How Being a Doctor Became the Most Miserable Profession

The biggest problem is just the AMA. They limit the number of doctors in America, so there are just too few. This drives up the salaries for the few doctors who live the tell the tale (but certainly don&#x27;t want to go into primary care, when other more lucrative jobs are on offer), and drives up the hours for everyone.<p>Making it easier to become a doctor would improve things immediately (especially given the recent research that makes it clear that nurse practitioners do just fine).

I don&#x27;t get why overworked personnel aren&#x27;t regarded as a dire safety issue. There&#x27;s a reason the FAA restricted the number of hours commercial pilots are allowed to fly per week without rest.<p><a href="http://www.usatoday.com/story/todayinthesky/2014/01/03/pilot-fatigue-mandatory-rest-new-faa-rules/4304417/" rel="nofollow">http:&#x2F;&#x2F;www.usatoday.com&#x2F;story&#x2F;todayinthesky&#x2F;2014&#x2F;01&#x2F;03&#x2F;pilot...</a><p>I met a resident the other day, and they routinely get four hours of sleep or less and worked for shifts that are insanely long that are basically dictated by patient demand. Why not just hire more doctors, maybe lower salaries by increasing supply, and give them a healthier lifestyle? Maybe medical school prices would go down with additional scale.

This is completely a story of industry structure and bad incentives, and how people react to them.<p>Currently, in the United States, we believe all of the following things: (1) Human physicians, are the only qualified parties to diagnose, treat, and&#x2F;or recommend courses of action related to health (not nurses, physician&#x27;s assistants, computer programs, etc.), (2) everyone has a fundamental right to healthcare, (3) health professionals must undergo expensive, lengthy, difficult courses of study and training, and (4) we reimburse for procedures, not pay for outcomes.<p>Given these incentives, it&#x27;s not hard to see why doctors are some of the most overworked, stressed-out, and generally miserable professionals out there. They&#x27;re at the nexus of a crushing conflict between keeping people healthy, a management system that demands more revenue (and remember that revenue=procedures, because we reimburse for procedures, so the only way to increase &quot;productivity&quot; is to do more, faster, with fewer breaks and longer shifts), and a legal regime which mandates DOCTORS perform procedures, and only after a lengthy course of study.<p>I believe the way forward is to shift the discussion away from procedures and more toward outcomes, and give medical professionals more operational and financial freedom to run their practices using tried-and-true free-market principles. I believe this outcome is inevitable, but will take a decade or more to surface, because it requires major shifts in how doctors and insurance companies think about billing, greater human trust in computers and recommendation systems, and a collective realization that the current state of healthcare is untenable.

Also relevant: I wrote &quot;Why you should become a nurse or physicians assistant instead of a doctor: the underrated perils of medical school&quot; (<a href="http://jseliger.wordpress.com/2012/10/20/why-you-should-become-a-nurse-or-physicians-assistant-instead-of-a-doctor-the-underrated-perils-of-medical-school/" rel="nofollow">http:&#x2F;&#x2F;jseliger.wordpress.com&#x2F;2012&#x2F;10&#x2F;20&#x2F;why-you-should-beco...</a>) based on watching the experience of my fiancée and her friends and peers.<p>EDIT: In the essay I describe why it can become so hard to leave medicine after one has invested more than a year or two in med school because of student loans; that may help explain the suicide issue: people who feel trapped may in turn feel like death is the only way out.<p>A surprisingly large number of doctors hit residency and realize they don&#x27;t want to become doctors. In most professions that&#x27;s not a tremendous problem, but in medicine the only way to pay back $100 – $250K in graduate student loans is by becoming a doctor.

A consideration of the economics would suggest that any doc who trained in the last two decades isn&#x27;t in it for the money - the ROI on an MD is far less than most other advanced degrees. If we wanted to be wealthy, with the grades and letters required to get into med school in the US, most of us could readily have chosen other professions. (Heck, some even walk away from startups, believe it or not). My impression as someone in practice for more than a decade, who cares for a large number of docs, and has run a large clinic: It&#x27;s really not the reimbursement. It&#x27;s the combination of dealing with payers determined to deny treatment, massive requirements in terms of documentation and ongoing accreditation, and - in particular - constant pressure to spend less time with more patients. Then, we read posts like these which buy into conspiracy theories about how we&#x27;re out to poison patients with expensive medications to line our pockets. The time problem in particular afflicts primary care docs the most, but even the surgeons complain about it. As far as ACA and its impact, there&#x27;s no question it&#x27;s a hack (and not a good one) - most economists not on the far right agree single payer would be optimal - but under the political circumstances, it was probably the best we could get. Regardless, we&#x27;ll move to a system where the majority of care isn&#x27;t delivered by docs. Then we&#x27;ll complain about it. But, it will be more cost-effective.

A comment here mentioned the absolute number of physicians in the United States, so I did some Googling and found a convenient website showing the number of physicians per 10,000 population in different countries. (The primary source for these data is studies by the World Health Organization, but the WHO website is not quite as user-friendly.) Note that in some countries the level of training and clinical experience to become a physician is much higher than in other countries.<p><a href="http://kff.org/global-indicator/physicians/" rel="nofollow">http:&#x2F;&#x2F;kff.org&#x2F;global-indicator&#x2F;physicians&#x2F;</a>

Suicide rates are about 17.7 per 100,000 for men and 4.5 per 100,000 for women, and 11.3 overall. There are about 535,000 male physicians in the U.S., and 234,000 female physicians, and 66,000 of unreported gender. So the expected number of suicides would be 113 rather than 300.

&gt; In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession.<p>OP missed a perfect headline opportunity: &quot;9 out of 10 doctors recommend not becoming a doctor.&quot;<p>But seriously, we wonder what&#x27;s wrong with healthcare. I seriously believe it&#x27;s because of the lawsuit-happy nature of patients nowadays. Yeah, something could go wrong during your surgery, or your diagnosis for that matter. But that&#x27;s an inherent risk in having something wrong with you that you need checked out.

You&#x27;ll find this is happening in many industries. Despite that it lowers productivity and increases costs.<p>The problem is that management is filled with perverse incentives. It looks good on the books to have fewer employees - until you realize you have highly trained specialists spending hours per week working on paperwork or rushing their actual job and increasing long-term costs.

In Canada our GPs are paid approximately $31 for a regular visit. They pay their overhead out of this $31 and still typically keep 65-70% of their billings.<p>It&#x27;s amazing that the billing costs in the US are a factor of magnitude higher.

Funny that the article links to <a href="http://www.dailymail.co.uk/news/article-2600319/Medicare-database-reveals-paid-doctors.html" rel="nofollow">http:&#x2F;&#x2F;www.dailymail.co.uk&#x2F;news&#x2F;article-2600319&#x2F;Medicare-dat...</a> which references the top paid doctors by medicare... I read an article last week saying that this data would be misinterpreted, as a lot of the &quot;top paid&quot; doctors actually are just like whole departments using the lead physician&#x27;s billing code, and they don&#x27;t actually get any of that money - and here we are.

There&#x27;s no evidence that the profession causes doctors to commit suicide. It&#x27;s not a stretch to hypothesize that people accepted to medical schools are self selecting for perfectionism and bipolar disorders.

&quot;Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care.&quot;<p>I&#x27;m curious how the arithmetic on that works out. The median pay for medical assistants is $14.12&#x2F;hour [1], which means that assuming the assistant is handling the insurance form, that works out to just over 4 hours per patient encounter. There might be some fixed costs (filing space, for instance, is not free), and some costs associated with communicating with the insurance company, but it&#x27;s really not obvious to me how any of those can add up to $58&#x2F;visit.<p>[1] <a href="http://www.bls.gov/ooh/healthcare/medical-assistants.htm" rel="nofollow">http:&#x2F;&#x2F;www.bls.gov&#x2F;ooh&#x2F;healthcare&#x2F;medical-assistants.htm</a>

I&#x27;ll bet that the half of doctors who want out of the profession, are the ones who are exploited by the other half. Naturally the profession wants us to see doctors as selfless workers saving our lives, not as rentiers who are ruining us.

did this article &quot;borrow&quot; from the air talk segment this afternoon on the radio: <a href="http://www.scpr.org/programs/airtalk/2014/04/15/6508/" rel="nofollow">http:&#x2F;&#x2F;www.scpr.org&#x2F;programs&#x2F;airtalk&#x2F;2014&#x2F;04&#x2F;15&#x2F;6508&#x2F;</a>

<i>And now that Medicare payments will be tied to patient satisfaction—this problem will get worse.</i><p>That just sounds crazy. Can you imagine if your car insurance had to pay less if you complained about your mechanic? Not to mention that medicare is for the elderly who tend to have a lot to complain about anyway.<p>Can I pay my taxes based on my satisfaction with the government?

Friendly warning, the article quotes Malcolm Gladwell uncritically.

For fun, reread this article with &quot;doctor&quot; universally replaced by &quot;teacher&quot;, and note the similarities. Then note that the doctor is probably taking home 4-5x the cash.<p>There&#x27;s also this: <a href="http://seattlepostglobe.org/2011/03/07/warnings-of-doctor-shortage-go-unheeded/" rel="nofollow">http:&#x2F;&#x2F;seattlepostglobe.org&#x2F;2011&#x2F;03&#x2F;07&#x2F;warnings-of-doctor-sh...</a>