In the rural area where I practice, two general surgeons recently retired, a medical oncologist moved out of the community, and two urologists left over a year ago. My patients with cancer are left wondering who will care for them. And this small community is not alone. An aging physician population, burnout, and understaffing of other health care workers all contribute to rising rates of physicians moving and leaving communities.
One in five physicians say it is likely they will leave their current practice within two years. Meanwhile, about one in three doctors and other health professionals say they intend to reduce work hours in the next 12 months.
Over the past 20 years, physician practice models have shifted. A majority of physicians, including me, are now employed by large health systems rather than owning their own practices. As a result, my patients are often surprised to learn that the clinic staff do not report directly to me but instead to a manager employed by the hospital. The business case for this setup is easy to understand. The onerous and ever-increasing administrative burdens of practice management fall to skilled managers, which allows me and the rest of the care team to focus on the medical care of our patients. This separation of powers, if not well-executed, however, can lead to conflict regarding what is best for the patient.
By removing physicians from staff oversight, the responsibility of ensuring their orders are followed falls to others. Physicians (and other health care workers) are often powerless to navigate the gap between the plan of care they recommend and what employees are directed to provide. Employed physicians must decide which decisions are worth taking to the mat and which they must let go. Put another way, if a doctor orders a treatment, but the staff is not obligated to deliver it, is it really an order at all? A physician offers a “suggestion” rather than an order, and the patient remains clueless as the system rolls on. Dr. Wendy Dean, a leading physician advocate and author of the book If I Betray These Words, acknowledges the impossible situation that doctors face: “Every time medical professionals have to choose anything other than their patient, it can be indicative of moral injury, or it predisposes them to moral injury.”
Health care is a team sport. When nurses and other support personnel are under tremendous strain or not able to perform at optimal levels, or when staffing is inadequate, the impact flows both upstream to physicians who then face a heavier workload and loss of efficiency, and downstream impacting patient care and treatment outcomes.
— L. Casey Chosewood, MD, MPH, director of the NIOSH Office for Total Worker Health
The vulnerable patients waiting at the end of this dysfunctional power structure are unaware of these “office politics.” Television shows like House and Grey’s Anatomy portray dramatic scenes of physicians fighting for their patients and letting nothing stop them from providing the care they know is best. Let me be clear: this does not happen in real life. Health care institutions exist to support themselves. The backlash to a “disruptive” physician is swift and severe. As employees, we are acutely aware of how replaceable we are, not to our patients but to our employers.
Accordingly, many health care institutions are beginning to prioritize consensus builders over mavericks when recruiting physicians. This approach, while admirable, ensures that only those towards the middle of the pack personality-wise will direct patient care. While employee satisfaction may be high, the patient may not always receive the best care. To keep this “demanding” physician, however, means supporting strong managers and setting high expectations for staff. In the current environment with persistently high staff turnover, this is a difficult balance for health systems to make. Often the decision is made to part ways with the physician to pacify staff members and weak managers.
From an institutional perspective, I get it. Mavericks are hard to manage. They are prone to disruption, pointing out difficult problems in the system, and refusing to capitulate to senseless regulations and ever-changing policies. Pleasant, consensus builders don’t end up in human resources or storm into C-suite offices demanding an incompetent staff member be fired immediately. Tied to practices by family, professional, and moral responsibilities, most doctors try to accommodate and accept low-level infractions which mostly do not result in harm. In high-risk situations, however, someone must make the final call, and those orders must be followed.
Medicine, like many fields, has begun the long work of addressing diversity and inclusion challenges. I would argue that diverse personalities are necessary to provide the breadth of patient care required by our increasingly complex human population.
Here’s an example:
After World War II, a civil war broke out in China. The Chinese Communist Party was eventually victorious, leading to the formation of the People’s Republic of China. For more than twenty years after the war, the United States limited trade and diplomatic relations with the newly established government and instead recognized the Nationalist Party which fled to Taiwan. The civil war stranded many Chinese citizens in the United States, including a young physician named Dr. Min Chiu Li ((李敏求).
M.C. Li was born in China and completed medical school at Mukden Medical College in modern-day Shenyang. Leaving his wife and two young children in China, he traveled to the United States in 1947 to study at the University of Southern California. Stuck in America, he became a U.S. citizen and, to avoid being drafted into the Vietnam War, traveled across the country to Washington D.C., joining the research laboratory as an assistant obstetrician assisting Dr. Roy Hertz at the National Cancer Institute.
While at the NCI, Dr. Li observed young women dying of a rare cancer called choriocarcinoma. Choriocarcinoma forms in the uterus when cells that were part of the placenta begin to rapidly divide. This can occur with a normal pregnancy, miscarriage, or ectopic pregnancy. It is extremely rare, occurring in 7 out of 100K pregnancies, but in the 1950s, it was uniformly fatal. Young women suffered through terrible pain and bleeding. Watching these young women die, Dr. Li became obsessed with finding a cure.
After studying the chemotherapy agent methotrexate, recently discovered by Dr. Sidney Farber and in routine use for the cure of childhood leukemias, he decided to start administering it to these otherwise terminal cases. He noticed that markers in the patient’s urine dropped after she received methotrexate. He also realized that detectable levels of the markers in urine indicated that microscopic cancer was still present even if all visible cancer had disappeared and the patient’s health had improved. Because of the presence of these markers, he continued to give therapy for days after their symptoms had disappeared, a concept unheard of in an age when the concept of microscopic disease was unheard of.
The first patient ever cured of choriocarcinoma was the 24-year-old wife of a U.S. Navy dental technician who was near death after a tumor deposit of choriocarcinoma in her lung ruptured. Dr. Li went on to cure 2 other women before he was fired. Officials at a government agency specifically tasked with finding a cure for cancer fired Dr. Li in 1957 after he documented the first cure of a solid tumor using chemotherapy. Undaunted, he moved to New York, where he joined the staff at Memorial Sloan Cancer Center and continued his research.
His insights that cancer was not cured if tumor markers remained elevated were a completely new way of thinking about cancer. Because he persevered after being fired, choriocarcinomas are cured today with chemotherapy as described by Dr. Li and his team. And yet, a colleague described him as “pugnacious, very difficult, very hard guy, and we attributed [this] to his loneliness and his privations.” So, a new immigrant, unexpectedly separated from his family with barely passable English and little to no money cures a deadly cancer, and they say he was difficult? Umm … OK.
When we eliminate “difficult” physicians, patients must be made aware of the cost. Is mediocre the low bar you seek? Will your loved one die in the middle of the night while a group assembles to discuss how to address a fatal arrhythmia? Or a neurosurgeon who risked it all to drill a bedside burr hole on your dying child was fired based on his personality rather than his skills? I doubt this is the care you really want, but as it stands, we’re unable to provide better.
Stacy Wentworth is a radiation oncologist.