Dear Bryan,

Thank you for this post and for staying with this topic. I agree with you 100%. I see very little enthusiasm among those I work with daily. In fact, Enthusiasm is on my to-do list for 2024. Both personal and professional. I have no idea what that will look like yet, but it’s a place to start.

I have managed to stay in the game by reducing work hours to 28 hours a week.

I can’t tell you how many physicians in and around my generation (50-60 yo) have left or seriously cut back on their work hours. Unbelievable amounts of experience and knowledge are now permanently lost to the system.

Even with that, I struggle to keep up with my non-face-to-face work. So do ALL of my colleagues. Leadership signals we are the “problem,” and the proposed solution is “Just Do It.” It’s not working. It’s a slow, passive-aggressive stalemate for everyone.

I feel hesitant about unions, but those seem to be taking hold, and I do see that as a positive sign that there is energy and appetite for change.

One fundamental problem is that payments are unfairly low and unequal.

It drives a bunch of what providers and patients suffer from. The answer has been volume, but that has long maxed out. Quality has been the new buzzword, but that’s not easy to measure or control, and providers are ultimately not recognized or paid for those efforts. It has transformed into an administrative and soul-killing exercise.

I wish I could say something positive. However, I do believe we are approaching a tipping point and the speed of that is increasing as it’s inversely proportional to falling satisfaction and ITL.

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All great points, and thank you for taking the time to break them down that way. I'll pick up on two things. The argument for unions has been raised with 'we need just some kind of change.' I feel it's a desperate move and one that will not give us what we need on the other side. The other issue is pay. Despite the disrespect of third party reimbursement, my experience in hiring a bunch of folks from toxic environments is that pay is not a primary driver of all this. While we all recognize that fair compensation is important, I think it's overstated. Maybe that's not where you were going with your point. But thanks for chiming in.

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I agree with those thoughts. Unions are not ideal. They do however indicate a shift to action to bring about change.

As far as pay: my personal solution to continue practicing was taking a part-time salaried position. It removed that constant background of RVU calculus and freedom from “overhead”. (I had my own practice x 15 years then a multispecialty independent group).

Instead of pay I should have said “reimbursement”. When payment denials are systemtized and prior auths are a part of “normal” daily business (among other things) it erodes operating in “good faith”.

Perhaps I sound naive. The other side to this is seeing how this impacts our patients and their care (or lack thereof).

Doctors are hard workers and its not the work that I think bothers us but the the feeling that a large part of our effort is directed to executing and overcoming these aspects that have exponentially increased over the course of my career. It's become about a whole different kind of “work”.

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I am a 41 year old physician, taking a leave of absence starting in April, pretty good odds I don't come back. Every time I see a doctor in their 50s or 60s I wonder what they're still doing here (when I'm feeling extra judgy I wonder if they had a bad divorce settlement). On the other hand, I can't imagine what will be lost, particularly at teaching hospitals if there's no one left over 40 to teach someone the art of medicine.

I think what I want to do when I leave is focus on healing the healers, but I'm still dreaming into whatthat looks like.

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I’m not a physician, but an elder patient with a few doctors helping best as they can. When I visit them, I often feel somewhat bad for them. Considering, all “the hard work, commitment, cost and time to be who they are and responsibility, liability etc. And, then to be ultimately directed by lawyers, insurance industry protocols, management types etc, and professional health alliance driven by politicians & bureaucrats, I’m also “concerned and ask the question, “am I receiving from my doctor his best advice”? I want to ask questions, “have I used up my allotted time”….am I too challenging…….is there, in all of the above, an unstated directive that limits, by cost involved and my age, the treatment I am receiving etc? “And” then there is the “system”……….. I never know what the true cost is, I never know what I am really paying, I never know “who is billing me” etc and I never know what I am paying for. And, and……………the nickel & dime stuff………..and the hours on the phone waiting for someone to talk to after pressing buttons and……….then wondering if you will still be alive by the time you receive a treatment or test or what ever.

Greed is the root cause, not by the medically trained pros, but by every other entity connected and leaching off those who have paid the price of hard work and commitment and of the AKA the customer/patient………..date of birth. Thank you Hillary, Obama, Joe etc

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Thank you for drawing attention to this. I'm an Emergency Physician, I was actually surprised to see that we were below the mean because burnout is so high in the ED, especially now. On the other hand, we don't have to deal directly with insurance companies so that helps. I really thought COVID made the problems we have been talking about for years so clear that we would have to actually address them, but both at the institutional level and the national level the response seems to be, "well that sucked, let's pretend it never happened."

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Thanks for your insights, Bryan,

The trend of physicians' disillusionment seems to spread like wildfire in various health services. What JAMA study shows is in same respect prevalent in UK and EU countries. I like that you give some framework ("Superfacta") to work on to counteract this trend. The next step how to sell it to decisionmakers and politicians.

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Wiktor -- I suspect that administrative leaders will need to recognize what needs to be done or deal with the dire consequences. And thank you for bringing up with UK/EU. I tend to be U.S. centric with my lens, but the UK for sure is a great example of what happens when safety and agency are not prioritized. Thanks for your thoughtful comment.

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I'm not a physician, but I am a family practice PA-C with over 20 years experience working primarily in private practice. This article struck a cord with me as well. I have no enthusiasm for the job anymore. The biggest issues for me are the take over of medicine by insurance companies and the rise of distrust in the medical profession from patients. Like Kim Lucas said below "It has transformed into an administrative and soul-killing exercise." My niece wants to become a PA-C and it is difficult to encourage her knowing how many colleagues are burnt out and frustrated with the state of medicine. I'm not certain how to change the system either, but all of us- physicians, PAs, NPs, nurses, and everyone involved in patient care need to do something together and advocate for ourselves.

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Julie - This is interesting because I always see our APPs as below the fray. But maybe I'm wrong. I need to give them equal attention in this struggle. One difference is expectations; they come in to the profession knowing they will be employees without tremendous independence. And so it's all easier to tolerate. Kim Lucas and myself, however, came in to our work way back when with the understanding that we would shape our own destiny on some level. But to your point, APPs feel this pressure as well. TY for commenting.

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I can tell you as an independent for the last 25 years.

Reasons for the disgust!

Hospital administrators, corporation, tyrant colleagues that try to get ahead by pressing others (not me, but have witnessed, learned to navigate). These are usually the incompetent doctors who ca not operate (in the case of surgeons) or have so many skeletons, that they ally with admin to protect their hide. Ridiculous medical board that allows anonymous vicious complaints without consequence, red tape, poor pay, unrealistic expectations, long hours and a the end there is only one person responsible for your own retirement, you!!

Just to name a few of the issues on the hospital side.

On the insurance side, impossible to do the right thing without being stopped, even though one is credentialed and board certified. Constant precept requirement, denial of clear claims for a small issue that is not even important, like a code that recently change, then denieal because even though you were disputing it, more than 90 days elapsed and you have to remind them now. Int eh mean time they are still not paying, and then you resubmit and they tell you, that you need to resubmit as new to tell you the error is still there or a new euro. etc. Blue cross owes me over 80k with this game.

So! , not something that the Ivory tower showed to some or ever looks to resolve as it is more important to gather the funds to continue growing the empire and the massive bureaucracy to enrich the few and submit the rest that allowed to happen.

I'll be expanding on this topic as I retire with gross details of negliges exposure I have witnessed and documented for a long time. I came to a profession with illusion and desire to help. Still do and still am here for that. IT is not what is rewarded anymore. Hope this help enlighten this topic. As Kim said I reduced my hours and minimize any involvement with hospital or ER. There is more to this but I would be writing. book here. My professional was a calling. true calling at the age of 10 with no docs in family. to be a surgeon to relieve people from suffering. I am partially disgusted with the way this has turned out.

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