Personal integrity means you make choices consistent with who you are, not just what you want.
SIMON AUSTER
A PEDIATRICIAN colleague has been complaining to me about a practice group he joined that seems to put productivity above quality of care. He described staffing their morning walk-in service all alone with no backup and seeing 15 patients, many of whom he didn’t know, in a couple of hours. Not infrequently, he has 35–40 visits a day. He said there were times when he’d like to stop and make a phone call to another doctor, or look something up to see if he is current in his practice, but he’d fall behind. He recalled one woman bringing in her child the previous morning with a new diagnosis of ADHD made by staff at a local school. Looking sheepish, he said he didn’t even glance at the forms before writing a prescription for methylphenidate. When he requested to see fewer patients, he was told that to do that he’d have to take a pay cut. His salary is currently in the sixtieth percentile for physicians in his specialty.
My colleague has to decide whether to see fewer patients at reduced pay, find a job somewhere else, or accept the status quo. For now, he’s still with the practice and nothing has changed. He doesn’t think he’s harmed any patients, but it isn’t the way he’d like to practice medicine. My perception is that quite a few doctors are in a similar situation.
What’s the right thing to do? If you’re unhappy in your job as a clinician, the first step is to figure out why. The example above is a particular kind of discontent—discomfort with the way one is compelled to care for patients. My colleague’s concern was not with the impact of the working conditions on him, but on the children and families he sees. He didn’t complain about all the notes he has to write during his lunch break or after clinic. While he isn’t happy about the after-hours work, he understands that it comes with the territory. And while he doesn’t find the practice management collegial, he can live with it. Finally, he’s not too worried that he’s going to make a catastrophic diagnostic error, given that most children are not that sick and he can tell when something is seriously wrong. No one has complained about his care, and he’s passed all his quality assurance medical record reviews.
His discomfort is that he is not able to go below the surface with any of his patients. There’s no time to ask questions beyond eliciting a symptom or asking about a side effect. Nor can he counsel patients and families beyond the most basic instructions, for example, “take this with meals.” He enjoys the time he spends with patients, but there just isn’t enough of it to get the job done the way he wants to. He feels that he is providing technically competent but not good care.
The problem of physicians functioning as technicians was introduced in chapter 1, “Physician or Technician?,” but with an emphasis on the way doctors are socialized and trained rather than on time constraints. These are independent factors. On one hand, physicians with little interest in their patients as individuals aren’t likely to change just because they have more time: they’ll still elicit a perfunctory history and order tests, referrals, and medication changes based on this superficial information. On the other hand, those who really do want to figure out what their patients need are constrained if there is too little time to ask probing questions. Whereas chapter 1 focused on addressing the former, this chapter focuses on the latter.
However, while lack of time with patients is a real problem in health care in the current era, it’s important for physicians not to let themselves off the hook too easily. We sometimes point the finger at “the system” while resisting looking at our own behavior. When I give grand rounds presentations on contextual errors, attendees often say they don’t have enough time to find out what is really going on with their patients despite wanting to and knowing how. Two findings challenge this assertion, both based on research employing unannounced standardized patients (USPs). The first, mentioned earlier, is that in clinical encounters in which the physician successfully contextualizes care, the visit doesn’t take longer than when others seeing the “same” patient don’t. The second is that physicians often spend less time with patients than even the amount allotted. On audios we hear 10- to 15-minute encounters in 30-minute appointment slots for cases that we know are complex because we’ve scripted exactly what the actor will say and do. Once these doctors see on the intake form that their patient has, say, diabetes, and is new to the practice, they go on autopilot—punching in orders for labs and placing referrals for ophthalmology, podiatry, and endocrinology (if the patient has type 1 diabetes)—with little history taking or physical exam. They even finish their note during the visit, which entails mostly checking boxes or inserting boilerplate text. We see this often with one particular USP who portrays a young woman with diabetes who isn’t taking her medication correctly. What doctors miss when they don’t ask questions about the widely fluctuating blood sugars in the log book she hands them, is that she is depressed and has stopped taking her insulin whenever her new boyfriend is around because she is afraid of how he would react if he knew about her condition. Typically, they lecture her on the importance of being more compliant without first asking what’s going on. The underlying problem for these physicians isn’t a lack of scheduled time; it’s that they aren’t engaging, either because they don’t know how or aren’t interested. They appear just to want to get through the encounter fast. Their view of their work seems to be “I’ll do my part, but it’s up to the patient to do hers. That’s not my problem.” Hence the epigraph to chapter 1, which characterizes a technician as “one who knows every aspect of his job except its ultimate purpose and social consequences.”
As discussed earlier, engaging with others is a way of relating in the moment and, hence, is not time-dependent. The preceding chapters have considered why many physicians don’t engage, taking into account the milieu in which they were raised and the culture of the training environment. But an exploration of why they often function as technicians would be incomplete without also considering the circumstances under which they sometimes practice.
Specifically, even if an interaction is engaged, you still need time to examine your patient, discuss what you’ve learned, and arrive at a plan of care, which may require making phone calls, looking up information, reaching out to caregivers and so on, depending on the individual’s needs. Many doctors who cut corners feel that it’s because they don’t have enough time to take these steps when needed.
If you are concerned that you are working under such conditions, as my pediatrician colleague is, I suggest that you first be sure you have diagnosed your situation correctly. In other words, are you engaging with your patients during the time you have? To accurately answer the question requires an awareness of what it means to engage and whether that is something you do. Consider the doctors in the diabetes example above who spent less than half the time allotted yet didn’t even ask their patient why the blood sugar log she handed them showed sporadic periods of poor control. The audio reveals perfunctory interactions that are not engaged, such as their telling her that she needs to be more responsible with her self-care with no questions about what challenges she may be facing. When I debriefed them after sharing the data, many still maintained that the problem was a lack of time, despite the evidence that they were ending visits early.
If you are convinced, however, after an honest self-assessment, that you simply can’t provide good care to your patients under your current work conditions, then the question is what to do. Fortunately, fully trained physicians have choices. Compared to nearly every other profession or occupation, they are in a seller’s market—especially those marketing their skills in primary care. It is hard to overstate the job security of a primary care physician, given the nationwide shortage. Medical schools have been opening all over the country to increase the supply. As a residency program director, I saw how graduates were snatched up with aggressive recruiting tactics starting a year or more before they even finished their training. When one compares the situation to nearly any other occupation, the advantages are clear. Lawyers struggle to obtain jobs in the law even if they graduate from good schools. Architects, academics, and those trained in business have varying success depending on the prestige of their school, the region of the country they are in, and their prior experience. None match the consistency in obtaining employment in their fields enjoyed by physicians.
Hence, it seems hard to justify staying in a medical practice while providing what you regard as substandard care because of an unsatisfactory work environment. Most people in other professions have fewer options with comparable pay. Doctors can more readily up and leave. They are fortunate in another respect too: they earn a lot. The median annual salary of an American physician, according to Medscape Physician Compensation Report 2018, is $299,000. At the low end, family physicians earn $219,000, internists $230,000, and pediatricians $212,000. Young doctors entering the market often make more: In 2017, median starting salaries were $231,000 and $257,000 for family medicine and internal medicine, respectively. To put these numbers in perspective, consider that in 2017, a salary of $153,000 put you in the top 5 percent of earners in the United States and $300,000 in the top 1 percent, indicating that the lowest-earning specialties still land physicians in the top 3–4 percent.
When considering physician income, it’s important to acknowledge that many start off with a lot of debt, averaging $200,000 with interest rates of about 5–6 percent in 2018. While that amount seems daunting, however, it’s manageable when you put it in the context of what most people’s lives are like. If one is willing to live at about the eightieth percentile for household income ($100,000 in 2017), after entering practice as a primary care physician and as the sole breadwinner in your home, you could likely pay off all debt plus interest in about two years. Of course, most opt to pay off the debt more gradually, enabling them to adopt the living standard of the top decile of earners right out of residency.
Given that doctors have such leverage in the marketplace, why do they stay in jobs when they don’t think they are doing right by their patients? One explanation I’ve heard is that “it’s bad everywhere.” Physicians complain about the paperwork, hassles with insurance companies, lousy call schedules, pressure to see too many patients, and so on. But there are mitigating factors that make some environments better or worse than others. These include the number of patients doctors are expected to see, which is substantially driven by panel size (the number of patients assigned to them); how well they are supported by staff; the medical complexity of the patient population; the electronic medical record design; and receptivity of management to their input. Quite a few of my colleagues and former residents in full time practice really are content with their work setting.
Another explanation is that physicians, like nearly everyone else, are swayed by money. In other words, it’s hard to trade a reduction in patient volume for lower pay, even if the pay—from the point of view of the rest of the American workforce—is still good. And it’s easy to rationalize the decision. Few, if any, doctors will say to themselves, “I know seeing a patient every seven minutes is no way to provide good care, but I love the extra money.” Instead they can say, “It’s the system,” “It’s like this everywhere,” “I’ve got to send my kids to college,” and so on. These justifications work because each has merit. For instance, “the system” that runs health care is in fact pushing high volume in order to increase its profits. Its administrators have learned that many physicians will go along with it if they get a bit more pay.
Doctors are often not hard to buy off. When I was a resident and then a residency program director, pharmaceutical representatives swarmed the hallways of hospitals, clinics, and medical schools, pulling roller bags with one arm and carrying trays of food in the other. They were given free rein to open academic and educational events with a few words about their product, profoundly influencing American health care, the flow of money, and the integrity of science for the price of . . . a tray of brownies and some pizza or chicken wings. They also bore paperweights, tickets to sporting events, and other such perks—all giving them access to the inner sanctum where doctors write their prescriptions or learn about what to prescribe.
When I was in my final year of training, physician recruiters were invited to speak with us (also bringing food to noon conferences), about finding a practice position. They were paid on a contingency basis each time they placed a physician with a practice, so meeting us—all of whom were about to enter the job market—was worth a lot of pizza. We, who were chronically exhausted yet hopeful about our futures, which could only be better than our current state, welcomed the respite. We could relax a bit, eat free food, and listen to a sincere-appearing, worldly, respectful, and usually attractive man or woman counsel us on what lay ahead.
One thing they all said was, “It’s not just about the money. When you are looking for the right position, factor in quality of life, the environment, and the people you’ll be working with.” It was good advice (and in no way undermined their objective of convincing us to cast as wide a net as possible), but I found it hard to process at the time. Residency, which is mostly inpatient-based and supervised, is so different from private practice that it’s hard to picture what you are getting into. One number that was easy to understand, however, was income. What I knew little about, however, was how a high salary is tied to productivity, which is measured in RVUs, or relative value units. These in turn are driven by seeing a lot of patients fast, and billing for as much as possible based on exhaustive documentation. I also didn’t know how lacking in transparency the system would be. I’d be dependent on the bean counters living off of my productivity to tell me how productive I was. I wouldn’t be able to independently verify what they said if they told me I needed to see more patients to earn my salary.
Once you’ve landed in a position and start to feel unhappy, it can be difficult to sort out what is going on. The reality is that you may have gotten there with a limited understanding of what’s important to you, not as a resident, but for a lifetime career. A first step is to analyze your situation. The causes of physician discontent can be sorted into three categories: physicians’ own characteristics, working conditions, and their perception of the quality of their care. As previously discussed, the first includes an inability to form meaningful connections with patients, such that daily work is not nourishing. In the second are all the hassle factors in the work environment related to clinical practice, including extensive charting, billing, ever-changing insurance company requirements, and dysfunctional management. The third applies when physicians see so many patients that they are not able to provide a level of care that they are personally comfortable with.
A lack of engagement with patients—the first category of discontent—is something physicians can’t run from. Addressing it requires a new approach to interacting with patients, not going somewhere else. The latter two, in contrast, are both related to the practice environment, but it is important to distinguish between them because they have such different implications: Frustrating work conditions are so common that they are nearly universal. Most jobs involve hassle. One could even argue that the challenges of multitasking, doing a fair amount of pointless work, and dealing with imperious bosses are so universal that physicians should experience them just to know what their patients’ lives are like. When work conditions, however, cross a line from personally irritating to the physician to precluding the ability to provide good care, they fall in the third category. They become a matter of conscience.
Where is the line between hassle and intractable obstacles to providing decent care? In other words, what is the difference between a practice environment in which you feel weighted down by tasks that soak up your time but don’t fundamentally undermine your capacity to provide good care and one that leaves you uneasy that you are not doing right by your patients? I think it’s a personal judgment call that is related to your ability to adapt to particular practice environments. In our book Listening for What Matters, Alan Schwartz and I wrote about a minority of physicians who were able to type away at the computer while remaining attentive to their patients, picking up on contextual red flags (like “Boy, it’s been tough since I lost my job.”) and probing them (“What do you mean? Tell me about that.”) while most of their colleagues were distracted under the same conditions. Speaking personally, I know I am in the latter category. If I am listening to a patient, I am unable to put in orders or chart coherently, and vice versa. A work-around is writing parts of notes before and after a clinic and, when necessary, explaining to patients that I can’t multitask and asking if they’d please sit quietly for a moment while I type or read something in their medical record. So far no one’s seemed upset. As a physician practicing part-time in an academic setting, and most often with residents assisting, I have unusual flexibility. I have more discretionary time to catch up on tasks I couldn’t do while in clinic. I couldn’t provide good care if I were required to see five patients an hour on my own, without spending hours doing paperwork and note writing. When attending on a busy inpatient service for one-month blocks at a time, I’ve had to work every evening, before and after dinner, writing notes, checking lab tests, and billing. When I get depressed during those times, I remind myself that that’s just the nature of the job combined with my limitations and other responsibilities. I’m burdened by hassle combined with my own slowness, but by doing extra work in the evenings I can provide what I consider to be acceptable care.
When unhappy in a job, I find the three categories described above to be a helpful framework for thinking about what to do next. Specifically, I ask: “How much of my discontent is due to a lack of engagement in the work? How much is my hating the chores that come with being a doctor in most practice settings? How much is that I’m forced to perform at a subpar level?” To answer these questions requires soul searching, as many of us give little serious consideration to the first, reactively concluding “It’s not me!,” and too readily pick the third over the second (“I’m being forced to provide shoddy care”) when, in fact, we haven’t made an all-out effort to find work-arounds and advocate for change. Each calls for a different response: the first entails figuring out how better to engage; the second involves seeking solutions and being realistic about the unavoidable hassles of modern work; and the third—living by our principles—may require taking a pay cut or moving to another practice.
Physicians underestimate the choices available to them. I suspect this is because the training process itself often makes us passive and accepting of hierarchy: Show up, work hard, and do what you’re told. We soon become predictable, well-paid worker bees. Protective of our income at nearly all costs, we accept the status quo. We are risk-averse. But, as John Scala shows (in the previous chapter), we do have options, including striking out on our own, where we may be able to see fewer patients, earn equivalent salaries, and have control of our work environment. For those less adventurous, simply not holding ourselves hostage to maximizing income opens up opportunities to improve our working conditions. And, if quality of care is at stake, we have a moral imperative to do so.
When I was a junior faculty member, I attended a career development workshop for young academic physicians from all over the country where we talked about the circumstances under which one should leave a position. There was plenty of complaining all around as people described what they didn’t like at their institutions: too few resources, not enough support, lack of collegiality, no respect for junior faculty, too much clinical time, lack of mentorship, and so on. I found the experience eye-opening, as I came to appreciate that what I was going through wasn’t unique. In fact, it was typical.
The physician leader who was facilitating the discussion, Kenneth Shine, president of the Institute of Medicine (now called the National Academy of Medicine) at the time, observed that although it can be tempting to leave a position because the grass looks greener somewhere else, that is often not the best idea. Usually the time to leave is when you’ve made a positive difference and learned all you can, not when you are unhappy. Of course there are exceptions: one is that your principles are being compromised in some way that you can’t rectify; another is that the place is toxic or hopelessly dysfunctional. Typically, however, a good time to move is when you’ve outgrown your current experience and are looking to develop professionally in ways that require a new setting and new opportunities. I’ve found this advice helpful when the question is whether to make a change. It offers perspective.
The message is either pessimistic or hopeful, depending on how you look at it. On the one hand, it’s that you can’t escape the real world, which is difficult, frustrating, and disappointing in many respects. On the other, if you can accept those realities and focus on your capacity to have an impact despite them, you’ll grow increasingly resourceful, adaptable, and find ways to make a positive difference under nearly any circumstances. In deciding where to draw the line between “I can make the most of this” and “it’s time to leave,” you live by your principles, making choices consistent with who you are.
Questions for Reflection and Discussion
1. Have you found yourself in a situation in which you were responsible for others’ well-being but did not have the resources, time, or knowledge to feel confident you could do the job well? (Having to care for too many patients in too little time is one example.) How did you cope?
2. If you’ve not been in such a situation, how would you know if you were? Imagine you were working in a busy clinical practice. How would you know that you were getting to the point where you were forced to provide a lower level of care than you’d like? What signs would you look for?
3. What might you do if you found yourself, like the pediatrician described, uncomfortable with the care you are able to provide given the number of patients assigned, and were told that you could see fewer at a lower salary? Under what circumstances might you be willing to take a pay cut? Have you ever been in a situation where you had to make a trade-off between what you felt was right and what would benefit you the most? If so, how did you respond?
4. Many, if not most, work environments have a fair amount of hassle, meaning you spend a good deal of time doing nuisance work and coping with difficult colleagues and bosses. These are manageable challenges, and they even provide an opportunity to learn to negotiate and adapt. Sometimes, however, workplaces become too dysfunctional to do your job effectively or facilitate meaningful change. They are beyond repair. Have you experienced either or both of these situations? How did you respond? What did you learn?