Straight Dope on Medicine: Physicians Quitting

Medice, cura te ipsum

‘“Physician, heal yourself.”  Luke 4:23

Physicians aren’t healing.

They are burnt out and quitting en masse.

So says Mayo.

What we found in that study was at the end of the second year of the pandemic, fully 63% of physicians are experiencing some sign of burnout across the United States. And that reverses a six-year downward trend that we've been observing in burnout rates. And it's a marked jump up from 38% just one year earlier toward the end of the first year of the pandemic.

And along with that, well, a year ago, about three-fourths of physicians would choose to be a physician again. A year later, at the end of the second year of the pandemic, that number has dropped to only half. So it says to me that burnout rates have gone up. Satisfaction in the role of being a physician has really dropped.[i]

Further, one in five physicians are planning to leave the profession. That is the tell. Of the remaining active physicians, one in three is contemplating cutting back their work hours.

Physician heroics

Sometimes we lose sight of just how valuable physicians are. They save us when no one else can.

What better place to go to witness physician heroics than the battlefield?

CMS member John Ogle, MD, MPH, is an emergency physician in Longmont and a colonel in the United States Air Force.

He told another story from Balad. “I’m placing a subclavian Swan-Ganz catheter and threading a wire through the introducer aiming for the right ventricle. It was the critical few seconds, and I was nervous that I’d screw up the delicate procedure. Thankfully the wire passed into the heart easily and we were all focusing on the arrhythmia that I was inducing to make sure the catheter would be in the right place.

Just at that moment, the daily mortars decided to rain down. The power goes out everywhere. Even the backup power goes out. What are the odds for this poor patient? The nurse and I were left standing in the dark in sterile garb, hands frozen in position trying to devise the next move since the catheter was not yet on the wire. Everyone else in the ICU tent was on the floor, attack in progress. Luckily guys came out with flashlights within seconds – though it seemed like hours – I withdrew the wire, aborted the procedure and stopped the bleeding. The power came back on, I took a big breath, opened a new kit and re-accomplished the pulmonary artery catheterization. The patient survived transfer to Germany eight hours later.”[ii]

Why?

·        workforce shortage of the clinical support staff.

·        physicians spend more than half their day on tasks that don't require their medical education (bureaucracy)

Ø  in primary care, women are spending 108 minutes more for every eight hours of patient schedule time on the electronic health record than male counterparts

·        loss of independence

Ø  physicians who rated their control over their work environment as high had 39% burnout compared to physicians who rated their control low, who had 75% burnout.

·        Chaos at work

Ø  burnout rates are about half in those who rate their work environment as not chaotic.

·        they are leaving their inboxes, that the rise in patient portal messages to 157% of what they were at pre-pandemic levels, the number of low-value notifications that are clogging up the inbox for physicians has just become unmanageable.

·        the “tripledemic” brought on by increases in seasonal influenza, respiratory syncytial virus infection (RSV), and COVID-19

·         Diminishing government, and commercial insurance payments, plus constantly rising overhead costs and unrelenting inflation equals an unsustainable business model.[iii]

Ø  The overhead required to run a private practice has increased by 40% in the last two decades, with rises in office rent, utilities, and office staff salaries due to inflation. According to the most recent MGMA survey, 90% of medical practices reported that their costs rose faster in 2022 than revenues, while only 10% said their revenues kept pace ahead of rising costs.

Ø  Unlike other businesses, there is scant opportunity to reverse the financial decline with increased production. There are already not enough hours in the day for primary care physicians, most of whom are managing full practices with no capacity for more patients. In fact, recent research from the University of Chicago provided this eye-opening statistic: following national recommendation guidelines for preventive, chronic disease and acute care would take a primary care physician 26.7 hours per day to see an average number of patients.

physician burnout costs over $5 billion every year by very conservative estimates.

The stats

A report published Thursday by Definitive Healthcare found that nearly 334,000 health care providers—including 117,000 physicians—left the workforce in 2021.[iv]

Overall, physicians experienced the largest loss, with 117,000 departures in 2021, followed by nurse practitioners, with 53,295 departures, and physician assistants, with 22,704 departures.

Among physician specialties, internal medicine saw the most departures, losing 15,000 providers in 2021, followed by 13,015 providers who left family practice, and 10,874 who left clinical psychology.

The report found that South Carolina experienced the highest level of staffing shortages, with almost 29% of hospitals reporting a critical staffing shortage. Similarly, about 20% of hospitals in Georgia, Vermont, Delaware, and Michigan, experienced critical staffing shortages in 2021. 

Full disclosure: some skepticism has emerged regarding the departure stats. Critics decry some exaggeration of numbers and the inclusion of psychologists, whom the don’t consider true medical practitioners.

Part of the issue stems from the way America’s population is shifting. “By 2035, there will be more seniors aged 65 or older than children aged 17 or younger—the first time this demographic imbalance has occurred in the nation’s history,” Taylor (James Taylor, group president of the leadership solutions division at AMN Healthcare, the largest health care staffing agency in the U.S.) says. This is significant because “older people see a physician at three or four times the rate of younger people and account for a highly disproportionate number of surgeries, diagnostic tests, and other medical procedures.”

Data published in 2020 by the Association of American Medical Colleges estimates that the U.S. could see a shortage of 54,100 to 139,000 physicians by 2033.[v]

The cure?

Anything positive to address the situation would be welcome balm.

Momentum is building to reform the broken Medicare physician payment system in 2023 and to reduce obstacles that interfere with patient care—including prior authorization.[vi] We’ll see. I have my doubts. Anything that cuts back on the sacred bureaucracy is typically difficult to achieve.

New legislation introduced in the House aims to avert an incoming 4.5% cut to Medicare physician payments set to go into effect next year. 

The Supporting Medicare Providers Act of 2022 takes aim at a 4.5% cut to payments that was included in the 2023 Physician Fee Schedule payment rule. Physician groups have clamored that the planned cuts are going to detrimentally affect practices, especially considering record inflation and the lingering COVID-19 pandemic.[vii] 

Emergency medicine physicians and consumer advocates are joining forces to stop the corporate ownership of medical practices. Physician autonomy is helpful. A report from Kaiser Health News notes that more than 30 states already prohibit corporations that are not owned by physicians from owning medical practices. The article notes that corporations, however, have figured out ways to sidestep those bans by giving physicians legal ownership of those practices—but giving them no authority in day-to-day operations.[viii]

Nearly 70% of physicians are employed by hospitals and corporations.

“Our change to a concierge medicine model has allowed me to continue practicing. I have plenty of energy and I look forward to coming into the office. It's a privilege to practice medicine in this way. And my only regret perhaps is, that we didn't do it five years earlier.” - Dr. C. B., concierge physician since 2020

What is concierge medicine?

Sounds highfalutin doesn’t it?

This type of care delivery model—called concierge care, or concierge medicine—boasts round-the-clock physician access, same-day appointments, and highly-personalized, comprehensive care. It comes with a cost, of course.[ix]

When the concierge medicine model first appeared in the mid-1990s with Seattle-based MD2 International, it introduced the idea of “luxury medical care” and came with a price tag to match—with patients paying up to $25,000 per year for the boutique healthcare experience. What’s more, this cost was paid in addition to regular health insurance premiums and didn’t cover the costs of hospitalization or specialist consultations.

Though some patients still pay a five-figure fee for their care, the average fee for membership in a concierge practice nowadays is between $1,500 and $2,400 a year—or between $125 to $200 a month.

In the past five years or so, the emergence of direct primary care (DPC) practices have introduced other lower-priced models of subscription-based, on-demand care. DPC is a similar care delivery model that charges patients a flat-rate retainer for readily accessible, highly personalized primary care.

Unlike concierge medicine models, DPC physicians do not accept insurance payments or participate in government programs like Medicare; they rely solely on patient membership fees. Direct primary care practices offer greater pricing transparency because of this—with patient membership fees averaging less than $100 per month for unlimited doctor visits.

References

[i] https://www.ama-assn.org/practice-management/physician-health/joy-medicine-continuing-reduce-physician-burnout-2023

[ii] https://www.cms.org/articles/physician-heroes-stories-of-service

[iii] https://www.medicaleconomics.com/view/where-do-you-want-to-be-in-2023-

[iv] https://www.advisory.com/daily-briefing/2022/10/25/workplace-departures

[v] https://time.com/6199666/physician-shortage-challenges-solutions/

[vi] https://www.ama-assn.org/practice-management/physician-health/how-ama-will-stand-patients-physicians-2023

[vii] https://www.fiercehealthcare.com/providers/house-bill-aims-get-rid-2023-medicare-cuts-physicians

[viii] https://todaysphysician.com/career-news-for-physicians-2023/

[ix] https://www.definitivehc.com/blog/what-is-concierge-medicine