The Health of Medicine

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A few weeks ago I received a message from a concerned premed about the recent “negative” news about physicians, more specifically the career outlook and morale. The article titled, “How Being a Doctor Became the Most Miserable Profession“, has been flung about almost all medically oriented socially sites, and has sparked a healthy conversation. A philosophical question, do you really want to go into medicine? Am I ushering you off a cliff by trying to help you get into medical school? Oh no! Well, I’m sure I’m going to regret this at some point, but let’s talk a little more about the details of this article.

There’s been a lot of rancor over the recent changes of healthcare, and what it may mean for physicians is still unclear, that much is true. However, let’s check out the premises of this article alone, without the “touchy-feely” parts:

A. Is being a doctor the most miserable profession?

“Nine of 10 doctors discourage others from joining the profession, and 300 physicians commit suicide every year. When did it get this bad?”

“In fact, physicians are so bummed out that 9 out of 10 doctors would discourage anyone from entering the profession.”

Isn’t 9 out of 10 an amazing number for anything? This mathematically, just sounds too astounding, so it warranted some investigation. I mean if this number can truly be extrapolated then it means that either every doctor I’ve met so far is that 1 out of 10 and I’m a lucky fellow, perhaps  I’ve met a band of liars in on a conspiracy, or this number is a little funny Well, I decided to look more closely at the methodology of the study. The author gave a link to a press release, and not the study, fortunately the actual study does tell us more about how these numbers were generated. You can find the original report here.

The report is generated by a insurance company for physicians, with 71,000 members. The response rate was 7.5% (~5,100). Of those primary care was represented at 31%, 39% were surgical, and the other 100 or so specialties were lumped into a nonsurgical group making up the remaining 30%. That sounds impressive, until we’re reminded that it’s a mail in survey. Mail in surveys have an automatic bias built into them, only people who care enough about the survey will return them. And if you’re a busy physician, the a good reason to return a survey is because you’re angry. So, really all this study has shown was mail in survey bias, and that the people who responded probably aren’t that satisfied. If the study wanted better results, they should of done this randomly (and release the question stem for us to evaluate) instead of releasing a “how peeved off are you” main in survey — it would be better to gain several hundred completely random surveys from physicians than measuring the dissatisfaction of those who bothered to reply. If we pretend survey does state that 9 out of 10 out of 7.5% of respondents would deter others from medicine, recalling that 7.5% of 71,000, and therefore would be sample of 2.3% PCP, 2.9% surgical, and 2.3% other doctors, this isn’t exactly a sign of max exodus. However, the report doesn’t ever try to start that all 7.5% even answered this question, so we can’t measure the statistical value of the “9 out of 10” statement. As And as stated before, the sample is  automatically biased, sort of like the people who bother to write reviews about professors on Rate-My-Professor are probably going to do so because they’re pissed. The average people, who had an unremarkable experience is less likely to bother responding.

B. When did physicians become miserable?

The author tries to answer this by using several points: 1) roughly 300 physicians commit suicide each year, 2) physicians are the second most suicide occupation, and 3) physician unhappiness is on the rise. Interestingly, these three premises are rather neutral and are fine. It was not until the author decided to make the editorial comments that I started to find things slightly odd:

Depression and anxiety in physician is a real happening, but  it’s not a sudden condition or a new problem. In other words, we shouldn’t trivialize suicide to say that miserable days at work logically are tied to suicide. People don’t just have a bad day at work, and then decide to off themselves (we’ll look more into this later). Medical students, and premeds are both ore likely to suffer have signs and symptoms of depression. The article used suicides as a barometer for physician satisfaction. While it’s a gut wrenching move, I’m not sure how scientifically sound it really is. After all, almost all people who commit suicide may have some form of mental illness. As physician, incoming residents and highest report the report of mental illness comes in the signs and symptoms of depression. But again, it’s hard to tease apart when a persons mental health took a turn for the worse. It sort of belittles medical students and premeds, to leave them out of the depression discussion — and leaves very little room to discuss the way we raise premeds and physicians. Also, US doctors don’t hold a monopoly on physician misery and suicide, other western countries follow this disturbing trend. So, perhaps we should take a closer observation of our environment. And finally, physician suicide hasn’t increased, it’s been more or less the same for a decade — so, it’s not very likely that we can use physician suicide as any type of strong correlation to responses in the changes of the healthcare environment. So, asking this question does well to tug at the heart strings but actually does little to identify why this is an issue — in fact, the article uses suicide as a tool of persuasion. This article doesn’t do much to address or inform the readers about how to reduce physician suicide, such as this actual study. Lastly, I can’t evaluate the last premise of whether physician unhappiness is on the rise, because the author provided a “emotional blog post“, not data for us to discuss. Case in point to how fickle this suicide argument is to look at the number #1 suicidal professional dentist who are well paid and yet onslaught from of changing healthcare policies.

So, then I really started to wonder, what was really the point of this article? It certainly wasn’t to seriously discuss physician suicide or depression. This was evident by phrasing used in the transition of using the “feels” to draw the reader into their tirade about the Affordable Health Care act and its perceived effects on primary care:

“After all, the public sees ophthalmologists and radiologists making out like bandits and wonder why they should feel anything but scorn for such doctors—especially when Americans haven’t gotten a raise in decades. But being a primary care physician is not like being, say, a plastic surgeon—a profession that garners both respect and retirement savings. Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor—but without the social status or union protections.”

[context: the author wanted to show that we shouldn’t scape-goat all doctors]

So, here is where I have to disagree. Just like the public shouldn’t use one outlier story to base their opinion, so to shouldn’t the author. Why I’m sure this “slight of words” was surely a joke, and they don’t mean to say some doctors deserve their pay more than others — well, maybe actually they did say that. While it’s true primary care is underpaid, It’s unfair and even insulting to even imply that those who don’t go into primary care are “less willing to do the work that no one else is willing to do”. I respect primary care, we need a whole more more, but after investing 180-250K I think we can also remember that we had dreams about what we wanted to do, and for not everyone wants to do primary care. Besides, that I’m not sure if other doctors will like hearing primary care physicians trounce all others on altruism and service to the public.

Towards the end of the article, there is some substance. The author is probably right, US physicians are hit by a barrage of continuing education requirements and certifications, and the patient load is increasing for primary care physicians. The author states the average patient/doctor time has dropped to just 12 minutes, and expects this trend to worsen as more patients are added into the system. Though, it should be noted that in Japan, where they have compulsory healthcare, and the doctor ratio to person is about half of the US, the visit time is about 7-8 minutes (primary care). So, the increased work load is a logical consequence of having more patients. Furthermore, primary care reimbursements (Medicaid) certainly does need to be increased, while the administrative work needs to go down. Though, these fees have been flat or non competitive for over a decade, so this isn’t a new problem. And while  doctor and many others are concerned about what it means to have the government involved in medicine, the American Medical Association was up in arms when Medicare first released but now embraces it though it still has its flaws.

Though I’m glad the author gained attention perhaps in our plight, I’m just not that impressed with out it was presented, and I’m not overly appreciative of some things I felt were manipulations in the readers emotions to get us to comply with their opinion.

My own verdict, I’m quite comfortable with my quarter of million dollar investment, and I’m sure many others are too. Though, we shouldn’t forget those who need our support as a unified medical community.

Information Addendum:

If you want to know more about medical student and physician depression and suicide you can find an excellent summary on the problem. There are also constructive elements for physicians who may be undergoing depression, such as leads on understanding your right as both a physician and a patient.

http://emedicine.medscape.com/article/806779-overview#aw2aab6b4

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