John McCracken, PhD
There is an epidemic of physician discontent in the U.S., and it’s having a pervasive negative effect on all aspects of healthcare. In a 2018 Medscape survey of more than 15,000 physicians in 29 specialties 57% reported feeling burned out or depressed. The symptoms include a loss of enthusiasm for work, feelings of cynicism toward the profession and frustration that interferes with the job.
When asked, physicians offer several reasons for their dissatisfaction, including too many bureaucratic tasks, loss of personal autonomy, reporting complexity and financial incentives that can strain professional principles. These are all true, but they’re symptoms, not the root cause. The real origin of physician discontent can be traced to the major transformation presently occurring in the organization and delivery of medical services.
Clinical medicine in the United States is undergoing a fundamental transformation,
- FROM a craft-based practice, in which individual physicians, organized around medical specialty or facility, create customized solutions for their patients based on their personal knowledge and core ethical commitment to the patient …
- TO a team-based practice, organized around population needs or disease state, where providers execute coordinated care delivery processes using agreed upon clinical guidelines and disease management protocols.
This transformation in the organization and delivery of medical care is being driven by payment reform. Traditional fee-for-service is being replaced by value-based payment models that put providers at financial risk for meeting pre-set cost and quality targets. This shift from volume to value is driving the reorganization of the medical service delivery model and forcing profound changes to doctors’ traditional practices and workflows, including:
- required adherence to pre-defined clinical guidelines and disease management protocols
- accountability for the overall cost and quality of care delivered to a defined patient population
- an erosion of personal autonomy and hierarchy in favor of clinically integrated, team-based systems of care
- a significant transfer of financial risk from payers to providers;
Most practicing physicians today—certainly those over the age of 45—were trained to act as autonomous decision-makers, not as leaders of care teams in an environment of shared decision-making. They tend to view themselves as self-directed, independent agents acting solely on their individual patients’ behalf, not as care team members with mutual accountability for managing the overall cost and quality of care for a patient population.
The transition from volume to value is not helped by the plethora of confusing, overly bureaucratic new payment models being promoted by the Center for Medicare and Medicaid Services (CMMI). It’s also constrained by the fact that most physicians have little experience managing the level of financial risk inherent in these models. For the time being hospitals in their role as ACO organizers are largely shielding physicians from downside risk, but that will eventually change as hospitals begin to pass it through directly to providers.
This transition from a craft-based to a team-base model of care delivery is still in its early stages of evolution, and it’s likely to require several more years—and the retirement of a generation of older physicians—before a new equilibrium is established. Until then, physician discontent is likely to continue to be a hallmark of American medicine.
John McCracken is Director of the Alliance for Physician Leadership, an educational partnership between the University of Texas at Dallas and The University of Texas Southwestern Medical Center which offers an MS/MBA program in leadership and management exclusively for physicians.