She came to the urgent care center with a sprained ankle. The primary care provider gave her excellent care, expertly applying evidence-based evaluation guidelines to her situation, and, thereby, avoiding unnecessary x-rays. By all measures, the provider’s care was excellent, but the interaction still ended up reducing his salary. You see, that patient’s only medical interaction that year was for this ankle sprain, and the provider was therefore held accountable for all of her primary care needs. Since she had not received a mammogram that year, or received a diabetes screening, he incurred an end-of-the-year penalty for failing to meet these quality standards.
Is it any wonder that many providers — primary care physicians, physician assistants, and even many beleaguered specialists — are increasingly dissatisfied with their jobs? What is happening to medical practice and what can we do to bring the joy back to being a health care provider?
I am early into a one-year quest to connect with leading thinkers from inside and outside medical care, so I can better understand why many clinicians are miserable in their careers, and much more importantly, what can be done to help them thrive at work even though an increasing number of outside parties are looking over their shoulder, assessing the quality of the care they provide.
These increasingly burdensome rules and regulations are making it hard to enjoy medical practice these days. Several decades ago, physicians largely practiced as autonomous professionals, governed by standards developed by their professional peers. Physicians underwent intense and prolonged training to develop the knowledge and skills to know how best to help patients with their problems. And the world generally stood back and accepted, on faith, that most physicians would provide excellent care to most of their patients.
In recent years, however, outsiders have increasingly tried to assess just how well physicians are performing their jobs. Insurance companies and Medicare administrators are measuring the quality of care physicians provide, and even holding them financially accountable when that care is not up to standards. In part, these external accountability measures have been put into place because people paying for medical care — insurance companies, Medicare administrators, and even patients — realized that the quality of medical care wasn’t always as high as it ought to be. And since the profession wasn’t doing everything it could to promote high quality, they recognized that somebody from the outside needed to hold physicians accountable for their practice. As a result, medical practice has shifted from being autonomous to supervised; physicians have gone from being independent decision-makers to being bureaucrats forced to check boxes.
There’s a lot going on here, and I will revisit and flesh out these ideas in later posts. But the gist is simple: Physicians are caught between professionalism and accountability. The more their attention and energy is focused on meeting accountability standards, the less they focus that attention and energy on making professional judgments about how best to address patients’ needs. This is a shame. After all, we select some of our brightest people into the profession, and put them through 7 to 15 years of intense and often low paying training. How can we, then, expect them to spend their time working their way through computer-generated “to do” lists?
One of the experts I have spoken with about this problem is Barry Schwartz, a psychologist at Swarthmore, who just published a terse and engaging book, Why We Work. Early in this fine book, Schwartz describes a hospital custodian who – despite a job overflowing with to do lists, and despite a career about as far as imaginable from that of an autonomous health care professional — nevertheless found great satisfaction in her work by going beyond her required “to dos” to find ways to improve patients’ hospital experiences. She would change the pictures hanging on the walls for patients during long hospital stays, for example, “so they know they’re getting closer to home,” she explained. (The custodian’s story comes from research conducted by Yale professor Amy Wrzesniewski and colleagues.)
That custodian’s insight might be part of the key to helping physicians and other health care providers thrive at work. It shows that even in a highly bureaucratic and dogmatically supervised environment, if people are given a little space and reminded of the important things they can do to help patients in times of need, they can take steps to make work more meaningful.
Physicians’ jobs are becoming increasingly bureaucratic. This bureaucratization can draw physicians’ attention away from the purpose of their work — making patients’ lives better. In holding physicians accountable for the quality of their work, we should not undermine this purpose.
Peter Ubel is a physician and behavioral scientist who blogs at his self-titled site, Peter Ubel and can be reached on Twitter @PeterUbel. He is the author of Critical Decisions: How You and Your Doctor Can Make the Right Medical Choices Together. This article originally appeared in Forbes.
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