The health care system is in dire need of reform, but it is difficult to know where to start. If you are a physician or allied provider, what are the options to improve the profession? What are providers willing and able to do to help?

Reform is a multistage process based on understanding that the system is working as designed. Physicians and providers need to be involved in any discussion of reform, if not take the lead. Unfortunately there are numerous causes and interlocking issues. One such issue is the lack of information the public has on how the system functions, and physicians and allied health professionals are hesitant to describe.

First, physicians and providers have a high degree of responsibility, but for multiple reasons, do not have the accompanying autonomy. The constant stress of seeing as many patients as possible, keeping them happy while spending more time inputting data than we do with patients causes the dreadful fear of missing something serious leading to harm. Another way to summarize our predicament is that we are assembly line data input specialists with medical training, working too much in your insurers’ business interests. The current system suppresses excellent medical care, leading to mediocrity of care.

Second, we are not doing well mentally, yet simultaneously feel the need to portray a positive veneer — the incongruity created by acting in opposition with one’s internal mental state amplifies the moral injury and lack of autonomy. The physician suicide rate, which is about 300-400 per year in the US, and drug and alcohol abuse rates are about twice that of the general population. The importance of this is to highlight that the system not only harms patients, but physicians, nurse practitioners and physician assistants as well. According to a Behavioral Sciences review of multiple studies, published in October 2018, 25%-60% of physicians report emotional exhaustion. The health care system can only provide excellent care if its providers have excellent mental health.

Third, the insurer contracts physicians must sign to become a “preferred provider” are the primary instrument leading to impaired mental health. “Preferred provider” is a euphemism for “insurer proxy” and these contracts contain the phrase “final medical decision making authority,” giving the insurer leverage against your physician, which indirectly influences your medical care.

Insurers vehemently disagree that they control physicians and claim to improve quality and reduce costs, but this argument falls flat as we have the most expensive system in the world. One objective example of how insurers control providers is the amount of time spent with data input. According to direct observational studies, time spent with an Electronic Health Record is 3.5-6 hours a day. Physicians can spend more time inputting data than thinking about what medical care you need, which is objectively stupid. Excessive data input also leads to inefficiency and of course burnout, which leads to fear of making a harmful errors and a sense of moral injury effecting a perverse cycle of worsening mental health. Even more time is spent on administrative, clerical tasks and message management. Attention and focus directed towards patient care, which is the basic function of health care, is squeezed to a minimum, necessitating too many shortcuts.

If you are a physician or other provider, are you providing excellent care? Do you have the emotional energy to keep practicing for years to come? If not, what needs to change and what are you willing and able to do about it? What could we do as a group to improve our daily professional lives and future? Is it better to actively manage our profession or continue as is?

Providers: Consider emailing me your thoughts at: coms@comedsoc.org

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