You May Be Right (We May Be Crazy)

A humanities friend of mine asked a question in response to the last post: if the intern workload produces bad incentives and potentially suboptimal care, not to mention emotional burnout/family trauma/car accidents[1]/general crabbiness, why the heck do we do it? There are certainly plenty of people who want to be doctors, not to mention the number of nurses/physician assistants/other providers who'd love to extend their scope of practice. Why would we set this up so that so much burden falls on the most junior (i.e., least competent) doctor? Are we, in fact, just nuts?

This is a question I work on quite a bit in my organized medicine activities. The answer is tricky. There is some of the problem that's good old-fashioned "I did it, I suffered, now it's your turn" mentality. But, there's also good economic reasons for it, and that's really what keeps it going (in my opinion, anyway). The economics from the hospital's side are simple. The median salary for a nurse practitioner in Seattle (if you believe salary.com) is about $90,000. My pay, as conveniently advertised on the web, is half that. I don't have a union, I don't have to be paid overtime when I work beyond 40 hours, and in general, I do perhaps 1.5 times the work (as measured by hours; productivity would be less) of a free-market NP for half the cost. If I save the hospital perhaps $50K a year, and there's at least 400 residents in the hospital, that's $20 million a year. That's not even counting the extra revenue that the surgical residents can generate because of the extra volume in high-reimbursement procedures.

It isn't just one-way exploitation, though. In theory, it's also designed to benefit me. Between the cap on the number of residents Medicare will pay for, and the general tight-fistedness of the accrediting bodies, the residency system acts as a choke on the physician supply. As you'd guess if we're working almost 80 hours per week, the supply is controlled to a level substantially less than demand, and has been for decades. Econ 101 tells us that high demand and low supply equals an increase in the price of the good. Or, in other words: the residency system creates an artificial scarcity of doctors in almost every specialty, leading to recruitment battles and higher physician salaries [2]. One of the major reasons everybody tolerates this system is that (again, in theory), in exchange for getting hosed while you're a resident, you thereafter get to be permanently employed with a salary in the top 3rd to 5th percentile. It also lets you feel a bit prestigious -- sure, you work hard and maybe it messes up the patients, but think about how much better you are than all the people who applied for your job but didn't make the cut!

The interesting thing is that aside from the twin profit motives above, there's a very anti-profit motive that also props up the system. Somewhere along the way, we acquired the notion that excellence in doctoring is comprised mainly of working harder. In general, many physicians' solutions to the problems facing health care as a whole, or individual patients, is simply to throw more of their own person-hours into the furnace. We're quite proud of it, too. We'll regularly boast about how many extra hours we put in to get the job done for that one particular patient. Whoever self-inflicts the most suffering is somehow ennobled. It's hard for me to say where this mindset comes from; as you can guess from my tone, I don't think it's quite right. You can't build a sustainable health care system on the notion of individual heroism. Yes, it's nice to know you've got the doctor who'll go the extra mile -- but do you still want him when, as almost inevitably happens, he burns out and loses the ability to care altogether? More importantly, who among us hasn't been told approximately a trillion times to "work smarter, not harder"?

And that, in the nutshell, is the real reason why a system persists even though it probably doesn't do anyone (except maybe the hospital management) much good. We could design something better, but to do so goes against the #1 survival skill taught during training: keeping your head down, working harder, and just plowing through. Furthermore, everyone's so focused on the short-term gain they expect to get out of the system that they ignore the broader interest. Unless physicians of all stripes get together and make the teaching system more sensible for doctors and patients alike, we're going to be so busy with nobly working harder that we won't notice while all those traditional prerogatives of the profession (prestige, money, the "right" to be "in charge", even being the only person on the team who's called "Doctor") get carved up and carried away by the many other players in the modern health care enterprise.

We willingly and perhaps even knowingly perpetuate a system that messes up our future colleagues, sets us up for economic problems in coming decades, and doesn't do any better by the patients. We are, in fact, nuts, or at least just really dumb. Unfortunately for me and many others, this turns out to be yet another one of those diseases I can't fix -- at least, not yet.

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[1] All of the above are, in fact, documented in the peer-reviewed literature. Yes, car crashes. It's in the New England Journal of Medicine. Brings new meaning to "work yourself to death", no?

[2] Econ 102 goes on to explain that supply-demand curves are ironclad unless a substitute good is available at a lower price. And that NP may be expensive at $90K... but he/she is a lot better than the median psychiatrist salary of $200K. (It's about the same for a hospitalist in general medicine.) So in fact, a rationally-acting hospital or health insurer will not pay physicians what they expect, but will instead substitute cheaper products when possible. The storm coming from that particular collision in expectations is another entry unto itself.