Doctoring Health Care Reform

Physician satisfaction: Seeing both sides of the debate

Students of the obvious might consider the topic of physician satisfaction one of mere folly. The “rich doctor” label is an easy one, and the recent Medicare data dump, which revealed hordes of physicians who were doing quite well, thank you, only strengthened it. Yet, when one moves past intuition, into analytical thinking, the contentment of doctors gains importance.

Rare is the person who goes from being perfectly healthy to peacefully dead in seconds. Rather, almost all of us will meet and depend on caregivers along the way. The mindset of doctors, therefore, is indeed far from folly.

That’s why I’d point you to an interesting online conversation that played out last week.

Internist and writer Daniela Drake sparked the debate with this provocative essay: Why your doctor hates her job. Drake can write, and she clearly explains why many doctors are miserable. She features the very real issues of excessive paperwork, farcical regulations, eroding public confidence and the recent piling on of the American Board of Internal Medicine. As good writers do, she leads with the most compelling complication of loss of control—the rise in physician suicide.

The essay went viral and in so doing brought out two major physician voices.

Indiana University pediatrician and health policy researcher Dr. Aaron Carroll took issue with the idea that being a doctor was miserable. Carroll argues that being a doctor is still a good gig. He’s an evidence guy and so he cites data to refute Drake’s arguments. Carroll has a knack for persuasion, and this post is no exception.

Dr. Kevin Pho, arguably one of the most influential voices in medicine today, took issue with Carroll’s dissent. Pho is known for his measured tone and ability to see both sides of an issue. That’s why it surprised me when he called out Carroll for taking such a progressive worldview, which “tends to discount many of the issues that physicians face.”

I’ve struggled with this topic since I began writing. I’ve written hundreds of essays on doctoring and have yet to resolve this issue in my own mind. Although at the end of this essay, I’ll offer my 2014 leaning.

Let’s start with Carroll’s side of the argument.

Even though it gets me in trouble with other doctors, I’ve tended toward progressive thinking at times. The master of the obvious in me thinks doctors don’t take enough time to reflect on the good we do, the respect we get, the financial comfort afforded us. For instance, when we bemoan how long it takes to become a doctor, I look back on my days at UCONN medical school and Indiana University residency and fellowship as some of the best days of my life. While my wife and I lived in crappy apartments, drove clunker cars, and graduated with tons of debt, we rejoiced in the joys of learning medicine. I’d do it again in a heartbeat—for a lot less pay. The argument that training is too long or too hard doesn’t resonate with me.

I also admit to still being in love with doctoring, especially, but not exclusively, electrophysiology. It brings me great pleasure to make a diagnosis with just my eyes and ears. I revel in seeing patterns in the squiggles of ECGs, or fixing things in the EP lab. And though I fail many more times than I succeed in convincing patients to take better care of themselves, it’s pure joy when a patient cites my words as the turning point in his life. Just words…imagine that.

And herein lies the problem: this sort of joy leads to attachment. Doctors are attached to being good doctors. We care. It matters. This is why all the nonsense makes us so miserable.

Of course we want to spend ample time with patients discussing the central issues of health, things like nutrition, and exercise and sleep hygiene. Don’t think for a minute most of us believe pills are the answer. But there are only so many hours in a day.

Of course we don’t want to order unnecessary tests. But it only takes one mistake to land yourself in the company of a plaintiff’s attorney. Even a whiff of a bad story changes decision-making for a career.

Of course we don’t want to implant a pacemaker in an elder with dementia. But then there is the third out-of-town family member to convince you aren’t on a death panel. It’s not our fault that pacemaker surgery pays much more than having a conversation about not doing pacemaker surgery, or that we live in death-denying culture.

Of course we don’t believe a 5-page electronic note improves care. We hate that the beautiful narratives of medicine have devolved into an invoice for services rendered. The thing about distrust is its toxicity.

Finally, the stupidity of undervaluing physician compassion and humanness is breathtaking. It’s akin to chronic inflammation.

You see the struggle.

Despite the nonsense, though, I remain a cautious optimist. Healthcare reform won’t be easy, but I cling to the notion that the new generation of doctors and patients will figure it out. I still recommend medicine to any young person who asks my opinion.

I’ll close with a certainty. Mr. Gladwell is right: conversations like these can only help.


One reply on “Physician satisfaction: Seeing both sides of the debate”

I basically agree with everything on both sides. I tell residents that I have a “love/hate relationship” with primary care. And that’s the best way to describe it.

As someone who does work in informed decision making, I definitely want trainees to be fully informed before choosing primary care as a career.

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