Physician Dissatisfaction: Diagnosis and Treatment
So how are docs doing these days?
Not so well, it seems. By some accounts, American physicians are severely stressed and unhappy. A 2015 study showed more physicians reporting signs of “burnout” in 2014 than in 2011. A 2013 RAND Corporation study identified a number of threats to physician well-being, including problematic electronic health records (EHRs).
Why should we worry about unhappy doctors? In a fine review, Lawrence P. Casalino of Weill Cornell Medical College and Francis J. Crosson of the American Medical Association probe the ways in which physicians’ reduced well-being and satisfaction could theoretically undermine their diligence, cognitive functioning, and relationships with patients. These effects could reduce the quality of physicians’ decisions and patients’ adherence to physician recommendations. Physician dissatisfaction is also the best predictor of early retirement and reduced work hours, which could exacerbate a predicted physician shortage, especially in primary care. Some experts are suggesting that the well-being of the health care workforce is important enough to be added to the iconic Triple Aim as a fourth central goal of health policy: better health, better care, lower costs, and now, joy in work.
Before panicking, however, we need to look at all the evidence on physician well-being. Despite some reports of increasing physician burnout, other studies show that physicians’ satisfaction with their careers has remained high. For example, a representative national survey of physicians in 1996–97 showed that 81 percent were somewhat or very satisfied with their careers. In 2013, the number had fallen to…80 percent. Several other surveys confirm that the vast majority of physicians remain satisfied. In 2012, Gallup even named physicians as having the highest well-being of any occupation.
Second, applications to medical school are at an all-time high (Exhibit 1). Perhaps the nation’s young people are naïve and uninformed about the fate awaiting them. Or perhaps they are just less concerned about some factors that are perturbing current practitioners: for example, using new information technology in their daily work.
Third, American physicians remain well compensated. They are by far the best paid in the world, and within this country are the most likely of all professionals to count themselves among the “1 percent” of earners.
Fourth, anyone who has studied physicians and their circumstances over time can remember other periods when the specter of a profession in crisis loomed over us. One was the managed care era in the 1990s. The profession survived this upheaval, as it has many others over the millennia.
Clearly, more research is needed to disentangle these conflicting streams of evidence. But let’s assume for argument’s sake that physicians are facing acute strains and pressures that threaten their well-being. The next questions are: Why? And what should we do about it?
Several factors seem likely causes of physicians’ alleged current malaise. First, stakeholders, including the government, private payers, employers, and patients, are demanding that that physicians account for the cost and quality of their work. A second cause may be the sheer complexity of the health system in which they function, and especially the proliferation of complex payment arrangements with which they and their patients must grapple. A third problem may be poorly designed electronic health records. Together, these influences add to the administrative burdens of practice—a recent study found ambulatory physicians spend two hours on EHR and desk work for every hour face-to-face with patients—and reduce physicians’ real or perceived autonomy. Autonomy, in turn, is a critical factor influencing physicians’ contentment with their work.
What could remedy these difficulties? With regard to reporting burden, the development of a streamlined set of consistent quality reporting metrics and methods should be a top priority for the next federal administration and for public and private actors generally. The National Academy of Medicine recently recommended a set of core quality metrics, and the new MACRA regulation takes steps in this direction.
Concerning the complexity of our payment systems, some may be unavoidable given our nation’s philosophical commitment to competing private entities as a way of providing health care coverage. To attract business and meet clients’ demands, private insurers create a multitude of products that vary in what they pay for, how much they pay, and the structure of copayments. Perhaps the only refuge for doctors in this enormously complex payment environment is to join organizations that can protect them from the daily hassles of billing and collecting. For better or worse, this is precisely what increasing numbers of physicians are doing.
Regarding physicians’ complaints about EHRs, these tools do need to be made more usable and capable of exchanging data. The federal government should use its full authority for certifying electronic health records to promote improvements. Congress may also need to step in to show that it will not tolerate efforts by some health care stakeholders to protect their economic interests by frustrating data exchange.
Whether or not American physicians are truly in crisis, their concerns point the way toward needed reforms to improve the quality and efficiency of our health care system.