Death of the Medicine Men
I don’t hate my job. Not really. But I hate what it’s become. Because back in the day, only a few years ago, I got to practice real medicine.
I’d better explain that.
I didn’t don a white coat and a stethoscope, diagnose diseases, and prescribe pills. Instead, I “practiced” medicine by understanding, educating, empowering, and motivating my patients. And I did that by spending the time it took get to know them as people, because that’s what you need to do to treat diabetes successfully. And I “practiced” medicine by taking the time to learn about my patient’s lives, too, because life gets in the way of diabetes. If your child just died, you don’t really care if you are checking your blood sugar or not. If the power company just turned off your electricity, you probably can’t afford your meds. If your boss sexually harasses you at work, you might not want to lose weight for fear of being even more desirable.
And I “practiced” medicine by getting to know my patients’ diabetes itself; because no two cases of diabetes, even type 2 diabetes, are created equal. Some type 2s have high blood sugar all the time, some type 2s have sugars that rise in the night, some type 2s have sugars that only shoot up after meals. Same disease. Different incarnations. And that means different solutions are required. A blind prescription pad is impotent. Diabetes treatment isn’t one-size-fits-all. Understanding the patients, their lives, their diabetes; and helping them cope with and conquer their diabetes made me a healer, I think.
It was glorious work. I was a detective, a social anthropologist, a counselor, a cheerleader, and a little league coach all rolled into one. I woke every morning excited about taking on a new day’s challenges. I slept well at night knowing I had spent my day actually helping people.
But now I don’t sleep so well at night. I dread the alarm clock, and I have to drag my ass out of bed every morning, because times have changed. I’m not “practicing” real medicine anymore; I’m not sure any of us are. Every few weeks our assorted masters at the federal, state, and local levels mandate new things we must do. We are told: You must create care plans on X% of your hypertensive patients or kiss your funding good bye. You must measure waist circumference or there’ll be hell to pay. You must print a visit summary before the patient leaves. You must… You must… You must… You must…
The “you musts” are endless.
Now I spend nearly all my time with my nose in my computer, charting all the required minutiae in all the right places. It’s no longer sufficient that I check a patient’s blood pressure. I must also enter it in just the right place. And I must check the box that validates that I have just checked the blood pressure and I have entered it in just the right place. And then I must, before I can go somewhere else in the chart—perhaps to make a note that the patient just told me about her boss sexually harassing her—I must weigh her and I must enter that information in just the right place. Oh and then I must calculate her body mass index, and I must chart that I counseled her on the fact she’s too fat, and I must print patient educational materials telling her she’s too fat, then I must make her promise to discuss it again in the future, and I must choose a date to do just that and I must chart that, too. In just the right place. Then, and only then, am I “free” to leave that section of the chart.
And on and on and on it goes.
At first this overwhelming flood of exacting requirements and new must-dos caused some push-back from the medical staff, who just wanted to make patients healthier. Then one of the middle-management people posted this sign on the wall:
Relearn, Relocate, or Retire.
So literally, the writing was on the wall. Way to motivate the troops. Caesar would be proud, no doubt. Or Kadafi. Or Saddam. But the sign did its job. Dissent evaporated. We put our noses to the electronic grindstone, not even realizing that the soul of medicine had just been sacrificed on the Altar of Must.
After months of generalized misery and persistent blues, I awoke this morning to the realization that I’m not having a conversation with my patients anymore. I’m not learning who they are. I’m not understanding the victories and defeats in their daily lives. I’m not bonding with them in a way that they will share their darkest fears and experiences with me anymore. I am neither educating nor inspiring. I’m not motivating, and I’m certainly not healing. I’m just interviewing my patients and recording their answers like a court reporter, rarely even having time to look them in the eye.
Now, instead of a Medicine Man, I’m a fucking bureaucrat.
And that realization depresses me beyond my ability to communicate. Perhaps its time for me to find another line of work. But this isn’t just about me and my job satisfaction. There’s something larger at stake here.
As a society, we’ve been down this path before with No Child Left Behind, a perhaps well-intentioned piece of legislation that ended up creating an environment in which educators could no longer educate our children; and all innovation, inspiration, and creativity was squashed as our best, brightest, and most passionate teachers as they were forced to teach to the test. It fully industrialized schooling—ironic, given it happened in the post-industrial age.
It has destroyed all that was best about American education. If you don’t believe me, just ask any veteran teacher if she’s happier, more satisfied, or feels more effective now than she was before Every Child Was Left Behind.
Why did I bring this up? Because, like education, the healing arts can’t be industrialized. One size doesn’t fit all.
Because practicing medicine to the chart is just like teaching to the test. And it could be the death of us all.
I was thinking "No Child left behind" as I was reading your post. Maybe the middle management folks should ask if the patients are healthier-- or happier. Where's the field for that on the chart?
And the costs keep rising, waiting times rise and doc visit lengths get shorter - and people wonder why we're unhealthy and don't want to go see the doctor. I'm sorry you're going through this, Wil.
This is just my opinion, but here goes. I'm licensed at the doctoral level by my state and classified as a specialist. Although there are a lot of people who can do what I do who are licensed at a lower level, our lobbyists and professional organization(s) are more powerful and thus keeping our pay where "we" want it. We want to be reimbursed well for our education and experience, so we favorably work the system to allow 10-20 minutes patient visits with bill rates at $170 on up for the visit, though the negotiated rate with an insurance company may be less. With ancillary services ordered, I have colleagues that can bring in a thousand or more per hour of work. This represents net income and overhead expenses (insurance, support staff, building, etc) are paid for out of this net income. Although overhead is very high, average salaries are also very high. I want to be compensated well for what I do, but the system as it is keeps driving healthcare costs up and is broken.
One solution has been to allow more flexibility and independence in lower levels of licensure. Although my colleagues can come up with a 1000 reasons why the less educated person is "unsafe" to practice, I haven't found consistent research to support that. In fact, I believe that it can be done safely, but here is where diabetes educators are getting the shaft. People are starting to recognize that these "lower" licenses (or certifications) can be just as efficient at helping a patient achieve their medical goals, but doctors can't give up too much control because only “doctors have the knowledge to practice safely.” What we are really doing is preserving our jobs and high rate of pay. So, we lobby for restrictions to be placed on your practice to make it "safer." After all, who wants to argue against safety.
I believe a better solution would be to revamp our education and licensure system. First, create a national licensure board that governs all states and territories. Base the educational standards on what research indicates is required for safe practice. Hell, within the next fifty or hundred years your computer will scan you and do all the doctoring. We need to begin changing with the advances in technology now. Secondly, we need to specialize high schools so that children can graduate with a “pre-med” high school diploma and go straight into medical school. College degrees would be set to whatever the National Licensure Board specified and their decisions should be made on what research says makes the best doctors for the specialization, NOT the current inconsistent, often arbitrary and overly complex standards that exist. It took me just over 10 years of full time post-high school education to become licensed and specialized in what I do and I believe that using the system I am proposing I could have been taught equally as well in 5 years (which would still include the residency).
Although shortening education by getting rid of the less helpful portions would lower the cost, we need to do more. As it is, many of my colleagues had to borrow money for school and ended up with 200,000 or more in debt. Imagine trying to pay that off in 10 years. We need to make it so a specialist can live off a lower level salary and not “need” to make $250k+ a year just to pay off their student loan. Well this post is going on entirely too long, so I will end it there.
Here is another perspective on the subject that is more comprehensive.
I too thought of "no child left behind" and then saw you had, too! Perfect example. No wonder I've turned to health coaching. I think our (well, not OUR) mentality is still stuck in the industrial revolution. Medicine and learning were never meant to resemble an assembly line but that's what we're doing. I think you're right on about everything. Our practice of medicine is in a serious crisis state and our schools are failing us. It's time to go for what is effective and realistic. And you just pointed that out. I'm sorry your day to day has been so affected. It's so sad that the system has removed so many good people's ability to help others. It's ironic...no other business would run this way-the people who came up with a failing system would be fired and replaced. And yet here...well, that's how far gone we are.
What a great blog. I use to see myself in the exact same predicament. 2 1/2 years ago I could not take it anymore and left my primary care position with the largest health system in Portland, OR. I was determined to find a way to be a "Healer" outside of the crazy system that you have so accurately described. Since I have left my prefessional life has improved dramatically. I am in private practice and although my salary is less, my job/life satisfaction is many times greater. It is important to find a way to be happy with your life and practice. You can step out of the system and find a better way that will utilizes your wonderful people skills and other strengths. We have developed a team approach using a health coach, counselor and CDE with wonderful results. We feel like we are developing "real" relationships with our patients again. Hang in there, you can find a better way to bring your skill set into the world to serve others.
Jeff Horacek M.D.
Perfect analogy Wil. I'm sick of the eternal tests all my kids in the US are subjected to. In Ireland it's much better. How can someone learn to research, digest and interpret if there's a 'quick' test every other week.
As for doctors, they do spend too much time with their nose in a computer. There's limited time for eye contect or physical exams. And those computer forms, ugly and complex. Probably because they're one size fits all. This will improve, it has to improve or we're all going to hell, though in a well-documented way. :-)
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