Today's physicians are burned out and battered by spreadsheets. Patients are suffering too.
What’s Ailing Our Doctors?
When Viktoria Koskenoja was in college, she sat in the hospital at the bedside of her mother, who lay dying of leukemia, and studied for her medical school entrance exams. She was determined to one day speak the language of the doctors who swooped in and out of the room discussing the case. Later, in medical school and then in residency, Koskenoja found herself drawn to emergency medicine, with its unpredictability, its tapestry of characters and its imperative to establish immediate trust with the constant stream of brand-new patients coming through the door. She had found her calling.
Her first position out of residency was her dream job, working in a Level 2 trauma center at a hospital in rural Michigan, where she’d grown up. And at first, it truly was a dream. “Small community, really great group of physicians, really great group of nurses,” she recalls. “It just felt like we had everything that keeps the hospital running.”
But the facility had just been bought out by a private equity firm, and Dr. Koskenoja watched in real time as things began to change. “Cuts were made everywhere in every possible way,” she says. Cuts that seemed harmful to patients, the very people they were there to help.
This was just the start of what lay ahead for Dr. Koskenoja, and it’s what medical professionals across America deal with every day. To understand the challenges shaping health care today, Reader’s Digest interviewed several leading medical professionals, including David Sherer, MD, author of Hospital Survival Guide; Rebekah Bernard, MD, author of Patients at Risk; Sharon Ortega, MD, a pediatric emergency medicine specialist; and Mitchell Louis Judge Li, MD, a board-certified emergency physician. Their insights reveal the pressures and realities impacting health-care providers and their patients—and what you need to know before your next trip to the hospital.
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Change sets in
According to Dr. Koskenoja, doctors and nurses were let go or had their hours drastically reduced. “I’d walk into a room,” she recalls, “and see a patient with a blood pressure of 60/40,” which is dangerously low. Before the buyout, “the nurses would have been all over that,” she says. “But I would have to find a nurse, if I could, and try to get them to start fluids, or start them myself.”
When her ER pediatric patients needed to be admitted to the hospital, Dr. Koskenoja would request a bed upstairs, only to be routinely denied by administrators. Confused, she asked a pediatrician what was going on. Pediatric admissions don’t pay well, her colleague said, explaining that the hospital could bill the insurance company more for adults who have been admitted.
As a result, the children would often remain in the emergency room for up to four days at a time, she says. The same thing happened with elderly patients, many with dementia, who stayed even longer while awaiting a spot in a long-term-care facility. It was, she says, an untenable situation.
“We didn’t have a system designed for taking care of someone for monthlong stays in an emergency department where it’s just supposed to be for a few hours,” Dr. Koskenoja says.
She describes sleepless nights agonizing over the responsibility of trying to care for patients in what struck her as impossible conditions. Children and the elderly stuck in the ER risked missing treatments because the drastically cut nursing staff was now so overstretched.
The hospital denies ever basing patient admission decisions on cost or reimbursement, and says its staffing models fall well within industry standards. Any issues, the spokesperson told Reader’s Digest, must be viewed in light of the broad challenges facing the health-care industry.
Dr. Koskenoja and her medical colleagues pushed back, but they were largely ignored, she says. Demoralized and ashamed, she and many others quit.
“I still get emotional when I think about it,” she says. “Most of us went into medicine because we love taking good care of people. When you’re set up by a system to not be able to do that just so some MBA can have a bigger bonus, it makes you sick.”
A prescription for burnout
America’s doctors are in crisis. Six in 10 physicians say they’re burned out, with burnout rates for some specialties, such as primary care, reaching 70%. When polled by the American Medical Association, 40% of doctors said they were considering leaving their practices in the next two years. Another study, conducted by health-care-industry publisher Elsevier, revealed concerns about mental health and burnout: 63% of med students in the United States reported that they had no intention of practicing clinical medicine after graduation and will instead work as lab researchers or academics. This is despite a predicted shortage of 124,000 physicians over the next 10 years.
Perhaps most concerning, suicide rates among doctors are alarmingly high. Male doctors are nearly one and a half times more likely to commit suicide than the general population, while female doctors are more than twice as likely to take their own lives.
“Doctors are fewer, and they’re more stressed,” says Dr. Sherer. “And when you get that combination, you’re going to have more medical errors. You’re going to have more mistakes made. I mean, it’s just not a good time to be a patient in the United States.”
You may recall a time when you enjoyed a closer relationship with your doctors. They took their time, got to know you, answered the phone, stuck around. Today, many factors have made those things appear increasingly quaint.
Thanks to ever-more-powerful insurance companies, doctors spend precious hours jumping through hoops to obtain prior authorizations from insurers so they can order tests, procedures or medications. During an exam, their gaze is often more focused on a computer screen than the patient because a 2009 law requires that all medical charts be kept electronically.
Far from making things more efficient, says Dr. Bernard. The way the law was rolled out “just really felt slapped together.” So, paradoxically, “the paperwork workload went crazy.” And because of corporate takeovers in the medical field and their mandates to grow profits, doctors are spending less time with patients in order to squeeze in more appointments. The result is that the average primary care doctor now spends two hours on paperwork for every hour spent with patients.
The time crunch on doctors has gotten so bad that even physicians often can’t get each other’s attention to make referrals. “Five years ago,” says Dr. Sherer, “I used to be able to pick up a phone and within a few minutes, the doctor would be on the phone with me. Now, it’s phone jail. You can’t do it.”
While the drivers of dissatisfaction among doctors are many, the growing influence of corporations has done more to change the practice of medicine than anything else. Today, about three-quarters of U.S. physicians work for hospitals, health systems and other corporate entities (up from about 25% a decade before), often clashing with administrators over a host of issues that boil down to profits versus patient well-being. Money, many doctors say, has now so infected health care that doctors are losing control over decisions that impact care, to the detriment of patients.
The result for physicians, says Dr. Koskenoja, is known as “moral injury,” the psychological trauma of being forced to act in ways that violate one’s ethics. It is, she says, likely a major source of doctor burnout.
“Just sign the chart”
Dr. Ortega worked happily for more than a decade at a community-based hospital in a midwestern city. But when the facility was acquired by a large corporation, executives began pressuring the physician group that employed Dr. Ortega to make severe staffing cuts. At the same time, despite a lack of demand for higher-level services, the company upgraded its ERto a Level 1 trauma center—a head-scratching hospital decision that made sense to Dr. Ortega only when viewed through a purely financial lens. “When you have that additional trauma status,” she explains, “you can bill at a higher level, even if you’re not using all those resources.” Great for the corporation’s bottom line, terrible for the finances of the patients’ families.
“It was shortchanging the kids in the community,” Dr. Ortega says. After her group pushed back, the hospital’s new owners put out a request for proposals to contract with another group. The final straw for Dr. Ortega was when her group conceded to furlough its pediatricians who had worked at the hospital for more than a decade, replacing them with nurse practitioners, or NPs.
These nurses receive from 18 months to four years of training to perform more advanced health-care functions than registered nurses, or RNs. To become certified, NPs must complete at least 500 supervised clinical hours. That’s significant, but far from the required 12,000 to 16,000 clinical hours, four years of medical school and three to seven years of residency before a physician is able to practice unsupervised.
While NPs were initially conceived of as assistants to doctors, practicing only under supervision, recent years have seen a push toward more autonomous practice. But in some states, doctorsare often expected to sign off on NPs’ work despite having not examined the patients. That’s exactly what Dr. Ortega saw happening at her facility—pediatricians being replaced by NPs, and the remaining few doctors being pressured to certify their work sight unseen.
To be sure, NPs play an important role, especially in parts of the country where there is a shortage of doctors. And Dr. Ortega, whose parents are both nurses, has deep respect for the profession.
“I’m not opposed to a collaborative type of practice with nurse practitioners,” she says. But she chafes at “being told, ‘Oh, you just need to sign the chart. It doesn’t matter if you have time to see the patient.’ No. If I’m signing the charts and my name is legally tied to a patient, then I want to be able to see them.”
If the corporation plays its cards right, it still can charge patients just as much as if they’d seen a physician. “A nurse practitioner who sees a patient alone is reimbursed 85% of Medicare fees,” says Dr. Li, who is also the founder of an advocacy organization dedicated to taking the profession of medicine back from corporate interests. But if a physician signs off, he says, “they can charge 100%.”
Making NPs even more attractive: They earn roughly half a doctor’s salary, according to the U.S. Bureau of Labor Statistics.
The prospect of signing charts without seeing patients represented a legal liability to Dr. Ortega, but she was also concerned about patient safety and the ethical considerations. So she quit—without ever signing a chart for a patient she hadn’t seen. She now runs a private practice.
How did we get here?
More than half of U.S. hospitals today are structured as corporations—and others have been called nonprofit in name only—mostly with nonmedical executives calling the shots. And 56% belong to chains of three or more facilities. Health-care entities make attractive investment targets for companies, seeing as how an aging population and surging health-care costs provide a stable and substantial source of revenue.
Given the prevalence of the corporate-owned model, it can be surprising to learn that, in most states, only doctors who have sworn the Hippocratic oath can make decisions affecting care. That would seemingly rule out large conglomerates run by those without medical degrees. But these norms have become eroded. Exploiting legal loopholes, corporations have overwhelmingly reshaped the health-care landscape, says Dr. Li. A provision of 2010’s Affordable Care Act effectively banned physicians from owning hospitals, out of concern that doctors might have a conflict of interest, while waving through a new breed of corporate overseers.
Before, hospital administrators were traditionally motivated by community ties rather than the profit-driven demands of distant corporate owners, whose imperatives can result in the erosion of the medical decision-making power of independent physician groups.
Sometimes, corporations come in to a situation and shake things up for the better. Struggling health-care firms may seek out private-equity buyers because they need an injection of cash to keep the lights on or to introduce innovations and new technology. And sometimes, greater size makes for more bargaining power when it comes to pharmaceutical pricing and negotiations with insurance companies.
But of late, as health-care giants have become behemoths by consuming smaller competitors, the Federal Trade Commission has begun to express concern that such growth can breed anti-competitive behavior. Some conglomerates have “vertically integrated” patient care, with pharmacies, pharmacy benefit managers, insurance and related services all under one roof. Consider, for example, Optum, a subsidiary of the massive health-insurance company UnitedHealth Group. Optum operates health-care delivery, labs, pharmacy services and a bank offering health savings accounts—and is now the largest employer of physicians in the country. Or CVS, which delivers health care via its Minute Clinics, owns a pharmacy benefits manager, owns Aetna Insurance and recently acquired an in-home patient evaluation company called Signify. (Neither UnitedHealth Group nor CVS is run by physicians.)
Such corporate models can maximize profits—one company with its own doctors in its own clinics prescribing medications for patients on its own insurance, at prices negotiated with its own pharmacy benefit manager, to be picked up in its own pharmacies. Another key benefit: A company could now charge Medicare more for some procedures by using directly employed physicians rather than those working for independent, physician-owned groups.
Proponents of the corporate model say they’re making health care more convenient and efficient while safeguarding safety. Responding to a Senate committee inquiry, a spokesperson for Envision, a private equity–backed physician staffing group, wrote, “Our number-one priority is always the well-being of our clinicians and the patients they serve.” And the American Hospital Association says that in rural areas, where many independent hospitals have closed, “mergers and acquisitions have played a critical role in preserving access to care.”
That may well be, but a study by Harvard doctors, published in December 2023 in the Journal of the American Medical Association, found that when private equity companies buy out hospitals, the rate of harm to patients rises sharply, with falls increasing by 27% and dangerous infections by 38%—likely the result of “reductions in staffing after acquisition,” according to Zirui Song, MD, a co-author of the paper.
Another study by researchers at the Harvard Kennedy School of Government looked at the narrow question of how colonoscopy patients fared when hospitals integrated physician groups instead of working with independent doctors. The corporations imposed measures such as scaling back expensive anesthesiologists and increasing the number of patients treated per day. Maybe unsurprisingly, the number of post-procedure complications, such as gastrointestinal bleeding, increased significantly.
After being acquired by a for-profit company, Mission Hospital in Asheville, North Carolina, has become a poster child for the perils of the corporatization of health care. “Mission Hospital used to be where everyone would go if they wanted good care,” former psychiatric and cardiac nurse Nancy Jaquins told NBC News. But after the acquisition, the facility began attracting the wrong kind of attention. In a scathing report, the U.S. Department of Health and Human Services declared the health and safety of Mission’s patients as being in “immediate jeopardy.” Investigators cited a string of deficiencies in care, including the case of a 78-year-old woman who showed up at the ER with a leg fracture, abnormal heart rhythm and low oxygen, and was found dead in the hallway after languishing for four hours. A spokesperson for Mission’s corporate owner HCA Healthcare points out that the state has recommended that the “immediate jeopardy” status be lifted, and says the facility’s quality of care is confirmed by various ratings organizations despite “national challenges, like staffing shortages, that are affecting hospitals across the country.”
Taking medicine back
A movement is building among physicians to regain control of their profession. Dr. Li founded an organization called Take Medicine Back, whose goal is to reinstate the historical prohibition against the corporate practice of medicine. The fight is playing out in various ways and on numerous fronts across the country, supported by political allies on both sides of the aisle.
In her state, Dr. Ortega successfully pushed for legislation requiring all emergency departments to keep a physician on staff at all times. She was motivated after reading about a 19-year-old college athlete named Alexus Ochoa-Dockins, who visited an ER where no doctor was on duty and who later died from a misdiagnosed pulmonary embolism. Other states are considering similar legislation.
In Arizona, at the state House level, physician turned politician Amish Shah, MD, successfully sponsored bills addressing the hassle of prior authorization and corporate retaliation against whistleblowers, both of which became law. As a candidate for the U.S. House of Representatives, he has his sights set on similar accomplishments in Washington.
Late last year, Sens. Chuck Grassley (R-IA) and Sheldon Whitehouse (D-RI) opened a Senate Budget Committee investigation into the private equity ownership of hospitals. A similar inquiry was launched this past April by the Homeland Security and Governmental Affairs Committee.
And in Oregon this March, a bill that would have closed the loopholes allowing corporate control over health care in the state died in the Senate Rules Committee after resoundingly passing in the House. The bill’s sponsor says he will reintroduce it next year. If passed, it may serve as model legislation for other states.
The goal of all these actions is to reduce the influence of the profit motive so that more health-care settings operate the way they used to. It’s a proven model, as evidenced by the success of the non-corporatized facilities and physician-owned practices that still exist. “There are places where you can practice and still feel like you’re able to deliver great care,” says Dr. Shah.
Dr. Koskenoja, whose story ends happily, is living proof. Unlike many of her colleagues who have left the field, she found work in a county hospital that she loves. “It’s run by the community,” she says. “So the people running it, it’s their neighbors that they’re taking care of. It’s not people making decisions in some fancy business suite states away who don’t really care.”
She agrees with Dr. Shah that good jobs for doctors still exist. “But,” she says, “a lot of us are worried that those jobs are going to get fewer and fewer.”
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Sources:
- Viktoria Koskenoja, MD, board-certified emergency medicine physician
- David Sherer, MD, author of Hospital Survival Guide
- Rebekah Bernard, MD, author of Patients at Risk
- Sharon Ortega, MD, pediatric emergency medicine physician
- Mitchell Louis Judge Li, MD, board-certified emergency physician and founder of Take Medicine Back
- Chief Healthcare Executive: “Doctors aren’t the only ones battling burnout. Many medical students are hurting.”
- AMA: “40% of doctors eye exits. What can organizations do to keep them?”
- Elsevier: “Majority of medical and nursing students planning careers outside patient care, as fears of burnout and clinician shortages leave them worried about the future”
- National Library of Medicine: “Physician Suicide: A Call to Action”
- Physicians Advocacy Institute: “PAI-Avalere Report on Physician Employment Trends and Acquisitions of Medical Practices: 2019–2023”
- U.S. Bureau of Labor Statistics: “Physicians and Surgeons”
- Journal of the American Medical Association: “Changes in Hospital Adverse Events and Patient Outcomes Associated With Private Equity Acquisition”
- NBC News: “Some workers at U.S. hospital giant HCA say it puts profits above patient care”
Originally Published in Reader's Digest
