Many changes in payment, practice are only paving the road to further physician discontent
We live in challenging times for physicians, who are required to do things that are wearing them out and making them feel bad about their jobs.
Surveys showing large percentages of doctors burned out, dissatisfied with their work or regretting their career choice point to something deeply psychological that is happening to many doctors—something that should make all of us very concerned.
The things happening to them are clear—their work is a daily treadmill of truncated, rapid-fire patient visits and cookbook medicine; they have too many administrative and infrastructure requirements placed under their responsibility; they must collect, document and report performance-related minutiae; they have been forced to use information technology in heavy-handed ways; they must lead “teams” while at the same time caring for individual patients on a full-time basis; and they work under their employers’ assumption that they have to be watched to know if they are doing their job correctly.
All of these dynamics are magnified for the large number of salaried employees working in more-controlling corporate work settings.
Making things worse is the move to “value-based payment” schemes, particularly through the recent Medicare Access and CHIP Reauthorization Act rolled out late last year. If you spend hundreds of pages, as the MACRA final rule does, spelling out how someone is going to get paid, in this case physicians, don’t expect that someone to believe that you have their best interests at heart.
You also may want to read up on the science of human motivation. That science, and my own research and observations over time, show that most doctors are indeed driven primarily by intrinsic desires, i.e., things such as the personal meaning in their work, strong interpersonal relationships with patients and the emotional rewards they get from helping people. A system based on extrinsic motivators and external oversight, inherent in MACRA and other pay-for-performance programs, further erodes doctors’ ability to pursue these intrinsic rewards.
The healthcare system still cannot acknowledge that physicians are trained to be independent, self-confident decisionmakers, often asked to act in the midst of high clinical uncertainty. The payment schemes placed on them now clash with this reality, mostly by producing the daily work environments described above, as does becoming salaried employees in organizations that dictate workflow and often give physicians little collective voice.
Meanwhile, the modern health quality movement—with its nonstop assembly line of “innovations” such as one-size-fits-all care guidelines, overuse of “big data” and management interventions such as Lean techniques—works under the false assumption that healthcare delivery is just like building cars on an assembly line or operating a hotel. It's not.
We are at a tipping point in bringing doctors back to the fold. We must avoid turning wide swaths of patient care into cheapened sets of low-level, superficial transactions that now define so much of our everyday world. Of course, we can’t go back to a pure “do more, get more” payment system. And our system certainly needs a recommitment to quality and maximum value for the healthcare dollar.
But the danger with payment systems offering incentives that oversimplify complex clinical workflows, while conveying little sense of trust in doctors, is that they turn healthcare settings into places no one, including patients, seems to enjoy being in, which for a helping industry is sad. We will retire thousands of good, experienced doctors because they don’t need to put up with things as they are. We will lose a generation of younger doctors who see their work in less-passionate ways, going more for the paycheck or for a convenient lifestyle rather than for the joy of going the extra mile in their work and seeing patients benefit firsthand.
Much is needed to improve our healthcare system. Giving physicians a better everyday experience and motivating them correctly should be moved quickly toward the top of that list.
Timothy Hoff is a professor of management, healthcare systems and health policy at Northeastern University in Boston and a visiting associate fellow at Oxford University.