A 2015 study conducted by the American Medical Association and Mayo Clinic found that over half the doctors in America are experiencing burnout.38 The rates have increased yearly in recent years, and are far higher than for the general population, even among people with similar education and work hours.39 They also are, by far, the highest rates recorded among physicians since Freudenberger identified the phenomenon. The study’s authors explain that this epidemic should be of grave concern to all Americans because, in addition to the personal toll on doctors and our rising suicide rates, “burnout appears to impact the quality of care physicians provide, and physician turnover, which [has] profound implications for the quality of the health care delivery system.”40 That’s bad news for patients, and we are all patients or potential patients. It’s also bad news for American health care, which is seeing more and more doctors reducing their work hours, giving up clinical practice, or taking early retirement at a moment when the Department of Health and Human Services predicts a shortage of forty-five thousand to ninety thousand physicians41 by 2025.
As a doctor, if one of my patients has a serious, undesirable side effect to a medication or treatment, I change that medication or treatment. I continue it only if there are no alternatives and the patient and I believe the outcome will be worth the attendant agonies. But those in charge of American health care seem unfazed by our current system’s many destructive side effects, including burnout and its harms to patients and clinicians. Much like our senators and representatives who deprive their constituents of health care coverage while continuing their own extra-special congressional health benefits, they behave as if they believe that people get what they deserve. Words such as resilience and self-care—the trait and skill, respectively, that we are encouraged to developed to combat burnout—suggest the failure is within America’s clinicians, that we have unwisely used up our precious fuel, that we are weak and don’t know how to take care of ourselves. The ubiquity of burnout across specialties and geographic regions suggests our distress is but a symptom alerting the health system to a potentially lethal underlying problem. In the same way a person can have arm pain during a heart attack when a critical artery is blocked, burnout is physician distress signaling that the health care system needs critical care.
Read any of the growing numbers of poignant essays about burnout,42 and you will find most doctors report what I, too, felt, even at my lowest point: that I still wanted to be a doctor, that the work for me has always been more vocation than job, but that the structures and demands of the health care system had begun preventing me from providing the sorts of care and healing I believed my patients needed, and that was something I couldn’t abide.
PRIORITIES
In the months after the snap, I had many doctor’s appointments. One week, I had two just days apart, one in general medicine and the other in orthopedics, both at the same highly ranked medical institution. Occurring so close together, these visits quickly morphed in my mind from personal experiences with individual doctors into metaphors for the current state of U.S. medicine.
I saw my internist first. Her practice is in an older part of town where I can sometimes find street parking and avoid the astronomical fees at the patient parking garage—fees not covered by health insurance, though of course I can afford them better than most. The offices are clean but drab, and the clinic runs relatively efficiently. It has separate lines at the front desk for checking in and out, and shortly after my arrival, a friendly medical assistant called me in to take my vital signs and review my medication list.
Ten minutes later, I was in a narrow exam room and thirteen minutes after that, my internist appeared, looking tired yet radiating her usual warmth and concern. She apologized for running late, and I told her it was no problem. I didn’t tell her that I always block out ninety minutes for my twenty-minute appointment and come prepared to work. As I answered her questions, we studied each other. I noted the subtle tension in her torso while we discussed my multiple concerns, each of which required decisions, tests, and referrals, and each of which she had to attend to given her broad skill set and primary care purview. Because of me, we both knew, she would end up running further behind.
At first, I had her full attention, but soon her fingers moved along her keyboard while we talked, and her eyes strayed from me to her screen.43 I knew she was working to fit my problems into the electronic record’s template with its dozens of menus, billing-required but often clinically irrelevant checkboxes, and subsections not sequenced in the way our conversation was proceeding.44 Meanwhile, as I knew all too well from my own geriatrics practice, her clinical inbox was filling with an ever-growing list of tasks,45 all amounting to hours of work for which no time was allotted in her clinic day.
Of course, many of the challenges my internist faced that day aren’t unique to primary care. That’s why some practices have adopted two work-arounds that increase efficiency—midlevel providers46 and scribes47—strategies I got to see in action later that week at my orthopedist’s office.
Although part of the same institution, my orthopedist works in a new, glass-walled building in a rapidly revitalizing part of town. There’s no street parking, but a café on the ground floor serves farm-fresh salads and organic drip coffee. I went to see her not because I needed an appointment but because I’d been unable to get answers to a simple follow-up question via the patient portal. The problem wasn’t that I couldn’t get a response, just that I couldn’t get one from her. I sent versions of the same query a few times, and each time it was handled without resolution by a different nurse practitioner who didn’t know me and either couldn’t, for reasons that might range from not having read my chart to not having the necessary knowledge, or wouldn’t—since I wasn’t their patient—answer my question.
After I checked in, the front desk person told me someone would call me shortly for an X-ray so I should sit by the X-ray room door.
I said I didn’t need an X-ray.
He said everyone got an X-ray.
“Before they even see the doctor and whether they need one or not?” I asked in as even and polite and cheerful a tone as I could muster.
I told him I’d already had an X-ray at this same clinic for this same doctor about this same problem, and nothing had changed. He called his supervisor and asked her whether a patient could be seen if she refused the X-ray.
Fortunately, the supervisor said yes. I sat down, and a short while later a medical assistant called my name and took me back into a large, sunny exam room, entered my chief complaint in the computer, and told me where to sit and what clothing to remove.
I had only just begun working when my doctor came in followed by a young woman carrying a laptop. We exchanged pleasantries and then I was introduced to the scribe, who sat discreetly to one side, saying nothing during the visit while her fingers moved quietly on the keyboard.
For the entirety of the appointment, I had my doctor’s full attention: eye contact, smiles, a targeted physical exam, and answers to my questions—the original one and some others I came up with to make the visit more worthwhile, though all related to the single body part that is her focus. She didn’t seem to miss the X-ray I hadn’t had and showed no interest in my other medical issues, or the parts of me that, while not orthopedic, might influence my treatment preferences and recovery. With some prodding—I used words like physical therapy and exercise—I was able to get her recommendations for approaches other than medications or the sort of high-tech surgery the medical center touted daily on local radio, television, and billboards but that was unlikely to address my primary concerns.
Once we’d made a plan, she left the room, telling me to wait there for her physician assistant, who would review with me my discharge instructions. Miraculously, she walked out the door, her note written, having done nothing but attend to me during our encounter. We were both pleased and relaxed as a result.
My internist and orthopedist are both highly trained, highly skilled, and
hardworking doctors. While I don’t know their specific salaries, annual surveys by the American Medical Group Management Association (AMGA) between 2013 and 2017 cite median compensation figures ranging from $193,776 to $259,765 for internists and from $525,000 to $759,086 for orthopedists, a two- to threefold difference that grossly exceeds their training time differential and belies my internist’s greater experience.48
And, of course, that’s only part of a larger and more complex financial system that incentivizes procedural and hospital-based care and specialties over relational and outpatient ones.
It would be hard, even morally suspect, to suggest that the salary disparities among medical specialties in American medicine are the most pressing inequities of our health care system. Yet they are representative of the biases underpinning health care’s often inefficient, always expensive, and sometimes nonsensical care49—biases that harm patients and undermine medicine’s ability to achieve its primary mission.
Usually when we discuss disparities in medicine, we are speaking of patient populations. But there are disparities, or “differences in access50 to or availability of facilities and services,” between my internist and orthopedist, too, ones that reflect systematic nationwide biases in how we value and reward different medical conditions and types of care. This favoritism toward certain sorts of doctors, medical conditions, and treatment approaches developed as side effects of medicine’s greatest twentieth-century successes. As scientific progress brought unprecedented gains in health and longevity, we assumed newer, more invasive, higher tech, and more specialized care was always better, and set up a system that prioritizes and generously rewards that sort of care. We confused the occasionally miraculous with the everyday essential, ignored the mounting evidence of economic and health harms of our faulty assumptions, and, in taking an increasingly business-based approach to health care, failed to recognize the ways in which human beings will always differ from other “commodities.”
Our health care system’s biases affect not just physician salaries but institutional, educational, and research priorities, and indeed, the very culture of medicine. At a recent meeting of the Harvard Medical School Alumni Council, a first-year student was asked about his debt. “Huge,” he answered, shaking his head and adding that he also had college debt. “What will you do?” asked the council president. The student grinned. “Oh, I’m not worried. I’m going into Ortho.”
In study after study, primary care has been shown to prevent illness,51 decrease mortality, and lower costs, all with higher patient satisfaction. A growing literature also demonstrates system-wide high rates of overuse and waste,52 as well as serious harms as a result of higher-tech, more aggressive, specialty-driven care. Internationally, the countries and regions with the most robust primary care systems have the best health outcomes. Yet primary care remains American medicine’s second-class citizen.
In most clinics, appointments are scheduled in a one-size-fits-all manner that distinguishes only between new and returning patients and not between mostly healthy patients and those with complex conditions. Every aspect of those appointments assumes that the doctor’s most important activities are diagnosis, prescriptions, and procedures. This discounts the entire range of critical activities that help clinicians match care to patients’ realities and preferences, increasing the chances that they can and will follow their treatment plan and that the plan will help them. Such activities include skilled listening to what the patient is saying, all that isn’t being said, and body language. It includes giving the patient time to absorb complex information or terrifying new diagnoses, express their concerns, and formulate questions relevant to their specific lives. It includes checking for alignment between what was said and what was heard, reading the medical record if you don’t know the patient or if they have been hospitalized or seen another clinician since their last visit, establishing truly informed consent, negotiating language and literacy and health literacy barriers, and doing values elucidation, medication review and reconciliation, motivational interviewing, patient education, and counseling.
The terms structural violence and structural inequality pertain here. As the physician-anthropologist Paul Farmer explained, these concepts offer “one way of describing social arrangements that put individuals and populations in harm’s way. The arrangements are structural because they are embedded in the political and economic organization53 of our social world”—in this case, the political and economic organization of American health care. A study of health care spending in eleven wealthy countries found costs in the United States from 2013 to 2016 far exceeded those of the other countries,55 all of which had better health outcomes, including lower infant mortality, less obesity, and longer life expectancy. The culprits? Prices, which reflect values and the structure of a health care system, particularly: administrative costs (all the paperwork and negotiation necessitated by a system-less system56 as well as, as one editorialist notes, the essential monopoly of some producers), “goods” including (especially brand-name) medications, and labor (some salaries more than others, clearly, but all driven up by the outliers’ excesses). A commentary added high-cost procedures such as joint replacements and unnecessary imaging (CT, MRI) to the list.
Follow the money and hype in medicine and you will find that in the United States we prefer treatment to prevention. Bones matter more to us than children or old people, and patient benefit is not a prerequisite for treatments or procedures. We seem to believe that drugs work better than exercise; that doctors treat computers, not people; that death is avoidable with the right care; that hospitals are the best place to be sick. We value not having wrinkles or warts more than hearing, chewing, or walking.
This situation brings the words of Charles Dickens to mind. Ours are the best of times in American health care, and ours are the worst of times in American health care. Ours is the age of tech and the age of inequality, the epoch of innovation and the epoch of burnout, the season of #blacklivesmatter and the season of colossal health center marketing budgets. In the twenty-first century, we can do so much for people, from quickly curing infections to replacing damaged joints and organs, but we fail to prioritize care that most helps patients,57 making it far harder for clinicians58 providing those types of care to succeed.
SYMPATHY
The first week after the fateful phone call that inadvertently shifted my burnout from suppressed to florid, I didn’t go to work. It was partly that I felt like I couldn’t and partly that I knew I shouldn’t. By the second Monday, I had returned, but only long enough to hand off, delegate, and delay before a fortuitously timed, long-planned vacation. By the end of those two weeks, I knew I needed to go on leave. I needed to do for myself what I would have counseled a patient to do: I put my health and well-being before my work.
Did I say as much to my colleagues as I should or could have about what was happening to me? I did not. I avoided some people, mentioned only the physical problems to others, smiled, and tried to look as normal and healthy and well as possible in public.
In a recent, deeply personal, and beautifully written essay in the New England Journal of Medicine, a trauma surgeon named Michael S. Weinstein, writing of his own burnout, noted that colleagues had tried to reach out and found him wholly unreceptive.59 His practice in operating rooms and the hospital was visible to others in ways that mine, making housecalls to patients in their homes and working on grants and projects in an office with a door, was not. Still, I can think of a couple of instances where I deflected queries. Much more common were unspoken questions leaking from kind eyes—those two administrators again, our clinic support staff, and two young doctors, very much my juniors, who helped me disentangle from all I could no longer do. There were also many lovely, supportive e-mails from colleagues, all of which I ignored. By definition, I was impaired.
I wished I could stop feeling so angry and hopeless. I had a meaningful career, a steady job, a good salary, and a happy home life. I was the one who had ignored
my body, health, and well-being, so there could be no question of who was to blame for my situation. And yet I hadn’t changed too much over my years as a physician, while health care itself and the daily tasks and demands of doctoring had.
For weeks after I went on leave, the worst part of each day was the time devoted to health care—procuring it, not providing it. I had terrific health insurance, the best plan my huge institution offered. I called my primary care doctor’s office, and they told me she could see me in six weeks or I could see someone else who didn’t know me or my history. I got around that by sending my doctor an e-mail, something that’s easier to do if you, too, are a doctor—an unfair advantage, since all patients deserve care when they need it. She helped with most of my problems, but we agreed I needed a specialist to help with my psycho-existential crisis. My costly insurance said it covered mental health. The primary website sent me to a secondary one and then to a third. The journey was long and slow, full of digital roadblocks, distractions, and dead ends. They seemed to be fulfilling the letter of the contract but not its spirit.
The list of potential providers was many hundreds long. Each required a separate secondary search to determine where the office was (since I couldn’t drive), what services were provided, and the doctor’s ability to take new patients. Very quickly I learned to start with whether they had openings, since most practices had none.
When a person is in crisis, even the smallest tasks are hard. Encountering this labyrinth of hindrances, I cursed and raged. If a doctor who understands the system, speaks fluent English, and has optimal insurance can’t get help, how on earth could anyone else?
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