Physician Retention—Why are We Leaving?
I’ve recently read in Dr. Douglas Farrago’s latest book, The Hospital Guide to Physician Retention, about the number of physicians leaving practice. He says that there were about 940,000 doctors in the United States in 2021, and 12 percent quit that year. As he notes, that means 117,000 doctors left their jobs in 2021. Although it is safe to say that some of these doctors became old enough to retire, many others were not old enough to retire but instead chose to find another kind of work. The question is why are doctors leaving their practices.
When I started medical school in 1973, being a physician was a calling, something we could be proud of and share our enthusiasm for with our peers. Back then residencies were notoriously difficult. You would be on call for 36 hours, off for 12 hours, and back on call for another 36 hours. This is something we all tolerated because we believed that the “ends justified the means.” After a 36 hour-shift, I often fell asleep at most stoplights while driving home. Most of my peers did too.
During my residency, we attempted to reach program directors with our concerns about the hours, but were confronted with the notion that they suffered through residencies with schedules like that, so why shouldn’t we. Thankfully, residency hours have finally become more reasonable. I have two children who are doctors, and they had much better call hours. My daughter had no call in her first year of residency and no more than 24 hours on at a time once a week after that.
During medical school and residency, the world of being a doctor was fun, almost magical. I worked in five different hospitals during my residency. At one of these hospitals, we got to sit in the doctor’s lounge and eat in the doctor’s dining room. Food was available 24/7 and was delicious. In case you don’t know it, one of the biggest problems of the 36-hour call-day is trying to eat. I’m 5’11” inches tall. By the end of my residency I weighed 140 pounds.
The accommodation of residents was much less friendly at the main hospital I worked in. The kitchen was only open from 7:30 in the morning to 6:00 at night. If we couldn’t get somebody to bring food in for us, we would simply go without. Sometimes smoking had to take the place of eating.
Being sleep-deprived and hungry is much worse than being sleep deprived and full. At my main hospital I had to stand in line 15 or 20 minutes to pay for my food. I eventually learned to eat my meal as I stood in line. At least that way, by the time I reached the cashier before rushing on to my call, I at least got to eat the food I paid for.
In my first practice I was lucky. The nurses were great, I was busy, the doctors were supportive, and the hospital administrator was at that time pleasant and helpful. Like my residency hospital with a dining room with good food, this hospital in this town had a pleasant dining room and the food was great. Good enough that I took my kids there for Sunday breakfast.
When I arrived at my first practice, I was surprised to find the c-section rate to be about 15 percent. In residency I had had a 10 percent c-section rate. I considered a 15 percent c-section rate was too high. I wanted to decrease it to 10 percent. I studied how to bring the rate down and I was successful in decreasing the c-section rate at this hospital down to 10 percent. There were no problems with anybody. The insurance companies, Medicare or Medicaid didn’t tell me if I could or could not do procedures to avoid C-sections. Nobody had any complaints. I was simply allowed to do what I have been trained to do and the results were good.
After three years in my first practice, I moved to a larger town with five hospitals. Each hospital was slightly different. At one of the hospitals there was still a remnant of the grace that was once part of practicing medicine. At our monthly staff meeting in the hospital cafeteria, the tables had tablecloths, the lights were dimmed, and there were candles. The atmosphere was sublime. A chef prepared delicious food and wine was served. Business was completed in a very congenial manner.
This congenial meeting routine lasted for two or three years until a new hospital administrator decided to end them. This administrator had a PhD in something but it wasn’t in medicine. In truth, we would joke his degree came out of a cracker jack box. This CEO’s performance was so offensive, eventually three of the more senior doctors decided they had enough of him. They went to the hospital board and requested the CEO be removed. And he was. Today these three doctors would probably be fired, and the administrator would remain.
By 10 years later, the grace which had been so much a part medicine, a form of medical practice which benefited everybody, including most importantly the patients, was quickly disappearing to be replaced by bullies which hyjacked a physician’s ability to make medical decisions with their patients and instead told doctors what they could and could not do. Insurance companies, HMOs, pharmacy benefits managers, Medicaid, and Medicare. Clearly, medical decisions were no longer in the hands of physicians and their patients, the two most important elements in good healthcare. It’s common today to hear discussions about how to bring health care costs down. I wrote about this 30 years ago in Modern Medicine: What You’re Dying to Know. The shift in control of health care had just begun back then, but the players are still the same and the changes I wrote about then have come about in spades.
In the beginning, the bullies would manifest themselves in subtle ways. Years ago, when Coumadin was the only method we had to provide anticoagulation, we could keep the patients in the hospital until the blood values indicated therapeutic range, that is in between too much and too little. There is very little opportunity today to hospitalize a patient on Coumadin for control of anticoagulants when tests showed the medication produced results wildly out of control. Today there are replacements for Coumadin which do not require regulation, but in truth, these medications are very expensive. Some patients continue taking Coumadin even today to keep the costs of medication down.
Under the control of the bullies, physicians were no longer able to make decisions in the best interest of their patients. A friend of mine stated in a patient’s chart that the patient was sent home before he thought she was ready, but the insurance company wouldn’t authorize another day in the hospital. Insurance companies hire doctors to review patient claims. In this case, the paid insurance doc called out and criticized my friend for this comment in his patient’s chart and subsequently a letter was sent to the my friend’s hospital criticizing this chart entry. This letter went in my friends employment record, to follow him wherever he went. The physician’s responsibility is to do no harm to the patient, but insurance companies have no such restrictions on their actions. In other words, regardless of the physician’s opinion about what patients might need, the decisions of the insurance company denying care to patients will be blamed on the physician.
As Dr. Ferrago says in his book The Hospital Guide to Physician Retention, retaining existing physicians by treating them well is much cheaper than abusing physicians and replacing them when they leave.
What’s so difficult to understand about treating physicians and patients well?