Where are the doctors?

A common refrain we hear in the clinical setting these days relates to long delays to be seen in clinic, either as a new patient or seeing your own doctor.  As a specialist, it has been common the last few years to hear that a patient has had to wait 3+ months to get in to see me.  When I wanted to establish with a new primary care provider for myself, I was faced with a very limited supply of options and I had to wait months to be seen.  Articles such as those provided by the AAFP and Scripps News talk about the rising wait times over the last 10-20 years across most specialties, though not seen in Family Medicine.  My own experience in rural Wisconsin argues against the data suggesting a decrease in wait times in family medicine.

The question then turns to why is it so hard to see a doctor and why does it seem to be getting worse?  Are there fewer doctors in the country, such as from retirement?  Are there more patients, such as from an aging baby boomer generation?  Are there an inadequate number of doctors due to artificially constrained training programs, perhaps as a means of limiting competition?  Each may have a grain of truth.  However, other factors may be at play.  Clinics and/or hospitals may be downsized or closed for other reasons, such as limiting costs from unprofitable services, such as behavioral health or obstetrics throughout Wisconsin.  In short, there are a multitude of factors affecting the availability of physicians in your community.

In my career, I have been fortunate enough to practice in a variety of settings, be it a large urban referral setting with over 1,000 beds and in other settings of 20 or fewer beds.  In one group, I was one of over 120 cardiologists covering less than 100 square miles.  In another group, there were times I practiced without another cardiologist in over 60 miles, effectively making me the only cardiologist in over 10,000 square miles.  Consequently, I have seen how different factors play into why doctors may feel different pressures in different settings.  The pressures a doctor feels working in an urban setting of nearly 2 million people will be different than the pressures felt practicing rural or even critical access medicine.  There is no one-size-fits-all explanation for an inability to access your doctor.

Burnout? – More Meditation

If doctors are fed up with their electronic health record, their interactions with insurance, and struggles with senior administration, is that all?  Is that why they leave medicine?  Is that why you can’t see your doctor?  Searching on the internet for reasons why doctors may leave a practice will typically generate a list topped with burnout.  Burnout was initially characterized in the 1970’s followed soon after by the Maslach Burnout Inventory (MBI) in the 1980’s.  The MBI included a quantified burnout by assessing exhaustion, inefficiency, and cynicism.  In the 2010-2020 decade, the idea of burnout accelerated in medicine.  Coincidentally, 2009 was the year “meaningful use” began and health systems were incentivized to implement their EHRs.  Around 2015-2016, we started to have system-wide meetings acknowledging burnout, but it was usually described as a flaw of the physician, an intrinsic imperfection.  Making matters worse, we were encouraged to spend more time on ourselves, perhaps with yoga or meditation, as a means of dealing with burnout, but time for these mindfulness activities needed to be carved out of the little personal time we had left after a full clinic day followed by pajama time, or charting at home after dinner.

I was fortunate to learn more about burnout from the business side while obtaining my MBA and found Ms. Moss’ book, the Burnout Epidemic, a fascinating read.  It was the first book I’d read to clearly point out that the issue of burnout was a system issue; burnout is a problem of the employer and not a problem of the physician.  Moss described how burnout was based on workplace problems in six areas:

1.      Excess workload

2.      Perceived lack of control

3.      Lack of reward/recognition

4.      Poor relationships

5.      Lack of fairness

6.      Values mismatch

The MBI has been criticized as it does not separate burnout and engagement.  To that end, the Utrecht Work Engagement Scale (UWES) was created to assess engagement.  Please consider assessing yourself with the MBI ($15) and the UWES.  Physicians need to be aware of how they are doing in terms of burnout and engagement, as physicians commit suicide at a rate that is two to three times that of the general population.  A physician dies by suicide every day.

What are the Next Steps?

If we acknowledge there is a finite supply of physicians, we need to ensure they are being utilized as efficiently as possible and ensure they aren’t being forced into career-ending burnout or, worse, suicide.  If we lose our physicians, we lose our healthcare.  The role of the public is to understand the doctors are being controlled in most clinical practices and the doctors have little control over their own practice environment.  So, if the public has a problem with their clinical situation, they need to direct their concerns at the health system leadership or their insurance company.  If the public doesn’t find any relief from those groups, it’s important to understand you have other options, utilizing other types of healthcare models.  Stay tuned and I’ll touch on the other options in an upcoming blog post.