Pandemics, Profits, and Physician Well-Being

Before coronavirus reared its ugly head, few topics permeated the healthcare discourse like physician burnout. Coverage in industry publications was unrelenting and startups seemed to launch each week touting a new technological solution to this very human problem. It’s easy to understand why: Burnout takes a tremendous toll on society. Then and now, much work remains to be done.

Outside of healthcare, however, the burnout story was being told differently, if at all. Occasionally, an industry liaison like Atul Gawande or Eric Topol would pen an op-ed or write a book, helping those of us in the healthcare community feel like our grievances had been aired. But rarely did we see anyone outside the industry attempt to raise awareness or build a solution for the problem, despite the fact that it affects all of us. Burnout brings a more than $4 billion per year price tag, poorer outcomes for patients, and the indefensible loss of physicians in the form of an exodus from the profession and, much worse, suicide. All of this remains true during a global pandemic, when it’s never been more apparent that every doctor counts.

For James Hamblin, a physician and staff writer for The Atlantic, the issue, as it so often does in the United States, comes down to dollars. On Jan. 28, while China was in the throes of an outbreak that has since consumed the world, Hamblin wrote this tweet:

A reason it’s tough to get journalists to respond to pitches about physician burnout is the average doctor makes $313,000. Even if they switched to part time to recover they’d still be in the global 1% and make more than the journalists asked to cover their plight. — James Hamblin (@jameshamblin) January 29, 2020

Many physicians responded to Hamblin with varying degrees of indignation. Others pointed out that claiming “the average doctor makes $313,000” is a gross oversimplification that ignores years of training and mountains of student debt. Still others noticed that, as a physician and a journalist, Hamblin brought a unique perspective to the burnout conversation.

I sense a kernel of truth in his claim. Eight years ago, I made a living (using the phrase lightly) writing for a group of local newspapers that paid $22,880 per year. Whenever I was writing about someone who earned a lot of money, it was because they were engaging in philanthropy or villainy, never because they were enduring hardship.

Are journalists gatekeeping physicians from larger conversations about human suffering because they earn high salaries? It’s possible, but I suspect we’ll never know. What’s more interesting is the assumption baked into this question—namely, that there is a price for everything, including human suffering, and that forcing a group of people to endure depression- and suicide-inducing levels of hardship and abuse is acceptable as long as the pay is good.

What Does It Mean To Be A Physician?

While reality changes abruptly and often, our assumptions don’t. We can see these competing processes in action as COVID-19 runs rampant throughout the U.S. (this is our quickly evolving reality), but some of us continue to believe we can still go about our lives as if this wasn’t the case (these are our slow-to-change assumptions).

The same can be said for our assumptions about physicians. Historically, many of us tend to lump physicians into the same brain space as lawyers and high-earning businesspeople, understanding them more by what they take home in salary than by what they give in service. Our suppositions include romantic visions of lavish lifestyles, perhaps because these are easier to stomach than realistic stories of the grueling, deeply sacrificial, life-saving work they do.

When we do think about the work itself, we tend to consider it from our perspective as patients. Being a physician, then, must be about caring—connecting with patients, fixing their ailments, and sending them off to live happy and healthy lives. Good pay and good purpose—talk about a dream job.

This may still resemble reality for some physicians, but as business and medicine continue to collide, our assumptions increasingly fail to align with the lived experience. Young people who were attracted to the profession because they want to help their community can become jaded when they find that their responsibility to patients is at odds with their responsibility to their employer’s bottom line. Those who decide to become physicians because they see it as a traditional path to wealth can be overwhelmed for decades by hundreds of thousands of dollars’ worth of student loans.

Ever have two tweets in a row in your feed that sum it all up? @SnarkyMD @sarahtumbleweed pic.twitter.com/ez8YAUjhLE — Katie Sharkey MD PhD (@katie_sharkey) February 11, 2020

Pre-COVID, many stories called out additional problems in medicine, like endemic racism, sexism, misogyny, and other abuses that start during medical education and permeate healthcare culture all the way to retirement. These problems may not be new, but the attention they have recently garnered is unprecedented. As for the sources of these problems, they’re complex and varied, but the result is usually the same: physician burnout, depression, and suicide.

What Does It Mean for Physicians?

What we’re left with is a profession where between a third and half of all doctors, according to a Medscape survey, are burned out. How can that be? Is it possible the profession hasn’t changed, but the professionals have?

Not according to Dr. Manvinder Kainth, a family practitioner who spent years employed by hospitals before launching her own independent practice in Plano, Texas. “We went through rigorous training for 12-plus years of our lives—we know how to handle multiple things on our plates,” she says. “The reason it’s all going downhill is because we’re being abused.”

Kainth is adamant that the semantics of the burnout conversation must be changed, because “calling it burnout makes it seem like we can’t hack it,” she explains. “We need to start calling it what it is—abuse.”

Whether burnout or abuse, the consequences of physician mistreatment have been scientifically proven and exhaustively restated in healthcare media. We’ve known that physician burnout costs the industry $4.6 billion since mid-2019. We’ve known that it causes a twofold increase in unsafe patient care since late 2018. And yet that knowledge has resulted in little change. Why?

People and Profits

It’s possible that Hamblin’s assertion is correct—physician burnout captures little mainstream attention because journalists don’t care to write about the suffering of a group of professionals who they perceive as earning five or 10 times their salary. It’s also possible that journalists’ opinions are representative of the average American, who earns about $31,000 per year. Perhaps these issues are linked and the average American is simply unaware of the problem because it’s so infrequently covered.

There are probably larger systemic pressures deflecting attention from physician suffering, like the American obsession with economic growth and profitability. Amid the greatest pandemic of our lifetimes, many pundits and politicians seem more concerned with shrinking profits than growing sickness and death, calling into question whether GDP is more valuable than public health. President Donald Trump recently tweeted that the cure to the coronavirus pandemic (a misnomer for social distancing, which slows disease spread as well as business profits) must not be worse than the disease itself, which, at the time of writing, has killed well over a thousand Americans.

If the most powerful and perhaps influential public figure in the U.S. is open about his willingness to trade human well-being for economic growth, how many leaders in business and healthcare are willing to make the same tradeoff?

It’s an impossible question to answer. Most leaders wouldn’t dare vocalize tactics so inhumane (excluding executives at Goldman Sachs, who can’t seem to come to terms with whether “curing patients is a sustainable business model”). Still, if we crunch the numbers, it’s not unreasonable to wonder whether this tradeoff is woven into the fabric of American healthcare, an industry that’s so rife with cash that some experts predict we’ll soon spend one out of every five dollars there.

What can we expect from this colossal investment? According to a recent study in the Journal of the American Medical Association, we can expect about 25% of it—or between $760 billion and $935 billion—to end up falling into the “waste” category. This comes at a time when doctors and nurses are playing Sophie’s Choice with dying patients and suiting up in trash bags because they lack basic personal protective equipment. One might be curious whether the study accounted for the billions of dollars we lose every year thanks to physician burnout, and how many times over that wasted money could solve the problem.

It’s important to consider that someone must be benefiting for things to continue the way they have, where we waste nearly a trillion dollars and stand idly by as physicians continue to burn out, leave clinical care, or die by suicide. While we might disagree about who this benefactor is, we all know who it isn’t.

Pressing Needs

Coronavirus has made it more obvious that the well-being of clinicians and their patients might not be the core aim of American healthcare. If there’s a silver lining to the pandemic, it’s that the disease has thrown so much about what we consider to be reality into question. Does it really make sense to commute to work an hour each way when many of our jobs are so easily accomplished anywhere we can find reliable WiFi? Why should we follow leaders who refuse to embrace science? Why do we elevate certain groups of people to hero status but not others?

In the middle of the greatest sickness of our lifetimes, it’s important to question the health of our assumptions. There’s no better time than now to ask ourselves how we can ethically, morally, and financially justify abusing physicians if it not only hurts them, but all of us.

–Tom Castles authored this post. Connect with him on Twitter and LinkedIn.

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