In the Kansas City Medical Journal’s December edition, Dr. Van Way wrote about the problem of physician burnout as a core symptom of the dysfunction in American Medicine. He describes a landscape that has eroded individual physician agency in multiple ways. He shares his opinion that, “Our physician workforce has been trained, over the last three or four decades, to become employees.” We agree.
Eyal Press, writing for the New York Times last June began a piece on the corporatization of American physicians by describing the work of Wendy Dean, a psychiatrist who became interested in the relatively high rate of suicide among American physicians.
Physician suicide is at least twice the rate of the general population and 30 - 40 % higher than the military. Press writes, “The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients.”
Reflecting on our own experiences, we have noted challenges in the local care paradigms that most of us find ourselves in. Some examples include: An early burden of large medical debt.
Complicated electronic medical record interfaces that demand disproportionately high overhead and a high price for security, are oriented toward billing and not easy to use. Patient volume loads that leave physicians and patients dissatisfied. Compromised and conflicted published medical information. A general lack of community among physicians that find themselves more and more isolated. A growing pressure to silence open conversations about the direction of our own practice and novel challenges.
We are certainly not alone in voicing concern about these problems. The article by Dean appeared in an online healthcare journal in 2018 explaining that physician burnout is better understood as moral distress. The authors write, “The increasingly complex web of providers’ highly conflicted allegiances — to patients, to self, and to employers — and its attendant moral injury may be driving the health care ecosystem to a tipping point and causing the collapse of resilience.” Because physicians have traditionally entered medicine out of a sense of calling as opposed to a sense of profit or compulsion, they have generally endured substantial sacrifices to get to where they are. But where they are is turning out to be different than where they thought they were going. The changes have been building for some time.
Democratic Socialists Barbara and John Ehrenreich coined the term “The Medical-Industrial Complex” in the 1970s to describe how insurance coverage and medical access was growing further and further out of reach of the poor and middle class, and that this phenomenon was not an accident, but rather a feature of a designed system where others were profiting from the needs of patients. By 1980, the NEJM recognized that the “Complex” was not going away anytime soon, seeing the rise of profit making as a central motivation for growth.6 These extrinsic motivations to healthcare are taking their toll.
All three of us have changed jobs and the way we practice medicine within the last six years to deal with these pressures on our practice and how we care for patients.
Paul Bauer is a pediatric critical care physician and has practiced in an academic setting for 20 years (including his training). He remembers clear teaching about the consequences of friendliness with drug reps who were banned from coming to the hospital. Training for residents and fellows invariably included education about the ills that flow from conflicts of interest. Since training, he has since noticed deeper conflicts embedded in the architecture of academic medicine. For example, participating in novel drug studies is problematic since the FDA relies on pharmaceutical companies for over 75% of its drug division budget. The FDA also relies on sponsoring companies to report their own safety data when a drug trial has reached the bedside as opposed to directly monitoring it. This is an inherent conflict for the sponsoring drug company.
Another worrisome trend is the pressure to be silent where open debate about reasonably difficult topics is warranted. As the pandemic exploded, independent and highly decorated academic voices were suppressed through official government pressure. In addition, warnings were distributed to registered members of the respective boarding agencies about what kind of communication about the COVID vaccine would
result in forfeiture of certification. There was a joint letter by the American Board of Pediatrics, Internal Medicine and Family Medicine issued early in 2021 notifying members that any guidance that might provoke a hesitancy among their patients in taking the vaccine would cause a suspension of certification. Dr. P. Bauer personally knows physicians, nurses, and other healthcare workers in the Kansas City metro area who have not openly talked about the physical harms they have experienced following vaccination because of the personal cost they would be engaging should they speak up. Instead, they found themselves alone in their experience. He believes that this atmosphere of silence, shame, and regulatory cooperation adds heavily to moral distress, isolates physicians and only results in what is inappropriately termed “burn out” and a loss of skill within the local community.
The environment in academia doesn’t have to be this way. Dr. P. Bauer has seen what is possible when administrative leaders are responsive to their frontline staff. He remembers working earlier in his career under an administration where many bedside clinicians knew the CEO, the CNO and the CMO on a first name basis and where there was a welcome approach to clinicians visiting the C-suite to share their needs and bend an ear. When administrators cultivate relationships with their hospital staff and are themselves oriented towards a partnership with those serving the needs of the patients, staff notice and the work environment benefits. Invariably, when a new administration emphasizes organizational growth and notoriety simultaneously neglecting the time and personal investment needed to build personal and trusting relationships with the clinicians who are taking care of patients, mistrust grows, and internal buy-in decreases.
Dr. Terese Bauer and Dr. Angelique Pritchett are family medicine physicians who own their own direct primary care practice and care for families in the Kansas City area. They have been emboldened by the success of their direct primary care clinic where they
enjoy caring for an enthusiastic patient population and have seen their practice grow to capacity within two years of opening.
Two important values underlie the success of owning and managing their own practice. The first value is honoring the patient with time. According to recent surveys, a patient spends on average only ten minutes face to face with a primary care physician. From their experience, this is simply not enough time to take a thorough history or provide adequate health education. In their direct primary care clinic, nobody is profiting from externally running their organization and forcing them to work at a dehumanizing pace. They can comfortably cover their overhead costs, provide higher-end salaries for their incredible staff, and still earn a competitive family medicine salary, all while spending a full hour with most of their patients. The second value that defines their practice is intellectual integrity. Rather than following protocols without understanding or debating them, they have the time to read the evidence-base and adapt the learning to their patients. During the pandemic, they learned to effectively manage COVID-19 across the age spectrum without pressure from larger corporations telling them how to practice. They honored patient autonomy by adequately describing the risks and benefits of the covid-19 mRNA vaccines and early treatment protocols. As a result of their freedom to practice medicine according to the best evidence and shared decision making, their patients have been free to make their own decisions without coercion, they have had minimal hospitalizations due to COVID-19, and they have had ZERO deaths.
Open debate in medicine is something we believe is very important. Dr. T. Bauer warmly remembers the intensity of debates on morning rounds during residency training. Whether at board sign-outs for OB or at an ICU patient’s bedside, there were sometimes intense disagreements for something as simple as giving a particular patient aspirin. Each attending was expected to support their own arguments by the
highest quality evidence. This process allowed for the application of the medical literature to each individual patient, and the arguments brought out better decision making. Dr. T. Bauer would like to see that same spirit of discovery and debate re-emerge in academic medicine for current controversies.
Dr. Gayln Perry is a Med/Ped subspecialist trained in adult pulmonary/critical care and sleep medicine living in Kansas City who resigned from corporate academic medicine two years ago to start a direct pay adult/pediatric pulmonary and sleep medicine practice. She believes that physicians walk in a sacred space alongside the vulnerable and the sick but that many hospital administrators and large non-profit regulatory organizations like the American Board of Medical Specialties and the Federation of State Medical Boards see this sacred space as an opportunity for their own growth. Her perspective is that physicians are squeezed on one side early in their careers with large medical school debt and mortgages while being squeezed in their professions with unreasonable administrative demands. For her, caring for a patient in less than 20 minutes is the hallmark of depersonalization. Reflecting on the moral landscape, she sees that physicians compromise their sense of duty and excellence by curtailing a detailed history and being compelled to throw prescriptions at the patient. Corporate Medicine has become a “pill for every ill”. However, caring for the sick and returning them to health often requires more time than physicians are ever afforded by insurance or academic payment schemes.
Over the last three years, Dr Perry witnessed ethical compromise in the academic setting. Regarding where patients could depend on solid information regarding COVID treatments, she listened to a prominent Bioethics Professor at her institution state that watching the news on television was sufficient to meet the bar for informed consent for certain new interventions. During a town hall meeting about a particular drug therapy, an Infectious Disease and Immunology colleague coerced nonmedical employees with medical absolutes and reassurances that were simply not possible to make.
Her newfound knowledge of relationships between pharmaceutical companies and medical journals was disorienting and profound. Over 10,000 papers were retracted in 2023.Conflicting relationships have been strengthening for decades. Dr. Marcia Angell, a long-standing editor of the New England Journal of Medicine stated after her tenure, “Journals are primarily a marketing machine. Pharma has co-opted every institution that might stand in it’s way.” And, “It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgement of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion which I reached slowly and reluctantly over my two decades as an editor of the NEJM”. If so much medical literature is compromised, where do we go for direction?
Dr Perry knows she is not the only one who sees fundamental problems eroding the founding principles of unconflicted medical practice. She is aware of at least five physicians in the KC metro area in the last 2 years that left corporate medicine, one of them quietly quitting. The burdens from insurance payment justification are equally heavy. She has colleagues in the Kansas CIty area who have been audited and served with fines for lack of adequate medical record documentation, only to have the fines removed after they themselves located the information the auditors could not. While these experiences are anecdotal, they are not isolated and point to deep problems with how medical care is provided.
Opening her own direct care practice has been life giving. Taking the time for a thorough history allows Dr. Perry to provide the excellent care her patients deserve for pennies compared to the dollar charged at a larger not-for-profit corporation. A recent patient shared with her, “I am so much better and all you did was talk to me about my sleep habits and it didn’t require any medication.” There is simply no substitute for the satisfaction gained from taking the time to connect with and help patients heal.
Dr Perry hopes that more physicians recognize they are being taken advantage of by a corporate model for care that sees patients as commodities in a for profit (often private equity) medical system. And when they do, she hopes they exit in great numbers to create and manage their own practices. Medicine is too noble a profession to allow this to continue.
In conclusion, we believe that a broad corporate approach to medicine at multiple levels both in academic and non academic settings is taking a toll on physicians and their patients. We believe there is a better way and that physicians need to recover their moral authority and a sense of community, re-establishing relationships with one another and administrators. We are not arguing for political solutions that invite more control and less physician autonomy. Rather we argue for a renewed respect of the bedside and the value of the relationship between a patient and her or his physician. We think exterior pressures that seek to unduly influence or independently profit from this relationship should be restricted and removed if possible. The space between a physician and patient is privileged and should remain so. So treated, it will encourage healing for the patient and satisfaction for the physician.
“What we need is leadership willing to acknowledge the human costs and moral injury of multiple competing allegiances. We need leadership thathas the courage to confront and minimize those competing demands. Physicians must be treated with respect, autonomy, and the authority to make rational, safe, evidence-based, and financially responsible decisions. Top-down authoritarian mandates on medical practice are degrading and ultimately ineffective.”
-Simon Talbot and Wendy Dean
References
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Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. 2018, July 26 https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury. Published June 15, 2023.
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Authors
Paul Bauer, MD
Terese Bauer, MD
Paul and Terese Bauer are married. They both graduated from the Medical College of Wisconsin in Milwaukee. Terese is a family practice physician. She completed her residency at Aurora Saint Luke's Hospital in Milwaukee.
She worked for several years at Family Health Care on Southwest Boulevard and currently shares a practice with Dr. Angelique Pritchett.
Paul is a pediatric critical care physician. He completed his pediatric training at the Medical College of Wisconsin and worked at Children's Mercy Hospital for over a decade. He was the medical director of the resuscitation committee and respiratory care. He currently works at Dell Children's Hospital in Austin, Texas.
Paul and Terese have five beautiful children and enjoy being outdoors, farming, and teaching.
Angelique Pritchett, MD
Angelique Pritchett, MD, is a board certified specialist in family medicine with special interests in women’s health issues, obstetrics and prenatal care, gynecology and infertility. She has been certified as a Creighton Model FertilityCare Medical Consultant. She believes the most rewarding aspect of medicine is the opportunity to connect with her patients. She is a graduate of the University of Kansas School of Medicine and completed a residency in family practice at St. Anthony’s Hospital, Oklahoma City. She has been in practice for 24 years and is co founder of a direct primary care practice in Shawnee, KS. She is also a wife and mother of four children.
Gayln Perry, MD
Gayln Perry graduated from Texas A&M College of Medicine in College Station, Texas. She did her Internal medicine/pediatric residency at University of Missouri Kansas City and her adult pulmonary and critical care fellowship at Kansas University Medical Center (KUMC) where she later grandfathered into sleep medicine under Robert Whitman, Phd.
She remained at KUMC after fellowship providing pulmonary and sleep medicine care for both the internal medicine and pediatric departments. In 2009, she helped start the pediatric sleep medicine program at Children's Mercy hospital in the role as the medical director of the sleep laboratory. She resigned her job in 2021 and has started a direct pay model practice (Perry Center for Pediatric & Adult Sleep Care) – link to: https://www.sleepdockc.com/ caring for all ages with general pulmonary and sleep problems. She has three children.
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