip about "It's not your first time, right?" or something to that effect, and went into the general process of developing new techniques which he claims is non-existent in the US right now, what with liability and the threat of malpractice squashing any incentive for innovation. He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour. My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.
minikites 7y ago
There's burnout in every field because capitalism places a higher reward on burning people out and finding fresh replacements instead of keeping your existing employees happy and balanced in their lives. The structural market forces inevitably lead to this outcome in the insatiable quest for efficiency and profits. You can't fix burnout without fixing the underlying structural cause.
pwthornton 7y ago
Wouldn't a good solution be to pay doctors less and train more doctors? We pay our doctors really well by international standards, but we are also really good at burning them out.
ZhuanXia 7y ago
The Doctor's guild does this to themselves by restricting supply to obtain their grotesque salaries. Zero sympathy.
werber 7y ago
I went back to undergrad to finish med school prereqs, after the mcat I decided to go back to coding and am so thankful that I did. I did it because of the earning potential, not passion, and I don’t think it’s possible to be happy in that career path if you’re just trying to get money out of it
Ghjklov 7y ago
Stuff like this make me question how those in the medical field can put up with this stuff. All that hard work, all that debt, all that lost time, and for what? Meanwhile there's a bunch of people in a handful of cities who make comparable if not greater salaries for writing software to freaking deliver ads to sell people shit they don't need (I'm exaggerating a little). And all while living a much more comfortable life! Time ain't free.
jackcosgrove 7y ago
I cannot find the studies now, but I have seen multiple times numbers to the effect that medical interventions/treatments are responsible for 10% of health outcomes. The remaining 90% is determined by diet, exercise, and genetics. Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing. The best ways to improve your health are to eat less, eat better, and exercise more.

227 points by eplanit 7y ago

_sbrk 7y ago

Paywall-free URL?

foopdoopfoop 7y ago
https://github.com/iamadamdev/bypass-paywalls-firefox https://github.com/iamadamdev/bypass-paywalls-firefox https://github.com/iamadamdev/bypass-paywalls-chrome https://github.com/iamadamdev/bypass-paywalls-chrome

Psyladine 7y ago

Anecdotal but my gen prac warned me on this 10 years ago, that obgyns were being driven out by high malpractice insurance. He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability. Sure enough you have conglomerate health services corporations absorbing small practices, cheaper prices for consumers with added bureaucratic noise & volume thresholds for practitioners.

Ididntdothis 7y ago
“cheaper prices for consumers” Has this ever materialized? I thought it was the other way.
bachmeier 7y ago
The article is paywalled, so maybe the title doesn't provide a good description, but what does malpractice insurance have to do with burnout?
- ksdale 7y ago
  I'm an attorney, not a doctor, but from my perspective, rising malpractice rates are connected to burnout because they indicate a working environment that feels hostile. Doctors generally become doctors because they want to help people, and they do all of their work in good faith, and it creates a lot of anxiety to constantly worry about being sued, and it creates even more when your take home pay is materially impacted by malpractice insurance. For competent doctors, this may be misplaced anxiety, but it exists nonetheless. This anxiety might cause the doctors to seek a work set up that limits their personal liability to relieve their own anxiety, but it creates other anxieties, like those that come with working for a giant company and lead to burnout. Lawyers, it may surprise some people to hear, also enter the legal profession wanting to help people, and the same mechanisms are at work. I may want to be a solo-practitioner for the flexibility and the ability to charge lower rates to help a broader part of the community, but feel pressured into joining a much larger firm just to protect myself from some crazy, one-off, life-destroying legal event. Like I said, it may be an irrational fear, but that, combined with a giant amount of student loan debt and an already rather stressful profession is a recipe for burnout.
  - RHSeeger 7y ago
    > protect myself from some crazy, one-off, life-destroying legal event It's funny, it's this exact type of thing that the recommendation "don't talk to the police" comes from. Most cops are wonderful people that do want to help. Then there's the one bad apple that ruins your life. I guess "don't talk to the police" isn't exactly solid career advice for a lawyer ;)
    - ksdale 7y ago
      Haha yeah exactly. I think this dynamic exists in a lot of places. I feel like there should be a phrase that communicates something like "I know you're acting in good faith, but I'm just trying to be cautious." Because it's easy to misinterpret that reticence to talk as some sort of hostility or distrust (though the best cops won't interpret it that way). I have a similar experience when someone is trying to sell me something, I don't bear them any ill will for doing their job, but also it's a waste of both our time for them to continue with the sales pitch. But it's hard to communicate that without implying that I think they're doing something untrustworthy. And from what I've read, there are a lot of cons that rely on people not wanting to be rude and not questioning something they don't think is right.
danans 7y ago
> He suspected this would ultimately lead to consolidation of doctors under health organizations to limit personal liability. That's not necessarily a bad thing. Safety in herds and shared risk pools work to limit individual risk for physicians. This can take the form of larger private practice groups like Kaiser Permanente's physician group (a distinct entity contracted with the Kaiser Permanente hospital/managed care corporation). It can also take the form of NHS in the UK which employs the vast majority of physicians there and represents them in malpractice cases. The risk inherent in medicine is real and has to be borne somewhere. Better by shared risk pools, however they are organized, than by individual patients or doctors.
hanniabu 7y ago
I've seen this with my own doctor. They said another reason besides the insurance was the increased demand for paperwork and electronic backups or something like that. So it's much easier and cheaper to have a single team manage the digital side for 20 doctors instead of just 1 or 2 doctors. From the consumer end I like this more because their new group has a wide variety of specialties so you don't need to keep filling out the same paperwork and they also can afford to maintain an electronic system so you receive text notifications for appointments and can make appointments online and such.
- mumblemumble 7y ago
  As a consumer, I'm coming to dislike it. In theory, that consolidation of redundant efforts should improve my care and reduce my costs. In practice, I've seen the opposite happen. My local health care market has consolidated down into a single large corporate entity that, like any good monopoly, has every reason to reduce quality of service while increasing prices. I guess I fill out less paperwork, but that isn't saving me enough time to justify all the little routine visits that used to cost me $50 out of pocket suddenly costing $300 out of pocket.

husarcik 7y ago

I can see the burnout starting in medical school and I would not be surprised if this trend continues to get worse.

kxyvr 7y ago
The physicians that I know talk about this a lot. From what I gather, part of the problem is that medical school is really expensive, so they take these really massive loans to get through school, which is generally on top of their debt from their bachelors and masters. Then, many of them discover that they're not in love with the field as much as they originally thought. The problem is that it's very difficult to back out at this point; they're hundreds of thousands of dollars in debt and dropping out leaves many of them with a degree that will not allow them to pay this debt down. As such, they power through. Then, they enter a profession were the hours are truly and utterly terrible. People don't get sick on a 9-5 schedule and unless you're working in something like dermatology, you're going to work nights and you're probably going to work shifts that range from 14-24 hours even as an attending. Yes, this depends on specialty, but hospitalists, emergency medicine, any surgical specialty, and most people doing procedures will end up with long night shifts at least a few times a month. And, this must be done for several years even after residency in order to clear the debt even if you just want to quit the profession entirely. Every physician I know of talks about an exit plan as soon as they enter the profession, which is generally not a good sign. Though, probably a smart one. Now, does this differ from any other profession where we take on debt to get a degree in a profession that we don't like just to work that profession to pay off the loan? For the most part, no. I think the distinguishing feature for physicians is the debt is higher and it takes more years to get into a position to pay off that debt, so the exit point is farther away. I do think physician hours suck far more than most professions. I also think the profession is far more abusive than most white collar professions, but that's debatable.

yayajacky 7y ago

Does this indicate that more physicians are needed in the market, or that current system/workflow is unsustainable?

nerdponx 7y ago
I'd guess both.
DiabloD3 7y ago
Yes.
dantheman 7y ago
Remember the AMA successfully lobbied to reduce the number of residencies and thus the number of doctors in the 90s. We need to open up the medical profession to competition and allow the # of doctors to meet the demand.
- neaden 7y ago
  I think this is the key, so much of of the problems physicians face were created by physician and their own lobbying. American Physicians are paid more then other countries by a lot [1] in large part because of high educational requirements that were supported by physicians. Resident burn out is awful, but the people pushing them to work insane hours aren't the hospital administrators, but older physicians who have the attitude that they went through it too. It's really hard for a physician from another country to immigrate to the US and practice, restrictions supported by, you guessed it, physicians! If you really want to lower physician burn out and decrease health costs we need to increase the supply of physicians in this country, and you'll have to fight the existing physicians to do it. [1] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0204 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010....
  - naveen99 7y ago
    American software developers also get paid multiples of their non-us counterparts. Same with many other professions.

tempsy 7y ago

hasn't this always been widely known? same with big law lawyers

6gvONxR4sf7o 7y ago

I think specialization is making labor markets more exploitative. If the market expects you to do things that aren't worth the wage, but you spend a decade and half a million dollars on training and switching to something comparable would take a ton more time and money, well, then you probably won't switch careers. And if too few people switch then there's little market pressure to adapt.

assblaster 7y ago

Physician practices get absorbed by large national corporations and patient care gets reduced to metrics that administrators can tweak to extract more revenue and profit. The benefits get paid to administrators as bonuses, while physicians see their salaries stagnate. The corporitization of physician practices is destroying the profession.

lotsofpulp 7y ago
The country also wants more supply of healthcare, at lower prices, while the supply of doctors remains constrained via the restriction on number of residency training spots each year. This is the root cause, insufficient supply in the face of demand, and it is manifesting itself in these various side effects.
- assblaster 7y ago
  This is incorrect. There is no supply/demand relationship for pricing services. Doubling the number of trained physicians will not decrease healthcare costs, it will simply drive down physician annual income. The main driver of inflated healthcare costs is administrative waste: hospital management, insurance management, government management.
commandlinefan 7y ago
> patient care gets reduced to metrics that administrators can tweak So they’re applying “agile project management” then?
rohitb91 7y ago
The takeover of real jobs by bullshit jobs

chkaloon 7y ago

I would like to see the data sliced by employed vs independent physicians. Independents (a majority of physicians) need to deal with all the billing and insurance headaches that now come with the industry, and have to deal with setting up their own EHR to deal with it. Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient. Would be good to see if there is a correlation there.

ses1984 7y ago
>Employed physicians in an integrated health system and plan (like Kaiser or Geisinger), in theory don't have to deal with those aspects as much, and can concentrate more on the patient. "Employed" physicians no longer deal with patients, they are called customers. Helps to keep customers happy and physicians focused on the profit motive.
- conro1108 7y ago
  Wouldn't the profit motive be stronger for an independent physician since they actually directly profit, rather than facing indirect pressure based on your employer's profit motive?
  - ses1984 7y ago
    Independent physicians are free to act as they see fit, some are very profit motivated, some aren't. Employed physicians are pushed to be as profit motivated as their employer wants them to be, or they get canned.
pasttense01 7y ago
On the other hand employed physicians in an integrated health system have to deal with their bosses and lack control over their working conditions.
- chkaloon 7y ago

conanbatt 7y ago

Almost all burnout in the medical profession stems from state intervention and the extremely complex lobby relationships between different actors in the market. Classical liberal policies would change everything in the market. In particular, there are a few things that crush doctors: Problem: Cost of education: You require licenses per-state, and a license can be gotten only after a very grueling and expensive educational process in the half a million dollars range or more in student debt. Solution: Make it legal to practice medicine with foreign education licenses. Doctors can study in countries where the education is free or nearly-free. ---- Problem: Too few people go into the medical profession per-capita in the US. Currently a 20-year in practice specialist doctor from any other country has to go through a lowly paid residency in the US to be able to exercise, plus compete in the very narrow H1B visa space. Solution: Make a special purpose visa for medical professionals (Nurses & Doctors) and allow them to practice medicine. ---- Problem: Malpractice insurance is extremely expensive due to the high levels of litigation in the medical profession, that far outstrip the typical responsibility of a professional. Some specializations require insurance of thousands of dollars a month! Solution: Allow for malpractice waivers that let doctors practice at a cheaper rate, and let patients decide what kind of risk they are willing to get or not. ---- Problem: US has the lowest level of Primary Care doctors per capita of developed nations in great part because they are the least protected specialization by the AMA which is mostly compromised by specialty doctors. One rule made here is that PCP's cannot collect 'kickbacks' or revenue by referring patients to a speciality doctor, and thus the PCP works for free to provide referrals to specialists. Solution: Allow for transparent processes of verticalization and monetization, which will bring PCP's to a more natural rate count. ---- Problem: The government subsidizes medical insurance by making it tax exempt. This makes it so everyone gets insurance through their employer which in turn makes it impossible for a doctor to compete with the insurance model that is tax exempt by being all-cash. The tax benefit allows insurance companies an oligopoly against small practices. Solution: Eliminate insurance through employer and/or get rid of the tax exemption. ---- Problem: The government pays a higher revenue rate if the medical practice is digitalized. This has pushed the entire industry into using electronic records to get that revenue boost long before its time, producing terrible technical solutions. (The biggest player in the space, Epic, collections millions of dollars a year per hospital and its made in Visual Basic) Solution: Get rid of all electronic record requirement laws, subsidies, programs, etc. ---- I can keep going. In the health industry market literally every single player has a legal advantage over every single other. Its everyone screwing everyone.

hhs 7y ago

Here's the full report: https://www.medscape.com/slideshow/2020-lifestyle-burnout-6012460?faf=1 https://www.medscape.com/slideshow/2020-lifestyle-burnout-60... Strangely, this "report" is a set of slides. It would have been useful if there was more information about how the Medscape authors conducted this study. On slide 28, it says the sampling size was "15,181 physicians across 29+ specialties met the screening criteria and completed the survey". What was the screening criteria and how many physicians did Medscape initially reach out? I wish the WSJ asked these types of questions.

adamc 7y ago

We need doctors. This is a serious problem. I wonder how this compares to countries with nationalized healthcare.

tempsy 7y ago
maybe we shouldn't saddle new grads with $1M in debt if we want to incentivize more people to go into the field
lend000 7y ago
It seems reported healthcare quality is highly correlated with physicians per capita, in developed countries. Notable exceptions are Japan and Singapore, but these countries tend to have more efficient infrastructure and populations with predilections toward above average health. Socialized healthcare countries like the UK and Canada, known for their absurd wait times, have comparable physicians per capita to the US [0]. Most of the other European countries with touted healthcare systems also tend to have significantly more doctors than the US. [0] https://data.worldbank.org/indicator/SH.MED.PHYS.ZS https://data.worldbank.org/indicator/SH.MED.PHYS.ZS

milofeynman 7y ago

It's even worse in Pediatric ICU. They're one of the lowest paid doctors due to ICU not being profitable. They have the mental/emotional stress of really sick and dead kids. They have to work 24+ hour calls with little to no sleep. I know one who worked 36 hours last weekend and got 2 hours of sleep. That can't be good for outcomes, but they can't hire more because again, the ICU loses money. They don't get big salaries from drugs like anesthesiologists. It's almost like healthcare shouldn't be run like a normal capitalistic business. I imagine burnout is much lower around the world and would love to see the data on that.

lotsofpulp 7y ago
The root cause is the people receiving the healthcare in a pediatric ICU don't have the ability to pay for it, and based on the lack of votes for taxpayer funded healthcare, voters also don't want to pay for it. Notice how people 65 and over have no issues getting their healthcare paid for. That group of voters has a very high voter participation rate.
rhinoceraptor 7y ago
IMO medicine is currently in a pre-germ theory of disease state when it comes to sleep. The importance of sleep is completely disregarded for residents, as well as for patients. There really isn't much that's more important than sleep. And it's a well known fact that the extreme residency model was pioneered by a cocaine addict [1], but yet no progress has been made. It's fucking absurd. 1: https://en.wikipedia.org/wiki/William_Stewart_Halsted https://en.wikipedia.org/wiki/William_Stewart_Halsted

xzel 7y ago

Both of my parents are doctors. In high school I had real thoughts of going into medicine. They strongly discouraged me towards going into that field. In college I was pushed towards a MD/PhD program by my lab's PI. I thought about graduating at 28-30 and decided against it. Jr year I interned at Amazon after that experience I knew I made the right decision. It is a really, really hard sell for this current generation to do another 5 years of school with residency and then specialization when you can quickly make 100k+ at a tech company. All of my friends who went into medical school are working hours like 6am-6pm or 8pm-8am. They get like two days off every two weeks. I think there are a bunch of possible solutions but the easiest one is making 5 year medical programs (2 years undergrad, 3 graduate) more common in the US.

mbbutler 7y ago
It's not that tough of a sell when you consider that many/most medical students are math-phobic and would most likely be unable to obtain a high-paying SWE gig in lieu of becoming a doctor. There is a significant difference between the skillset that produces a medical student (work ethic and drive) and a SWE (analytical reasoning).
- NotSammyHagar 7y ago
  That doesn't seem right to me. They have to get through chemistry and physics. They have to memorize a giant decision tree that they employee when evaluating people, questions to ask. They have to adjust that over time, then they get a speciality and they learn new things. There's a difference in skill set that is developed over time, but doctors have to be able to have mental models of how bodies work, how things work in the body, "just like us".
pkaye 7y ago
Another solution is allow more doctors to be licensed so they don't need to be as overworked.
- sodosopa 7y ago
  Is that from lowering educational requirements or from lowering standards?

kingkawn 7y ago

Medicine burned me to the ground

univalent 7y ago

Please lobby the AMA to not artificially limit the supply of doctors by creating regulations around residency. I personally know of many people with MDs from India who don't work here as physicians because they could not get a residency 'slot' in the Bay Area where their family lives. Relevant thread with links on StackExchange: https://skeptics.stackexchange.com/questions/4561/does-the-ama-limit-the-number-of-doctors-to-increase-current-doctors-salaries https://skeptics.stackexchange.com/questions/4561/does-the-a...

tmh79 7y ago
to be fair, there are very few residency spots in the bay area in any specialty anyway. My wife went through the residency match program last year and the bay area programs are ultra competitive because it is a desireable place to live. Adding more residency slots is a good idea, but they're going to be spread across the US.
neonate 7y ago
Dean Baker has been arguing against this medical protectionism for years. Also as a factor why costs are so high.
nradov 7y ago
The AMA isn't limiting the supply of doctors. The actual limit is in the number of residency program slots funded by the US Federal government. If you actually want to increase the supply of doctors then lobby Congress for higher residency funding. https://www.ama-assn.org/press-center/press-releases/ama-fund-graduate-medical-education-address-physician-shortages https://www.ama-assn.org/press-center/press-releases/ama-fun...
- benjohnson 7y ago
  The AMA backs the residency requirement. In my opinion it potentially gives doctors bad habits: Tolerating a miserable sleep schedule, placing too much value on quick diagnosis, equating long hours with effectiveness, and perhaps not placing enough value on teamwork with nurses.

code4tee 7y ago

I was interested in medicine in high school. I was able to shadow a few physicians and talk about career options. At the time I was shocked that most of the physicians I talked to said they would take a different career path if they could do it over again. The common theme was that they felt it used to be a respected profession but now they’re broadly just cogs in a healthcare system that given them little freedom for professional discretion and lots of paperwork. I ultimately didn’t pursue medicine.

boyadjian 7y ago

Well well, I think most people have financial problems nowadays, it's not a secret that the human world is on the descending slope.

drewr 7y ago

I'm sure this isn't the case for every doctor, but what I've observed is that scale seems to be killing everything. When you have 10 minutes with a patient, have no long-term relationship, ship them off to a specialist that has even less context of their overall health, and ultimately just prescribe them meds to treat a symptom, that person does not get healthier. Over thousands of patients that starts to challenge any sense of moral obligation you originally had when entering the field. Then you become disillusioned and burn out. The irony is the part about everyone becoming less healthy. That creates more demand for medical services. Rinse, repeat. We truly have the worst system imaginable in the US. It evolved over time. It's nobody's fault. It's everybody's fault. It needs to be burned down and rebuilt. It seemed like we had a chance with the ACA but it was pretty clear early on that it wouldn't fix the root causes and it hasn't.

wincy 7y ago
There’s a few doctors in my city who charge a $50 a month fee for a 30-39 year old and you can call and see them whenever. Insurance doesn’t cover it at all. I’d also imagine if you tried to really abuse the relationship and show up constantly for no reason the doctor might fire you. I feel like it’d encourage a relationship of respect both ways. I interviewed a couple of them and one talked to me for an hour about health and diet and exercise, just a friendly chat to see if I wanted to use him. He said he was getting ready to retire from medicine after years of ER work when his doctor friend encouraged him to try direct primary care. It was so different than the regular medical system, cutting out all the middle men.
- wise0wl 7y ago
  My parents have a concierge medicine relationship with their physician. It's fantastic. He is a complete professional who cares deeply about all of his patients (he works nights and weekends, does research outside of business hours, works around insurance and exploits every legal loophole possible to help them) but holy crap is it expensive. They are paying for their normal insurance plus this service ($3000 annually). This is what it's come to in the US---to be able to have a semblance of a relationship with your physician you need to pay a premium on top of the gouging that your "insurance" already charges you. Note: My parents are not* rich, they scrape by on social security and my dads part time work fixing sprinkler systems.

wavepruner 7y ago

I have seen this happen as a chronically ill patient for the past 30 years. There is a wave of poorly understood chronic illness and doctors are powerless to treat it. It must be exhausting to tell so many people that there is nothing they can do. I say this with 100% sincerity. It must be a nightmare to work so hard without the reward and satisfaction of significantly improving people's lives.

neonate 7y ago

http://archive.md/HZOmv http://archive.md/HZOmv

overlyLogical 7y ago

Physicians spend hundreds of millions of dollars making competing with them illegal. Now they can't handle the demand. But hey physicians make 300k/yr...

overlyLogical 7y ago

Nice job marrying someone in medical. I too married a doctor. Should be set for life.

teej 7y ago
In my partner’s speciality, a job in SF or Oakland pays less than a starting software eng at Google or Facebook. A medical degree costs easily 5x an undergrad CS degree.
pc86 7y ago
What a gross way to frame it. I hope your spouse doesn't see this.

beerandt 7y ago

Mandated electronic medical records is the problem, not some constrained supply of doctors. (Not the concept of electronic records, but the implementation. Scanned paper records probably would have been fine. Epic and competing software solutions are not.) It means the same supply of doctors has less time for the same (or increased) demand. Forcing doctors into a workflow dictated by software is what's causing 12 hour days to turn into 16-18 hour days, with no additional pay, and no reduced hours to compensate. Also results in doctors focusing on the computer instead of the patient. You didn't see burnout levels increase until electronic charts were forced.

jshaqaw 7y ago

What is the baseline of burnout for all mid-career professionals? I'm a mid-career guy and most of my friends/peers are a little burnt out no matter what they are doing. Balancing any serious career with kids on one side and aging parents on the other is tough.

arkades 7y ago

There are a lot of misconceptions and misinformation coming out in this thread. I'm going to try and shed some light on them. (HN says my post is too big, so I'll have to split up a bit). There are four major groups of physicians: -Residents. These are the folks that just completed medical school, and are doing four-plus years of training in a hospital setting to become independently practicing physicians. In year one they are called interns. By year three or four they have various amounts of independence: in internal medicine, family medicine, etc. they are basically practicing as full physicians, with some light supervision (the heavy supervision is years one and two). They are one of the hospitals most valuable employees: taking into account supervision costs, they are producing about 80-90% of the revenue of a "real" physician, for less than 1/4 the cost. These are the guys who work 80+ hours per week without exception, do all the scut, etc. These are not "mid career physicians". This is where "old physicians had to go through it, so young physicians have to go through it." --Resident Training: the AMA has been pushing to expand resident training spots for years. The funding is part of Medicare legislation, and no one has been willing to back expanding medicare spending in the name of training physicians. I know the AMA has been backing this because I've attended the Region 7 and national meetings where the resolution to push for it has been passed, repeatedly. Literally, hit DDG and enter "AMA restricted residency training funding" and your entire page of results is the opposite. They may have done so more than a generation ago, but... let's move onto things that were done by, and affect, people not currently retired, eh? -Hospitalists. These guys have completed their residency training, and elected to work for a hospital, doing in-hospital medicine. Their specialty is "hospital medicine." They have no private clinic, no private patients, and are paid a salary by the hospital. Whether this is an integrated system like Kaiser, or ... every other hospital in the market, they're very common. Their practice patterns are heavily dictated by the hospital, which is heavily dictated by the Centers for Medicare/Medicaid Services and the major insurers. Their work is increasingly focused strictly on documentation, since documentation is the way that CMS and insurers (a) find excuses to refuse reimbursement, and (b) the way that CMS and insurers outsource collection of "quality" information, by forcing docs to structure their input in very discrete ways. These physicians don't have to deal with billing directly, but they are constantly being pulled into trainings for the ways documentation requirements are constantly evolving, the ways in which payors want them order tests and in what order, etc. They constantly get phone calls from "helpful billing people" raking them over the coals whenever there's a mistake. THe hospital keeps running tallies and reports on doctors' mistakes in this arena, aiming for public pillorying and, ultimately, withheld wages. (Docs don't generally get bonuses, they get withheld wages - except for high-revenue services like procedures, where they may get a bonus for very high productivity.) These are "mid career physicians." They tend to work an official 10-12 hour day, ten days on, ten days off. In reality, due to documentation requirements, and the fact that they get more patients than anyone could ever see and document in 10-12 hours, they tend to work 14+. -Private Practice. These guys completed their residency and either opened their own private practice (almost no one can do that these days, with the complexity of the documentation and EMRs required by CMS and insurers, and attendant overhead costs) or have become employed by such a practice with the medium-term goal of buying in as a partner. They are likewise having their arms heavily twisted by insurers and CMS, without any sort of leverage to fight back and negotiate better terms. These guys are going out of business left and right. These are "mid career physicians." Hours worked here are highly variable, depending on the specific practice pattern, number of employees and partners, etc. -"Private Practice." Because of the complexities and overhead that are now required to stay open, many practices... can't. They sell to a local hospital - often at cost - and become hospital employees. The hospital offers solid salaries for the first couple of years, and then drives them out, replacing them with younger employees. Many of the "private practices" you go to are thus actually practices run by the hospital, with an employee acting as the physician. These are "mid career physicians." These tend to work 9-5 with one evening hour a week, or none. The spread of this is why no one can find a doctor to see in the evenings anymore. Key to Understanding Medical Reimbursement: This is not a free market. It is fee for service. You get a patient visit, it is coded as a particular service (usually a Level 3 Evaluation & Management), and a fixed amount of reimbursed, assuming you meet various documentation requirements. If you do not, the amount is decreased or denied altogether. Private insurers peg their fee schedules to CMS, so CMS - directly or indirectly - drives all physician reimbursement. If you own a geographic area (such as part of a sweeping hospital network), that network will negotiate better reimbursement (e.g., "112% of Medicare"), but that is not passed along to employee physicians. Total revenue for a physician is amount of work-time per year divided by time-per-average-service, times reimbursement-per-average-service. That's it; that's your cap. Thus, most services patients want are strictly cost centers. The sort of things that other businesses compete on - e.g., ambiance, good front desk staff - are problematic for physicians, because you can't pass that along to patients in moderately higher prices. The only way you can compete on service, and be free to set your prices accordingly, is to refuse all insurance and only take cash patients. There are vanishingly few such patients, largely due to a cultural expectation that insurance = healthcare. Actually paying cash for a primary care physician, at least, isn't that expensive, but since that doesn't cover all of your other healthcare costs, who can afford to pay that extra premium? Only upper-middle-class and up.

SkyPuncher 7y ago

My wife just graduated medical school and started residency. The burn-out affected both of us and we're just starting to get over it. * Med school is a freaking grind. She was either at class, at rotations, or studying. Pretty much 80+ hours/week for 4 years. * We had to move a lot, which has limited my social life. Ended up spending a lot of time just "working" while she'd study in the evenings. * Major life impacting tests nearly every year. Low scores or failures on a single exam can kill any career aspirations. * Insane debt load. We're looking at total payback costs around $310k. That was with no undergrad debt and my job paying for all living expenses. If you don't become an attending, you're fucked financially. * Not enough residency spots for the number of medical schools. Less than 80% of candidates matched into a residency spot. Follow on matching is very low. * That's right, pretty much 1 in 5 doctors will not go on to practice medicine because they cannot get a residency position. * Residency salaries are complete shit. It's not unheard of for residents to have to take out loans to payback loans during residency. * Resident have absolutely no leverage. They are literally slaves to the program they're "matched" to. Program director changes, hospital gets bought out, peers are insufferable - sucks to be you, you're stuck until you graduate. * Financially being a doctor doesn't make any sense. Everyone looks at doctor's salaries, but completely forgets about the 8 to 10 years doctors (a) make nothing (b) pay for education (c) make pennies. Even with the "doctor salaries", it will take my wife well into our 50's to be financially ahead had simply pursued a career in her STEM field. There's a lot of life that can be live in 30 years that a "big house and a fancy car" doesn't make up for. * Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives. I could rant for hours about all of the bullshit my wife went through (and, lesser myself). If you're thinking of becoming a doctor, do yourself a favor and do something else. If you really want to work in medicine, becoming an NP or PA is a looking like an increasingly attractive route.

throwaway5752 7y ago
Thank you so much for posting this. If you rant on about this for hours in this thread, I for one would be interested. I have a feeling that your observation that, "Mid-levels and lesser credentialed, like PA's and NP's, providers are being allowed to take on more and more responsibility. For medicine overall, I think this is the right direction. I believe technology means mid-levels can function at a much higher level than in the past. For physicians, it sucks because it's killing any financial incentives." is dead on. Further I think the technology side really has to start servicing the physician. A GP's office doesn't have to be the place to get an ECG, and a GP doesn't even necessarily have to see the readout barring some kind of change over time. So much of that should be automated and/or done in specialized clinics. I know how it's complicated by data format standardization, privacy, security, and regulation but it's a shame that we can help doctors be more efficient. I will spare the rant about slightly (and slighty justified if I'm being fair) Luddite tendencies among physicians.

zyang 7y ago

It's not so much the profession itself, but not finding one's true "Ikigai". Too many smart people getting medicine for the money and prestige. Unless you truely enjoy helping sick people, you will get burned out at some point..

trey-jones 7y ago

While I was having a vasectomy late last year I had a conversation with the doctor performing the surgery. It started with a quip about "It's not your first time, right?" or something to that effect, and went into the general process of developing new techniques which he claims is non-existent in the US right now, what with liability and the threat of malpractice squashing any incentive for innovation. He gave a specific Urological example of a technique that was developed at MIT and took 6 hours, impractical for all purposes. European doctors have since come over and trained US doctors on a means of the same outcome that takes 1 hour. My first thought was that the stagnancy of the field would contribute to burnout, but thinking about it more, I think just living under the imminent threat of malpractice lawsuits is probably enough.

minikites 7y ago

There's burnout in every field because capitalism places a higher reward on burning people out and finding fresh replacements instead of keeping your existing employees happy and balanced in their lives. The structural market forces inevitably lead to this outcome in the insatiable quest for efficiency and profits. You can't fix burnout without fixing the underlying structural cause.

pwthornton 7y ago

Wouldn't a good solution be to pay doctors less and train more doctors? We pay our doctors really well by international standards, but we are also really good at burning them out.

ZhuanXia 7y ago

The Doctor's guild does this to themselves by restricting supply to obtain their grotesque salaries. Zero sympathy.

werber 7y ago

I went back to undergrad to finish med school prereqs, after the mcat I decided to go back to coding and am so thankful that I did. I did it because of the earning potential, not passion, and I don’t think it’s possible to be happy in that career path if you’re just trying to get money out of it

Ghjklov 7y ago

Stuff like this make me question how those in the medical field can put up with this stuff. All that hard work, all that debt, all that lost time, and for what? Meanwhile there's a bunch of people in a handful of cities who make comparable if not greater salaries for writing software to freaking deliver ads to sell people shit they don't need (I'm exaggerating a little). And all while living a much more comfortable life! Time ain't free.

jackcosgrove 7y ago

I cannot find the studies now, but I have seen multiple times numbers to the effect that medical interventions/treatments are responsible for 10% of health outcomes. The remaining 90% is determined by diet, exercise, and genetics. Genetics is out of everyone's control. But the fact that 1/6 of the American economy is focused on that 10% is mind blowing. The best ways to improve your health are to eat less, eat better, and exercise more.