HealthHealth NewsHealth Care

Doctor Exodus Signals a System in Distress

Save
Doctor Exodus Signals a System in Distress
(Shutterstock)
Amy Denney
2/23/2023
Updated:
3/8/2023
0:00

A crescendo of circumstances burdening physicians to the point of burnout is reshaping the already fragile health care system of the United States.

A mass exodus of doctors from some practices, reduced hours among others, high suicide rates, and an increase in cash-based practices are straining an already stressed system. While some doctors are courageous enough to speak up—often after leaving corporate health care positions because of lack of respect and workplace autonomy—others silently suffer under pressure.

At the heart of it seems to be an inability to offer the kind of care that steered them into their chosen profession—but their departure under duress may ultimately leave their patients even more underserved. It’s a simple supply-and-demand catastrophe that affects anyone who relies on the medical system.

“We’ve seen the terrible direction medicine has moved into since physician independence has gone away,” Dr. Suneel Dhand, who specializes in internal and lifestyle medicine, said. “We’ve gotten ourselves into this position because the old way of practicing is gone.”
Today’s doctors are most often found working within a corporate model. Nearly 74 percent of U.S. physicians are employed by hospitals, health systems, or other corporate entities—up from 62.2 percent in 2019, according to a study sponsored by the Physicians Advocacy Institute.
One problem with corporate practices is a higher likelihood of undue influence on patient-care decisions, Dr. Craig Backs explained to The Epoch Times. Backs, who has worked at a private clinic and for a hospital, now owns an independent practice, The Cure Center.

“The reality is, it used to be that the patient–physician relationship was an important one not to be interfered with, having elements of privacy, and the interests of the patients over the interests of the physician. I think that’s really changed,” he said. “There’s also been massive growth in the number of administrators who have never uttered the Hippocratic oath.”

Physician preference for the stability and predictable income that comes with a corporate job has upended traditional health care, with the current model handing over more and more power to insurance companies. These realities are forcing many doctors to take a discerning look at their careers and, ultimately, to find a way out. Their departures—and their dissatisfaction when they stay—are creating reverberations in the entire health care system that echo most loudly on patient care.

The Price Patients Pay

The effects of burnout—mental exhaustion, depersonalization, and a decreased sense of personal accomplishment—increase the risk to patient safety, decrease quality of care because of reduced professionalism, and lower patient satisfaction, according to a 2018 meta-analysis in JAMA. Physician departures from the system also put more pressure on those left behind to juggle increasing demands.
“We are seeing a lot of patient errors that are happening currently,” Dr. Nadia Ali told The Epoch Times. Ali, an independent functional family practitioner, resigned a corporate job after microaggressions resulting from her desire to spend time with her patients led to moral injury. “What we know now is physician burnout doubles the risk of adverse outcomes in patients.”
Burnout, workload, and COVID-19–associated stresses are motivating health care practitioners to leave, according to a study in Mayo Clinic Proceedings in December 2021. The study found that 20 percent of physicians and 40 percent of nurses among more than 20,000 polled said they planned to leave their practice within two years. An additional one-third of physicians and nurses said they plan to reduce work hours in the next year.
“Our study demonstrates that the U.S. health care workforce is in peril. If even one-third to one-half of nurses and physicians carry out their expressed intentions to cut back or leave, we won’t have enough staff to meet the needs of patients,” the study’s lead author, Dr. Christine A. Sinsky, wrote in an American Medical Association article. Sinsky is also the American Medical Association’s (AMA’s) vice president of professional satisfaction.

Demands of Insurance

The AMA has launched STEPS Forward, a resource that offers strategies for reducing workload, streamlining administration, and managing inboxes. But there’s an element of health care outside the purview of physician organizations that’s increasingly stifling doctors’ practices: insurance rules and reimbursements.
Dr. Armen Nikogosian was operating an independent practice that he opened in 2003 with a handful of doctors when Blue Cross Blue Shield dropped reimbursement rates with a month’s notice about 13 years ago; he had to make the difficult decision to drop 40 percent of the clinic’s patients when reimbursement rates shifted from $80 for a follow-up visit to $35, which wasn’t enough to keep his clinic afloat.

“Maybe you could make it work if you had free rent and everyone volunteered to work for you,” Nikogosian said. “That was a lesson that insurance companies are very unpredictable. They didn’t care whether they paid me enough so that I could make my practice sustainable or not.”

He said that unfortunately, most practices “take what they give you even though it’s not the way you want to run your business.” Smaller clinics have little bargaining power, so they simply adjust the time they spend with patients, cramming up to 10 visits into an hour.

Nikogosian knew a cash practice was the way out, but with his wife expecting their fourth child, the time wasn’t right for such a risk. He closed his clinic and took a position with a U.S. Veterans Affairs clinic while he slowly went to work on setting up a practice. His second son’s autism diagnosis influenced his decision to open a practice geared toward autistic children and adults in 2016, after he saw firsthand that conventional medicine was almost useless for their needs.

He makes less money, and it took time to become sustainable, but the pay-for-service model makes sense to Nikogosian. When patients are happy with what he’s doing, they pay their fees, and there’s no third party influencing care.

Direct primary care clinics are also on the rise, with nearly 2,000 now operating in the United States. A 2022 report on direct primary care (DPC) trends in the United States found that DPC membership grew 241 percent from 2017 to 2021. While there was a 6 percent increase in the number of active primary care providers per 100,000 people in that timeframe, the number of active DPC clinicians per 100,000 people increased by 159 percent.
“Health insurance completely dominates the doctor’s life and increasingly, the patient’s life,” he said. “It was clear they were trying to affect the way the doctor was trying to practice. To me, that’s a risky proposition. It made me unhappy. It makes plenty of doctors unhappy.”

COVID-19 Doctor Doubletake

Pressures of the fiduciary obligation to hospital boards and government mandates have put doctor decisions under a microscope for decades. The pandemic revealed the systemic corruption to a watchful public. Hospitals received government kickbacks for COVID-19 cases, including extra funds for the number of patients put on ventilators. Doctors in favor of other medical treatments sometimes lost their positions or licenses for prescribing ivermectin off-label.

“When you are working in an environment where you’re strongly encouraged or forced to do things you don’t want, it takes a tremendous toll on one’s physical and mental health and soul,” Backs said, adding that constant demands from many parties are dizzying. “What happens is your moral compass will eventually go on the fritz.”

After years of practicing within the system, Backs is now able to holistically treat his patients—whether for COVID-19 or anything else—without regard for how higher-ups or other doctors might react. In corporate care, he said there’s tremendous peer pressure to stay away from diseases outside one’s specialty.

Because Backs focuses on arterial disease, his practice looks at myriad symptoms that would cross a handful of disciplines in a larger clinic. In those settings, there’s an unspoken agreement that doctors won’t try to eliminate diseases that a colleague’s livelihood depends on.

Weight of Burnout

Burnout is under-recognized and under-reported among doctors, according to a 2017 article in Clinical Gastroenterology and Hepatology. It may affect more than 60 percent of family practice providers.
The costs are tremendous to not only doctors but also the health care system. Doctors facing burnout experience increased rates of depression, addiction, and suicide. It also affects their relationships at home, with higher rates of divorce—and at work, where patient dissatisfaction and friction among coworkers increase.
Female doctors, who statistically have better patient outcomes, are at higher risk for burnout, according to a 2022 Frontiers in Public Health article. A 2020 New England Journal of Medicine article reported that female physicians are paid less and spend more time with patients and documenting health records.

Of these issues and more, Ali said there’s “no awareness, no consequences, and no accountability.”

She shared her story in the book “Thriving After Burnout,” a compilation of female physicians’ stories of triumph after struggles with abuse, aggression, and discrimination in the health care system.

Ali, who grew up in Pakistan, overcame extraordinary hurdles to become a doctor in the United States. But she was blatantly belittled and consistently disregarded by leadership in the hospital where she worked. She was losing sleep, unable to take care of her health, and constantly striving to prove herself. Finally, her husband wrote a resignation letter for her, and she turned it in.

“I wanted to be a healer. I didn’t want to be the person who writes a prescription all the time,” she said. “I wanted to sit with patients and hear their stories. My husband said, ‘Do what you love. Do it with all your heart.’ So that’s what I did.”

Now, as a functional integrative physician working for herself, she can not only serve her patients the way she wants, but also practice what she preaches. Ali said she’s grateful for the people who mistreated her—herself included—as it was instrumental in her journey to discovering self-worth.

Looking Forward to a Better Future

Administrators who acknowledge and appreciate doctors and give them more autonomy in the workplace could reverse some departures. AMA data from physicians showed that feeling valued was strongly associated with lower odds of reducing hours or leaving.
Those in the AMA survey with more control over their work environment had lower rates of burnout (39 percent) than those who reported a low amount of control (75 percent).
The problem is that corporate entities and doctors aren’t aligned in their goals, Dhand said. He and a couple of other physicians launched Docdox six years ago, which is like a “dating service” for health care institutions that need doctors. The doctors negotiate their own contracts and either moonlight or work on a regular basis.

It solves the problem many clinics have of a high turnover of primary care physicians, allowing patients to have more continuity of care with doctors who feel appreciated because they have autonomy and forge better patient relationships.

“A lot of doctors realize there’s a supply and demand mismatch. And there are opportunities to take matters into their own hands,” he said. “We have to make it easier for physicians to practice independently again. The health care system, under the influence of corporate interests, is failing both patients and physicians, and the current model is unsustainable.”

SHARE THIS ARTICLE
Amy Denney
Amy Denney
Author
Amy Denney is a health reporter for The Epoch Times. Amy has a master’s degree in public affairs reporting from the University of Illinois Springfield and has won several awards for investigative and health reporting. She covers the microbiome, new treatments, and integrative wellness.
Related Topics