Editor’s note: The following article contains observations and insights from Dr. Pearl that are more thoroughly explored on his website (robertpearlmd.com) and in his 2021 book “Uncaring: How the Culture of Medicine Kills Doctors & Patients.”
Every doctor knows that properly diagnosing an ailment is the first step toward implementing a proper treatment. The same is true with physician burnout, one of the most pressing challenges in the medical profession today.
According to a recent Medscape poll, 42% of physicians are experiencing burnout, which comprises a troubling constellation of symptoms: exhaustion, frustration, dissatisfaction, and a sense of failure.
Clinicians report feeling sapped of their time and their love for medicine. But the consequences of the problem are even more dire than that. According to occupation studies, unhappy physicians are prone to working less, losing focus faster, and making costly mistakes. Dissatisfied doctors are also more likely to experience depression and die from suicide.
In self-reported surveys about the causes of burnout, doctors indicate feeling beaten up by the broken health care system, which has become increasingly computerized and corporatized. Doctors cite the system’s endless regulations and excessive paperwork as contributing to their distress. They also attribute burnout to insufficient reimbursement, which requires doctors to treat too many patients per day. In anesthesia, specifically, physicians must navigate incessant calls for increased productivity, along with 24/7 clinical demands and clunky computer systems not designed to meet their clinical needs.
All of these systemic issues contribute to the frustrations of both doctors and patients, but they are only one part of the problem. There’s another contributory issue in medicine that’s rarely discussed and insufficiently understood.
Beginning in medical school and residency training, doctors inherit a set of norms, beliefs, and expectations that shape almost every decision they make. These elements combine to form the culture of medicine, an invisible yet powerful force that follows doctors throughout their careers.
Like gravity, the culture of medicine cannot be seen by the naked eye, but its effects can be observed (for better and worse).
For example, during the early days of the COVID-19 pandemic, health care workers risked their lives to provide emergent care to anyone in need. Doctors, most of whom lacked proper PPE, donned salad lids for facial shields and garbage bags for smocks. They worked around the clock to save lives. As patients arrived in the emergency room or ICU, unable to breathe, these doctors did the unthinkable. They passed tubes through the mouth and down to the lungs, knowing full well that the physician performing the procedure was fully exposed to a cloud of exponentially multiplying viruses in the patient’s airway.
Still, they did it anyway. Selfless acts like these are at once heroic and foolish. Above all, they are a shining example of the positive influence physician culture has on the decisions of doctors and the health of patients.
But physician culture does not always have a positive effect. One strange truism about medical culture is that its members are often completely unaware of its existence. They don’t recognize or appreciate the power that culture has over their own thoughts and actions. This degree of cultural immersion frequently produces a “hive mentality.” And because doctors acquire and share the same biases, beliefs, and stories, they frequently fail to challenge collective wisdom. As physicians observe and follow shared norms, they overlook or ignore the negative consequences of their actions on others.
In my 2021 book “Uncaring: How the Culture of Medicine Kills Doctors & Patients,” I examine one such instance in a chapter titled “Human Shields.” The chapter explains the practice of sending surprise medical bills to patients for out-of-network services. Ask doctors in a variety of specialties about this norm and they’ll describe it as something they are forced to do to protect themselves from greedy insurance companies. What these doctors fail to see or acknowledge is the impact their actions have on patients. As pointed out in the book, half of American patients now say that one large medical bill would force them to borrow money, sell their home, or declare bankruptcy. Surprise billing is frequently the precipitating event. No physician would consciously choose to harm a patient, but harm is often the result.
Physicians are not trained to handle the many stresses of practicing medicine. Thus, when they encounter anxiety from the death of a patient or stress from treating COVID-19 victims or the agony of unintentionally inflicting harm on patients and their families, they undergo psychological damage. To defend their psyches against unwanted emotions, doctors use repression and denial, defense mechanisms they mastered while learning to survive the rigors of medical school and residency. Although these defenses help physicians function, they create “blind spots,” obstructing their ability to recognize when colleagues, or themselves, are responsible for negative outcomes in health care.
For example, physicians only begrudgingly acknowledge their role in contributing to the 250,000 American deaths each year from medical errors. They overlook the fact that one-third of all antibiotics are inappropriately prescribed by doctors, putting the nation at heightened risk for future superbugs while jacking up health care costs. And though it was reported in the New England Journal of Medicine that one third of established medical practices are “no better than a less expensive, simpler, or easier therapy or approach,” physicians reject the possibility that economic waste results from anything they personally do in their clinical practice.
This pattern of repressing uncomfortable thoughts and feelings, and denying personal responsibility for negative outcomes, results in a vicious cycle of blame and retaliation, leading insurance companies to impose even more bureaucratic demands on doctors. In turn, physicians perceive insurers and hospital administrators as greedy and uncaring, and they resent the administrative tasks that take time away from direct patient care. Physicians feel they should have fewer restrictions, higher reimbursements, and greater freedom to practice medicine as they were trained to do. Insurers and administrators see things very differently. They feel frustrated by doctors who order unnecessary tests and fail to follow evidence-based guidelines. They chide doctors who recommend expensive and ineffective medical treatments, running up health care costs without any improvements in patient outcomes to show for it.
Doctors are convinced that the problems of American health care would disappear if they had full autonomy over medical decisions. Insurers and hospital administrations fear that outcomes and costs would become worse. The question is how to break this vicious cycle.
To reduce burnout, both the system of medicine and physician culture must evolve and change. The best way to accomplish both is by changing how physicians are reimbursed. More specifically, rather than being paid for the volume of care they provide, physicians will need to embrace reimbursement approaches that reward superior clinical outcomes at lower costs. The best of these options is capitation.
Capitation involves groups of doctors working together as one and receiving a prepaid sum for all the medical care provided to a population of patients for a define time period, usually a year. This reimbursement methodology benefits both doctors and patients. It rewards preventive medicine, the elimination of medical errors, and better management of chronic diseases. Capitation allows all physicians to do better financially by eliminating the 30% of medical care that has been shown to add little or no value. It encourages doctors to reduce delays in treatment on weekends – a problem that exists in nearly all hospitals. Further, capitation leads to the effective use of technology, including telemedicine and home-monitoring.
Changing how doctors are paid will evolve the physician culture as well. Moving from fee-for-service to capitation will encourage doctors to value prevention, maximize patient safety, and minimize complications from chronic disease far more than today. And as a result, it will reduce health care costs, allowing insurers to eliminate many of the bureaucratic requirements that currently erode the physician’s satisfaction and fulfillment.
Some physicians will reject this approach, insisting that they are victims. Asking doctors to lead the process of health care transformation is therefore akin to blaming the victim. What they have yet to accept is that no matter how loudly they yell or how many fingers they point at insurers and administrators, the current restrictions and bureaucratic demands that doctors despise won’t be lifted until care delivery becomes more efficient and effective and the needs of patients are better addressed than today.
And that will require physicians to take the lead. Doctors are not powerless. I am optimistic that when physicians lead the change process and improve the health of our nation, their own satisfaction will increase, their sense of fulfillment will expand, and the rising tide of burnout that threatens the lives of all will begin to recede.