A silent epidemic is ravaging our health care system — an epidemic of burnout among doctors. A paper published in the December issue of Mayo Clinic Proceedings reports that the percent of physicians admitting to at least one symptom of burnout rose from 46 percent in 2011 to 54 percent in 2014. By contrast, burnout in the general population over that period stayed at about 25 percent, way below the rate among doctors.
Other research has confirmed this problem. The Star Tribune reported in May that a national survey showed a 21 percent increase in burnout among doctors between 2011 and 2014.
The media, including the Star Tribune, is doing a good job of reporting on the problem and its immediate causes — more paperwork and less autonomy. But the media is not explaining why paperwork is going up and autonomy is going down. Why are doctors spending more time at their computers? Why are so many people who don’t belong in the examining room looking over the shoulders of doctors to second-guess them, grade them and subject them to financial incentives based on their grades?
It is only a slight oversimplification to compare the treatment of doctors to the treatment of teachers. Just as teachers have been subjected to deprofessionalization — and to some extent demonization — in the name of improving education, so doctors have been deprofessionalized and subjected to grossly unfair and inaccurate criticism in the name of improving medicine.
The main difference between the campaigns to rob teachers and doctors of their autonomy is that parents and students have rallied to defend their teachers. The No Child Left Behind (NCLB) law, and the obsession with measurement that it reflected, provoked a backlash among parents. No similar movement has arisen among patients to defend doctors.
That’s because the methods used to rob doctors of their autonomy are much less visible than the methods used to deprofessionalize teachers. The NCLB forced students to spend more time taking tests and teachers to spend more time “teaching to the test.” These consequences were quite visible to anyone who wasn’t living in a cave.
But the consequences of the physician deprofessionalization movement — let’s call it the No Patient Left Behind movement — are harder to see. Although patients are the ultimate victims of the obsession with micromanaging doctors that has constipated the minds of the health policy elite, we do not see the injury being inflicted on our doctors. For that reason, and because the injuries we as patients suffer as a result of physician burnout are also hard to perceive, we are not outraged by the No Patient Left Behind movement as parents and students were by the NCLB.
We should be.
The micromanagement of doctors, directly through “utilization review” by bureaucrats and indirectly via financial incentives tied to report cards, has taken a dreadful toll. By turning medicine into “factory work,” as the Star Tribune put it in its May article, proponents of micromanagement are driving doctors into early retirement and degrading the quality of services delivered by the physicians who remain in practice. Micromanagement buffs are also driving up costs (all of those computers, all of that data entry, all of that number-crunching and all of that third-party supervision have to be paid for somehow).
So what can we as ordinary patients do? We must stick our noses into a debate that has for too long gone on over our heads. Over the last half century, an unholy coalition of large employers and insurance companies has persuaded leaders of both political parties that U.S. health care costs are double those of other industrialized nations because U.S. doctors order too many services for their patients.
Never mind that underuse of medical care is far more common than overuse, even among those of us with insurance. Never mind that people in other industrialized nations use just as much health care as we do. Never mind that insurance company bureaucrats don’t know how to reduce overuse without aggravating underuse and driving up administrative costs.
The unholy alliance made up its mind that overuse — not excessive administrative costs, not excessive profits and prices — was the reason why U.S. health care costs are high, and that someone had to force doctors to stop ordering all those unnecessary services.
The solution the unholy alliance adopted came to be called “managed care” by the late 1980s. The terminology that managed-care advocates use has changed over the intervening decades, but the basic tactics remain the same: Micromanage doctors directly by vetoing their decisions or making them get approval for a treatment from insurance industry bureaucrats, and micromanage them indirectly by exposing them to the risk of financial penalties if their patients cost “too much” or if patients with one of a dozen diseases don’t get “quality” care as the bureaucrats define it.
These counterproductive efforts to control physician behavior are what are burning doctors out. They are also driving doctors into the arms of large hospital-clinic chains called “accountable care organizations” (ACOs), where their autonomy is even further reduced. (ACOs are HMOs on training wheels). Both problems — the rising physician burnout rate and the takeover of our health care system by a few enormous corporations — have occurred with no public debate.
The deliberations of the Minnesota Health Care Reform Task Force are typical of the problem. The task force is supposed to issue a report to the Legislature in January on how to improve our health care system. But it has devoted no time to the physician burnout problem. It has, however, spent many hours discussing more measurement of doctors and pushing more doctors into ACOs.
If Minnesota patients remain oblivious to the physician burnout problem, we will soon regret it. We should let our legislators know that we want the problem addressed. And we don’t mean massages and therapy for our doctors. We mean a restoration of physician authority to make decisions based on evidence and patient values, and an end to the managed-care tactics that are burning out our doctors.
Kip Sullivan is a nonphysician member of the board of the Minnesota chapter of Physicians for a National Health Program.