Moral Injury and American Physicians
Abuse of physicians is finally becoming recognized as a major problem in the American healthcare system. The New York Times Magazine recently ran a shocking story about the moral crisis of America’s doctors. The article postulated that the demands of hospital executives and payors force physicians to stray from their ethical principals and prevent physicians from providing the care they want to provide their patients.
Some years ago, a psychiatrist named Wendy Dean read an article about a physician who died by suicide. Such deaths were distressingly common, she discovered. The suicide rate among doctors appeared to be even higher than the rate among active military members, a notion that startled Dean, who was then working as an administrator at a U.S. Army medical research center in Maryland. Dean started asking the physicians she knew how they felt about their jobs, and many of them confided that they were struggling. Some complained that they didn’t have enough time to talk to their patients because they were too busy filling out electronic medical records. Others bemoaned having to fight with insurers about whether a person with a serious illness would be preapproved for medication. The doctors Dean surveyed were deeply committed to the medical profession. But many of them were frustrated and unhappy, she sensed, not because they were burned out from working too hard but because the health care system made it so difficult to care for their patients. In July 2018, Dean published an essay with Simon G. Talbot, a plastic and reconstructive surgeon, that argued that many physicians were suffering from a condition known as moral injury. Military psychiatrists use the term to describe an emotional wound sustained when, in the course of fulfilling their duties, soldiers witnessed or committed acts — raiding a home, killing a noncombatant — that transgressed their core values. Doctors on the front lines of America’s profit-driven health care system were also susceptible to such wounds, Dean and Talbot submitted, as the demands of administrators, hospital executives and insurers forced them to stray from the ethical principles that were supposed to govern their profession. The pull of these forces left many doctors anguished and distraught, caught between the Hippocratic oath and “the realities of making a profit from people at their sickest and most vulnerable.”
Abuse of Physicians by Insurers
Insurers are among the largest and most profitable corporations in the country. They did not get to the pinnacle of American capitalism by prioritizing care over profits. Insurers seem to have perfected the art of abuse of physicians through judicious use of pre-certification requirements to assure “medical necessity” of anything the patient’s physician orders. Certainly, there have been isolated instances of physician self-referral (which is why there is a Stark Law). But constructing an entire payment system around the implicit assumption that physicians routinely order unnecessary care is asinine. Pre-certification requirements require physicians to spend countless hours justifying their orders. This is time that has to either come out of patient contact hours or the physician’s unscheduled (and, of course, uncompensated) time.
The abuse of physicians by insurers is furthered through drug formularies designed to provide their paying customers with the most “efficient” (i.e., cheapest) drugs. Massive pharmacy benefits managers’ (PBMs) excessive approval processes devour physician time and, sometimes, patient’s health. Stories abound of lengthy delays just to be granted a peer review. Physicians who foolishly order the best medication for their patients are often required to spend their precious time convincing the corporate nurse that the person with hands on the patient knows what is best. Once again, precious hours are wasted while physicians attempt to obtain the treatment they have determined is best for that unique patient.
Abuse of Physicians by Hospitals
The constant pressure from hospital administrators in particular has frequently caused me to ask (not really hypothetically) are hospitals evil? In my mind, the unequivocal answer is YES. Hospitals engage in the abuse of physicians through outrageous demands on everything that impacts physicians:
- patient contact hour requirements that seem to assume that a physician isn’t working if they aren’t face to face with a patient (because charting, medical staff meetings, fighting with managed care companies, etc. should presumably be done in a physician’s spare time);
- call coverage requirements that leave open the possibility that the physician may be working 24/7 365 days a year;
- outrageous requirements in physician productivity compensation formulae that not only require production that is far above median, but allow the institution to reduce a physician’s compensation if these productivity requirements are not met (even if the reason for the decrease in productivity relates to hiring new physicians or other circumstances completely out of the control of the physician);
- moving all physicians in a department to the same physician compensation model regardless of experience (because anyone with a white coat will do, and years of experience mean nothing);
- physician covenants not to compete that would require a physician to move out of town and start over if they left that hospital.
Add to these abusive contractual terms the maddening tendency for hospital administrators to talk down to physicians who raise legitimate concerns about working conditions or patient care- what I have coined “hospitalsplaining” – and it begins to become clear that the employment by hospitals can be very bad for a physician’s physical and mental health.
One could reasonably assume that abuse of physicians by hospitals is limited to the multi-billion dollar publicly traded hospital systems. However, in an era where “non-profit” hospitals are giving their CEOs multi-million dollar paychecks, it seems like no hospital (with the probable exception of physician-owned hospitals) will have an incentive to treat physicians as anything other than fodder for the machine.
What Can be Done to Reduce the Abuse of Physicians?
I wish I could drop the magical formula that would stop abuse of physicians. Unfortunately, there isn’t a magic bullet to end abuse of physicians. But there are baby steps that can make a (potentially imperceptible) difference for physicians.
Abuse of physicians by insurers is being addressed on multiple fronts. Both physicians and patients are shaming insurers online to reverse authorization denials, with some success. Causation can’t be proved, of course, but there has been some reduction in prior authorization requirements.
Abuse of physicians by hospitals can be addressed on multiple fronts. Unionization of physicians, as unpalatable as it is for some professionals may help (although it’s too early to tell). I personally do what I can by crafting one individual physician contract review at a time. Each physician I help may just be a drop in the bucket of misery, but I can sleep well at night knowing I am doing what I can to reduce the abuse of physicians.
If you would like me to review your physician employment agreement, you can start your review. If you would like to talk to me about your special circumstances, feel free to set an appointment. We may not be able to stop the abuse of physicians, but there is hope that it can be alleviated!
