I love what I do for a living. Every day I get the chance to make a difference in someone’s life, which is incredibly rewarding, and I make a comfortable living. Based on conversations with my colleagues I think my joy in my work may be an anomaly. Job satisfaction amongst physicians is nowhere near what it used to be, and many physicians are thinking of retiring early. What happened? What happened is that a large chunk of the joyous parts of our days are being crowded out by parts that are discouraging and depressing. At times it takes effort to focus on the blessings. Here are some of the negative things that have had an impact on physician's attitudes-
Disrespect. It used to be that patients respected their doctor’s opinions, most still do, but the ones that don’t are a real challenge and can consume large chunks of time. In the last week I dealt with a 21 year-old who would not put her cell phone down (and got angry when I asked her to), exchanged 7 emails with a patient who refused to accept my choice of cholesterol medication, (he instead wanted something weaker and not recommended) and spent 30 minutes with a patient who thought he was constipated but wasn’t (he was going EVERY day), only to have him demand a specialist when I told him I could not find anything wrong. Physicians typically don’t mind honest questions, but we do need the “easy” stuff to not be so hard!
Insurance companies. Insurance companies make more money when they don’t pay for care. A new trick, when a doctor bills for an office visit and an injection (such as a flu or tetanus shot) they will pay for the shot and deny the visit charge. We have to appeal if we want to get paid. When you have to fight to be paid for what you do, discouragement can follow.
Medication denials. I am currently dealing with a patient who has severe nerve pain. He was prescribed a medication twice a day that provided good relief, but did not last the full 12 hours. Since the medication is indicated to be prescribed 2 or 3 times a day I upped the dose to three times a day to cover the hours when his pain was not treated. The medication was denied as it exceeded the insurance plans quantity limits. I wrote a letter explaining the patient’s condition and was denied again. I called and spoke to a “doctor” who informed me that nothing I said or wrote mattered, the medication could not be approved unless I wrote another letter and sent it to an appeals board. A patient suffered and my time was wasted. This happens frequently. Nothing kills your professional soul more than having to fight for the obvious.
Paper work. The fact that I have a computer does not mean I do not have to do paperwork. Disability forms, worker’s compensation forms, return to work letters, letters saying a patient had a physical exam (findings irrelevant), records requests, excuses from jury duty, the list is endless. Add this to medication refills, referral forms and reviewing lab results and one can understand why a 10 hour day may include only 6-7 hours of patient care. As the drudgery of such work comes at the end of the work day, it is no wonder many physicians go home discouraged.
Quality Standards. Everyone wants better quality care, but the arbitrary nature of the standards set by insurers adds a significant amount of stress. For example, good care for a diabetic is defined as a blood pressure below 140/90. If you treat a patient who originally had a blood pressure of 200/130 and get results of 141/92 you get no credit, you have failed according to the standards. Take a patient who started at 141/92 and edge him down to 138/89 and you are considered to be providing stellar care and worthy of a bonus.
MediCare. Low pay and ridiculous restrictions, such as MediCare refusing to pay for some recommended tests or a lab test done one day to early according to guidelines. For HMO patients we are forced to search our records to find evidence to support documenting for meaningless diagnoses such as alcoholism 30 years earlier, mild calcifications the aorta or the normal decline in kidney function that occurs with age, all because MediCare pays more for these "sicker" patients. More important and impactful diagnoses such as dementia and anxiety add nothing to reimbursement, even though good care for these patients takes significant time.
I recently heard someone on the radio say doctors should not complain as we have a good life. We do. But we would be happier and more satisfied if we were able to devote more time to taking care of people and less time to mindless work. Something to remember the next time your doctor seems rushed and grumpy!
- Bart