What Have We Done to Doctors?
(excerpted from “Care Evolution: Essays on Health As A Social Imperative”)
In their 2014 book Scarcity, Harvard economist Sendhil Mullainathan and Princeton cognitive psychologist Eldar Shafir make a compelling case for how the perception of threat to personal resources has a significantly adverse effect on cognitive function. While nidus of their work focused on the correlation between poverty and counterproductive behaviors, subsequent work demonstrated that the concept of threat was relative and independent of income or even wealth; adverse neuropsychological consequences can be triggered simply by the perception of looming or impending peril.
Over the last few decades, the profession of medicine has been buffeted by many forces of change, none so powerfully as the competition for its economic and social capital. Physicians have been largely destabilized and rendered vulnerable to those with less selfless and less generous agendas: a commercial community unimpeded by the cultural and academic mores that have been the historical underpinnings of the medical profession. What Dr. Arnold Relman, former Editor-in-Chief of the New England Journal of Medicine called the ‘medical-industrial complex” took advantage of doctor’s vulnerability by increasing unpredictability in fee schedules, offloading administrative responsibilities and costs to the physician community and disintermediating the traditional doctor-patient relationship.
Physicians tried to fight the battle, but the rules of engagement of the free market were largely foreign to their professional culture. The effort ended up driving more of a wedge into the professional community; physicians organized around specialty identities and entering a zero-sum game, with primary care and specialist physicians bickering over how dollars are divided among themselves while payers doled them out like parents deciding if they earned their allowance. This fragmentation, pitting physician-against-physician, only served to weaken the profession even more — with the patients losing trust as physicians were distracted and reduced in their capacity to share the work of worry about their health.
You can’t walk into Home Depot and name your own price for a refrigerator, but in healthcare, payers regularly reduce, and often deny, payments, even after services have been rendered. This occurs under the guise of a set of rules called “medical necessity”, which pits the professional judgment of practicing physicians against insurance company determinations. The requirements of documentation required to receive payments — know colloquially as “reimbursement” — are burdensome and designed in favor of the payer keeping their cash as long as possible. The phrase ‘reimbursement’ is a euphemistic acknowledgement of the fact that the physician has already delivered value to the patient and shouldered the economic responsibility for the costs of their staff, supplies, and infrastructure. While there are appeals process for denials, this further shifts the practices resources, time, attention and energy away from patient care. It also shifts the work of worry by physicians from their patients to their own well-being, a dangerous fragmentation of professional focus.
I don’t know anyone that went to medical school to get rich. For those with the academic rigor necessary for medical school admission, there are many other options for generating wealth that do not involve urine, stool and vomitus. This is not to say that economics is not part of the equation; but for most medical students, aspiring to be a physician is largely driven by intrinsic motivations: the challenge of intellectual and technical mastery, the capacity to positively change people’s lives, professional autonomy, and the social capital associated with the place of the physician in community and society.
A study in the Proceedings of the National Academy of Sciences examined the careers of West Point graduates and noted that for those with intrinsic motivations, adding an extrinsic motivator like money was more of a negative influence on their career success and satisfaction. This can explain why doctors — even when employed — don’t respond to the same kinds of economic stimuli as business people.
From an economic perspective, a medical career is far more about financial security than accumulation of capital. Those that grew up in modest circumstances may be ‘richer’ than where they came from but are not wealthy (especially if you train in pediatrics); for those that came from families of real means, even the upper echelons of medical practice would barely give them parity with their social strata. The average medical school debt is close to $200,000 and during the subsequent 3–7 years of required postgraduate training, salaries average only between $50,000 and $60,000 a year.
As Mullainathan and Shafir make clear, it is very hard to sustain your desire and commitment to care about others when you perceive your own well-being as threatened. It may seem dissonant to consider the well-being of professionals who live well above the poverty line, but, while the motivation and context for their commitment may transcend economics, financial stability is critical to healthcare professionals because it provides the secure base from which they can pursue non-economic goals such as the lifelong learning, demands of professional life and have the emotional capacity to shoulder the work-of-worry about the well-being of others; people who are forced to worry about their own well-being are generally not able to invest as much in the lives of others.
Health professionals take on an extraordinary depth of responsibility for other people’s lives; as such, their confidence, optimism and professionalism must be nurtured and protected; these elements — critical to successful performance of their duties — cannot survive when left exposed to the elements. Our society seems to understand this dynamic when it comes to the performance of our elite athletes and entertainers, but we can’t seem to make the same respectful accommodations to the critical performance of those we entrust with our health and our lives.
Unfortunately, for most physicians today, the environments in which they work, whether in independent private practice or as organizational employees, are killing this vital spirit and undermining the very contribution physicians are expected to make to the success of the system. One of the fundamental requirements of the successful practice of medicine is the sense that your efforts — your studies, your discipline, your mastery, and your work of worry — will be channeled to achieve some form of positive results for your patient and be valued by the community. By treating physicians as production workers, rather than elite athletes, we’ve undermined their intrinsic motivations, removed the economic stability that supported selfless behavior, snubbed their normative needs for recognition and respect and fragmented their sense of professional community. This has not served patients, nor the physicians themselves, very well.
For decades, physicians have reacted by trying to fight the battle of professional devaluation on someone else’s terms — largely economic — and trying to fight on other people’s terms is almost always a losing proposition. The key to success is to shift the battlefield to one in which they dominate: the science of solving human problems.
Rather than deploy resources across multiple battlefields, the profession need to rally around a singular decisive infection point: redefining the foundational role of the physician, independent but inclusive of all specialty perspectives or competencies — medical, surgical, behavioral — and reclaiming the profession, reinforcing a commitment to excellence and human service and revitalizing the experience of care for patients and professionals.
Two forces are in their favor. The first is the evolutionary principle, as described by Edmund O. Wilson that “within groups, selfish individuals beat altruistic individuals, but groups of altruists beat groups of selfish individuals”. This means that if physicians organize around and commit to their fundamentally altruistic professional mission, they will have a better chance of winning the battle for professional identity than if they keep trying to compete on goals of self-preservation.
This shift away from primary defense of economic status will be offset by the second force in our favor: the free market. It is also well established that people will pay a premium for the perception of value; the Ford Taurus you rent from Avis is exactly the same car you can get from Budget, yet people show preferences and are willing to pay a premium for one over the other. By regaining control over professional identity, physicians will also revalue themselves in the marketplace.
So society faces two choices when it comes to our expectations of physicians: either work-around the current state of the medical profession (furthering their isolation) or develop new systems of care and practice of the kind that Thomas H Lee and Toby Cosgrove, both physicians and, respectfully, the former network president of Partners Healthcare in Boston and Chief Executive Officer of the Cleveland Clinic, outlined In a 2014 article in the Harvard Business Review, to “help physicians to live up to their aspirations as caregivers (and) to understand that giving up their autonomy is not actually surrender but a noble act of humility in the interest of their patients.”
In healthcare collaboration, physician participation is defined by shared vision and purpose. with a fundamental mission to provide the patient and their family with a concordant experience and sense of harmony and tone. This becomes the basis for the new ‘secure base’ for physicians, redefining their value proposition in our emerging systems of care
The bigger challenge is to reenergize the capacity of America’s physicians to take on selfless work of worry about their patients. This will require us to provide both economic stability and some form of social capital, and ensuring that human factors are considered in our treatment of professionals in the evolution of our systems of practice.
In “Inside Out”, Pixar Animations 2015 blockbuster movie, we watch as 11-year old Riley, whose life to-date has been largely driven by Joy, learns the value of Sadness as she comes to grips with a life changing event. In so doing she has to let go of a piece of her childhood self but ends up a better-balanced person and closer to her family.
What most movie-goers don’t know is that the story has an academic foundation in the work of, among others, Dacher Kelter, a psychology professor at the University of California Berkeley and an expert in the social functions of emotion, whose insights also have reflective implications on the practice of medicine and delivery of care.
Looking at the frustration, dissatisfaction and anger of the medical community, Dr. Keltner’s research helps us to understand how a physician’s underlying emotional state may have adverse effects on their capacity for clinical appraisal and potentially interfere with their ability to meet societal expectations for quality of care and clinical outcomes
At its essence, the successful delivery of healthcare is fundamentally a human endeavor and, as such, the productive evolution of our systems of care must reward the value of human connection and commitment. Revitalizing the experience of care for both patients and professionals will require us to shift the definition of “value” in human, not economic, terms.
