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.
While Medicare covers almost all of it, it became so nauseating to read the outrageous EOB totals that I tried to put a end to it - I requested that unless the on call nurse (after hours) or physician (during business hours) deems the fall to be a life threatening emergency, they are to be kept in the facility.
They found a workaround for that real quick - it's nearly always deemed life threatening because they are 1) unable to determine internal bleeding 2) unable to determine if a bone was fractured/broken.
The obvious solution to this is to have an xray machine on site, because since everyone in the chain gets paid huge $, and it removes the liability from the nursing home to ship them off to the hospital, the merry-go-round of insanity continues. We have two family members in an assisted care facility for almost eight years now, and between the two of them, they've tapped Medicare for just under $700K. Together, the sum of both their incomes throughout their entire working lives never totaled that amount. This is why I call it a ponzi scheme.
Elderly Americans experience about 29 million falls per year, which costs Medicare $31 billion. At about $1,000 per fall that seems quite reasonable. 27,000 older Americans die from falls each year. In an institutional setting like a nursing home, the rate of death per fall is even higher.
$700,000 for two people in assisted living for eight years is about $43,000 per year. That's not unreasonable for the cost of assisted care plus medical expenses.
https://www.medicare.gov/about-us/how-medicare-is-funded/med...
Oh, but it gets worse. It's bad enough that the government is being bilked for hundreds of thousands of dollars on behalf of those without the ability to pay, but even for those with significant assets, there are "perfectly legal" tax dodges that can be set up for $XX,XXX so that Medicaid pays the $XXX,XXX bills while the family inherits the $X,XXX,XXX estate. And if you pay the lawyers a little more, they can probably even figure out how to avoid paying capital gains on the distributed assets if they are below $10 million.
I don't see much hope for the insurance reform in the US until we can get end-of-life costs under control. I don't if "Ponzi" is quite the right term, but it's definitely a system rife with fraud.
More generally, "House of God" is a stunning inside look on how the US medical system actual works: http://slatestarcodex.com/2016/11/10/book-review-house-of-go...
There's a strong medical education research unit in the UK (Edinburgh?); I remember one of their reports on a series of med student interviews making the observation that it was unnerving how the top performing medical students weren't the most compassionate, they were the most ruthless.
I'm taking my boards soon and I have to say, the ability to commit to the task, regardless of the emotions of your self, patients, peers, support staff, and family can definitely be an asset at times. Do I hope to take a kinder view when I start working in a few months? I'm not sure kinder would be the word. Supportive of a somewhat different set of ambitions, perhaps.
Unfortunately, that ability to deny the emotions of both self and other in pursuit of good clinical care is difficult to separate from 1) the punishment of self-loathing, and 2) the behavior of someone who has been rewarded too long for blind obedience.
I'm also working at a healthcare tech startup aimed at reduced the administrative burden to doctors, administrators and insurers of managing their patients at home, which is where the worst outcomes often happen.
Each segment we work with feels this burden, it is not isolated to the physicians.
Healthcare is one of those fields where there's no guarantee on the quality of the service. There's no pay for performance. Actually, doctors who perform too well would reduce healthcare spending.
There are plenty of reasons to keep developers happy because it directly affects the end product and profit.
Docs and hospitals have been dealing with 'P4P' for decades and the ACA ramped it up significantly for the CMS.
The worst part is that many doctors often defend and work to perpetuate the system, rather than organizing to make it sane. It is truly boggling.
It's worth reading more about the history of medicine to truly understand what's going on here -- the culture of abusive overwork in American medicine goes at the very least back to Osler and the invention of the modern residency program, and has as much to do with cocaine than any corporate malfeasance. Certainly hospitals and the medical industry profit from this culture, but they hardly created it.
Also, on what basis do you say that longer hours with fewer tradeoffs don't improve patient outcomes? You frame it as though it's obvious but is there any evidence to back that up? My wife and most other doctors I know all claim they'd rather have longer hours with fewer handoffs.
Doesn't it sound like medicine is like a web service infrastructure where everything is on fire, and there's just no time to really fix the root causes?
FWIW, my mother is an MD, a Family Practitioner. She eventually became head of FP for a small commercial hospital chain in the US. Two years ago, after perhaps 18 years of professional practice, she moved to New Zealand and is a FP in a small town. She takes 3 days off a week, has reasonable hours, does less paperwork, does more with her own hands which she would refer to specialists in the US. She absolutely loves it.
I do think the increasing corporatization of medicine in the USA has accelerated the loss of autonomy and satisfaction, which makes the abuse and overwork far more difficult to take.
If you're exhausted or in physical pain or have a cold, you not only power through it but you suck it up and refrain from complaining, even if you're assisting a surgery. You may be officially encouraged to know and respect your limits, but if you actually do this you quickly go from being a "brother in arms" to weak and unsuited for the profession.
A software engineer is hired for their skills (at least ostensibly). No one is required by law to hire someone with a specific degree and specific post-degree training and specific exams.
Contrast this with healthcare. To do certain sorts of procedures, you have to hire a physician. Not because it's demonstrably necessary to have someone with an MD and a residency in such-and-such area do this, but because it's required by law.
As someone else pointed out, this is just the tip of the iceberg. That residency? Residents have no bargaining leverage over their conditions by fiat of residency rules--they cannot leave an abusive residency, for example, to change conditions. Financing the residency itself? Businesses won't cover the expenses because it's not actually worth the costs, so the government foots the bill. And once you leave residency? Well, subspecialty organizations are deciding that it's good to carve out even more regulatory capture with subspecialty credentialing.
People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety." It's like terrorism or crime: no one wants to be branded as soft on terrorism or crime, so the government becomes more and more invasive and draconian, and the costs of maintaining the military-police-industrial complex increase and increase. Similarly, no one wants to be soft on safety, so the government becomes more and more invasive and draconian, and the costs of maintaining the medical organization-physician-insurance-industrial complex increase and increase.
There's something disingenuous for physicians to complain about being overworked, and then fight against the things that would alleviate their burden the most: letting perfectly competent professionals with different backgrounds do what they do just as well. But that would mean admitting that you don't need an MD at the apex of healthcare.
To some extent, financial market pressures are doing what I'm saying anyway, as hospitals are realizing that MDs are too expensive as they are. So maybe this is just the first sign of things to come. But the downside of the current system is that administrators aren't allowed to go elsewhere for alternatives, so they just crank up the hours expected of MDs. The upshot is they get devalued without even being given the benefit of being let off the hook.
I guess to address your comment directly: if healthcare were actually a transparent free market, my guess is physician salaries would go down, but their workload would also decrease also. What you'd see instead is much more diversity in who you see for any given service.
The biggest sin of the government in the healthcare debate is willfully ignoring the costs of healthcare, by failing to increase competition, choice, and transparency in pricing. We talk about who pays, but not why we're being charged what we are, and whether or not it's worth it.
Also, exorbinant salaries and good hours are not to be found in the hospital system. Yes, specialist doctors get paid "well", but not exorbinantly, when adjusted for required training, education, experience, and opportunity cost. In private practice, the hours are better, yes -- but only in certain subspecialties. But this is like saying major airline commercial pilots should just fly private charters for a better lifestyle, or that software engineers should just work at hedge funds as quants for better compensation.
It's the hospital system, not private practice, that shows us a healthcare system where doctors are being put to their unique purpose of advanced clinical treatment. And that's where the market is failing.
Healthcare requires the hospital system to provide the most advanced and emergent forms of care, and that is where doctors are overworked and undervalued.
As for the free market, I wish you were right that it could fix the US healthcare system. But patient health is, unfortunately, not valued correctly by the market. The market rewards chronic treatment, whereas society prefers one-time cures. The market tries to monetize patient-doctor interactions, whereas society would prefer fewer doctor visits with fewer hospitalizations. The market treats doctors as a cost center whose hours needs to be billed out at a profit, and society would prefer doctors as a value center who are given the professional leeway to use clinical judgment in assigning time to cases and patients.
I love market systems, but only when they work.
The other thing is that with the current system (i.e. medical doctor prescribes), there's liability coverage through the doc's liability insurance, which unless psychologists are interested in taking on huge liability insurance premiums...
> People do not grasp how much of this insanity is codified by law and rule, and when they are informed of it, they shrug it off in the name of "safety."
Not to make minimize the problem, but this feels a bit like privacy in IT (or lack thereof) due to government overreach.
People care much less about something when they are not directly impacted (or think they're not impacted).
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.
Contrast that with what exactly is provided by healthcare insurance executives, bankers, lawyers, lobbyists, and certain departments in government.
To be blunt: once you note the fact that other countries in the world can provide healthcare at fractions of the cost, it's obvious those insurance execs, politicians, and lobbyists are eating value, not creating it. The contrast is that Doctors actually produce something of value.
And even if I were to agree with your premises, do we really want a system that selects for the kind of doctors who are willing to put themselves and their loved ones through years of hell in exchange for an eventual high and stable paycheck? What kind of people are these? Are they the kind of people you'll trust to treat your scared child gently and empathetically?
It isn't clear how much the grueling training actually factors in to limiting the supply.
I will say thought, that this is a really typical path in the US, at least:
* 4 years undergraduate ($200K debt, high competition/workload)
* 4 years medical school ($250K debt, high stress/workload, 50% odds of not being accepted)
* ~3 years residency (pay only $50K/yr, famously high stress/workload, possibility of being separated from loved ones or making hard choices in residency match)
So assuming starting undergrad at age 17, you have had a tough 11 years and are at least $300K in debt by the time you are 28 and getting your certification. This is ignoring specialties with fellowships. I don't have the time, but I'm sure it's possible to estimate the quality of the time sacrificed to education and lost compensation during that time and then amortize that over a typical career.
And the field is different... after all of that training they get to spend an inordinate amount of time doing paperwork/fighting with insurers, which (seems to be) leading to more group practices with workloads like those described in the article.
The hourly rate for some doctors (mostly non-procedural) are much much lower than people realise and is only made up for my doing ridiculous hours. This is just not right.
This delusion that all doctors do well financially draws more poor students into the long training commitment only to find out at the end that with all the debt and sacrificed family hours and stress (having been through this) they are going nowhere financially.
Looking after patients can be a great and fulfilling career but this depends so much on the particular speciality you choose and the work life balance that it provides.
Next time you see your ED physician or family practitioner feel sorry for them. The shit and conditions they deal with and poor renumeration is something you simply don't understand.
I wonder how many doctors would be up for "sharing work (and compensation)" - in other words, would a doctor be OK with dropping his comp to $150K (from $200K) so the savings can be used to add a third more doctors to the staff? The "relief" in working conditions may well be worth it, for the doctor's sanity of course, but also for the patients (and all of the benefits down the line from having fewer mistakes, etc).
It's obviously not the only dimension that can be played with to help, but it's one that could be fairly straightforward to implement, as long as there is enough supply of applicants to increase the workforce.
My wife is a pediatric emergency medicine physician and I get paid more than her because I'm in tech. Also, I started my career and began earning an income right after college, whereas she went to medical school and a fellowship before she could begin earning income.
I always joke with her that, in terms of income efficiency, my field is way more profitable than hers. And a lot less stressful too.
Is this the case? Or do they not adhere to the working time directive?
I think a UK doctor's hours are probably easier than a US doctor's but we all break the EWTD (except for some specialties like psychiatry). For example I am rostered to work an average 48 hours a week, although there are some weeks I work more, and I will often stay behind to get things done. My total hours per week is probably around 50 - and I'm in a job that isn't considered busy!
I'm willing to bet that something to relieve the massive amount of "other" stuff needed besides the Doctor would go a LOOOOOONG way...
That doesn't even tackle stuff like inability to see how much something actually costs - and shop around for stuff other than the ER.
15 minutes per patient isn't the answer...
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.
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/
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.
I recommend reading "When Breath Becomes Air". The author's friend (a general surgeon) has a patient die on the table. He goes into great emotional distress, eventually committing suicide.
Brilliant, good hearted people being pushed to self destruction. Not the way an industry should want to behave.
Cuba decided they wanted more physicians, so they invested in them to the point that they could use them as an export. If we have a shortage of doctors (which I think we do), the people with the power to change that either don't believe we have a shortage or have a vested interest in keeping a shortage.
It is, however, subject to stricter licensing/certification constraints which are mostly in the hands of the existing body of practitioners ...
Scalable work, where tools multiply worker effectiveness exponentially (tech, finance, manufacturing),
Non-scalable work, where tools multiply worker effectiveness linerarly/constant (everything else).
It is a little bit of a Taleb's world where exponentials live side by side normal distribution.
Scalable work is much more profitable than linear work. Where I work, being scaleable is a requirement. If it is not scaleable, we are not doing it.
This creates incentive to make everything scaleable. Which is a big problem for those whose work is inherently linear: teachers, doctors, waiters. They get put in optimization straightjackets for marginal improvement. And it sucks the soul of what they do. It makes world a less happy place, filled with 15min doctor appointments, restaurants where tables must be turned every 2 hours for profitability, etc.
The compound problem for doctors has been that they have to perform highly creative, high impact tasks while inside the optimization straighjacket. That's got to hurt.
Many medical specialities have concerns with depression and suicide. ER and ICU are among the two with which I have personal experience that face these issues quite acutely. If you have a loved one in one of those departments, the last thing you want to hear is that your physician may be dealing with depression and suicidal thoughts.
Personally, I don't think the advantages outweigh the disadvantages. I suspect removing the shift schedule nature of emergency medicine may have a remarkable improvement. Many ER nurses and clinics have already moved away from a rotating shift schedule, and I haven't heard of any serious repercussions. I really hope emergency physicians follow suit someday. Or, find an alternative model that doesn't incur such health issues.
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.
I hate when this gets brought up, because it inherently implies that we can't improve them. Everyone talks about increases in handoffs causing increases in medical errors. I think handoffs have a long way to go, and we need to better utilize technology to help in this (ie make better EMRs).
The overworked doctor is just as bad IMO. I've been there on solo 28 hour calls going on my 11th admission. In the morning I'm next to useless and my handoff to that team was less than stellar.
A couple thousand hours of flying, many of which can be paid work (like flying an add banner).
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
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.
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)
[1] http://www.usatoday.com/news/health/2005-03-02-doctor-shorta...
A few possible conclusions. I don't have enough knowledge to pick one. Some of my speculation might even be wrong.
(A) DOs and MDs filter through different or mostly different residency pipelines. Thus, residency limits for MDs don't affect DOs, so the DO population can grow more quickly.
(B) DOs and MDs do filter through mostly the same residency pipeline, and the increasing number of DO graduates is causing an increasing number of residency applicants to not be admitted to any residency program. (This malicious situation would be similar to the situation with law schools, which admit and graduate far more lawyers than the industry can possibly sustain and support in its current state.)
(C) There's enough non-government funding of residency slots that residencies are not as bottlenecked as the first answer claims. If so, this re-raises the question on whether MD admission is being rate-limited to increase scarcity and thus salaries.
(D) Perhaps something else I'm not thinking of.
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.
It's quite clear to me what needs to be done here. America needs to import medical professionals. They're out there, they're needed here.
Or at least, more practitioners. We don't need doctors with huge amounts of training to do every evaluation.
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...
> 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...
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.
I think knowing a doctor, or someone becoming a doctor, has changed my perception of doctors entirely.
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.
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.
She said she likes it because she can define her own templates and "dot phrases" that make it easy to set up her own workflow. Also that it's nice that everything is all in one app - in other systems you'd have to be jumping between apps to look at lab results and patient messages for example.
This is something I don't understand. I'm a medical student, and the amount of time I've seen wasted watching older physicians type notes is staggering. Just have them dictate the notes and hire a secretary. Perhaps for legal/liability reasons doctors need to write their own notes but it's just such a waste of time, and we pay a lot for it.
Do we really though? I'm assuming a doctor is a salaried position so the more busy work they get the more hours they work? Doesn't this mean their time becomes less valuable?
I used to work at a medical lab and there were transcriptionists, billing dept, a dept. for quality assurance of every report a doctor wrote, customer service, etc. Hospitals have all of that plus nurses (RNs, CNAs, etc.), physician assistants, and probably many others.
Part of the problem is how much paperwork/procedures/diagnostic reporting is legally mandated to be done by doctors. The other part is...money. Businesses want to/need to squeeze as much money out of the doctors and that requires seeing as many patients as possible.
Are you referring to:
> In the mean time, I field 12 phone calls from ED, GP and other units. … I get called four more times between midnight and 6am.
These are clinical calls: the other units need information about previous treatment, or clarification about current treatment, or updated instructions due to a change in conditions.
E.g.
> Ring, ring
> Hello, this is the Levi residence, Dr. Levi speaking
> Hello Dr, patient XXX's vitals have changed/is reporting discomfort, do you want to change treatment?
> Yes, administer X ccs of Drugaline and call back if their situation doesn't improve in 2 hours
> OK, thank you Dr
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.
Karl Marx
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.
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...
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?
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.
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.
* Golden handcuffs
* Sunk cost
* Rewarding mastery
* Deep specialized knowledge with no other remuneration prospects for that knowledge.
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.
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.
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.
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...
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.
*Probably would need to be government as would need exceptions from tons of laws.
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.
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...
[2] http://www.businessinsider.com/ibms-watson-may-soon-be-the-b...
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.
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.
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.
