Friday, June 20, 2008

Once Again, Doctor Discontent

Dr Sandeep Jauhar recently wrote in the New York Times, that doctors are getting fed up with the practice of medicine. (See Fed-up Doctors.)

Not because they don't love medicine, they do; but because it is increasingly hard to find the pleasure, the fervour and the contentment in the practice of modern day medicine.

Essentially many doctors feel that their professional autonomy in medical practice is slowly but surely eroding away--and they gradually lose their enthusiasm for idealistic and caring medical practice.

There simply are too many restrictions, too many obstacles, too much work and effort with too little returns whether professional, emotional or financial.

Denial of treatment options and irrational oversight from managed care organisations (MCOs) simply takes the joy out of practicing medicine for many.

Then, there's contending with progressive cuts from Medicare (latest 10.6% reduction) reimbursements which makes continuity of care difficult and frustrating. Some physicians are opting out of having to see Medicare patients.

Many private solo practitioners, generalist or specialists are also opting for office care only, finding that hospital rounds are too time-consuming and simply not worth their while.

Unproductive travel and parking, time lost in traffic, checking lab tests for a small handful of patients, and caps on professional fees, all make the prospect of care inefficient and unrewarding. Thus, many patients now lose the continued care of their primary physicians when they are admitted to a medical facility, where care is transferred increasingly to new unknown hospitalists who practice full-time inpatient care only. Some contend that medical care may be compromised due to this poorer coordination and breakdown in continuity of care.

But this is not all, there's always the background spectre of medical malpractice and its progressively rising liability premiums.

Many are fearful of medical errors and are deliberately medically defensive, to forestall just such possibilities--which create problems of their own--as many as 30% of hospitalisations are denied by managed care gatekeepers!

Then, there's that increasing number of internet-savvy and empowered patients who demand more and more, including and expecting unorthodox or unnecessary tests or medications--placing a lot of strain on professionalism and the doctor-patient encounter.

Thus, it is not surprising that doctor discontent is rising, with some physicians even contemplating giving up medical practice altogether. Is this phenomenon more widespread than just in the United States?

Undoubtedly, yes. In Malaysia, we are now facing more and more challenges from a finite number of increasingly influential MCOs. Some are now testing the waters on how to cut what is perceived to be excess fat from the system, as well as to maximise profits and returns for both employers, their shareholders/owners, and some entrepreneurs (who are jumping into the bandwagon strictly for the piece of the expanding pie of health care ringgit!)

Unfortunately, the brunt of their cost-limiting measures seems to fall squarely on physician fees, as these are the most clearly delineated. This, in spite of the implementation of the Private Healthcare Facilities and Services Regulation 2006, which clearly stipulates the fees applicable for various procedures and services.

One of the largest MCOs has been pressuring private hospital administrators that fees and costs are business affairs and therefore negotiable, except that these have been pushed down our throats with bullying threats of non-coverage or removal of privilege as healthcare provider!

Clearly dealing from such powers of corporate strength are intimidating and crass, as it places the patient at the bargaining table of trading for volume discounts. This devious compact, we have argued is similar if not identical to fee-splitting! It is good that the MMC and the MOH has decreed that this is indeed fee-splitting and therefore unethical, as it places profit (via volume discounts, thus splitting increased utilisation and higher turnovers for each) ahead of patients' rights and interests.

But this saga is likely to resurface, as these cash-rich corporations will doubtless use their considerable financial clout to influence politicians who may just scuttle our efforts thus far. We have to keep our fingers crossed that sanity and fairness will prevail.

It cannot be denied that most private doctors remain bitterly opposed to this affixing of the fee schedule into the Regulations which makes deviating from this schedule unlawful! Worse, once signed into the regulation, we are now at the mercy of the tardy bureaucrats and the MOH to amend these figures from time to time, as professional fees should justly move in tandem with inflationary trends.

In the context of our current fuel price hike, we can safely predict that inflation will skyrocket as well, making utilities bills, nursing and assistant wages, travel, car maintenance, rentals and other services much more costly!

Already the fifth schedule of fees are ready from the MMA, and we have now to pass this along to the MOH for inclusion into the Regulations as agreed to in the recent Memorandum Of Understanding with the Minister. The question then would be when these would be incorporated, implemented and signed into law.

But I would not want to go away with the thought that reimbursements and wages are all that endears doctors to the profession and the vocation of medicine.

Other issues which continue to plaque doctors include the growing encroachment of their space by community pharmacists, business-owned medical laboratories, who act and impersonate as medical practitioners dispensing without prescription all manners of medicines; checking BP, carrying out in situ blood and urine tests, as well!

Traditional and complementary health practitioners are also vying for their piece of action.

Housemanship training has been doubled and therefore compulsory service for medical graduates has been extended to 5 years. Training and specialty course availability are still bones of contention for many young aspirant doctors. To be fair, doctor remuneration in the public service has improved a great deal with promotional prospects much clearer and fairer--thanks to the far-sighted efforts of our current DG and the past Ministers. More is expected and perhaps more goodies will be given in due course.

Overcrowding of urban clinics are also severely crippling the once revered general practice. Close proximity to each other has turned practices into brutal competitive sometimes un-viable businesses. Many who have failed in their solo practices, are forced into permanent but shifting locum tenens positions, with no end in sight, literally eking out a living despite having raked up huge debts and loans.

Then, there's medical malpractice premiums and concerns, increasing patient complaints against disgruntlement with the doctor-patient experience, lack of informed consent, physician neglect or rudeness, unexpected untoward outcomes from treatment or surgeries, unsightly scars from lifesaving operations, etc....

Thus, is becoming a doctor nowadays worthwhile? Or are we all expected to remain altruistic angels of mercy, maintaining a stoic permanently smiling facial (perhaps vacant) expression, in a system where runaway problems continue to beset our practices?


Richard said...

Aha! I think I am qualified to make some comments about this topic having walked away from a fast-lane practice mid-stream and that too not too long ago!

About the kindest thing I have done for my brain has been the career change and reinvention process that I continue to undergo.

I have learned that life after medicine has to be entered at an age where it is temporally still possible to carve out a new career. The unlearning of thinking habits and the re-gaining of wider perspectives from outside of the privileges accorded by society to doctors has been refreshing, vital even.

My suggestion to jaded doctors - get out before you lose the mental energy to make the change! In the private practice context (as opposed to academic medicine) once one has 'peaked' there are not many track options apart from downhill or running on the spot, or in endless circles!



Dr D Quek said...

As usual Richard, you have hit the nail on the head! I agree with you that like all life cycles, we have to undergo constant renewal and finding new interests in our humdrum lives. so that more meaning and joy can permeate our "downhill" lives.

For my part I find uneconomic interests in societal affairs and fraternity issues still worthwhile contributing, if occasionally frustrating.

I am still a die-hard believer that we can still contribute ideas and opinions which can/may influence the greater good to emerge from a majority of people out there.

I paraphrase Robert Kennedy's quote on how small little currents criss-crossing from many diverse sites can merge to form a force of reckoning, is one living epigram that I adhere to, still...