Within the clinics, hospital corridors, and halls of medicine, a new phrase has emerged and taken hold of the practice of medicine. Whenever confronted with the challenging, inconvenient, undesirable, underinsured or maybe when just overwhelmed, health care personnel have begun to utter the phrase “I’m not comfortable with …”
Upon the utterance, all responsibility to the patient, institution or the honorable practice of medicine is immediately and completely discharged until the situation however small or large can come to rest with the health care provider who is “comfortable.”
It seems some physicians have become “uncomfortable” with assessment of common conditions. Emergency physicians became uncomfortable with discharge of patients, and finally, hospitalists at other facilities became “uncomfortable” with attending to any patient who might have a remote chance of requiring assessment by a specialist physician not on their hospital medical staff. All that is necessary it that they state “I’m not comfortable,” and patients must be transferred elsewhere.
So, who really is “comfortable” in 2019?
The answer eludes me. Specialists have sub-specialized and left significant portions of their training behind. Physicians seek out non-hospital-based specialties to avoid the rigors and inconvenience of emergency call. Concierge and boutique practices expand, ready to serve the patient right up until the moment they are seriously ill or unable to pay the premium fees.
Primary care physicians rarely see patients when hospitalized and routinely defer routine matters to the emergency department. As physicians defer more patient care duties, they lose important clinical skills and become progressively less able to treat seriously ill patients competently.
The phrase “I’m not comfortable” has become so powerful that it leaves no room for question. Instead of the phrase explaining a lack of ability, knowledge or training, doctors, nurses, and medical technicians can now deftly wield this phrase and produce an impenetrable shield against all that is unwanted, difficult, unpleasant or just inconvenient. It absolves responsibility and deflects potential liability. It is the perfect defense for anyone who is stressed, burnt out or doesn’t wish to be bothered with a difficult problem or just additional work. It is now heard from nurses all the way up to the sub-specialized physicians who may prefer to avoid caring for the most challenging, common and least rewarding conditions in medical practice.
In today’s medical world, “I’m not comfortable with accepting/treating this patient or condition” has become the equivalent of telling a colleague to “go-fish,” meaning I won’t take this, find someone else.
In my opinion, the expansion of hospitalists, residency work hour restrictions, governmental regulation, medical liability, and defensive medicine are at the root of this statement.
Hospitalists assumed care of patients that previously might have been admitted by the primary care physician, cardiologist, neurologist, gastroenterologist, and even medical oncologists.
“I’m not comfortable” is increasingly prevalent in the most recent generation of physicians, trained in the era of limited duty hours during residency and accustomed to the hand-off of patients to the next shift doctor.
Governmental regulation including EMTALA (Emergency Medical Treatment and Active Labor Act) regulations obligate facilities with specialized capabilities to accept any patient for which transfer is requested. All one must do is say “ I’m not comfortable,” and the transfer process will begin.
The fear of litigation caused some physicians to flee from emergency call and limit practice to outpatient centers, focusing on low-stress and low-risk problems. Some have resigned their privileges to treat certain conditions or left the practice of medicine altogether. Specialty hospitals skim the well-insured, healthy and straight forward patients off the top and send the underinsured ill elsewhere, Specialists reduce exposure to litigation and escape emergency call at the general hospital. When patients under the care of these providers encounter a serious problem, or perhaps just call after hours, they are directed elsewhere.
Defensive medicine motivates doctors to request more consultations to limit liability and responsibility, referring to specialists with a symptom only, often without treatment or testing. Difficult patients are placed on a referral merry-go-round seeing one specialist after another without any clear plan or treatment.
If a higher level of care exists, it must be sought out to exclude any possible diagnosis regardless of how unlikely it may be. Every symptom must be assigned to a specialty and consultation must be obtained for each item on the problem list. The hospitalist or emergency room physician becomes little more than a triage specialist in some instances. It’s little wonder medical care has become so disjointed and expensive. So, it seems that no one is comfortable anymore.
The net effect has been an insidious growth in apathy among doctors.
There have always been physicians who found ways of avoiding extra work and unpleasant patients, but the change we are experiencing is much more widespread in my opinion. We create boutique medical practices, neurologists and pulmonary critical care physicians choose to practice sleep medicine instead of caring for acutely ill patients and newly trained medical doctors unaccustomed to working more than the regulated hours of residency choose to limit practice to maintain a lifestyle they feel is balanced. When physicians in my field of neurosurgery trained to care for patients with life-threatening neurosurgical conditions relinquish the privilege of performing cranial surgery in to avoid emergency call and liability, we have a problem.
The 2018 update to the American Association of Medical Colleges titled “The Complexities of Physician Supply and Demand 2016-2030 “ estimated a physician shortage of up to 120,000 physicians by 2030 and is currently at 40,000-60,000 fewer physicians than needed. The population is expected to grow approximately 11% by 2030 and simultaneously is aging significantly. Furthermore, since 2002 there has been a trend among physicians to work fewer hours, with the effect of 32,000 fewer full-time physicians in practice. Even though the supply of hospitalist physicians has been growing the demand will most likely exceed the available hospitalists. Many physicians have left practice or plan to retire early, and more than one-third of active physicians will be 65 or older by 2030. Many of these physicians will leave practice.
All of these factors have concentrated the care of seriously ill patients among the remaining physicians obligated or willing to accept them. The numbers of patients continue to increase. It is little wonder that burnout rates among such physicians are high. The real physician shortage lies in the reality that more patients who are often sicker and older are in the care of progressively fewer physicians. According to the 2018 AAMC report, it is predicted that even with increasing numbers of medical school graduates, physician assistants and nurse practitioners, delayed retirement of existing physicians and static work hours, the demand will continue to exceed the supply of physicians by 2030.
Those of us left are certainly not comfortable.
Jackson B. Salvant, Jr. is a neurosurgeon.
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