A year ago, during a news show rerun in the middle of the night, an ad came on, and I haven’t stopped thinking about it. The voiceover said something like: “Using the skins of cranberries grown high in the alps, in the gardens formerly reserved for kings and queens, we’ve identified the essential oil that leads to long life, physical strength, and flawless memory. Our scientists have been working tirelessly for years and now it is available to the public for the first time.”
Then comes the low volume, fast speed rambling that protects them from liability, I guess. And then the line they must think really protects them, which I remain fixated on. “If you have any questions, please consult your doctor.”
I’ve been a doctor for years. So was my dad. So was his dad. Still though, maybe I’m slow because when I heard that ad and the consult your doctor line at the end, it was the first time I realized, wait a minute. They mean me.
Medical schooling has its flaws, but the public will be relieved to know they don’t waste future cardiologists’ time with cranberry extracts and other things found mostly in late night infomercials. Nevertheless, producers of these supplements feel perfectly entitled to the time and knowledge of medical providers without paying for it. You pay for it, directly and indirectly. This is just how your paid-for community medical services are being used, and supplement companies are not alone at taking advantage of the system.
Burnout is an interesting concept. We all know it when we see it, we all know it when we feel it, but we don’t all agree on its definition. Ken Coleman defines it this way:
“Burnout is a feeling of exhaustion, frustration or overwhelm that happens when stress and toxicity build up over time. It’s when we put so much effort into taking care of everything — without rest, recognition or results — that we drain ourselves of energy and sap our emotional and physical wellness.”
And it should come as no surprise. Most reports on health care spending go on about rising costs and stagnant benefits. Stipulated, that’s a serious problem. But day to day there is actually a price ceiling, the co-pay. $15-25 is the average out of pocket price for a primary care visit. But the costs billed out are probably 10 times that, maybe more. With the remaining costs covered by third parties.
The effects of price ceilings have been known to economists forever — shortages. Think 1970s era gas lines, or many modern day ER, or doctor offices, waiting rooms. Thomas Sowell in “Economic Facts and Fallacies” defines the four effects of shortages this way:
Increased use of a product
Reduced supply of a product
Not good stuff, and there’s a price ceiling imposed on patients.
If you accept as maxims that free markets increase wealth and that wealth isn’t just financial, it’s the most efficient possible allocation of scarce resources, then some of the problems in health care start to come into focus.
It starts with increased use of a product, unnecessary doctor visits. These happen because it’s been recommended seemingly by an authority, or often times more aggressively, because we’ve been told go see the doctor or our needs simply will not be met (think confusing 5-10 page forms from DMVs, or the schools, or a new referral to the same specialist you’ve been seeing for years because insurance said the doctor had to send a new one, for some reason).
These things add up and reduce the supply of the product — time for the necessary doctor visits. Which then brings us to quality deterioration, an inefficient use of scarce resources. Have you ever been properly sick and couldn’t figure out why you had to wait so long to be seen? And when you were finally seen, was surprised at how little was actually done or explained? I can promise you, no one is being lazy. They’re bogged down in something, and it probably is less medically relevant than what you came in with.
Market inefficiencies, I believe, are an underlying cause of burnout, and I don’t believe it’s widely acknowledged. It is, however, unpleasant at times, and people are leaving, contributing to a shortage.
In 2021, doximity published a physician compensation report where they discussed an “increasing cumulative physician retirement,” (They link it to COVID. Just a sense I have, but I doubt it. COVID may be a factor, but not the solitary factor, and the retirement trend line was going up before the pandemic. Just not as fast. Doctors tend not to be afraid of sick people. Besides, COVID isn’t going anywhere, so even if true it doesn’t change anything.) And, amongst doctors who retire early, burnout is a commonly cited reason. Not good things for the physician shortage written about so often, and generally expected to worsen over time.
Just as a practical matter, it’s best if leaders in the health care field handle this internally. Not everything needs to be a national debate, and keeping this lower level makes solutions seem possible. Problem is the answer looks like no, they can’t.
Here is a list of real life programs for physician burnout. They’re not good.
Go to the bar
Have coffee with a friend and discuss that silly thing your kid did
It goes on from there. You’ll notice none of these things change the health care marketplace. It’s either work less or sacrifice free time. You’ll also notice most of these things are not actually within the purview of the highly-paid not for-profit executives who run hospitals. What if you don’t bowl, drink or want to embarrass your kids in front of your colleagues? What then?
I have some thoughts. Though I should acknowledge up front it’s complicated, and I’m still thinking it through. In the outpatient setting I’d like to see non-medical issues start to get decoupled from the medical doctor appointment. For example, a lot of time is spent figuring out what medications will even be “covered.” Or failing that, what the out of pocket cost will be. The actual medical decision-making is often fairly quick when starting a new medication, but everything around it takes a lot of time and is often frustrating. Especially for scared sick people who want a straight answer and aren’t getting it.
And the forms. The lawyered up forms are endless, and I have my doubts there’s much medical merit to them.
In the hospital, a common scenario is someone being medically ready for discharge, but the placement, meaning finding a nursing home, rehab or whatever new services the patient may require, takes days. A week would not be a record. As it currently stands, there is no reduction in hospital resources put towards a patient pending placement compared to an acutely ill patient still being actively medically treated.
This is incandescently inefficient. Leaving aside the obvious solution, insurance companies moving faster to get approval for the next appropriate step in a patient’s care, I’ve long thought there should be a designation of discharged pending placement. Meaning the doctor does not still round on that patient every day, but is available as needed. The nursing ratio could go down (instead of 5 patients to 1 nurse, it could be something like 7-10 to 1 nurse) and other appropriate reductions in hospital resources could also be implemented.
Changes that remove non-medical, and medically stable, issues as much as possible would be best for patients who need health care the most, alleviate the shortage and the burnout, and be more efficient generally.
David Tennant is a primary care physician who specializes in obesity management.