In recent years, the difficulties inherent in the practice of medicine seem to have intensified: hours are longer than ever, but thanks to managed care, they are less productive and less...
In recent years, the difficulties inherent in the practice of medicine seem to have intensified: hours are longer than ever, but thanks to managed care, they are less productive and less well-compensated; regulations now come from dozens of authorities, often impede effective patient care, and change more frequently; and malpractice lawsuits have increased in number and frivolity. Of course, the career has its benefits, as well, including but not limited to the personal satisfaction deriving from improving the life and health of a patient, the respect and admiration accorded the physician by the general public, and the ability to make a comfortable living in financial terms. Nonetheless, with the factors outlined above conspiring to make the profession less attractive to current and potential physicians by the year, it seems pertinent to ask of doctors in practice today “Was it worth it? Would you do it all over again?” We posed this very question to our readers; over the last six months, we sent a series of online surveys covering the blessings and frustrations associated with the practice of medicine to the thousands of doctors currently registered for one of our electronic mailing lists. More than 1,100 physicians completed a survey, a response rate that indicates just how deeply this issue resonates with our readers.
Answers were often surprising and remarkably passionate. Two-thirds of respondents would do it all over again, given the choice, but a strong minority of 34% of doctors surveyed would not; more than one-half have at least considered giving up their practice altogether, and nearly 60% would not encourage their children to become doctors, developments that do not bode well for the future of the workforce. The reasons for this discontent included fear of malpractice litigation, loss of physician autonomy, and a swelling workload coupled with declining compensation. Perhaps most importantly, respondents expressed frustration with a general alteration in the way the physician is perceived by society. “We’re no longer ‘doctors’ or ‘physicians,’ possessed of unique and valuable skills and worthy of respect,” said one respondent. “We’re now ‘healthcare providers,’ just replaceable cogs in the medical machine.”
The frustration of those doctors disenchanted with the practice of medicine is summed up elegantly in this statement, from a psychiatrist in Florida: “The social contract now seems to be that one pays for [medical] education in time and money, then is rewarded by having a target on one’s back, poor family life and poor job satisfaction, with outsiders telling you how much you may earn and how you may practice.” Said a primary care doc from Tennessee, “I couldn't believe that in just seven years I could be so burned out doing exactly the job I had always wanted.”
Our Readers Take On...
In this article, you’ll hear from more than a dozen of your colleagues in their own words on the reasons behind their discontent, and also on why some of them still love practicing medicine. Some offer well-reasoned critiques, others anonymous explosions of frustration and anger; taken together, this collection of responses affords a fascinating glimpse into the mind of the modern physician.
A startling 67% of our respondents saw their malpractice premiums increase by at least 25% in the last five years; 32% reported an increase of 50% or more, and 13% said their premiums had more than doubled in this period. A total of 17% of our respondents cited medical malpractice as the single greatest source of their frustration with the medical profession.
“The current liability system is entirely driven by lawyers, who know very little about medicine. The system is designed to compensate the attorney, not the patient who is harmed. It is as if oncologists were to determine the rules for professional discipline for attorneys and judges. We as physicians, working in concert with attorneys, have to create a system that can reduce medical errors, appropriately educate physicians who make the mistakes, compensate patients who are hurt, and remove the truly incompetent physician. Ever since I was involved in a malpractice case, I view most new patients as potential litigants. Some of the best and smartest physicians I know…think the same way. I am certain that needless consults are called and tests ordered daily because of this fear of litigation. If we want the smartest and most dedicated people to continue to provide medical care for us, we need to reform the malpractice system.”
-Regina Resta, MD, oncology/hematology, New York
“My greatest joy in life is what I do; I truly love my patients and consider it a privilege to care for them. However, the issue of malpractice has left me very bitter. Every patient is now a liability risk assessment for me. The pressure of malpractice and the fear of getting sued is a true mental strain, and I don’t know how much longer I can do this.”
-Name withheld, primary care, Maryland
“The one thing that bothers me the most is that the majority of states do not have a cap on malpractice lawsuits. Which, in turn, means that we can be sued for enormous amounts of money, including future wages…People are so quick to sue; in a study that I read a year or two ago, it was found that the three ways [many] people believe they can improve their financial situations are lawsuits, inheritance, and the lottery.”
-Tia Konzer, DO, psychiatry, Michigan
...Loss of Physician Autonomy
HMOs/insurance companies were cited as the biggest cause of frustration by 26% of our respondents, and dealing with paperwork by 25%.
“Outside agents tell me what I can prescribe, whether I can hospitalize, when I must discharge, and how many outpatient appointments I am allowed. These agents are employed at great cost by various agencies; I am certain these decisions sometimes reduce the benefits patients would otherwise accrue. This is like playing tennis with blind linesmen calling the shots based on the sound of the bounce.”
- Robert Fornal, MD, psychiatry, Ohio
“I think that sometimes we perform tests—laboratory or otherwise—to rule out extremely rare diseases. Even if we are very sure of the diagnosis, we are required to run these tests to rule things out, which leads to an increase in spending for the patients or their insurance. [In general], all of the rules and regulations are confusing and hard to understand, especially since we have no training in medical school for this purpose.”
-Tia Konzer, DO, psychiatry, New York
“Medicine is far too driven by the pharmaceutical and insurance industries: ‘Quickly Doctor, in 15 minutes or less, make a reimbursable diagnosis and prescribe the ‘right’ pill. And don’t be too concerned about whether the patient really understood the specifics of the lengthy ‘history’ questionnaire, or provided all the facts, or about timely follow-up, or whether the patient can afford the pill.’ The latter is obviously more than a bit theatrical but has been all too common in my practice in several states during the last 20 or so years [less so before that].”
-Bob Gale, MD, psychiatry, Arizona
...Workload, Compensation, and Reimbursement
Our respondents generally agreed that physician compensation relative to workload is on the wane—not just financial remuneration, but compensation in terms of the intangible rewards of being a doctor: patient contact, popular respect, etc.
“The art of medicine, taking a history, getting to know your patient, doing a physical exam: these are no longer respected skills. Generating money and paperwork, quickly turning out product (patients), correct coding, and covering yourself legally are the skills required today.”
-Name withheld, rheumatology, Idaho
“The hours are long and the personal sacrifices are many. I work night and day and weekends just to keep up with the volume. I promote health and balance of lifestyle and yet I work so much that my own life has lost its balance. I eat on the run if I have time to eat at all. I don't get in nearly enough exercise or sleep. I am in the worst physical shape of my life. I am heavier than I have ever been. I can't remember the last time I had time to sit down and just enjoy my life. If it weren’t for the debt that I have accumulated in getting where I have gotten, I would get out of medicine so fast it would make your head spin. I can’t pay my loans back bagging groceries for Winn Dixie, [although] an 8-hour day at Winn Dixie with a guaranteed salary each week sounds like a pretty good deal.”
-Name withheld, primary care, Tennessee
“My medical school and residency training seem useless when a nurse practitioner who has about two years training beyond college, compared to my eight, can state in a national pediatric infectious disease newspaper that nurse practitioners do the same thing as doctors, and have the physician editor agree.”
-Name withheld, pediatrics, Illinois
...The Future of the Profession
What will become of the field of medicine as new waves of physicians enter the fray? Do current physicians encourage others to become part of the healthcare industry?
“The kids going into medicine that I teach are not dedicated to the patient and curing disease. The best and brightest are not pursuing this field anymore.”
-Name withheld, urology, Pennsylvania
“This field has directly led me to divorce twice. I had to give up my dogs, as I had no time for them. My migraines have worsened because of the interrupted sleep. Also, for the first time in my life…I have heartburn/ reflux/ gastritis. I am stuck in this profession as I know nothing else. I actively recommend to college students that they not go into this field. The benefits no longer outweigh the cost.”
-Anonymous, neurology, Arizona
“I wouldn’t do it again in my era, but I do hold a minority belief that medicine’s best years are shortly ahead, that advances in personalized genetic-based therapies and diagnostics, and in EMR technology and reimbursement methodologies, will make it worthwhile to practice certain specialties of medicine again in the next 20 years (making it possible that I’d recommend the profession to my son and daughter, who are ages five and one years, respectively).”
-Name withheld, primary care, California
“I believe that as a profession and as a country we have reached the point where we have to make a decision; will health care be a public service with room for recognition and incentives for quality and excellence among physicians as a highly valued societal resource, or will it continue to be a competitive business that sways with market trends?”
-Name withheld, primary care, South Carolina
...The Bright Side
The majority of respondents were happy and optimistic, albeit cautiously so, about their chosen profession.
“It is a profound honor to hold the trust I have with my patients, and to have the privilege of serving the sick.”
-Name withheld, anesthesiology, California
“I have seen a deterioration in the attitude of the government and the insurance carriers toward doctors, but the fundamental wonderful rapport and mutual respect I share with my patients survives all this.”
-Name withheld, primary care, New York
“There is not a more rewarding profession. The benefits are numerous: the exchange of ideas, the colleagues with whom I work, and the enjoyment of helping someone go from sickness to health included.”
-Name withheld, pediatric neurology, Wisconsin
Conclusion: Outlook Uncertain, Ask Again Later
It is difficult to say at first blush what these responses actually signify for the present and future of healthcare in the US. Certainly, if only a fraction of the 54% of respondents who say they have considered leaving the profession follow through on this urge, the additional burden placed on the medical community could be crippling. Further, if the frustration that seems to surround the profession causes it to become less attractive to potential physicians, the result could be a serious future shortage. Of course, the rewards of the profession remain substantial; it falls to medical schools and individual physicians to emphasize these qualities in dealings with physicians-in-training and young people, prepare them for the difficulties inherent in the profession, and advocate aggressively for the changes that will benefit patients and physicians alike.
More than two decades after graduating from UCLA medical school, Judy Willis, MD, traded in a successful neurology practice for a decidedly different method of shaping and improving human brains: she became an elementary school teacher. To read our discussion with Dr. Willis about her decision and its impact on her life, visit www.mdng.com.
Inside the Numbers
Here are the relevant results from the series of surveys on which this article is based, sent in summer and fall, 2005.
1,105 complete responses, including 398 from primary care physicians, 165 pediatricians, and 173 psychiatrists.
Q: What is the greatest source of frustration in your practice?
Dealing with HMOs and Insurance Companies: 26%
Issues Related to Medical Malpractice: 17%
Q: By how much have your malpractice premiums increased in the last five years?
100% or more: 13%
Q: Are you now considering or have you in the past five years seriously considered giving up your practice?
Q: If you answered “yes” to the above question, which of the following would you pursue?
A nonclinical area of health care: 35%
A career outside of health care: 28%
Another medical specialty: 7%
Q: Would you recommend that your children follow in your footsteps and pursue a career in medicine?
Yes: 41% No: 59%
Q: If you could go back and do it all over again, knowing what you know now, would you still choose to become a doctor?
Yes: 66% No: 34%