My wife worked as a retail store manager for twelve years. We often joked that her customers were one psychiatric hospitalization away from turning into my patients. As my career progressed, our jokes became a disappointing reality. My meetings with insurance reviewers, outpatient clinics, and even hospital administrators referenced “consumers” and “clients.” The issue with the use of the term “provider” becomes more important if our patients are seen as a source of income, rather than a person in need of healing. Medicine is a big business that costs 18 percent of America’s GDP, but it does not mean we have to succumb to private equity’s view of physicians as money-makers.
Individuals with more knowledge than me have written at length about medical consumerism. A quick search reveals hundreds of articles for and against this trend. Physicians are already familiar with MACRA and MIPS, Press-Ganeys, and reimbursements tied to patient satisfaction and quality outcomes. The Yelpification of hospitals, practices, and physicians gives our customers patients the ability to judge us before they even meet us. This system makes sense for restaurants and stores providing services easily understood by their customers. But does it make sense to allow comparable reviews of the complexities and nuances of medical decision-making? How is a physician supposed to respond to an irate patient who insists on antibiotics for their second day of a viral infection? This is particularly troublesome for psychiatrists who treat patients on an involuntary basis. If you look up your local psychiatric hospital, the reviews are often a minority of happy families and a majority of disgruntled, sometimes actively delusional, patients angry about their forced treatments.
I am not here today to beat the dead horse of contributors to physician burnout. I am here to share a personal story that contributed to my own burnout. I am an early-career physician, but I would never encourage my future children to enter medicine. Many of my colleagues share similar opinions. I am a big proponent of “do what you love.” However, it’s hard to love something that constantly criticizes you, berates you, and tells you to do more with less.
I am a psychiatrist working in North Carolina. The medical board consists of eight physicians, one physician assistant, one nurse practitioner, and three members of the public not affiliated with the health professions. Board members are appointed by the governor or general assembly to serve three-year terms. No current member is a psychiatrist. Complaints to the board require a response from the physician within 45 days. You receive an official email with multiple PDFs. They encourage you to hire an attorney at your own expense. After responding, months pass in limbo until the board sends an email with the outcome of their review.
Last year, I received a professionalism complaint from an individual who cares for mentally ill patients in the community. I was accused of being rude and verbally abusive to this individual. The complaint included details in direct contradiction to my recollection of our conversation. My initial contact with this person occurred during routine discharge planning for the patient. I was concerned about delays in discharge that would lead to a violation of the patient’s right to freedom from confinement and inappropriate utilization of limited inpatient psychiatric resources. Soon after explaining my concerns to this individual, I was berated and threatened with medical board action. I was informed that I was now being recorded, and an individual who did not have authorized consent to hear about the patient was also present on the phone. After several minutes, I felt it was prudent to end the phone call to maintain privacy. I immediately documented the conversation with this individual in the patient’s medical record. I did not do this because I felt it was required for patient care; I did it because I wanted documentation of the interaction as supporting evidence for any future complaint. I provided this documentation in my response to the medical board.
Five months later, the board informed me no action would be taken. The complaint would be kept in my medical board file but would not be publicly reported. The board commented on challenging clinical situations and emphasized the need to maintain professional communication, which applied to facility staff and community partners. The board encouraged me to reflect on how my “tone” may have contributed to the situation. No reference was made to my description of the complainant’s communication.
The mission of the North Carolina Medical Board is to “protect the people of North Carolina, and the integrity of the medical profession, through just and vigilant licensing and regulation.” This is an important mission, especially when potential abuse, negligence, and boundary violations affect patient health and well-being. I can understand there may be situations in which an adversarial process must take place to “protect the people.” But what “people” does the mission statement refer to? Individuals who feel upset by a physician’s line of questioning? Patient citizens who remain inappropriately confined due to community resource issues? Taxpayers who foot the bill for all of this?
Integrity is defined as adherence to a code of especially moral values. When I take care of patients, I have a moral and legal duty to care for them. I cannot deny them care, transfer them on a whim, or abandon them without risking a lawsuit or license revocation. I act as beneficently as possible while minimizing maleficence caused by involuntary commitment and side effects of psychiatric medication. My duty is not to a community partner that is unwilling to discuss discharge barriers in a productive manner. It rankles me that community housing resources, insurance partners, and outpatient clinics are not expected to maintain the same obligations for patient responsibility. What integrity is protected by the board’s action? To what standard for professional communication was the community partner complainant held? I do not understand how the process protected the patient’s rights to freedom from confinement.
When we forgo common sense and logic to grease the squeaky wheel, doubts fester. Did I do something wrong? Is my livelihood at risk? How can I take care of my patients if I always must look over my shoulder? Do I need to record every interaction I have to prove my integrity? In a profession marked by a 42 percent burnout rate, how much more stress can we tolerate? Insurance companies already deny our patients life-saving care. Real wages are falling. Forty-nine percent of physicians consider early retirement or another career due to overwork. Since the COVID-19 pandemic, trust in doctors and hospitals fell from 71.5 percent to 40.1 percent. This is not an article about politics, but we cannot ignore what the politicization of science has done to the public’s perception of us. Scope creep and the inappropriate use of the term “doctor” for non-physician practitioners devalues the sacrifice we make to pursue rigorous careers.
I am not asking medical boards to brush off complaints. Independent oversight is necessary when lives are at stake. I am asking everyone in the medical field and adjacent partners to practice patient-centered care. For the patient’s benefit. I am asking people to respect the integrity of physicians. I advocate for mutual respect and fair and equal treatment of everyone. It does not matter if you are a customer, a manager, a consumer, a physician, a client, a social worker, or a residential facility manager. We are all humans who deserve to be treated with dignity and respect.
Ryan Kaufman is a psychiatrist.
