I left primary care this month. As difficult as this decision was, I’m confident it was the right one. A cursory glance at emails from the medical world these past few weeks confirms the dire situation facing healthcare in our country: The Entire Healthcare System is on the Brink of Breakdown, New Numbers Portend a Severe Physician Shortage, Turned Away by Rural EDs, What’s Mild about Hospitals at the Breaking Point?
I’ve been writing about problems in our healthcare system for several years now. Like anyone paying attention, my concerns intensified when the pandemic forced its shortcomings to the forefront. Still, it seems like those with the authority to make desperately needed changes aren’t responding with the urgency the situation demands. I hope with all my heart that I don’t have to watch it fall apart.
I’m not alone in escaping. According to a survey by Medscape released in October, one in five physicians considered leaving clinical medicine. And it’s not just physicians leaving. The global data intelligence company Morning Consult also reported in October that one in five healthcare staff has already quit. Another 12% were laid off. Of those remaining, more than a third have considered changing jobs with the majority of these contemplating leaving healthcare altogether. Four out of five healthcare providers still working report being personally impacted by the shortage of medical professionals.
Nurses, in particular, are feeling the repercussions. I worked as a school doctor for many years. In the past year or so, I witnessed weary school nurses struggling to meet increased responsibilities with decreased resources. Formerly, these compassionate caregivers provided medical aid and comfort to the children they served. During the pandemic, school nurses unwittingly became gatekeepers against covid, monitoring students for symptoms and tracking down potential exposures in a valiant effort to keep students safe. They were bombarded with demands by the Department of Health, by their administration, and by frightened teachers seeking advice and reassurance. Despite valiant efforts, they fielded calls daily from angry, sometimes abusive parents.
I watched as nurses working in primary care triaged frustrated patients, guiding them about how to get tested and where to go for treatment. I saw frazzled nurses in Assisted Living trying to comfort confused elderly patients suddenly confined to their rooms. The situation may be even worse for nurses working in the hospital. Despite bonus incentives doubling or even tripling hourly pay, many choose not to work the extra shifts because of sheer exhaustion. Those who do (or who regularly cover extra patients because of chronic understaffing) know how unsafe this can be for patients (and for their own health). A member of my own family is a hospital nurse. She works masked, gowned, shielded, and gloved for hours on end. When she finally contracted covid, quarantining away from her job seemed almost a relief rather than a burden.
The intensity of stress and low morale has serious ramifications not only for patients but for their caregivers. A recent survey from the University of Maryland’s School of Nursing revealed prescription drug misuse among nurses to be nearly double that of the general population. The rise in substance use is likely directly related to staffing shortages combined with increased patient needs, both impacting a nurse’s ability to provide safe care. Clearly, an overworked nursing pool (with nearly 10% admitting to substance misuse) can have potentially devastating consequences to patient care.
We’ve known for years now about shortages in primary care. Population growth and aging will further strain demand. Physicians, too, are aging. According to the Annual Report on Physician Supply and Demand by the Association of American Medical Colleges, two out of five working physicians will turn 65 or older in the next 10 years. Burnout and other pandemic effects will likely entice aging doctors to retire even sooner, further diminishing the supply. Young doctors are choosing to specialize rather than join unhappy mentors. With working doctors leaving, older doctors retiring, and newer doctors steering away from primary care at a time of heightened demand, we may truly be on the “brink of breakdown.”
The impact isn’t just endured by healthcare workers, though. Many Americans felt the results of the shortage even before the pandemic. They felt it when they were sick and called for an appointment with their doctor but were directed to urgent care because there were no openings. They felt it when they relocated and couldn’t find a single doctor taking new patients. During the pandemic, they experienced the shortage firsthand as they waited for hours on end in the emergency room for a few minutes with a harried doctor who seemed dismissive of their legitimate health problems because they didn’t require oxygen. My sympathies are torn between sick people seeking help and the worn-out providers struggling to provide it. Last week my own father, who developed a serious leg infection that probably warranted hospital admission for IV antibiotics, was sent home with pills after a cursory evaluation. I can’t imagine how many others needing care were turned away because there was not enough staff to care for them much less room to keep them. I’m grateful that at least my father has my mother, a retired nurse, to monitor his infection.
While many who’ve left feel guilt over abandoning struggling colleagues (I know I do), I wonder whether this is what it will take to finally prompt an overhaul of our healthcare system. In a recent interview, Dr. Craig Spence of Columbia University Medical Center spoke of the staffing shortages, hospital morale, and systemic problems facing the healthcare industry. He explained how, as a business, medicine focused on the bottom line – often at the expense of providers (and, I would add, patients). We entered the current crisis already overburdened. As healthcare providers left (or were sick or laid off), hospitals became even more short-staffed. Spencer argued that we can’t continue to rely on overworked and overstretched providers, but instead “need to make the policy choices to turn healthcare into healthcare first and a business second, if at all.”
In an article in JAMA last June titled Humanism Before Heroism in Medicine, the authors proposed that labeling doctors as “heroes” may have unintended negative consequences. They explained how heroic narratives undermine the transformation desperately needed in the system. To illustrate this, they focused on three heroic traits that healthcare providers embody. Individual skill, long-rewarded in medical training, runs counter to the team-based approach shown to improve quality. Willingness to sacrifice, or go above and beyond professional obligations, is another trait admired in medicinal professionals. But, they reason, if doctors are willing to make personal sacrifices to overcome the shortcomings of a dysfunctional system, leaders are less likely to fix them. Stoicism in facing physical and emotional hardships, also common in healthcare, results in providers not recognizing their own needs. Doctors are not machines. Concealing vulnerabilities risks emotional exhaustion, burnout, and even suicide.
The National Academy of Medicine Report on Physician Well-Being recommends reframing the culture with an emphasis on humanism. The authors of the JAMA article concur:
Rather than envisioning medicine as a province of brilliant individuals saving lives without a thought for their personal regard, the aim should be to achieve a culture of teamwork that acknowledges the human needs—both physical and emotional—of clinicians and does not ask them to sacrifice their well-being on a routine basis.
Heroism has its place in medical emergencies, as demonstrated by the pandemic. However, to give health care providers the capacity to respond in these rare circumstances, broader support and systemic changes are needed – celebrating teamwork and embracing humanity in the workforce. The authors concluded, “These approaches could transform health and healthcare and would enable capable professionals to have the fortitude and resilience to respond heroically in an emergency, because they would not have to do so every day.”
Clearly, systemic changes are necessary in our healthcare system, but what about changes in how we care for patients? Chronic diseases are killing Americans. Some argue that they’re responsible for America’s high mortality from covid, as it infected an already-sick population. According to an article written before the current crisis in The International Journal of Environmental Research and Public Health (An Empirical Study of Chronic Diseases in the United States: A Visual Analytics Approach to Public Health), chronic diseases cause seven out of 10 deaths in the US – 70%! Even more heartbreaking, most of these conditions are preventable. The World Health Organization reports that at least 80% of heart disease, stroke, and type 2 diabetes and over 40% of cancer could be prevented.
The above study concluded that “The road from sickness to wellness requires integrated efforts from physicians and patients—physicians can coach and guide the patients but the ultimate cross-over to wellness lies in the patients’ hands.” People with chronic diseases aren’t to blame for their illness, though. The positive effects of individual responsibility can only be fully realized when there is equitable access to healthcare and when healthy choices are supported by a range of providers dedicated to wellness.
Switching the focus of modern medicine from chronic disease management to prevention, will not only improve the well-being of patients, but also the doctors who serve them. Chronic diseases don’t usually cause sudden death, but rather make people progressively more ill and debilitated over time. Doctors working in a supportive system, with the renewed purpose of preventing health deterioration and suffering in their patients, will find more gratification in their work and therefore will be less likely to run away from their calling. Lucky patients of these reinvigorated doctors will reap the rewards.
In my new role working in an integrative medicine model, the people I provide care for will benefit from the expertise of nutritionists and physical science experts, as well as a mental and spiritual health team. This is what preventative medicine does and (for me at least) is much more satisfying than adding yet another drug to the growing pile needed to treat chronic disease.
Holistic healthcare – attending to mind, body, and spirit – is the pro-active approach America needs to prevent and control chronic disease. Unfortunately, preventative medicine is not prioritized in our for-profit system (where bariatric surgery is more likely to be covered by insurance than a consult with a nutritionist). Sadly, I had to leave primary care to be able to practice medicine this way. Despite saving money (as more than 75% of healthcare costs come from treating chronic diseases), preventative care is still a luxury of the privileged. It’s well past time that we embraced this model of health for all patients. It truly must become the future of medicine if we are to save both Americans and their healthcare system.
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