Debt, stress, bureaucracy: The challenges of being a doctor in America

  1. Student debt is the leading cause of mental health difficulties for medical students
  2. Corporate influence on decisions traditionally made by doctors is a source of frustration for medical community
  3. Significant number of doctors regret their job choice

For an individual who falls sick or is injured, the most pressing concern isn’t the national cost of healthcare, or which president is blamed or given credit for the system. It’s the quality of the treatment they receive.

Doctors are some of the best-paid professionals in the United States, according to medical news outlet Medscape. It reported in 2017 that specialists earn $316,000 a year and primary care physicians (PCPs) earn $217,000, with the average being $294,000 per year.

But getting to this earning position comes only after years of school and training. And once there, doctors deal with workplace challenges that can affect the treatment a patient receives.

While physicians are well compensated in the United States, they face disproportionate levels of debt, bureaucracy, and career pressure that need to be addressed in order to lower the country’s enormous healthcare costs.

Expenses and debt

Medicine is hardly a fast track to wealth. First, there’s the daunting cost of medical education. Would-be doctors require a four-year undergraduate degree, four years in medical school, and three to seven years of residency training in order to become eligible for medical licensing (Houston Chronicle).

A medical student with no financial aid can end up paying more than $250,000 for those four medical-school years alone, according to the Association of American Medical Colleges. While most students will manage to pay off their debt, the pressure to do so is the number-one cause of mental health difficulties for medical students, which can affect their performance (U.S. National Institute of Health).

Once in the profession, a significant overhead cost is medical malpractice insurance, the price of which varies among states and specialties (National Association of Insurance Commissioners). Location is a key factor impacting costs. In California, a doctor may pay over $5,000 a year for insurance, whereas a surgeon in New York City may pay over $20,000 or even $100,000, according to insurance company Gallagher. In response to the cost of malpractice lawsuits, clinicians are known to indulge in defensive medicine, in which they intentionally overuse health services to reduce their liability risk, according to the same study. The effect of liability risk management on doctors, patients, and the cost of healthcare is one among many complex issues facing current efforts at healthcare reform.

Serving institutions over patients

A major shift in the healthcare industry over the past two decades is the increased number of doctors choosing to work at hospitals as opposed to being independent providers. A 2016 report by Medscape showed that roughly 80 percent of physicians today are employed by hospitals, with 20 percent of physicians reporting a self-run practice. (Study also found on the healthcare blog Lauth O’Neill.)

In hospitals, physicians are employees who may give up a substantial degree of professional autonomy. As employees, they face more institutional rules and regulations, feel increasing pressure to practice according to prescribed patterns, and labor under escalating productivity demands (The Atlantic). But by working for a hospital, doctors don’t need to worry about the business of running a medical practice or dealing with the administration behind insurance companies. They have more financial security and less risk. 

Self-employed doctors may have the freedom to focus on the patient, and what they think is best for the patient. But with that comes pressures of running a business, a plethora of government regulations, and not having other specialists on hand. Autonomy can come with the added stress of long hours, along with the complications of complying with terms and conditions imposed by insurance companies.

Dealing with insurance companies

Independent doctors’ bottom lines are diminished by the cost of hiring staff to deal with insurance companies. But that cost is not the main concern of those physicians and their patients. Under the “managed care” system, insurance companies can interfere with the quality of care a doctor is trying to deliver (U.S. News). In their drive to cut costs, insurers can limit coverage for certain treatments. This process requires a doctor to request approval from the patient’s insurance company before prescribing a specific medication or treatment. The treatment a doctor prescribes will be covered only if it’s approved by the insurance company.

This corporate influence on decisions traditionally made by doctors is a source of frustration and concern for many men and women practicing medicine in the United States.

The practice of step therapy, commonly known as “fail first,” is an example of insurance companies limiting what a physician can prescribe.

Step therapy requires patients to try a cheaper drug before the insurance company agrees to cover a more complex or expensive doctor-prescribed medication (Blue Cross Blue Shield). Only after the cheaper drug fails to improve the patient’s condition will the insurer cover the cost of the medication originally chosen by the doctor. 

Insurance companies can also refuse to cover certain medications altogether, claiming they are too expensive or ineffective. The Patient-Doctor Rights Project reported that one in four privately insured patients could be denied a prescribed drug.

Unhappiness

A significant number of doctors regret their job choice. A recent annual survey from Medscape/Web M.D. shows rising dissatisfaction among U.S. doctors. In an online questionnaire of 24,000 doctors representing 25 specialties, only 54 percent said they would choose medicine again as a career, down from 69 percent  in 2011.

Doctors are also troubled by the stress of uncertainty about what lies ahead for them in the ever-shifting healthcare system. According to the American Foundation for Suicide Prevention, physicians have higher rates of burnout, depressive symptoms, and suicide risk than the general population.

“Physicians and trainees can experience high degrees of mental health distress and are less likely than other members of the public to seek mental health treatment,” according to the report.

According to another Medscape survey, employed and self-employed doctors are almost equally satisfied. Those who moved from a hospital to a private practice, however, reported job satisfaction at a higher rate than those who make the inverse switch.

Consumed by politics

Given the politicization of healthcare that heated up with the Affordable Care Act (ACA) – and the previous replacement plans from President Donald J. Trump’s administration – doctors have become accustomed to being immersed in the national debate over what healthcare should look like.

The GOP Doctors Caucus is an example of how opinionated members of Congress are on the healthcare issue. The powerful group of conservative physicians has sought to overturn the ACA since it passed, and was involved in Trump’s attempts to repeal the Obama-era law (NPR).

Working outside of Congress, advocacy groups span the spectrum of the medical community. Among doctors in general, a majority of physicians are warming to the idea of moving away from private insurance. In a survey by Merritt Hawkins, a healthcare research group, 56 percent of doctors registered either strong support or were somewhat supportive of a single-payer plan, a system in which the government pays for medical services. Physicians for a National Health Program is a nonprofit research and education organization of roughly 20,000 physicians, medical students, and health professionals who support the national health insurance model.

Pending the adoption of a reformed system, some doctors are thinking about how best to deliver healthcare on their own. Two new models that have gained popularity are concierge medicine and direct primary care (DCP).

At the core of both the concierge and DPC models is a membership fee paid by the patient, or sometimes the patient’s employer. Concierge practices may bill the patient’s insurance company for covered services, while DPC practices usually rely solely on membership fees to cover costs. The intended advantage of both models is that patients receive greater individual attention and communication from their doctors, who are better able to focus on patient care with fewer worries about issues related to practice management. That results in greater autonomy for doctors.

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