E D I T O R I A L
A Flashlight While Stumbling Around in the Dark: Organized Medicine Meets the COVID-19 Pandemic and Physician Burnout Head On Jennifer Joiner Bryan, MD
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oronavirus – One word has turned the entire world upside down. As I watched this virus escape Wuhan, China, and spillover quickly to other nations, my mind raced. It was raging like wildfire and moved so quickly that it felt like an alternate reality. As I interacted with the public, I grieved that they did not yet realize the tidal wave was coming– the new normal. We are now living in the new normal. Most physicians realize that we are finding our new normal through this and that the old normal isn’t returning anytime soon… if ever.
administrators stop short of telling physicians where to refer patients. However, reminders are often given for those clinics that are recommended to use and currently practicing within or financially supporting the system. Many physicians are given little say in their own time management and clinic flow, and there is significant micromanagement (little of which has anything to do with actual medical care and most designed around billing practices). Physicians are deemed “providers” and witness first-hand the death of medical expertise.
Prior to the pandemic, physician burnout was at an all-time high. Physicians, taught to put others first, have been attacked from every direction, and yet remain resilient. Depression, substance abuse, and suicide are serious threats to our workforce, and regulatory issues have become quite a burden. Physicians, who in years past had kept a box of index cards that listed things such as “strep throat, gave penicillin” slowly became data entry clerks. “Click here or don’t get paid…” “Make sure you meet your patient’s ‘quality’ measures even though you just spent a halfhour listening to them cry over their divorce.” “Didn’t code that visit right?” Fraud. Did you call in a refill on your neighbor’s blood pressure pill when they ran out while out of town? Well, that might threaten your license. Medical school? Why did you waste all that time and money? Everyone knows you can go online to become a nurse practitioner and do nearly the same thing. Look at your patient and hold their hands as they weep? There’s no time. Type. Click the boxes. Get it done. As the regulatory burdens increased, physicians slowly gave up autonomy. Just before the pandemic, 51% of United States physicians were employed. With Centers for Medicare and Medicaid Services (CMS) requirements and an everchanging regulatory environment, it is not feasible for most to own their own practice. Or it hasn't been feasible until recently when regulations were slashed in the name of easing the burdens of the pandemic crisis.
As practices shifted to outpatient care separate from inpatient care provided by hospitalists, an even greater disconnect began. It affected medical care, and we all knew it. Doctors in the hospital cared for gravely ill people whom they had never met before. Why didn’t outpatient doctors want to go to the hospital anymore? The answer was simple. Their lifestyle could no longer sustain it. Many could not keep up with the quality measures and charting systems, which were again designed primarily for billing purposes, and still care for their patients in their hours of greatest need. Doctors who had to type and “button click” quality measures began to employ nurse practitioners and physician assistants just to keep up. The scope of practice battles waged and burnout taskforces were created across the country to determine what was causing this “mysterious” burnout. At national physician-run meetings, the message was clear. Physicians knew why they were burned out (a hint for the nonphysicians reading this: it is all of the above things and more), but there has been too much money at stake for stakeholders to stop the current processes and rethink what we have been doing in health care. And then the coronavirus pandemic happened.
Over the past 15 years, health administration became big business. Physicians became employees but still held that medical decision making was autonomous. In reality, that autonomy looked like, “You can order what you want, doctor, but we (the insurance company) are just telling you what we’ll pay for. The patient can have the test, but we’ll bill them the thousands of dollars for the test unless you order what we tell you we will pay for.” That same policy goes for prescriptions. Health systems have grown their own networks of clinics to support their hospitals. To get around Stark Law issues on self-referral, etc.,
Despite what some may think, physicians are generally nurturing people who went into medicine to help people. They are peoplepleasers, and somewhere along the way became so wrapped up in trying to juggle all the balls in the air that they gave up a lot of autonomy. They realized they were caught up in a system of prior authorizations, insurance denials, disruption of care between outpatient and inpatient, devalued expertise, and it was all too BIG. It was so big that no one really knew how to change it, and so they quietly burned out. At the dawn of the pandemic, the health care workforce found itself at a critical point of experiencing burnout, and some even have called it moral injury. Physicians who took an oath knew that there were fundamental differences between what drove them and what drove other stakeholders, but never was it so exposed until the pandemic.
vol. 61 • no. 6/7 • 2020 171
