Richard Reece, MD

The Mayo Clinic recently conducted a survey to quantify how many physicians show signs of burnout; of approximately 7,300 respondents, almost half did.

Their conclusion – the practice of medicine should be more of a team approach. Mayo has thrived on a consensus approach to care, but Mayo is not representative of the rest of the U.S. where 60 percent of physicians practice in groups of six or less.

 article sent by a colleague. He thought it was important, and he is correct - it is. Not for the obvious conclusion, but for the validation that the backbone of our healthcare system is in trouble, as physicians struggle to cope with forces of market and government-induced reform.

Whether or not this sounds like you, read on. Our observations will be either informative or cathartic.

The pressure on physicians comes from many directions. Too many or too few patients; insufficient and dwindling reimbursements; uncertainty; frustration; a struggling economy; second-guessing by insurers, regulators, and trial lawyers; practice, hospital, and peer politics; overreaching and overreacting regulation; financial woes; speculation; failed purpose syndrome; misinformation; too much information; inadequate time to properly care for patients; a looming flood of Medicaid patients; 78 million baby boomers becoming Medicare eligible at the rate of 10,000 patients a day; and the list goes on.

The degree of change is individual, the combination is regional, and the problem is national.

Today’s system trains and equips physicians to practice medicine exquisitely and to deploy the best technologies, but it fails miserably to prepare them for the business side of practicing medicine, leaving many vulnerable and increasingly easy prey, and fully liable, for changes mandated by others.

We have watched this build over nearly two generations, much of it from our respective perches in the C-suites and as physician leaders and defenders, and today on the front lines as advisors and weekly commentators.

Many practices have become insular with almost a siege mentality, while others have become suspicious of outsiders, resigned, or are whistling past the battle lines as if nothing has changed, or will.

Then, there are those who have dropped out, gone to other careers, retired, or taken jobs with hospitals or clinics. In the words of Skip Holtz, the University of South Florida’s head football coach, “The grass is always greener on the other side until you have to mow it.”

This is not a “woe is me” moment; it is a clear and present danger to the healthcare delivery system and much of it is self-inflicted, particularly the growing problems with alcohol and substance abuse.

As individuals and small groups, physicians, like anyone or anything, are relatively powerless against large systems on a mission, even well intentioned ones.

The attitude of the large systems is often that eggs have to be broken to make an omelet. This is all well and good until you’re one of the eggs, sitting nestled in your little cubby in the carton, all alone and easy pickings.

It’s when the eggs team up with the chickens that things get interesting.

To spare us all from continuing with this analogy, strength is in numbers, and voices are heard only when one speaks up.

Burnout occurs when someone else is in control. It is often reversed when one has or is represented with an equal seat at the table. Every specialty is organized; every state has a medical association. Being involved and getting that seat at the table is more than therapeutic for those on the road to burnout; it is the missing link to a functional and sustainable healthcare system.

Richard Reece, M.D. is the author of "The Health Reform Maze."

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The backbone of our healthcare system - the physician - is in trouble, as physicians struggle to cope with forces of market and government-induced reform.

Physician Burnout Symptomatic of Healthcare's Current State

When Edward Lorenz, a Harvard mathematician and meteorologist, coined the term “The Butterfly Effect” 40 years ago, he used it to simplify his broader “Chaos Theory” by saying that extreme weather in Texas or New York could be caused by a butterfly flapping its wings in Brazil. The Chaos Theory also holds that an outcome in any field of human endeavor is highly sensitive to initial conditions.

When Congress passed the Affordable Care Act (ACA) in an attempt to redirect the unsustainable trajectory of our $2.9 trillion, extraordinarily complex healthcare system, it did so with about 2,600 pages of potential progenitors of the Butterfly Effect.

The casualties of the first flutters wrote large are being seen already. They are doctors being driven out of private practice and into the safe refuge of employment by hospitals, large clinics, and integrated health systems. These consolidated systems, with near monopolies in many geographic regions, will be powerful enough to demand higher rates and new fees from payers. As a countermeasure, government reformers are pushing accountable care organizations, with bundled bills, budgetary caps, and capitated rates, shifting risk to closed systems of physicians and hospitals.

Will big box medicine actually lower costs? There are valid grounds for doubt. If and how long the federal government can afford to keep the new system afloat with cash as it conversely heaps on mountains of new regulations and unfunded mandates lengthens the odds of success considerably.

Exacerbating the entire situation is the present public health concern of physician shortages building to crisis proportions as so starkly outlined by Annie Lowrey and Robert Pear in their July 28, 2012 New York Times article, 

“Doctor Shortage Likely to Worsen With Health Law.”

Putting physicians who have invested a decade or more in intensive training with six figure school loans out of business and into a big box lab coat is far removed from putting a general store owner out of business and into a big box retail vest. The level of dissatisfaction among physicians is already profound, and worsening. Of greater concern - they have choices other than clinical medicine and resources to pursue them.

So, the question is: Is driving a systemically distressed, contracting, dissatisfied and undercompensated physician sector to be forcibly absorbed by a traditional antagonist, but symbiotic hospital sector on the edge of distress itself and binding them together with miles of red tape and questionably reachable incentives going to reduce costs?

In a July 16, 2012 op-ed in the Boston Globe, Lynn Nicholas makes a compelling case that Massachusetts experience with “Romneycare” proves that 

reducing payments to hospitals doesn’t reduce healthcare costs

; it just shifts them to someone else. The converse being true is equally logical. Shifting risks from one entity to another doesn’t reduce health costs; it just shifts risks – in this case from payers big enough to absorb them to providers, who are not.

One proponent of passing risk and reward to providers is David Lawrence, MD, chairman emeritus of Kaiser Permanente, who reasons that team-based medicine - coordinated care with physicians working in teams - replacing independent, fee-for-service physicians with structured organizations and salaried physicians, will bring order out of chaos with lowered costs

.

On the other hand, Dr. Brenda Zimmerman and her co-authors in their groundbreaking book, “Edgeware: Insights from Complexity Science for Health Care Leaders,” believe that combining workable systems rather than unworkable master schemes and mixing cooperation with competition, rather than emphasizing one or another, is the key to success

The smart money, however, is on the “Cyrus Vance 2 1/2 Rule,” which has proven true time and time again: “Always remember that everything takes twice as long, costs twice as much and works half as well as the original projection.”

Vance was Deputy Secretary of Defense back in the 1960s. His was no theory.

 David Lawrence, “From Chaos to Care: The Promise of Team-Based Medicine,” Perseus Press, 2002


 Brenda Zimmerman, Curt Lindberg, and Paul Plsek, “Edgeware: Insights from Complexity Science for Health Care Leaders,” VHA Inc, Irving Texas, 1998
 

Under the Affordable Care Act, private practice physicians are closing up shop and joining big box medicine in a plan to trim healthcare costs.

Author | Richard Reece, MD

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