6 Reasons Doctors Can't Get Their Act Together
Presented by Commons Clinic
Hospitals and health systems don't treat patients. Pharmaceutical companies don't prescribe medications. Device manufacturers don't perform operations. CMS is a payer, not a provider. Though all these are necessary components of our health care system, they aren't sufficient to make it run. Front-line health care workers are the engines that power the machine. And, for now, physicians sit atop the care delivery hierarchy. With a strong nod to allied health professionals — without whom we could not do our jobs — docs still run the show.
Despite our frustrations, criticisms, and critiques, physicians seem unable to shift the balance of power in our favor. Autonomy is rapidly declining (more docs employed than ever). Advocacy efforts increasingly fall on unsympathetic ears (another year of payment cuts). Legislation remains restrictive (CON laws, moratorium on POHs, Stark and anti-kickback laws). If so much of health care runs through us, why does the ability to make systemwide impact escape us?
Why can't we get our act together? The answer is complicated and multifactorial. This week's edition of The Surgeon's Record presented by Commons Clinic outlines the factors preventing physicians from affecting change and offers solutions to change the dynamic.
The Top Reasons Docs Can’t Get Their Act Together:
Infighting
Fragmentation
Ethics
Golden Handcuffs
Risk Aversion
Regulatory Barriers
Infighting
Doctors are constantly in competition with one another. We compete in college to get into medical school. We compete in medical school to get into residency. In residency, we compete to get prestigious fellowships. Coming out of fellowship, we compete for the best jobs. Within those jobs, we compete for patients, academic titles, research grants, OR time, and on, and on. Maybe it's selection bias, but we thrive on competition.
The downside is that constant competition leads to infighting. Doctors are doctors' harshest critics and worst enemies. In medicine, we have a term for this: "turf wars." One specialty pitted against another for limited resources and shrinking health care dollars. Tribalism begins once a specialty is selected and grows throughout training.
Infighting is exemplified by the RVS Update Committee (RUC), a multi-specialty committee of physicians tasked with assigning value to the work we do. The committee is regularly criticized for favoring surgical and procedural specialties over cognitive ones. Critics argue the RUC system incentivizes expensive and unnecessary procedures and devalues primary care and preventative services. The reality is that, while doctors haggle over the size of their slice, the pie continues to shrink for all. We have accepted the zero-sum game. While competition and disagreement are healthy, infighting limits our ability to present a unified voice and advocate for our profession as a whole.
Solution: A rising tide lifts all boats. Specialists should support higher payments and better resources for primary care. Primary care should support specialists’ transition to value-based contracts. And we should all reject the zero-sum game. The real turf war is external, not internal.
Fragmentation
A byproduct of infighting is fragmentation. There simply is no organization that represents the best interests of physicians as a collective group. What about the American Medical Association (AMA), you ask? In the 1950s, the AMA represented around 75% of doctors. By 2011, that number sagged to just 15%. The decline of the AMA is multifactorial and includes the organization’s support of the ACA and ties to healthcare industry. The AMA might still be viewed as doctors’ lobbying arm. However, it’s hard to argue it represents the interests of most physicians given low membership and frequent physician criticisms.
Most doctors are loyal to their specialty organizations and societies. Within specialties, there are subspecialty societies too. For instance, I'm a member of both the American Academy of Orthopaedic Surgeons and the American Association of Hip and Knee Surgeons. It probably wouldn't shock you to learn that these two organizations don't always see eye to eye on issues facing musculoskeletal care. We're fragmented even within specialties.
Practice models fragment us too. Opinions and goals vary among academic physicians, employed physicians, and private practice physicians. Interests aren't always aligned among these groups. The challenges facing rural, urban, and suburban doctors are often different. How do you get everyone on the same page when they're not even using the same playbook?
Solution: Some feel unionization is the only way to unite physicians. Interest in unions is growing as the number of employed doctors reaches record highs — although only 8% of physicians are currently union members. Strength in numbers through collective bargaining may help bring solidarity and drive change. But unionization — long taboo among doctors — has its downsides. Better collaboration among specialty societies and creating an AMA-alternative with broader support might be a better option.
Ethics
Although unionization is a powerful instrument capable of galvanizing physicians for a common cause, it raises significant ethical concerns. Should collective bargaining efforts break down, is it right for doctors to go on strike? Many would consider this a violation of the Hippocratic Oath. Medical ethics dictates that we put the needs of our patients first. Trust in physicians, while still high, is declining. Aggressive union tactics could do irreparable harm to the doctor-patient relationship and further erode public perception of physicians.
Dropping out of Medicare is another commonly cited mechanism by which physicians could fight back. Leaving Medicare frees doctors from administrative hassles, removes barriers to patient care, and allows for more cost-conscious, transparent care. Some feel continued reimbursement cuts have forced their hand. The movement to drop Medicare is small but growing — the number of opt-outs has more than doubled since 2009.
For years, physicians have warned that declining payments could threaten access to care. However, dropping out of Medicare could be seen as abandonment. Many patients can't afford to pay for care otherwise. The Medicare population is growing, and access is already a problem. One of my mentors in fellowship attempted to leave the Medicare program. Though he was a renowned surgeon, patients couldn't or wouldn't pay directly for his services. The guilt was tremendous, and he opted back in before the grace period ended.
Soultion: Physician unionization and Medicare opt-outs will continue to slowly gain traction. I doubt they'll ever become widespread. I'm leery of physicians relinquishing what's left of the moral high ground. "Primum non nocere" still resonates. We can do a better job allying with patients to make our message heard. We should lean into our ethics and role as the moral compass of medicine. Wielded responsibly, doing so is a powerful position.
Golden Handcuffs
"Live like a resident" is a common piece of advice given to early career physicians. For many, it's difficult advice to follow. After years of working 80-plus hour weeks, that first attending paycheck is validation of the sacrifice it takes to become a doctor. Who can blame physicians for wanting to enjoy the fruits of their extensive labors?
My first big attending paycheck purchase was a new bed and mattress. Throughout medical school, residency, and fellowship, I slept on the same used mattress and rickety frame. You could feel the springs, and the bed creaked and rattled with the slightest movement. (Of course, I was so exhausted most of the time it hardly mattered.) That pillowtop, box spring, and sturdy wooden frame was like a gift from heaven. Who knew sleeping could be so damn comfortable?
Educational debt, high salaries, and the desire to live the "doctor lifestyle" create golden handcuffs — tethering physicians to traditional medical machinery. It's hard to shock the system when biting the hand that feeds you has significant consequences. The deeper into the doctor lifestyle you go, the tighter the handcuffs become. Feeling financially trapped worsens burnout and reduces the willingness to take risks necessary to challenge the system.
Solution: Escaping golden handcuffs isn't easy. It's probably best never to put them on in the first place. However, that does mean eating ramen noodles seven nights a week or sleeping on a used mattress. For young doctors, setting financial goals and understanding wealth planning is essential. There are plenty of resources available (I'm partial to this book by Nick and Amanda Christian). For older docs, side gigs can supplement income during a transition period. It's never too late to devise a sensible financial plan. Calculated risk-taking is the key to removing golden handcuffs.
Risk Aversion
What qualifies as a "calculated risk?" Unfortunately, doctors are every bit as risk-averse as we are competitive. Again, this might be self-selection — risk reduction is innate in what we do. While minimizing risk in clinical situations is a positive trait, being overly cautious can be a detriment to driving systemic change. The boat needs rocking, and there may be some initial pain that comes with that.
It's incredibly difficult to extract oneself from the health care machinery without risking significant drop-off in patient volume, losing insurance contracts, being dropped from networks, and facing a painful reduction in take-home pay. You can end up on a very lonely island. But it is possible to push through the initial pain and be successful. Many direct primary care doctors have done so. A handful of specialty docs have too. (The Surgery Center of Oklahoma is a shining example here.)
Risk aversion also prevents us from embracing novel technologies and alternative care models. Anything perceived as a threat to workflows or the established way of doing things becomes a bridge too far. There's little incentive or desire to adopt voluntary value-based programs. Call it inertia or resistance to change but accepting "the way we've always done it" is one of the biggest reasons we can't get our act together.
Solution: Rip off the Band-Aid and take the pain. While it may seem scary at first, many have done it successfully. The more of us that do, the easier it gets. Finding forward-thinking partners can de-risk the transition and soften the landing. Not to get too meta, but what attracted me to Commons Clinic is that the company's model accomplishes this exact goal.
Regulatory Hurdles
If you have "regulatory capture" on your health care buzzword bingo card, congratulations. Let's review the many rules and regulations that limit physicians' ability to get their act together. In no particular order:
Stark Laws and anti-kickback statutes
Moratorium on physician-owned hospitals
Non-compete clauses
Certificate of need laws
Licensing and Maintenance of Certification requirements
And there's more regulation coming. As we covered before, laws like CAB 3129 meant to curb bad actors have unintended consequences that hamper innovation. Mandatory programs like MIPS and MACRA, and the continued shift to patient-reported outcomes measures create administrative burdens and drive up practice expenses. Many view joining a health system or becoming employed as the only means of survival.
There's growing frustration about the ineffectiveness of advocacy efforts among specialty societies. Doctors have traditionally been apolitical and loath to engage in lobbying. As discussed above, many don't feel the AMA represents their interests. There may be some regulatory help on the way. The FTC moved to ban noncompete clauses last spring — a move broadly celebrated in the health care community. In July, a bipartisan House bill was introduced that would peel back restrictions on physician-owned hospitals. As expected, such measures will be challenged by hospitals and health systems in court and through lobbying. It will be some time before the impact of such measures (if any) comes into focus.
Solution: As painful as it might be, we must get more involved in politics. Collaborating with others whose regulatory interests are aligned with ours creates strength in numbers. Free market health care advocates, employers getting crushed on health care costs, and venture capital or private equity firms backing innovation can be powerful allies.
The barriers preventing physicians from uniting to change health care are numerous and complex. However, they are not insurmountable. By addressing our internal divisions, equipping ourselves with the necessary skills and knowledge, and strategically engaging with the political and regulatory processes, we can begin to reclaim our role as leaders in health care reform.
The path forward requires commitment, collaboration, and courage. We must be willing to step outside our comfort zones, challenge long-held assumptions, and sometimes make short-term sacrifices for long-term gains. We have the knowledge, experience, and moral authority to drive meaningful change. Instead of waiting for others to determine the future of health care, we should unite, raise our collective voices, and take an active role in shaping the future.
The challenges are great, but so is our potential impact.
Ben Schwartz, MD, MBA
Editor-in-Chief, The Surgeon’s Record
Commons Clinic Senior Clinical Fellow
