The U.S. has a critical shortage of health care professionals: nurses, mental health therapists, and especially physicians. Burnout of these clinicians is the proximate cause of the shortage. Maximum wait times to see a primary care doctor can exceed four months resulting in death by queue.
Death by queue (British word for people waiting in line, a queue) was coined for Great Britain’s vaunted NHS (National Health Service) where Britons died waiting for life-saving medical care that didn’t arrive in time to save them. NHS is also experiencing an “exodus” of burned out physicians similar to the U.S., especially senior ones, with catastrophic consequences on delivery of medical care. In addition to worse delays in caring for current patients, what experienced physicians will teach the next generation of doctors how to care for future patients?
Proposed solutions for burnout shortage include AI-assisted documentation, in-migration of care givers from other countries, virtual care givers, online toolkits, and rest/eat well/exercise/ask for help. As these solutions do not address the causes of burnout, such fixes will fail and could make things worse.
The apparent causes of burnout are the following. An underlying common theme connects them all.
Physicians cannot exercise their best judgment when making care recommendations to patients. They must follow clinical guidelines, crisis standards of care, pharmacy benefits managers’ drug limitations, federal advisories, CDC mandates, and FDA prohibitions. All this advice and guidance are effectively orders. They seem designed to protect the patient from the doctor, replacing his/her judgment with government authoritarianism. Doctors feel the weight of responsibility for the patient but are denied the appropriate authority. Physicians always get the blame but rarely any praise.
Clinical care givers endure years of school and training along with long hours and great emotional as well as physical stress for one reason above others: the psychic reward. Maslow described it as the highest of human needs, self-actualization, discovering the meaning for that person’s life and achieving it. As one nurse described the psychic reward, “When my babies [her patients] do well, it feeds my soul.”
The current healthcare system disconnects patient from physician emotionally. The depersonalization that patients rightly resent is felt equally by care providers. My former personal physician had an assigned list of more than 900 patients. Surgeons often first learn the patient’s name from that day’s operating schedule. The lack of psychic reward combined with overwork especially from BARRCOME lead to burnout.
When Washington regulates the healthcare system, guides care, and establishes insurance rules, it does so through BARRCOME: bureaucracy, administration, rules, regulations, compliance, oversight, mandates, and enforcement. The manifestation of BARRCOME in healthcare is third-party decision making by Washington directly through Medicare, Medicaid, and Tricare (171 million Americans) and indirectly through federal rules and regulations governing employer-supported private insurance (134 million Americans).
Third-party decision-making producing bureaucratic diversion and disconnection is the ultimate cause of physician burnout.
Bureaucratic diversion refers to healthcare spending that is dollar inefficient, i.e., money spent that produces no medical care. In 2022, the U.S. expended $4.3 trillion on its healthcare system, an amount greater than the GDP of Germany. Half of that “healthcare” spending was diverted from patient care to pay for BARRCOME. That translates to $2 trillion worth of care that Washington denied the American people in order to pay itself.
As Medicare and Medicaid repeatedly lower allowable reimbursement schedules, aka payments to physicians for care, wait times get longer, patients die waiting, and physicians burn out feeling frustrated and devalued.
BARRCOME’s third-party decision making “disconnects” in two ways. It disconnects patients from their money. It disconnects doctors from their patients emotionally (along with financially.)
The average American family will expend $32,065 on healthcare in 2023. More than 80 percent will go to an insurance company where unaccountable, faceless bureaucrats, not the family that earned the money, decide how to spend family funds. As most families are healthy and have low medical expenses, they get no value from the expenditure of their $25,652.
Disconnection of patients from their money indirectly promotes physician burnout. Patients see massive spending on healthcare, intolerable wait times despite exorbitant physician charges (not payments, which are generally a small fraction of charges), and direct their anger at physicians. Doctors quickly burnout if they get up at 3AM to see a patient, and they are rewarded with disdain and physical violence.
A fiduciary connection is the key to a successful therapeutic relationship: it is also a preventative for burnout. In medicine, fiduciary means one person (the patient) gives up medical autonomy – control of body and/or mind – to another person (the physician) to be used exclusively for the benefit of the first person, the patient. This is an intimate, emotionally intense relationship between two people. When the patient and physician are disconnected by the third party, there cannot be a true fiduciary relationship. Without such a connection there is no trust and no psychic reward. The result is burnout.
The cure for physician burnout follows from the root cause. Since third-party disconnection via BARRCOME is the cancer, excise it. Eliminate third-party – federal government – decision making from healthcare and health ... care, which will reconnect.
RECONNECT patient with his/her money, so patient not third-party decides spending.
RECONNECT patient directly with chosen physician, with no third party making medical (or financial) decisions.
This reestablishes both medical freedom and the fiduciary relationship, which can cure the problem of physician burnout and its consequent MD shortage.
Deane Waldman, M.D., MBA is Professor Emeritus of Pediatrics, Pathology, and Decision Science; former Director of the Center for Healthcare Policy at Texas Public Policy Foundation; and author of the multi-award winning book Curing the Cancer in U.S. Healthcare: StatesCare and Market-Based Medicine.
