February 24, 2020 Thomas L. Schwenk, MD1 1Office
of the Dean, School of Medicine, University of Nevada, Reno JAMA. Published
online February 24, 2020. doi:10.1001/jama.2020.0146
The practice of medicine is founded on a simple
transactional relationship between the physician and the patient. The role of
the physician has always been one of gathering patient data and treating
disease, of caring and curing, and of bringing science and humanism together to
benefit patients. This role has defined the profession across time and
cultures. The continuity of clinical information was often dependent on the
continuity of the relationship, with clinical data documented only to the
degree necessary to inform memory.
Physicians were seen as community resources, but they
were not responsible for community problems. Physicians focused on medical
diseases and the patients who had them, not the larger world that the patients
inhabited. They were often “married to their careers,”1 sometimes to the detriment of their
family responsibilities and personal health, but their job was clear. Now the
job is not at all clear with the emergence of new themes of population health,
health equity, social determinants of health, and work-life balance.
Most physicians have traditionally relied on their own
talents and skills to meet their decision-making responsibilities, and are
modest about their successes and accountable for their failures. Their work
life is characterized by the cumulative effect of thousands of individual
patient encounters. Medical students are selected for these traits and talents,
which are then enhanced during training.
That simple role is now being challenged. Modern
physicians have expectations and responsibilities not experienced by their
predecessors. These expectations may seem to be natural extensions of the
physician’s responsibility and incrementally appropriate, but the cumulative
effect is to radically alter the traditional ways that physicians have
functioned. The result is a high level of identity confusion, leading to
professional dysphoria and dissonance.
These disruptive forces derive from at least 4 sources:
(1) a dysfunctional, profit-driven health care system that requires physicians
to fulfill nonclinical functions; (2) changes in physician expectations
regarding work commitments and income; (3) disruptions in relational and
information continuity with patients; and (4) failure of the public health
system.
A Dysfunctional Health Care System
The expensive and wasteful US health care system has
caused private and government payers to burden physicians with a wide range of
regulatory, financial, and productivity pressures that conflict with or are
antithetical to fundamental professional responsibilities.2 Productivity-based reimbursement
systems violate the physician’s duty to provide any and all necessary care to
individual patients. Profit-driven financial pressures increase administrative
costs and regulatory burdens on physicians and their practice finances,
detracting from core clinical responsibilities.
Physicians are required to support clinical documentation
systems that meet business and legal needs but have limited clinical value.
Physicians are held responsible for hundreds of quality measures that are often
redundant if not in conflict, not to mention expensive to measure and difficult
to report.3 Patient satisfaction measures are
sometimes used to influence physician performance and income, but these
measures frequently focus on whether physicians respond to patient demands, not
objective measures of professional quality.
Physician decisions are sometimes overruled by
nonclinical corporate personnel based on financial considerations rather than
clinical metrics. Pharmacy formulary and medical device decisions are often
influenced more by corporate lobbying than clinical value, constraining
physicians in their ability to fulfill fundamental patient obligations.
Changes in Work and Income Expectations
Older physicians made commitments to their patients and
practices that often harmed their personal health and family relationships.
Many younger physicians now expect strict limits on work commitments and work
hours. This is not necessarily inappropriate, and may even be laudable, but it
has occurred without any compensatory mechanisms for managing informational and
relational continuity to serve patient needs.
The profit-driven health care system has provided
opportunities, even incentives, for physicians to develop and promote the use
of medical products and treatments that conflict with professional ethical
principles. Medical students have responded to medical school debt and income
expectations with skewed specialty choices, practice styles, and employment
arrangements that may not serve their talents or patient needs.
Disruptions in Continuity
Reimbursement pressures and organizational barriers
impair patient-physician continuity during specialty referrals and
hospitalizations. Despite the electronic health record, patients have often
become their own information managers, relaying information from one physician
to the next. Insurance contract negotiations often lead to physician network
disruptions, the need for patients to restart complex treatment plans with a
new set of physicians, and expensive out-of-network referrals. All of these
disruptions are exacerbated in rural areas and smaller communities without a
critical mass of services and physicians.
Failure of the Public Health System
An increasing awareness of the role that social,
behavioral, demographic, and educational forces have on health care outcomes
has naturally, but inappropriately, led to making physicians responsible for
their solution. The focus on social determinants of health is appropriate but
making physicians responsible for their mitigation is not.4 Physicians are not prepared for this
role. Health care systems do not have the requisite resources or expertise.
Neither have control over the necessary interventions. Physicians are charged
with leading teams of health care professionals who may be better positioned to
address these sociodemographic failures for which physicians have no training
or basis for leadership.
Physicians are highly educated and bring many cognitive
abilities to their role, but leading multidisciplinary teams of diverse health
care professionals is not usually one of those talents. This work is not
consistent with, and likely detracts from, core clinical decision-making roles
and medical skills. Addressing social determinants of health and encouraging
health promotion and disease prevention are critical objectives of a
high-functioning health care system. The current system is anything but high
functioning, and physicians are neither prepared nor supported to compensate
for these inadequacies.
Conclusion
Solutions to these assaults on physician identity may
seem daunting, not to mention expensive and disruptive, but they simply need to
focus on the primacy of the patient-physician relationship. Physician
compensation plans should focus on quality, as measured by empirically tested
standards, rather than volume or piecework.5 A single-payer health care system would
simplify and reduce administrative burdens. In any payer system, health care
decisions need to be based on clinical, not financial, benefit. In a direct
observational study of the daily work of 57 physicians in various specialties,6 well more than half of their time was
spent with computers rather than with patients. Little of that screen time
enhances patient-physician communication or clinical quality and should be
managed by someone else.
Job sharing could support a better balance in work
responsibilities and personal health but requires creative approaches to
physician-physician communication that are both explicitly and implicitly
endorsed by the profession.7,8 Primary care physicians and
hospitalists need to jointly and actively manage transitions in care. Physician
network participation should be based on the quality of physician performance,
not skewed economic constraints.
Physicians should not be responsible for addressing
social determinants of health, rather they should work synergistically with a
well-funded public health system in a way that enhances the physician’s primary
responsibility to individual patients. The physician has an obligation at the
personal and professional level to maintain the primacy of the patient-physician
relationship to the greatest possible extent, but that is, in fact, what has
led to so much frustration and dissatisfaction—the frustration of trying to do
the right thing for patients on a daily basis when so many forces work against
it.
So this is what it means to be a physician—to uphold long
traditions of professional obligation, to maintain focus on the needs of each
individual patient, and to protect the sacred covenant between patient and
physician that has been disrupted by financial conflicts of interest, corporate
employment, loss of continuity, poor communication systems, and a failed public
health system. These changes have affected both patients and physicians, who
should join forces to restore the primacy of the patient-physician relationship.9
Corresponding Author: Thomas L. Schwenk, MD, Office of the Dean, School of
Medicine, University of Nevada, 1664 N Virginia St, Reno, NV 89557 (tschwenk@med.unr.edu).
Published Online: February 24, 2020. doi:10.1001/jama.2020.0146
Conflict of Interest Disclosures: None reported.
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