Physician burnout, prostitution, contracts, shift-work, small-town medicine, and the doctor-patient relationship – why do we take oaths, anyway?

As a junior resident on the days in which I was assigned to the clinic, in an urban hospital in the largest city in the United States.

It was not uncommon for me to see more than 100 patients between 8am and 6pm, including the time to document what I had done. 

That’s not counting the patients that I saw on rounds, starting around 5am. 

100 patients over 10 hours amounts to 10 patients per hour, or about 6 minutes per patient. 

Mind you – these were specialty patients, and many of them, perhaps 25% on a given day, needed diagnostic procedures done, including nasal endoscopy, flexible laryngoscopy, cerumen disimpaction under binocular microscopy, fine-needle aspiration, etc. 

In those 6 minutes..

I was expected to speak with the patient, find out the patient’s concerns, examine the patient, obtain an informed consent for a procedure, order tests, review test results, make a diagnosis, begin the treatment process, and document all of that in a way that would make sense to the next person who saw the patient. 

In those days, before the widespread use of electronic medical records (EMRs), it would take me between 30 and 90 seconds to document the patient interaction. 

“Why do we take oaths, anyway?”

Today, it’s estimated that approximately 60% of a physician visit is spent on documentation. 

In other words, of the 6 minutes that I was allotted for the patient visit, in today’s milieu, I would expect to spend 3.6 minutes on documentation, and 2.4 minutes doing all the other stuff.  

Some might suggest that the patient volume (and resultant diminished patient experience) was driven by profit and greed..

and that as a physician, I was only interested in seeing that many patients in order to make more money. 

Let’s take a closer look at that assertion. 

At the time, my annual salary was $45k. 

It was a flat salary, not based on volume, independent of how many patients I saw. 

I worked about 100 hours per week, averaged out over the year. 

That amounts to 5200 hours per year. 

I’ll do the math for you – a little over $8.65 per hour, or just under $0.87 per patient for a greedy doctor like me. 

Keeping in mind that the visit for that day cost the patient significantly more than $0.87, I’m left to wonder where the rest of the patient’s payment went?  More on that later.

Some might rightly point out that I didn’t spend the entire 5200 hours per year seeing 10 patients per hour.

They’ll point out that much of the revenue that paid my extravagant hourly rate was generated by surgery and time in the operating room.

Averaged out over the 5200 hours, however, patients were still responsible for far more than $8.65/hour for the care that they received. 

I would also argue that my training, expertise, and risk carried far more value than that of a job flipping burgers, which would have paid comparably in that day and age. 

We’ll take a closer look at this in the coming discussion.

Others have argued that I was a full-fledged adult when I chose this path..

that I had every opportunity to know what I was getting into, and that I could have chosen differently along any step of the way if Medicine was such a millstone around my neck. 

This, too, is a concern that we will examine more closely in a later chapter of this discussion.

I’m sure the other physicians reading this can relate. 

This story is not unique to my experience. 

Stories like these are often cited as a cause (sometimes THE cause) of skyrocketing physician burnout.

So, how did we get here?

Let’s take another journey back through history to see if we can find some answers.

Medicine today is largely contractual. 

Our physician relationships, whether with patients, other doctors, hospitals, other healthcare workers, or society at large, is transactional. 

As modern medicine has developed, particularly over the last 50 years or so, we have seen an increase in patient volume and a decrease in the time each patient gets to spend with the doctor. 

As an employee in my father’s physiatry practice, I would see him spend 1 hour with new patients, and half an hour with follow-up patients. 

Anecdotally, I know that today, physiatrists don’t typically spend 1 hour with new patients.

Additionally, we need to take into consideration the personnel required to run a physician practice. 

Many modern physiatry / physical medicine & rehabilitation (PM&R) practices include the physician, the receptionist, nurse, referral manager (both for managing outgoing as well as incoming referrals), billing personnel (1-4, depending on the complexity of the cases and variety of payers), medical records personnel (to handle incoming and outgoing records requests), possibly a transcriptionist, and a manager. 

As modern medicine has developed, we have seen an increase in patient volume and a decrease in the time each patient gets to spend with the doctor. 

In some practices, the physician does the electrodiagnostic studies himself, but in others, there is a technician who performs the test, and the physician interprets them. 

Altogether, that amounts to 5-10 personnel to run a modern solo PM&R practice. 

In the case of my father’s practice (read more about that time in A Healthcare Nightmare: How Did We Get Here?), he had himself, a full-time manager who ran the front desk, telephones, billing, medical records, and referrals, and then a part-time assistant to help the manager, as well as work on medical transcription. 

He did the electrodiagnostic studies himself, because he found that he got more useful data when he could vary the test dynamically with the patient.

I also know peripheral nerve surgeons (like myself) who have as many as 10 personnel to handle their practices (including as many as 6 billing specialists to handle coding, billing, appeals, prior authorizations, etc), or as few as the surgeon and one administrative person to keep things running smoothly.

One could argue that the complexity of medicine has advanced so much that we need the extra support to keep things going. 

In the case of PM&R, however, most of the physiatrists I know today have patient populations and practices that mirror what my father saw and did. 

The same is true of peripheral nerve surgery. 

Even though surgical techniques have evolved in the intervening 40 years, those advances in surgery haven’t been the primary impetus for the tremendous growth in the associated administrative needs. 

Instead, the administrative burden has increased for other myriad reasons.

While it’s beyond the scope of this article to delve into all the factors..

that have contributed to the increase in administrative tasks associated with running a physician practice, it is well within this discussion to examine the philosophical influences that have led us to where we are today. 

In part 2, which you can find here, we’ll dive into this discussion and take an even closer look at how we got here.