
Physician burnout widespread, especially among those midcareer, report says - eplanit
https://www.wsj.com/articles/physician-burnout-widespread-especially-among-those-midcareer-report-says-11579086008
======
xzel
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.

~~~
pkaye
Another solution is allow more doctors to be licensed so they don't need to be
as overworked.

~~~
zionic
The medical cartel will never allow that. They have a complete stranglehold on
both licensing and education.

~~~
nradov
By "medical cartel" are you referring to the US Congress? Because the actual
bottleneck in physician production is in the shortage of residency training
slots, and the vast majority of those are funded by the Federal government.
The American Medical Association has been lobbying for more residency slots.
Every year students graduate from medical schools but are unable to practice
medicine because they can't get matched to a residency program.

[https://www.ama-assn.org/press-center/press-releases/ama-
fun...](https://www.ama-assn.org/press-center/press-releases/ama-fund-
graduate-medical-education-address-physician-shortages)

~~~
goodells
Why do we need the federal government to fund these slots at all? Hospitals
work resident physicians to the bone and bill patients exorbitantly for it.
Their hours are capped at 80 per week yet they receive no overtime pay[1].
Yes, the residents are "in training" but it's not like it's a burden for a
hospital to take them on - they are the workhorses that handle a huge number
of cases and drive hospital revenue.

[1] -
[https://en.wikipedia.org/wiki/Medical_resident_work_hours](https://en.wikipedia.org/wiki/Medical_resident_work_hours)

~~~
gamblor956
Most hospitals operate at a loss.

The ones that don't nickel and dime their patients, or even engage in outright
billing fraud.

Do you really want to move more hospitals to the latter form of doing
business? Because they would be a huge net loss for everyone except the
hospital CEOs.

~~~
MrBuddyCasino
Given the medical costs in the US, this really begs the question: why?

~~~
a2tech
To receive federal and state funding as well as accept residents hospitals
have to run an ER and accept patients regardless of payment ability. Some
facilities will do their best to help a patient that will be unable to pay.
Others will simply stabilize the patient until they're not going to die
immediately and then kick them out. Since medical care is very expensive a
single non-covered ED patient could EASILY cost the hospital 250k+ per visit.
For example maybe a homeless person is found and brought in unconscious.
They're then discovered to have untreated diabetes, rot in their feet, and
psychiatric issues. They'll be in the hospital for at least a week, surgery to
clean up any rotten tissue, and then maybe a stay in the psych ER or other
facility. Every day wracking up huge charges which the hospital will never be
compensated for..except by spreading the loss around to others.

~~~
MrBuddyCasino
This looks like a crude version of socialised healthcare to me. Other
socialised healthcare systems around the world should in theory face the same
problem, wouldn't they? But AFAIK they do not nearly have the same cost issues
as the US, at least I'm not aware of this here in Germany.

One theory I've heard that sounds plausible is that

a) insurers do not pay anywhere near what hospitals bill to uncovered patients

b) hospitals do not even expect patients to pay the whole bill, but more like
20% of it, so it is always good to contest the bill

So the problem is that hospitals are cash-strapped for systemic reasons, but
can't get it from insurers or the state because those have contracts in place.
So hospitals try to squeeze uninsured patients as much as they can with
inflated bills, with predictably horrifying consequences. Insurers don't mind
because that makes the case for buying insurance even stronger.

So one solution might be to pay for poor/homeless care via state/federal
budgets. This could cover poor people up to an income level that can afford
insurance.

~~~
a2tech
Most/many of the homeless that come in are eligible for Medicaid or other
government benefits (veteran healthcare for instance). However figuring that
out can be very difficult. Many of them are incapable or unwilling to give up
their names or stay long enough for social workers to get their paperwork in
order. Or they're afraid of being located (for example they have warrants out
for their arrest). Then you have regular uninsured people who are simply
incapable of paying that come in and give fake information.

Fun fact, if you're unable to pay the full amount most hospitals will do
almost ANYTHING to stop from having to send your bill to collection. Even if
you say 'I'll pay $50/month forever' thats way better than they'll get from
the debt agency that buys your debt.

~~~
MrBuddyCasino
Thanks for the explanation. Hospitals shouldn't be left alone with this, I
can't imagine forwarding the costs to Medicaid would be a worse solution than
the accountability problems that arise when having patients with no names,
like fraud.

------
univalent
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-a...](https://skeptics.stackexchange.com/questions/4561/does-the-ama-
limit-the-number-of-doctors-to-increase-current-doctors-salaries)

~~~
nradov
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-
fun...](https://www.ama-assn.org/press-center/press-releases/ama-fund-
graduate-medical-education-address-physician-shortages)

~~~
beambot
Apprenticeships in many (most?) fields are sponsored by the professional
organization (akin to a guild) and paid for by laborers at lower-than-master
wages. And yet, here is the AMA itself saying the problem lies with federal
government funding. Curious. Seems like a convenient scapegoat.

~~~
Ensorceled
I think you are significantly underestimating how much a medical residency
costs.

Also, most apprentices end up working for/with the company/professional that
trained them. I'm not sure there are many doctors who employ
"apprentice/junior" doctors to work along side them the way a
plumber/bricklayer/blacksmith/electrician would.

------
SkyPuncher
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.

~~~
cloverich
Speaking as someone who quit after medical school and codes professionally
(going on 10 years), I'd suggest temperance on the recommendation. Debt is
high but so is salary, if they are in it for the long haul they'll be just
fine. If you think you want to be a physician, shadow some. If you like what
they do, you might like being a physician. I met many doctors who I think
would be happier not being a physician, but also many that I think wouldn't be
happy doing anything else. I'm happy with my decision overall but frankly i
couldn't imagine going back as an NP, PA, Dentist... or anything in the field
that wasn't an MD. Those all have much better work life balance, but you need
to realistically understand what it means to do each if you want to be happy,
and select the one that feels right. (And if it doesn't feel right, Dentistry
has the absolute best work life balance, pay, and ability to help people who
legitimately need it).

~~~
SkyPuncher
> Debt is high but so is salary, if they are in it for the long haul they'll
> be just fine.

This is exactly why I recommend against medicine. You have to be in it for the
long haul. If you find you hate medicine in your 3rd year (when rotations
typically start), you're already $100k in debt.

------
code4tee
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.

------
chkaloon
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
>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
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
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.

------
hhs
Here's the full report: [https://www.medscape.com/slideshow/2020-lifestyle-
burnout-60...](https://www.medscape.com/slideshow/2020-lifestyle-
burnout-6012460?faf=1)

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.

------
drewr
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
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.

~~~
majos
Is this in the US? I would think that US malpractice laws, and the
corresponding malpractice insurance costs, make this impractical.

~~~
jt2190
I have a friend here in U.S. who runs their practice like this. They don't
make any money at all at this kind of price. They should be charing each
patient more like USD 200 per month.

------
assblaster
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
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
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.

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

~~~
dantheman
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
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....](https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2010.0204)

~~~
naveen99
American software developers also get paid multiples of their non-us
counterparts. Same with many other professions.

~~~
lotsofpulp
Except there is no organization limiting the number of software developers. In
fact, I can't think of another field out there with so many free resources for
one to educate and prove themselves a capable programmer.

~~~
naveen99
Nurses make more in the us, then most doctors outside the us. There is a
shortage of people in general in the usa, and we have the INS artificially
limiting immigration for everyone.

------
jshaqaw
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.

------
Psyladine
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.

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

~~~
kxyvr
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.

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

------
arkades
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.

~~~
arkades
This has been manipulated since roughly the eighties to increase HMO profit.
There was a thesis that most physicians are not trying to maximize revenue,
but trying to hit a target upper middle class lifestyle. If you cut FFS
reimbursement down by 20%, they'd increase the amount of patients they pack
into a waiting room by 20% (rather than taking a 20% pay-cut by seeing the
same number of patients, or saying "fuck you" and no longer accepting patients
from that insurer). And that's precisely what happened. That has driven the
ongoing trend since in which revenue falls, number of patients per hour
increases, and the result is physician income that hasn't kept up with cost in
education or changes in purchasing power. You, too, would be very upset if you
were being asked to work more and make less.

This also makes physicians a target for every spending adjustment measure.
Physicians are not the primary driver of cost growth in america: new
procedures and changes in drug prices are (when was the last time an internist
raised his prices 5000%? Never, because his reimbursement is set by Medicare).
But they do write the prescriptions and orders and referrals. This means that
the entire system converges on controlling physician activity.

This plays directly into government willingness to expand on training
positions. The government has a budget to hit; in fact, CMS is required to do
studies showing that any changes they make will ultimately be budget-neutral,
because they're legally obligated to protect the Medicare Trust Fund. As you
see above, healthcare costs for the nation scale linearly with the number of
physicians: if a doctor's total revenue for the year is capped at available
time * service unit revenue/time, well, CMS' costs are that plus the cost of
whatever service or drug he prescribes in that unit time. Double the docs, you
double manpower costs, and double the opportunities for prescribing, in the
context of trying to minimize healthcare cost.

So why are physicians burning out? Why are fewer and fewer "best and
brightest" applying to medical school?

\- Increased accountability with decreased authority. As the centerpoint for
changes in documentation and prescription patterns, everyone is twisting
physicians' arms to act in very precise ways, whether or not those ways are
what the physician believe is good for the patient. Physicians get the
scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!"
"why are doctors doing Y?!" \- and none of the power to actually decide any of
this.

\- Decreased authority in the hospital. Hospitals are suffering the invasion
of the MBAs (and MPHs, and MHAs), and have more and more people with zero
clinical knowledge setting policy. The big trend has been in nurses getting
MBAs (and MHAs and MPHs) and going into administration, combining "I saw what
doctors do from the side, I must totally know what's going on in their heads,
right?" with MBA acumen. It's deeply problematic. "This patient has
depression, and you didn't give them an SSRI! Malpractice! What's wrong with
you?"

"This patient has multiple comorbidities that are more serious than their
depression. I have them on medications for those comorbidities, and those
drugs are all second-line therapies for depression. Time has shown that this
combination has been effective for controlling their depression, and as a
bonus, I avoided risking the side-effects of putting this patient on a third
medication."

You cannot imagine the absolute pleasure of being regularly second-guessed by
someone with a tiny fraction of your training. I imagine it's rather like a
senior engineer having their code regularly criticized by someone that just
finished "learn python in one week!". And they will then go to the EMR folks
and have them add an alert, so that I can never place an order w/o SSRIs for a
patient w/ depression without going through a whole Alert! rigamarole. There
are so, so many alerts that alert fatigue is ubiquitous.

Additionally, in (fair) response to bad behavior of physicians in the past,
nursing and other auxiliary services have moved into parallel reporting
structures.

So, when patients are mad at something that has happened in the hospital, they
call the doctor and yell at them! How could the hospital have done such a
thing! I have no authority over the nurses that did it, or the nurse MBAs that
made the policy, but I will get to take the scolding, the risk of malpractice
suit (because patients don't sue over errors - they don't know enough medicine
to identify errors - they sue over breakdowns in relationships with
physicians), have zero authority to change or fix anything, and if I say a
word, it's outside of my operational stovepipe and I will be both ignored and
ultimately ignored by nurses. The latter means that my future care orders will
be ignored or given low priority, and I can rely on that ultimately affecting
my patients. So I have to keep my mouth shut over anything less than egregious
problems.

\- Increased time doing things unrelated to patient care. There's a myth that
somehow all this new documentation is meant to improve patient care. It does
not. The three major reasons have absolutely nothing to do with patient care:

\---Many of the increases in documentation have to do with increasing
specificity that strictly increases opportunities for error, and thus
reimbursement denials.

\---CMS wants increasing information on practice patterns, and wants to
extract this from EMRs. Because they can't spend any money to collect this
information (as I said above, they are required to be budget neutral), they
shift this cost onto hospitals, which shift it onto physicians (it's
worthwhile for hospitals to comply, because otherwise CMS brings out the
reimbursement stick.)

\---EMRs make billing more reliable, and reporting data to CMS more easy, and
are required now as part of the ACA. EMRs are slow as fuck, because the end-
user is not the customer. Their UIs are just fucking atrocious. There aren't
words enough to relate how bad they are. Most can't even present lab results
in a decent way.

The result is more documentation, done more slowly, for reasons unrelated to
taking care of the patient in front of me - but that none the less take time
away from _seeing the patient in front of me._

And there is a constant media barrage about how terrible physicians are, which
studiously ignores that 99% of the things they are describing and criticizing
are systems-level issues physicians have no control over.

On top of all this, I have only rarely met a physician without a real sense of
professional pride. That we are ordering tests we don't want to order,
creating delays we don't want to create, hiring shitty front desk staff we
don't want to hire, creating massively packed waiting rooms we'd rather not
have, while patients are being bled dry by their pharmaceutical companies, all
while working our asses off, getting scolded for it, and having trouble paying
off our ever-growing student loans is... it's fucking heart-breaking.

It's heart breaking.

You have no idea what a tide of idealism enters medical school, and what a
shambling army of heart-broken zombies is left by "mid-career." If anyone was
willing to pay me my current salary to see a dozen patients a day rather than
thirty, to give every single one of them the extended visit to collect a
rigorous history and give them the scrutiny they deserve, I'd take it in a
heartbeat.

You want me to be that doctor. I want to be that doctor. The delta between
that, and what the system allows me to be, hurts us both.

~~~
neplus
Because your post is quite far down, I'm not sure it'll get many
views/replies. Just wanted to say that I read it all and it's both
informative, interesting, and (regrettably) demoralizing.

In my first year of college I wanted to be a doctor and landed an absurd
position - in hindsight - over my freshman summer where I was in the operating
room with my surgeon nearly everyday (he led the residents). I tagged along
through all the rounds, operations, and (of course) the tedious paperwork and
billings.

By the end of the summer I was entirely jaded and switched programs. I still
often think about whether or not I should have stuck it out.

However, what I ultimately saw (as you mentioned) were residents at this top,
well-funded hospital who deeply loved medicine when they began medical school
fall into a deeply jaded, pessimistic state. They made no money (while living
in a high CoL city), were consistently overworked, and riddled with anxiety
about where they would actually get a job post-residency.

Becoming a doctor - a surgeon in particular - struck me as a dozen year
journey of constant make-or-break tests, quasi-lotteries with regards to
residencies/fellowships, and then complete ambiguity as to where you would
actually work when it was all done and you hit your mid-thirties. It also
seemed increasingly devoid of any kind of professional autonomy and, most
surprising to me, was how ungrateful and mean-spirited many patients were.
Their lives would be saved, but they would yell at the surgeons over cosmetic
concerns about the scars.

I often wonder whether my experience was not representative or simply too much
to absorb as an 18-year-old at the time. However, the only folks I've talked
to who seem to be truly satisfied and content with their careers are family
doctors operating (largely) on their own terms and making 200-300k a year.

EDIT: I should say, I wish you the best moving forward and hope you find a
level of contentment and happiness in a bruising - to put it mildly - system.

~~~
arkades
> I often wonder whether my experience was not representative

Everything you described is concordant with what I saw on my surgery rotations
in medical school, and everything I've seen of surgeons in the hospital since
then. Especially the mean-spirited and ungrateful patients. The ones that
hurt, though, are the ones that come into the hospital hostile and
confrontational from the outset.

"I know exactly what I need, and exactly what you need to do, and you're going
to do it, or I'm going to have your balls!" I mean, that might be true.
Sometimes it is. Sometimes it isn't. But nothing about talking to me like a
rabid dog is going to make the process any better. And honestly, if you know
your health, that's great - that will be very helpful. But ignoring other
things it can be that masquerade as what you've got would be tragically
irresponsible, so please don't bite my head off when I address the other
conditions on my differential. I'm not ignoring you, I'm just trying not to be
negligent.

Some patients will understand that, if we're given time to talk to them like
human beings. But we basically never are, which makes things terrible for
everyone.

The constant make-or-break tests and quasi-lotteries are a particularly apt
description of medical school, and why - IIRC - the most recent stats put
medical student rates of anxiety disorders at almost 50% of med students, and
depression at approximately 30%. We absolutely destroy young physicians right
at the outset. Studies of physician compassion have found that med students'
compassion drives into the ground somewhere in third year - not with their
first "your entire career relies on this" exam, but with their first exposure
of what medicine has become, and how patients will be treating them.

------
trey-jones
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.

------
beerandt
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.

------
Ghjklov
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
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.

------
wavepruner
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.

------
6gvONxR4sf7o
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.

------
milofeynman
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
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.

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

------
werber
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

------
neonate
[http://archive.md/HZOmv](http://archive.md/HZOmv)

------
kingkawn
Medicine burned me to the ground

------
pwthornton
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.

------
adamc
We need doctors. This is a serious problem.

I wonder how this compares to countries with nationalized healthcare.

~~~
lend000
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)

------
zyang
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..

------
minikites
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.

------
_sbrk
Paywall-free URL?

~~~
foopdoopfoop
[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)

------
overlyLogical
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...

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

------
conanbatt
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.

~~~
kingkawn
It is definitely not state intervention alone that explains the culture within
the medical profession overemphasizing hierarchical relationships and
deemphasizing direct patient care

~~~
conanbatt
You would be surprised! That is exacty the history of american medicine,
depicted in the seminal work “the social transformation of rhe americam
physician”

~~~
Fomite
I believe the correct title is "The Social Transformation of American
Medicine".

Dry as hell, but an insightful book.

~~~
conanbatt
Thats correct. One hand typing from memory XD

