
The Dark Side of Doctoring - dy
https://ericlevi.com/2017/05/13/the-dark-side-of-doctoring/
======
pixelmonkey
My wife is a medical resident and the issues described by this doctor are
absolutely pervasive in residency.

The strange part is, the overwork also seems to be pervasive among the
attending physicians who have been out of residency for decades. Not just the
residents.

As a tech founder analyzing the system from the outside, I think this writer
has nailed the core issue: "... a doctor is just one of the many commodities
in this complex industry. It’s no longer about the patient. It’s about the
business of hospitals."

If doctors were viewed in their industry the way software engineers are viewed
in ours -- as specialized skilled labor with _extreme_ leverage and limited
time -- then we would have well-supported, well-rested, and well-compensated
doctors.

But as it stands, we have overworked and overtired doctors buried under a
mountain of clerical work, who need to slot their patient in to 15-minute
"encounters" in clinic to keep the profit machine running. Meanwhile,
administrators, health insurance executives, and medical equipment CEOs work
9-to-5 and earn millions. It really boggles the mind and infuriates me, as a
technologist.

p.s. Don't listen to any of the comment threads here that say long hours are
required to reduce patient handoffs. Yes, it's true, patient handoffs cause
some danger. But tired doctors make mistakes. Period. And, as this post
indicates, a perpetually tired doctor burns out and either quits the
profession or (worse) commits suicide, which is the _worst_ possible outcome
for the system.

~~~
slackingoff2017
It's well known within the medical field that being a doctor is really really
tough. It takes a lot of smarts and grueling years in residency before you
officially become a doctor.

However it also pays incredibly well. Even moreso for specialities and
surgeons, who can make over 200k a year even in low cost of living areas.
Despite the difficulties of being a doctor it's harder to get into medical
school than ever. The difficulties are not deterring med students.

I don't feel bad for people that go into this profession then complain about
how hard it is. It's extremely well known within the medical field that being
a doctor is grueling. That's why it pays so well. And it's not like this is a
new development. It's been like this for decades.

Complaining about it is akin to working on an oil rig and complaining about
poor work conditions. It's pretty damn obvious that you're going to have poor
work conditions from the start.

Nobody is forcing you to be a doctor, your school credentials plus MD is
probably enough to swing a decent job in almost any field. Doctors are some of
the most employable people out there.

I just find it rediculous that were having a "poor doctors" discussion when
it's the second highest paying profession in the richest country in the world.
Get over it.

~~~
seanp2k2
200k is also on the low end. A friend of mine just finished her residency and
is making almost twice that now. I did some on-site PC service for a few
doctors in a job about a decade ago. They literally all had 911s and mansions.
Anecdotal sure, but from what I've seen, doctors here are loaded.
Anesthesiologist always seemed like the best gig....you work a few days a
week, set up your schedule months ahead of time, bring in your kit and pump
the person full of drugs, sit there and watch the screen for however long the
surgery takes, bring them back to life, then go home with a few grand. The
anesthesiologist is typically an independent contractor.

~~~
throwaway5752
It's great until a patient dies and you have to inform their families. You are
keeping a living being in a state between life and death chemically while they
are undergoing massive trauma. Do you know how much their malpractice
insurance is?

It's not just hard work to become a doctor. It's hard work and sustained
excellence. You don't just put in the hours, you have consume an enormous
amount of information and are tested on it constantly through the education
process. You have to take on enormous personal risk financially in loans. You
very frequently have to make large personal sacrifice in your life to get to
the point of board certification.

Some get paid great, most get paid well, but if you know more than a few
doctors you would probably be less glib. /me not a doctor.

~~~
stickfigure
_You are keeping a living being in a state between life and death chemically
while they are undergoing massive trauma._

Why can't this be automated?

~~~
VLM
Its almost exactly analogous to being an airline pilot, everything easy enough
to automate was automated multiple human generations ago, now the primary
purpose of the human is judgment calls, emergencies, monitoring, what boils
down to non-computer systems administration using hopefully sterile
biochemical machinery rather than CPUs and disks, equipment failures ...

------
pc2g4d
So... because the supply of doctors is restricted but demand for doctors grows
proportionally to the population, the amount of work per doctor gradually
increases and doctors, persuaded by their ethical obligation of care, put up
with it as long as possible until they snap.

Yeah?

I just recently had a friend completely burn out of medicine, sell his house,
and start traveling the world. He was brilliant, a good doctor, a good person.
It's a shame he's been driven out, and so many others.

I also recently had the experience of seeing a young doctor bright-eyed and
busy-tailed treat me once, and then six months later see him again. The toll
that those six months took on him was visible. He was just about haggard with
the work. It's easy to imagine he won't last long.

I feel there's an interesting parallel with teaching. Teaching and medicine
both have licensure requirements, both have a strong appeal to people who care
and want to make a difference in the lives of children/patients. And in both
cases the profession is gradually being taken over by administrators and
subject to increasingly onerous regulations.

I also recently had a friend burn out of teaching. She's set to work in a
completely unrelated industry now. She put up with crap for a long time due to
her care for the children, but at last she couldn't take it.

My libertarian side says these are two improperly functioning markets, with
massive human casualties. It's a shame.

~~~
djsumdog
This is what I felt when I read the article. It was surprised even the
Australian system is just as overloaded as our American system. I feel like a
lot of these problems could be deal with if there were simply more doctors.

That being said, it's a difficult profession. Not a lot of people want to do
it. Even fewer in such specialised positions as surgery, where mistakes
literally cost people lives. There's no rolling back to a previous release or
taking a break. Everything that happens, happen on that table with that body
open.

Tack on the insane costs, at least in America, for going to school to be a
doctor and you also have a situation where few people feel they can afford to
be GPs (even though that might be what they really want to be; and the world
needs more GPs desperately) and you also have doctors who are now locked into
a profession to simply paid their debts.

> I just recently had a friend completely burn out of medicine, sell his
> house, and start traveling the world.

I don't think this is a bad thing. Everyone who can afford to should really
save up and take a sabbatical every few years:
[http://khanism.org/perspective/minimalism/](http://khanism.org/perspective/minimalism/)

~~~
pc2g4d
The high cost of medical school seems directly related to the restriction on
the number of physicians. Because only N seats are available whereas maybe
10*N seats would be desired in a free labor market, each school can charge
immensely for each seat. The most idealistic will still be willing to apply
and take on the debt.

Of course, I'm no expert in this stuff, this is just my hot take. I'm sure
it's hugely more complicated.

I don't think a sabbatical is a bad thing at all. But this is more than that,
and it's driven by burnout rather than a simple desire for refresh and
reflection. That's what I think is negative here.

------
protonfish
The FAA enforces work limitations on pilots, but we schedule our health care
workers like this? How are there not even civil cases against errors caused by
this kind of administrative foolishness? Overworking doctors like this is
insane.

~~~
macrael
There is a tradeoff that is used to justify the long hours. On the one hand,
having a well rested doctor is obviously good for them to be making good
decisions. But on the other hand, patient handoffs are dangerous. The more
times you change the person responsible for a patient, the longer the game of
telephone you are playing with their care. This has been measured as being bad
for patient outcomes.

Now, that doesn't seem to justify the fact that long hour shifts are placed so
close together. It seems like you could give doctors a longer break in between
shifts than they have. Residents have the worst of it. The attending actually
do get a fair amount of time on/off. Residents already work a lot less than
they did 50 years ago, some think that their training should be extended to
cover the loss of density.

~~~
pdelbarba
Maybe OT, but pilots have a lot of time off between shifts and it's starting
to come to light that their depression rates are much higher than anyone is
comfortable admitting. This may from a different source though, since flying
is very much about precise repetition and less about _complex_ decision making
(ADM is hard, but not the same level of mental stress that doctors endure),
you eventually realize that you're a very highly trained bus driver.

~~~
devdas
Regulations for pilots currently mean that any treatment for depression means
the pilot will no longer have a valid license.
[https://www.faa.gov/about/office_org/headquarters_offices/av...](https://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/pharm/antidepressants/)

~~~
pdelbarba
Which is part of the problem. They never report completely treatable issues
because of the bureaucracy surrounding the FAA medical program.

------
robbiep
Here is some context for this article: Dr Levi is n Australian surgeon. He is
responding to a letter from the wife of a gastroenterologist who committed
suicide recently.

Last week was the Royal Australasian College of Surgeons Annual scientific
Congress in adelaide so physician wellbeing is well and truly on the radar,
_in particular_ following 3 suicides in the last 6-9 months of junior
trainees, one of whom was a friend of mine from medical school.

There is now an enquiry into Doctor suicides and wellbeing being performed at
the state level in NSW and we (doctors) expect this scope to be broadened to
nationwide

~~~
Gatsky
I wish I could applaud this. But what sort of professional organisation waits
until its members are actually dying before putting well-being in the radar?

The RACS, RACP etc are sclerotic organisations run by old white men in bow
ties (I've met several of them) with no real incentive to improve conditions
for trainees. The only way I have seen actual change happen is when junior
staff band together and effectively go on strike.

~~~
robbiep
Couldn't agree with you more re RACS, I attended their 'gala ball' at the end
of their ACS last year and was sickened by the pomp and bullshit. The (female)
RCS president, visiting from England, also appeared weirded out by the pomp
(and that the RACS had not had a female president).

Having said that within both organisations there are people who strongly and
fiercely advocate for innovation and change, but you are right, they are
severely sclerotic (even to the point of RACS making an absolute motza out of
their trainees, they've got over $60m in the bank and our exams cost $4,000)

~~~
Kali909
I don't know too much about the RACS etc (father was a radiologist but can't
recall him complaining about their equivalent in Aus too much, though it's
likely the same).

If you have to be a member of this, and that's government mandated, then them
profiting from that arrangement is a blatant monopoly isn't it?

~~~
robbiep
They've been taken to the ACCC previously for anticompetitive behaviour
however the focus of that was on nepotism ie the way trainees were selected.
The process is more blinded now (to the extent that is possible in a country
the size of Aus/NZ with somewhere around ~100 trainees for general surgery a
year).

I actually attended the ICOSET conference for 2 days prior to the ACS and
there was much discussion over it.

For example, compared to the US situation, where surgical training is run by
the universities, surgical accreditation is done by the Board Examinations,
and the ACS is essentially just a bit of a union/membership organisation (You
can not pass your boards and practice surgery in the US although it cant be
good for your insurance), RACS is both trainee selector and accreditor.

There is talk about accreditation being devolved (Macquarie University
Hospital is apparently trying to do a course for Neurosurgery) and the
Orthopaedics guys left the RACS a few years ago to start their own body (but
with similar principles, ie they select trainees and accredit). The MUH model
seems interesting but has it's own problems because rumour is they want to
charge ~$150k to do their training course. So essentially we have the
americanisation of our quaternary training, which I don't agree with.

It's hard to see a real way forward; and even if another organisation came
around and said they were going to start training surgeons, they have a couple
problems: getting surgeons to say that they are happy to be the Trainers for
them and getting hospitals to allow that organisation to train them.

A similar problem exists with the RACGP and it's (my opinion) much better,
more nimble and beneficial to the Australian Population Australian College of
Rural and Remote Medicine. ACRRM has been steadily building up to become a
formidable training force for GPs particularly in rural and remote australia
wityh a focus on TRUE generalism, ie GPs that run scope lists, minor surgery,
obstetrics and aesthetics. The RACGP has a firm focus on city GPs and City
training despite a desperate need for ACRRM/rual generalists. RACGP this year
has put the state governments over a barrel and said that trainees must now do
X amount of time in a big city, and that rural training is not going to count
for as much; with the result that current ACRRM trainees may not make cutoffs
in terms of time worked in city practices and fail to achieve their final
qualifications. So basically RACGP is making moves to push ACRRM out of the
way by introducing changes that benefit it over ACRRM.

all terribly interesting/boring, depending on how much you care about petty
politics :)

------
drewg123
It seems like we have an undersupply of physicians. My understanding is that
the AMA limits medical school admissions[1] in order to keep salaries
artificially high. This naturally leads to overwork in addition to high
salaries.

[1] [http://www.usatoday.com/news/health/2005-03-02-doctor-
shorta...](http://www.usatoday.com/news/health/2005-03-02-doctor-
shortage_x.htm)

~~~
EvanAnderson
Here's the go-to that I send people to when this comes up:
[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)

~~~
qudat
tl;dr Federal health spending is the limiting factor.

Question: Why do we need the government to fund residents? The fact that every
single going-to-be physician must do so through government funding boggles my
mind.

On top of that, depending on the number of hours worked, many residents barely
make minimum wage.

~~~
jakewins
It's needed because the private sector isn't paying for it.

There's no law that says private hospitals can't fund residency slots - in
fact they fund many of them - but, as the source you're commenting on says;
"[medicare is] the principal source of residency funding".

~~~
killjoywashere
And the "private sector" is the existing physicians. Every dollar they pay a
resident can't be used to buy their spouse more Prada or new tires for the
Porsche. But the AMA had kept the valve throttled so long, society was
desperate. Seeing a bunch of short-term greedy louts who apparently didn't
study much math (don't get me started), the government seized the opportunity
to pay for residencies, which created a Venturi effect where they can suck up
not just the MDs, but added the flow from two other pipelines: the DOs and
IMGs. And the flow has been so vigorous and steady that additional medical
schools have opened outside the US borders (the Caribbean, Middle East, etc)
to support the flow.

------
kendallpark
This is a problem in medical school as well. I can't tell you how many
anonymous posts have been popping up on r/medicalschool lately about being
depressed, isolated, lonely, and/or suicidal.

Missouri just passed the first bill of its kind to try and combat mental
health issues in med school.

[http://krcgtv.com/news/local/medical-student-suicide-
prompts...](http://krcgtv.com/news/local/medical-student-suicide-prompts-
proposed-missouri-legislation)

> The bill, also known as the Show-Me Compassionate Medical Education Act
> would establish a committee to study mental illness, suicide and depression
> in the state's six medical schools. The bill would also prohibit any medical
> school from restricting a study on the mental health of its students.

The absolute disturbing part is right here:

> While lawmakers debated the legislation, Frederick said the deans from each
> of the state's medical schools sent him a joint letter expressing opposition
> to his proposed law.

In other recent news, Saint Louis University fired their med school dean that
was the absolute champion of promoting the mental health of SLU's students.

[http://news.stlpublicradio.org/post/slus-medical-school-
remo...](http://news.stlpublicradio.org/post/slus-medical-school-removes-dean-
lauded-preventing-student-depression#stream/0)

Furthermore, as part of the licensing process, you are asked whether you were
diagnosed with a mental illness in the past. There will likely be an
investigation if you say yes and it could impact your career.

This stigmatizes mental illness within the profession and keeps people from
seeking help when they need it.

~~~
hbosch
I have a friend who is graduating from med school this week and starting
residency. The stories of med school drama, gossip, backstabbing and cheating
are insane - on par with anything on television drama. Moving into residency,
they also feel alone, exhausted and anxious... I don't know how many people
manage.

I think knowing a doctor, or someone becoming a doctor, has changed my
perception of doctors entirely.

~~~
kendallpark
I am fortunate that my school seems to vet the students well for character. Or
perhaps it's self-selecting because we do PBL which requires collaboration. We
don't have the issues with backstabbing and drama that I've heard from other
schools. I think my classmates are perhaps my favorite part of the med school.

The scariest thing in med school is how vulnerable you are to someone with
authority screwing over your entire future. Piss off an attending? Well, they
could right a terrible letter for you that hurts your ability to match into
the specialty you want. You could straight up witness mistreatment of a
patient by a superior, report it, and have your entire future altered forever
because of people above being petty or vindictive.

------
Gatsky
Bear in mind this ENT surgeon is still in training, and probably close to 40
years old assuming he started Uni at 18. Training is often brutal because
towards the end you are probably among the most important and useful people in
the hospital in terms of delivering care, but also have very little control,
so of course you get abused. Eg this guy has to write medical certificates as
well as perform emergency life saving surgery at 2am and have crushing family
meetings with patients dying from untreatable head and neck cancers.

Simplistic supply and demand analysis of this issue is annoying and ignores
basic economic theory.

You don't want to increase doctor supply, you want to increase the capacity of
the healthcare system to deliver good care (obviously?). Doctor supply is one
part of that, but if you pump medical students in at one end and do nothing
else, you will fail - this is what the Australian gov has done, and you can
see the result here, where trainee conditions are poor (so much competition
that you don't complain about conditions, power is concentrated in hospitals
and senior drs in charge of training programs and hiring who align the system
in their favour), and incumbent physicians like the one that committed suicide
work like demons and burn out.

The financial corollary is fiscal stimulus without any production capacity -
GDP doesn't go up, inflation does.

As always, it doesn't have to be this way, but nobody is in charge who cares
enough to fix it, and all the stakeholders look after their own interests.

------
aabajian
It's worth noting that the incredible success of Epic EMR software is because
it tightly controls all of the administrative billing issues, NOT because it
makes clinician's lives easier. There are _endless_ check boxes in Epic and
each site has its own interface. It's a huge mess and difficult to
navigate...but arguably still better than the other vendors.

~~~
markroseman
Absolutely it's about the administrative end and not patient care. We've got a
situation in our regional health authority (Vancouver Island, BC, Canada)
where they're trying to roll out a significant update/expansion to their EMR
(Cerner-based) in the hospital in Nanaimo. Despite immense pressure, some docs
have been now suspended for refusing to use it and switching back to paper,
despite the massive increase in time it takes to provide the same patient
care, and also because of notable examples where the EMR has endangered
patient safety. (Google 'ihealth nanaimo' if you're curious for details, then
rinse and repeat for the same story in so many other places)

~~~
epmatsw
This is a pretty shocking opinion to see expressed. Like, you may as well have
said "A bunch of developers at <place> decided to go back to C89 because
writing code in Rust was too slow, plus did you see the bugs in its borrow
checker?" . Do you really believe that paper is a safer alternative?

~~~
mklim
Can't chime in on safety issues, but on usability: I know a physician who
transitioned to using EMR roughly five years ago. It doubled the amount of
time they need to take notes, to this day. They can't see nearly the same
amount of patients they used to because so much of their day is spent going
into and out of full screen surprise submenus in the EMR software and flipping
through different tabs and re-entering information into multiple forms and
scrolling through dropdowns with multiple hundreds of options. GP's post is
100% believable for me. It's nothing like Rust vs C89. It's more coding with
punch cards vs an IDE, except the EMRs are the punch cards.

------
joshuaheard
I am a lawyer, and if this was a lawyer's story, this would be my advice for
the firm. First, they need to hire more lawyers. This guy is way too busy and
will make a mistake. Second, he needs a receptionist, secretary, and paralegal
to support him. It is wasteful to pay him a doctor's salary to answer phones.
Third, they need to streamline their record keeping so he doesn't spend so
much time filling out paperwork.

~~~
pmiller2
What's the medical equivalent of a paralegal? A good nurse?

~~~
ars
Nurse practitioner.

A tremendous amount of stuff that normally only doctors do can be done by a
nurse practitioner, and since it's much easier to train them, (because they
don't need as much schooling) there are far more of them.

Basically give them the "easy" stuff and reserve the harder stuff for the Dr.
Or have a Dr. consulting for a team of nurse practitioners and they go to him
with questions and summary.

------
Melchizedek
_The bourgeoisie has stripped of its halo every occupation hitherto honored
and looked up to with reverent awe. It has converted the physician, the
lawyer, the priest, the poet, the man of science, into its paid wage
laborers._

Karl Marx

------
logfromblammo
It would appear that the relentless dehumanization of the skilled laborer by
business interests has finally spread to the professional classes.

I can't even recall how many young software companies I have sent my resume to
that turned out to be in the business of building software for insurers and
hospital systems that end up telling physicians how to do their jobs. Of
course, the metrics all back this up as a solid plan that increases
productivity and reduces expensive errors and negative outcomes due to
inattention, but I know it just has to suck for the docs to have to experience
exactly the same thing that has already happened to most other jobs.

------
Mz
From what I gather, one of the reasons physicians like Direct Primary Care is
that it is a saner system than what you see in most American medical
facilities.

I am sort of a medical system drop out. I took my toys and went the fuck home.
(No, I was not a doctor. I was a patient who could not get my needs adequately
met and walked away from conventional medical treatment for my condition.) So,
a lot of people assume I am very anti medicine. They think I am some crazy who
just hates modern medicine.

This is absolutely not true. But I do hate certain aspects of the system. I
think Direct Primary Care would be a step in the right direction.

If you are interested in reading a bit about that, I have written a few pieces
about Direct Primary Care.

[http://micheleincalifornia.blogspot.com/search?q=direct+prim...](http://micheleincalifornia.blogspot.com/search?q=direct+primary+care)

------
douche
This sounds like unrelenting Taylorism, trying to scrape too little butter on
too much toast.

If all this administrative work needs to be done, do surgeons necessarily need
to do it? Can we hire more clerical specialists to offload that work onto, or
more PAs or RNs to handle less specialized work?

A few measly hundred million in the federal budget could probably be dredged
up to subsidize medical school tuition and take some of the sting out of the
long, expensive marathon of medical schooling, maybe?

------
themantalope
I'm a medical student at a top 20 allopathic school in the U.S. This article
resonated with me.

I think the part that struck me the most was his comments about time. I have
diverse academic interests. I studied math and bio in undergrad. I love
machine learning and software development (esp python). I lived in China to
study the language for a year. All that gets sucked out of medical school
though. We are expected to learn a ton of material in the first two years.
Then in the second two years, we are basically working a full time job in the
hospital/clinics while also studying. We are constantly evaluated. We are also
expected to do research and publish papers. I've forgotten what a guilt-free
day off feels like.

------
johan_larson
Why continue in a job that sucks that hard? Is it the money? The prestige?
Family expectations? It seems like a terrible way to live.

~~~
Jtsummers
The doctors I know, despite the toil and suffering, really, really like being
doctors. They like what they do for other people. To a one, they are more than
capable enough to jump into any other career, likely more profitable (when
seen as a ratio of time/money or pain/money at least).

This isn't true of all doctors, but you'll probably find that ones that suffer
through like what the author (Dr. Levi) discusses find that their practice is
a calling, not an occupation or job. As a calling, it's part of their
identity, giving up on it just doesn't make sense to them.

------
electriclove
Let's create MORE doctors.. There is no shortage of capable people interested
in becoming physicians.

~~~
JabavuAdams
Do you really believe we've maxed out on capable people with the interest?

~~~
electriclove
Not at all.. the supply is constrained for all the wrong reasons.

------
erikb
Life gets harder the more we dive into the financial crisis. Blue collar
workers sometimes don't even get a job anymore, or work 3 at the same time
just to pay rent. White collar workers work themselves to death in one job,
although I have to admit it's maybe only 80% as harsh for IT as in medical.
Even the rich that we all complain about lose more and more control over their
money and their investments. We just don't like to see that, since who wants
to admit that someone above oneself in the foodchain may also be struggling?
Then we would also need to admit that the dream part of why we slave off
ourselves so much will never be true as well.

I don't think that we're heading into a zombie apocalypse level destruction.
Highly skilled people will always have one of the best lives. But it gets
harder for everybody, and no matter how much we complain there isn't anybody
who can give us a better life at the moment. Everybody is losing something.

------
markroseman
Dr. Pamela Wible has long been a very loud voice on the issue of doctor
suicide. Check out her website
[http://www.idealmedicalcare.org](http://www.idealmedicalcare.org), which
includes a link to her TED talk on the subject.

------
markroseman
One theme coming up here is the idea of just graduating more doctors, but even
ignoring artificial pressures to keep supply low, it's not that simple. Many
disciplines, particularly things like surgery, have a lot of requirements
beyond just doctors, i.e. nurses, anaesthesia, OR's, hospitals, etc.

In Canada, we have a fair number of people in certain specialties that cannot
find work - think a radiation oncologist who needs some pretty specialized and
expensive equipment that only exists in a few places to be useful. But also
even more basic... gastroenterologists who can't get enough OR time to do
scopes on their patients.

------
harmonicon
I am not a doctor, though I have many friends that are either med student or
residents and do hear about the harrowing workload and stress quite a bit. I
just want to point out the sentiment expressed here should all sounds very
familiar to anyone who has ever had a job.

The managing class (Company CEO, Hospital/University administrators) is ever
in the pursuit of more profit, euphemized as "efficiency" or "optimization",
at the expense on everything else. How can we squeeze the employees a little
harder so we don't have to hire as many? How can we increase "productivity" so
more patients can be seen(and pay up)? How can we eliminate waste (lower cost
of care as much as possible so we can make more) to the patient? How can we
make more money by tweaking our charging model (Insurance rewarding loyal
customer by charging them more, Hospital Chargemaster etc)? Oops, I see people
are complaining a lot. Let me pay some lip service about appreciating our
employees and valuing our customer/patients. Heck I am feeling extra generous
right now , let's put up some cheap program they can participate in. There,
they should feel happy now.

This is all too familiar in the corporate world. Any employees with a half a
brain will get the message loud and clear: employers do NOT care. Or maybe
they do, just nowhere near money. See, their incentive is aligned quite
nicely: cost cutting/profit increasing actions are how they justify their pay
and the profit it generates is how they pay themselves. Everything else can be
sacrificed.

Caring for a patient is a very intellectual, specialized and dare I say it
creative task. Doctors are paid well above many other professions though one
can argue it is not for the years they have to invest into training and the
work hours. The point is, at the end of day they are glorified laborers, being
told by their boss what to do, just like the rest of us. Prestige has shielded
the medical profession for decades but now the grip of corporate America has
finally caught up. And lo and behold, what scant voice and influence do we
have!

We absolutely do need managers/administrators. We need them to make sure
companies/hospitals are running smoothly, is well funded and serve the
customer well. But the lack of voice and the power imbalance in employment is
suffocating. We are partners not servants or slaves. And the all consuming
focus on money has got to stop. Human welfare deserve to be at the top. not
profit.

------
tejaswiy
After working in healthcare IT, I can atleast attest to the general UI
clunkiness and terrible software quality that is prevalent in the industry.

Innovation in Health IT happens usually because CMS (Agency that administers
Medicare, Medicaid etc) looks at the landscape and comes up with a carrot /
stick rewards system to force Hospitals and practices to update their
software. They generally do things like:

* Hey you need to store records electronically. If you do this by X, you will get Y$. If not, you will be penalized Z$ every year after X.

* Hey the system you built - It needs to actually be able to talk to other systems. If you do this by X.. you get the point.

* The data you're collecting in your system is stupid. We need X, Y and Z reports to ensure you're actually using the system as we meant for you to use the system. Do this by X.

Several other misc things I noticed:

The industry by itself is extremely complex with business requirements that
vary between hospitals, practices, labs and so on. This makes connecting
systems together a nightmare. Even when you manage to integrate systems, each
hospital and practice has a set of business practices (forms they collect, the
way they organize information etc) that make rolling software out very hard.
Configurability is king. Making everything configurable and having
configuration engineers set things up makes automated testing very hard at a
UI level. This leads to some sharp corners and contributes to bugs and general
UX clunkiness.

UX design isn't generally valued and suits / "business requirements" /
timelines are prioritised over usable, stable, secure software. This is a
typical UI: [http://uxpajournal.org/wp-
content/uploads/2014/07/smelcer3.g...](http://uxpajournal.org/wp-
content/uploads/2014/07/smelcer3.gif)

Standards are out of date and the only thing pushing innovation here is CMS
doing its best. The problem with this is that they're a govt agency, so
they're generally slow and they're an insurance company, so their primary
motivation is to cut cost of care.

Doctors are generally smart, and you can sometimes get good feedback from
them, but they're already overworked and can't really vocalize what they find
frustrating about software.

I hate to generalize, but in my experience atleast, all other people (middle
management, front-desk staff) are useless. By that I mean they just don't
understand how software works.

There are some smart CIOs, but they care about their position and the hospital
bottom-line, so trying to sell them something that doesn't exactly line up
with the CMS carrot / stick model is basically impossible.

------
qrbLPHiKpiux
Another modern problem is private equity in the business of health care making
money hand over fist with all libiality on the individual physician. All risk
shifted from the partners.

------
yakult
According to my GP, selection for doctors include psychiatric profiling
designed to select for the most compassionate. While I can see why the
hospitals would want this - compassionate doctors are good PR -this seems to
be a case of misaligned incentives. Those with less compassion would suffer
less and cope better when surrounded by death and suffering on a daily basis.
On the whole, this probably means they'll do a better job, too.

~~~
krallja
What country are you in?

------
known
[http://blogs.law.harvard.edu/abinazir/2005/05/23/why-you-
sho...](http://blogs.law.harvard.edu/abinazir/2005/05/23/why-you-should-not-
go-to-medical-school-a-gleefully-biased-rant/)

------
Ericson2314
So clearly healthcare in the US is fucked end to end. Has anyone (government
or private sector) tried or proposed some sort of trial hospital where we just
clean-slate redesign and evaluate the whole thing?

*Probably would need to be government as would need exceptions from tons of laws.

~~~
markroseman
Or look outside the USA at dozens of other countries that may have some
problems with their healthcare systems, but aren't anywhere close to as
completely fucked up.

Read the comments and listen to the debates, and understand that it isn't
going to get better until Americans believe that the availability of
healthcare shouldn't be solely dependent on income, and that "freedom" around
payment and insurance shouldn't be the primary value.

------
k__
Why do we do this to people who save our life's? Why do we let them burn out?

------
hourislate
Perhaps the solution to the unreasonable demands placed on Doctors/Surgeons is
moving forward with A.I, Stem Cell research, Robotic surgery, etc. Technology
should relieve some of the pressure.

~~~
eplanit
That is one of the primary targets for IBM's Watson, and it seems ready[1][2].
More and more my subjective risk calculation favors AI for diagnosis. This one
aspect I believe accounts for most of the overall time/effort spent in dealing
with patients.

To apply AI at the start of the process makes a lot of sense --
reduce/eliminate errors at the start and allow doctors and their time to be
better used.

[1] [http://www.nydailynews.com/news/world/ibm-watson-proper-
diag...](http://www.nydailynews.com/news/world/ibm-watson-proper-diagnosis-
doctors-stumped-article-1.2741857)

[2] [http://www.businessinsider.com/ibms-watson-may-soon-be-
the-b...](http://www.businessinsider.com/ibms-watson-may-soon-be-the-best-
doctor-in-the-world-2014-4)

------
timwaagh
a surgeon is considered replacable? they just might be the least replacable
professionals out there. i don't know what he is thinking. doctors are the
elite. at least where i live a surgeon can out-earn even government ministers
and CEO's.

indispensible. irreplacable. the rest of the industry should therefore be
focussed on getting as much value out of these doctors. which means they
should be focussing on taking any paperwork out of docs hands.

------
novalis78
Maybe he would be much happier working at a place like the Surgery Center of
Oklahoma which seems to do much better on the administrative side of things.

------
woodandsteel
I wonder if there are any research projects comparing physician workload and
satisfaction in various countries with various health care systems.

------
bluetwo
Where does the AMA stand on this?

~~~
killjoywashere
They actively pursue minimizing the number of medical school seats and their
lobbying has been tightly aligned with Republican health care policies for
decades. Check out Paul Starr's _The Social Transformation of American
Medicine_

~~~
kyouens
The limiting factor to creating more skilled physicians is not medical school
admissions. It's residency training slots. Most residency training slots rely
on federal government funding. Pretty much everyone, including the AMA, agrees
that there is a looming undersupply of physicians. There may be disagreement
on the best way to address the issue, but there is little disagreement among
physicians about the fundamental problem.

I have seen comments talking about "physician cartels" purposely encouraging a
labor shortage to drive up physician pay. There is no physician cartel. Only
about 15% of physicians even belong to the AMA, and only a subset of those
have any political involvement at all. It just doesn't exist.

One of the things that I think contributes to the general dissatisfaction of
physicians in 2017 is the increasingly negative public opinion of the medical
profession and the imputation that there is some sort of evil conspiracy at
work. A lot of the negative opinion is misdirected. It should be aimed at the
for-profit health care system itself. Most physicians I know have very little
control over the things people complain about, including cost.

~~~
killjoywashere
Depends on who's complaining about a bottleneck.

The AMA caters to a base that is not happy with the influx of IMGs and DOs.
The AMA inflates their numbers by auto-enrolling every allopathic medical
student. The AMA is equally unhappy that the government using large scale
funding levers at the residency level to overwhelm their efforts to tighten
supply. By using money and their exclusive access to legislate, the government
creates such a Venturi effect that they suck up all the available MDs, and all
the available graduates from two other pipelines: the DO programs and the
IMGs.

In 2017, the dissatisfaction of the 85% of physicians who don't belong to the
AMA is ultimately driven by too much work.

Source: am physician. Have worked primary care, seeing 40+ patients a day, now
completing a specialist residency. My work as an underpaid primary care doc
was enough to keep 3-5 people fully employed (reception, x-ray certified
assistant (sometimes 2), office manager, owner) from 8 am to 10 pm 7 days a
week, while sending overflow to others.

Every one of the 85% of physicians who aren't in the AMA declined to renew
their membership at some point. Many align with other orgs: almost invariably
their specialty's organization, which aligns with the AMA but they are more
professionally beholden to (for CME, board certification, etc). Many try to
offset the ill effects of the AMA by aligning with other orgs like PSR or MSF
or their local public clinics.

But the AMA has a bunch of offices in DC, and has had people in those offices,
paying mortgages in McLean or Chantilly, or Silver Spring, <insert DC suburb
here> for a century. Those people are motivated to continue their mission of
lobbying in support of the legal grip of allopathic medicine, long past their
original call to arms (licensure laws to cleanse the field of snake oil
salesmen).

~~~
kyouens
I'm also a physician. I am generally satisfied with my work, but I do feel
distressed by what feels to me like erosion of the social contract between
doctors and society that flourished during the second half of the twentieth
century. It sounds like we agree that some of that erosion has occurred
because of nakedly self-serving political action by medical professional
societies.

When I made the decision to become a physician twenty years ago, I thought
medicine was my calling. I believed that the personal sacrifices one makes to
be a physician--and there are many--would be rewarded with professional pride,
the respect of my community, the gratitude of my patients, and a secure and
well-paid living. I have gotten a little wiser, I think. I make a good living,
my work is interesting, and I still think medicine is a great career. But
times have changed, and I no longer consider medicine a calling for which one
should be willing to sacrifice one's personal well-being. I find myself
defending my profession on the internet a little more than I'd anticipated :)

Those who control the business of medicine take economic advantage of the
patient-first mindset of our medical tradition, and it cheapens what we do,
both literally and figuratively. It is for that reason that, despite its many
flaws, I do think organized medicine does have redeeming qualities. It gives
physicians at least some voice in politics, where they would otherwise have
none at all. Maybe one day health care reform will right the ship.

~~~
killjoywashere
Don't get me wrong, we have a great gig. A fellowship director once expressed
shock that I would advice my kids to go into medicine. I asked him "Have you
looked for another job? I had a job before this, and had to look for another
before I got an acceptance letter, married with two kids. Have you looked at
the job market? What other job pays half as much, is half as satisfying, or
gives you half as many further opportunities?" His reply: "Yeah, I mean, when
you put it that way..."

Well, what other way are you going to put it?!

I'm all for organized medicine. But I favor PSR and MSF. They represent the
ideals of the modern liberal social order. The AMA needs to be starved off the
face of the earth.

------
Floegipoky
Related: [http://www.wbur.org/commonhealth/2017/05/12/boston-
electroni...](http://www.wbur.org/commonhealth/2017/05/12/boston-electronic-
medical-records)

I always see people ragging on EMRs. They're inefficient, have poor UX,
require way too much documentation, etc. These are all fair criticisms, but I
don't think people spend enough time asking why. Why are all the major EMR
systems shitty in exactly the same way?

I think there's 2 main parts to the answer. The first is the sales process.
The people selling EMRs to hospitals aren't selling their product to
clinicians, they're selling their brand to the hospital administration. It's
like the saying "nobody ever got fired for choosing Oracle", but far worse.
The end result is years-long implementation processes, broken promises, and
terrible tools that are optimized to allow the hospital to fire a few members
of the low-level administrative staff (billing, coding, etc) instead of
providing better care to the community they serve.

The second part of this problem is overregulation. The justification is that
EMRs should be able to meet a certain level of functionality. Based on
personal experience working with these regulations, I'm convinced that the
real reason these certifications exist is to prevent new players from entering
the market. They are very much in the spirit of "well all these legacy systems
do [something], so _obviously_ everybody else should too" without ever leaving
room to come up with a better solution. They shackle you to terrible design
choices and assume that all hospitals, from a 10-bed critical access hospital
to a 500-bed academic medical center, should all be run the same way. And
worst of all, they make it impossible to design a system based on what the
HOSPITAL needs, because half of the system is devoted to what the GOVERNMENT
needs. Kind of like how people complain about interoperability between
electronic medical systems. So the government introduces legislation to
mandate interoperability, by requiring implementation of poorly-defined
"standards" (designed by committees comprised mostly of, you guessed it,
representatives from legacy vendors). From personal experience, I can say that
every. single. one. of the interfaces required for federal certification is
completely unable to be reused by actual hospitals. But that's the entire
purpose, that's exactly why lobbyists paid so much money to get the
regulations passed in the first place! If potential new competition has to
sink thousands of man-hours every year into building useless functionality,
that's thousands of man-hours that didn't go into making their product
competitive and disrupting the marketshare of legacy systems. Meanwhile,
legacy systems are maintaining their market share, not by improving their
product and helping healthcare providers do a better job. Instead they're
actively creating situations where smaller hospitals are forced to choose
between buying onto the licenses of larger hospitals or shutting their doors.

Obviously this is all just my personal opinion.

------
kapauldo
Hard to feel sympathy for millionaires living a life of their choosing.

~~~
markroseman
My wife is a doctor, over a dozen years in practice. Tell our mortgage about
how she's a millionaire. And to me, a life of her choice would likely have a
lot less stress and shorter hours, and not worrying that the income would dry
up if she has to stop working.

------
andy
What other dark side of doctoring issue can I think of? Well, the doctors and
nurses at Fairmount kept me prisoner without the ability to call my friends or
family, denied me water, physically tackled me and tied me down. I was not
allowed to use a lawyer of my choosing. I did not hit back when they tackled
me. I never committed a crime. I feel like I am being repetitive. That is
completely on purpose. The dark side of doctoring is at Fairmount Behavioral
Health in Philadelphia, PA. It's a hellhole and should be closed.
[https://surroundedbyspies.com](https://surroundedbyspies.com)

