Unhappily Employed - Annals of Internal Medicine: Fresh Look Blog


Wednesday, February 14, 2018

Unhappily Employed

I was recently at a meeting of thoughtful physicians who gathered to discuss their profession, from their goals of improving patients’ lives and well-being to the personal challenges practicing medicine. A common theme emerged: The practice of medicine is rewarding but incredibly frustrating. Many in the group were outpatient physicians employed by hospitals as described in the Annals of Internal Medicine article, "Changes in Hospital–Physician Affiliations in U.S. Hospitals and Their Effect on Quality of Care" (1). These physicians felt that they spent more of their time documenting than providing medical care and were not using their minds to the peak of their abilities. I am only a few years into this profession, but I can easily relate to the group’s frustration. The 1 day per week I spend in my outpatient clinic is wrought with inefficiencies. I click the EMR about 127 times to get through a complete visit. If I am allotted 20 minutes with a patient, the first 10 are devoted exclusively to documenting. My story is not unique, and many physicians have this same experience every day of the week.

One model intended to address these issues is vertical integration of hospitals. The Annals article mentioned above studied the association of hospitals employing physician groups with quality-of-care measures. The model is well-intentioned. Hospitals employ physicians directly. Those physicians use the same information systems to streamline communication. As a system, hospitals and physicians share common goals in meeting quality metrics for patients (a proxy for truly improving quality of patient care). Employed physicians are salaried, decreasing incentives to make more money by providing potentially unnecessary care.

The authors of the Annals article completed a comprehensive retrospective cohort study over 9 years, looking into whether quality metrics improved when physicians went from being independently employed to being salaried hospital employees. Despite the theory that outcomes would improve with vertical integration, the results showed that there were no changes in quality metrics.

I work in a hospital that recently employed its physicians in this model. I have not yet experienced a revolution in quality or the way outpatient clinics run, but I have seen some changes. I see an emphasis on quality and a collaborative approach to improve care in our system. This culture shift is progress in and of itself, because change occurs only if there is a shared effort to innovate. Robert F. Kennedy famously said, “There are those that look at things the way they are, and ask why? I dream of things that never were, and ask why not?” As internists, if the trend is that most of us will be employed by hospital systems, why don’t we ask more of our employers? Why can’t quality for our patients be better? Why can’t we work together to design a more efficient office? Why can’t we practice at the top of our training? Have we become complacent?

The observations reported in Annals prove to me that the health care system may be evolving, but the practice of medicine is staying the same. The good intentions of vertical integration have not yet panned out in terms of quality of care. I feel like things are changing for the better, but my colleagues and I continue to feel burdened.

The main issue raised by my colleagues at that meeting was that they spend as much time doing non–patient care–related work as they do seeing patients. They imagined an ideal medical clinic where clinicians saw patients, other providers were used to the maximum of their abilities, medical assistants helped with documentation, and patients had records at their disposal. In a well-run medical practice, these physicians could see even patients and more of their day would be spent in direct care of those patients. If the problem is that our time isn’t being used efficiently, shouldn’t we be addressing it? I accept that thorough documentation is needed to enable accurate billing and good communication to others involved in a patient’s care. However, why do physicians need to be the ones typing away? If scribes documented for us, would we have the time to focus on quality?

Medical practice will not become less frustrating unless it changes. If hospitals are to become the main employers of physicians, then we physicians must work with our employers to ensure that we are being used to the best of our ability. Use me to see patients; don’t use me to check boxes.

  1. Scott KW, Orav EJ, Cutler DM, Jha AK. Changes in hospital-physician affiliations in u.s. hospitals and their effect on quality of care. Ann Intern Med. 2017;166:1-8. [PMID: 27654704] doi:10.7326/M16-0125


  1. WHY are things the way they are in practice?
    because there is no incentive for the medical industrial complex to change.
    hospital based physicians earn a salary and have to justify that salary by generating income for the employer. ever see jobs where a "production bonus" is part of the package? do more, order more tests, refer more to colleagues and you make more, as long as the hospital or employer can bill insurance.
    if you practice quality, "less is more" medicine, you order less, and earn less for the employer and soon you can be replaced by 2 nurse practitioners who can see 2 x as many patients. i have seen this happen multiple times.
    no dr syed, nothing will change as long as we have an ineffective AMA that caters to "stakeholders" (everyone other than drs) and as long as we have specialty colleges that are the cesspools of the ABMS, a racketeering organization that has hijacked the medical profession.

  2. Nurses feel the same way. THey spend as much time documenting and gathering materials as they do in actual patient contact and care. Maybe more. The system needs to be fixed.


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