Our pediatrician is somewhat of a Sherlock Holmes. Our daughter broke out in a rash on her face the other day, prompting a sick visit. I was off work that day and planned to spend some time together with my son, but he had to come to the doctor with us. With him complaining bitterly all the way, we set off to the pediatrician’s office. The three of us were in the exam room when our doctor entered, gave his kind hellos, and asked about why we had come. He sat across the room from us, listening and observing. He surveyed the room and made conversation with our son about the end of school. After a few minutes, he carefully explained his diagnosis of the skin rash. He had noticed that my son had a similar though lesser reaction on his arms in the sun-exposed areas. This, which I hadn’t noticed, was a clue to his reasoning. He had come to his diagnosis not just by examining her the patient but by taking in all the others in the room. It reminded me of all the times he has demonstrated his level of observation and skills as a physician and of how he thinks about people and families as a whole.
Over the last four years, we’ve come to know and greatly appreciate our pediatrician. He’s an excellent doctor and a kind man. As a primary care physician, he’s always been there for us. He’s patient, thorough, knowledgeable, and he always seems to know what’s wrong when our children are sick. He talks with us of not only our children’s physical health issues but also their emotional development. For parents, having a good relationship with a trusted pediatrician is important for your parenting sanity. The same is true for the child. It can be difficult for children to feel comfortable sharing their physical or emotional pain with others, and it takes time for them to establish this trust with someone. This doctor-patient relationship can serve as a vitally important resource as the child grows up and their relationship with their body and emotions becomes more complex.
At our daughter’s recent checkup, our pediatrician announced he would be leaving the practice. I’ve been grateful for him and I’m sad to see him leave. My secondary concern, beyond losing him as our care provider, is the volume of patients being care for at our doctor’s office. Three out of four physicians have left this practice over the past three years. As a parent, I worry how the remaining providers will have time to care for my children. As a local doctor, I’m concerned about how they will care for the children of our community. We live in a rural area, and this is the only pediatric practice in our town. I am fortunate enough to have resources, but there are other people who may not drive, have a car, or be able to afford to pay for the healthcare if they needed to go elsewhere.
Professional Concerns
It’s becoming more difficult to retain medical providers, especially in primary care (pediatricians, family practice, and internal medicine). Many of these providers are vital parts of the lives of their patients and families for years or even generations. So, why are many of them leaving the practice of medicine? The NY Times guest essay “Doctors Aren’t Burned Out from Overwork. We’re Demoralized by our Healthcare System” is a brutally honest description of the reasons behind physicians leaving the workforce, listing, among others, an aging population of physicians, pandemic concerns, excessive bureaucracy, reduced time with patients, and reduced insurance reimbursement from managed care companies.
Providers of all types have long lamented the loss of time with their patients since the advent of managed healthcare in the 1980s. Managed care is defined as the delivery system of healthcare in the United States that includes a group of activities originally intended to reduce costs and improve care. While those sound like great goals, the reality hasn’t turned out quite so well. One of the activities that aim to reduce costs is the negotiation of reimbursement rates. When a provider is in contract, the insurance company has more leverage over negotiating what they are willing to pay the provider to see a patient or perform a procedure, regardless of what it costs the provider or the facility to do so. This process drives down reimbursements and thus creates pressure to increase productivity by seeing more patients and spending less time with each person in order for the individual provider or the hospital to make enough money to cover their costs. Most insurance companies base their reimbursements off of the Medicare reimbursement rate. In 2021, this reimbursement was increased as part of the COVID-19 stimulus package. Prior to this increase, the Medicare reimbursement rate for medical providers had not increased for thirty years, despite the increasing costs of care.
Another example of insurance companies failed attempts at reducing costs and improving care is their requirements for conditions that must be met for them to pay for diagnostics (labs, imaging) and treatments (medications, procedures). The aim is to decrease what they consider to be unnecessary tests and procedures. I’ve often found this rationale curious since it’s difficult enough to motivate patients to even go for necessary procedures and I barely have time to review necessary tests, let alone unnecessary ones. Rather, the results of these insurance requirements more often take the form of me and my colleagues spending the already limited time we have arguing with insurance administrators without medical degrees for tests to help us determine what is wrong and treatments that patients could really benefit from or absolutely need. Often, more expensive medications require insurance approvals, and when you call for them, you end up speaking with a non-medical professional reading from a form asking if you’ve already tried a few medications the company thinks should be tried first. This algorithmic approach rarely takes into account the complex realities of people’s bodies, minds, and lives, not to mention scientific advancements that may now offer newer medications that work better and have fewer side effects.
Violence, Stress, Burnout, and Litigation
Another contributing factor to the exodus from healthcare and social service industries is workplace violence, which has been on the rise since 2011 but peaked during the pandemic. Most studies show that healthcare workers, particularly nurses, are at far higher risk of workplace violence than most other professions. The Bureau of Labor Statistics reports that 10.4 in 10,000 workers in healthcare experience some sort of workplace violence, which is significantly higher than the 2.1 in 10,000 across other industries. In 2021, a survey of more than 500 physicians in the US found that 24% of female and 22% of male physicians had been harassed on social media and that the main mode of harassment was death threats. Workplace violence is associated with psychological consequences like PTSD, burnout, depression, anxiety, and a willingness to leave the profession. The pandemic brought an increase in violence against physicians and healthcare workers as anxiety, frustration, and aggression toward physicians reached an all-time high around the globe.
Violence was not the only concern for healthcare providers that rose during the pandemic. The word burnout has become commonplace in many health care institutions. According to the 2019 book Taking Action Against Clinical Burnout, between 35% and 54% of American nurses and physicians were feeling burned out, and this was written before the pandemic even began. In 2021, The Atlantic published “Why Health-care Workers are Quitting in Droves,” a grueling account of the moral distress spurred by the previous two years. The author states “Several healthcare workers told me that amid the most grueling working conditions of their careers, their hospitals cut salaries or reduced benefits, and canceled raises; forced staff to work more shifts with longer hours; offered trite wellness tips, such as keeping gratitude journals, while denying paid time off or reduced hours.” The Bureau of Labor Statistics estimates that the healthcare sector has lost half a million workers since the pandemic started in February 2020.
For those that stay in the profession, many don’t feel the same as they used to about their jobs. A survey by the Physicians Foundation found that more than two-thirds of physicians feel negatively about their profession. These negative emotions can have devastating consequences. In Danielle Ofri’s “An Epidemic of Disillusioned Doctors,” she cites evidence showing that disillusioned and burned-out doctors are more prone to medical errors and even depression, substance abuse, and suicide. In the 2021 Medscape report, one in ten physicians surveyed said they either considered or attempted suicide.
In a Time magazine article, “The Unspoken Reason Why Many Doctors and Nurses Are Quitting,” Dr. Gita Pensa, an emergency physician, acknowledges reasons similar to what I discussed, namely that physicians are worn out after working through the COVID-19 pandemic, the staffing shortages, and the “daily roadblocks set up by intransigent health insurers, error promoting electronic health records, and C-suite executives with little understanding of the boots-on-the ground-perspective.” However, she believes a less spoken reason is litigation. As a physician coach for those experiencing litigation-related issues, she outlines the stress and shame physicians feel when involved in litigation, even if no wrongdoing had taken place. Of course, medical errors do occur and those who have been negligent should be accountable, but she points out that this is not always the case. The majority of suits end in non-payment, and even when cases go to trial, the physician proves their innocence 85% of the time. However, regardless of the outcome of the suit, litigation remains a significant cause of physician stress, suicide, burnout, substance use, and mental health crisis. She skillfully sums up the situation by asserting that physicians “are tasked with the impossible, and blamed when unable to achieve it…. People are dying that would not be dying, if we only had the time and resources to do our jobs as we were trained to.”
Supply vs Demand, Shortages
Aging physicians, exhausted by stress and professional challenges, eventually retire, but there are more people leaving the workforce now than those entering it. When queried, the American Medical Association (AMA) cites increasing cost of higher education in the United States as a barrier to adequate physician supply. It claims that most doctors graduate with at least $200,000 in medical education debt. When I read this I actually thought is was a conservative estimate. When I graduated from medical school in 2010, the tuition and living expenses for the four years already amounted to a little over $300,000 of debt at graduation. Additionally, if one had undergraduate debt, the number could be even higher. After graduation, you go to residency training, where the average gross income is $36,884 the first year, leaving hardly enough to pay your bills and certainly not near enough to make much of a contribution to your substantial debt. By the time one completes residency training three to four years later, with the added interest, the debut could amount to near half a million dollars. Due to lower reimbursement rates from insurance companies, compensation for primary care physicians in the United States doesn’t make it easy to recruit more young doctors to those professions.
What is the Solution?
There’s no one answer to solving this complex problem but I ask readers to consider this: First, primary care is very important because when we don’t take care of the physical body or mental distress early, it often goes on to become a larger problem that’s not as easily ameliorated, ultimately leading to higher burden of disease, higher mortality, and higher costs, not only to the individual but to the community as a whole. Investing in our primary care physicians, particularly in those who work to prevent disease, is investing in everyone’s future health. Secondly, as the available healthcare providers in primary care continues to decline and shortages occur, eventually we will all be affected. We need to have trusted primary care providers available. Everyone has been a patient in their life (and will likely be one in future). Reflect on how you felt in that moment, think of a provider who helped you and please support the work of these care providers so that they can be there to support your families, your children, and you when you most need it.