Why are physicians so angry? (Physician Anger).

ONE CAN HARDLY GO TO a party or a board meeting these days without encountering physicians who are discouraged and cynical about the practice of medicine. Why are they angry? How widespread is this anger? What is the relationship of physician discontent to the political gridlock in Washington that makes significant changes to the health care system unlikely in the next five years? Is there a relationship between physician anger and larger trends that are affecting all of us as we enter the 21st Century? These are questions worth exploring, because the health care system and patients cannot afford to have physicians who are not totally dedicated to their important work.

A New England Journal of Medicine editorial entitled "Doctor Discontent" generated an unusually large number of letters to the editor in early 1999. (1) David C. Squillacote, MD, of Fort Lauderdale, Florida wrote: "I believe you understate the situation a bit in your editorial. Words such as 'unhappy,' 'dismayed,' and 'frustrated' could easily have been replaced with 'angry,' 'dispirited,' and 'hostile.' Many of us feel we were sold a bill of goods." (2) Richard A. Kendrick, MD, of Modesto, California shares with journal readers that he will retire at 51 because "It is just no fun being a doctor anymore." (3) A physician's wife also wrote in to complain that my spouse's judgment...(is) constantly questioned by nameless and faceless corporate minions armed with rule books." (4) These letters from all parts of the country give a flavor of the passion felt by physicians, but they do not really get at the source of the discontent.

Survey results also give a sense of the magnitude, but not the cause, of the problem. An often quoted Michigan survey by A. Levin of nearly 30,000 physicians in 22 cities revealed that 46 percent often think about leaving clinical practice and that nearly 70 percent are against managed care. (5) A 1999 report of a national telephone survey found that negative views of managed care are widespread among medical students, residents, faculty members, and medical school deans. (6) Feldman and Gracely's survey of about 1,000 Pennsylvania primary care physicians demonstrated that respondents believe managed care has made them less able to avoid conflicts of interest and place patient concerns first. (7) Robert B. Klint, MD, writing in The Physician Executive, regards managed care as "an icon for health care change" and the most commonly cited 'cause for the physician's lament." (8)

A number of surprising developments also support the conclusion that physician discontent is widespread and growing. Disability claims from physicians seeking to receive benefits have increased to the extent that some insurance companies are leaving this sector of the business entirely, and an article on this subject even questioned whether doctors have lost their work ethic. (9)

Physicians are going to court to try to circumvent labor and antitrust laws that restrict them from organizing as unions. Efforts to join unions that at first examination do not seem to have much in common with physicians (United Food and Commercial Workers, the American Federation of State, County, and Municipal Employees, and the International Association of Machinists and Aerospace Workers) have been reported in different parts of the country. Responding to a mandate from the rank and file membership, the American Medical Association founded PRN a year ago, a physician union that is attempting to expand the influence of physicians without resorting to strikes. Executive MBA programs targeted at physicians who want to leave clinical practice are growing at a rapid rate, and reports of physicians moonlighting by starting home businesses to sell vitamins, herbs, and cosmetics have been published. (1)

Attempts to understand why physicians are so upset have been limited. The Physician Executive last year devoted a special issue to "The Dance of Anger: Helping Physicians Cope with Change." The common themes from the collection of articles included loss of professional control, frustration with managed care, loss of income, financial incentives that conflict with professional core values, and loss of status and prestige.

Daugird and Spencer's article on this subject, published in The Archives of Family Practice, applied the Kubler-Ross grief model to examine the 11 kinds of losses that physicians are experiencing. They identified losses in financial security, status and prestige, independent clinical decision-making, independent clinical resource allocation, the option of small group independent practice, power in hospital governance, freedom of choice in practice location, freedom of choice of specialty, physician collegiality, physician patient relationship, and autonomy. (10)

Pros and cons of managed care

Many physicians identify managed care as the source of all their complaints, and the public also has voiced concerns about restricted provider panels and the possibility of inappropriate rationing of medical care. Managed care first gained prominence during the Nixon administration as a way to control health care costs so that American business would be more competitive in an increasingly global economy.

Health care economists have long pointed out that the United States, when compared to other industrialized nations, spends more of its gross domestic product on health care. They also state that this extra expense does not translate into better outcome measurements, like lower infant mortality and higher life expectancy rates. And managed care has been successful in cutting the GNP percent of health care spending from a projected 15.7 percent to 13.5 percent. This 2.2 percent gap translates into $154 billion that American businesses did not have to spend on employee health care benefits.

Physician opponents to managed care like to point out that the outcome measurements may be flawed, that we should spend more than other countries on health care, that core values of patient-doctor relationships are being violated for business reasons, that the savings associated with managed care are one-time-only benefits that are not sustainable, that managed care does not allow for rapid introduction of new medical technology, and that patients and physicians will not put up with it much longer.

Without addressing the merits of the arguments on both sides, it is important to recognize that, since World War II, health care benefits have been largely controlled by employers who use them as a way to attract workers. Employers have more say about what kinds of health care insurance are offered than patients or providers.

Two conflicting values

Predicting the future of health care is a hazardous business, but almost all writing on this subject does not see the demise of managed care any time soon. Thomas Bodenheimer wrote in the New England Journal of Medicine "The necessity for physicians to practice in an environment of fixed budgets is unlikely to change. The conflict between the potential of medical science and the reality of limited dollars is permanent." (11)

Thomas J. Ruane, MD, of Detroit, Michigan links physician discontent to society's inability to deal with the economic realities of medical care:

"Perhaps we physicians are in a state of denial as we suffer from this discontent. Like the patient with a worrisome symptom, we seek relief while avoiding the diagnostic process that might reveal an ever less welcome underlying disease. Until physicians and organized medicine are willing to participate fully in the discussion about necessary and appropriate constraints on health care costs, this discontent can only remain a nagging and worrisome symptom." (12)

Except for a few brave voices like former Colorado Governor Lamm, who has talked openly about how medical rationing does occur in fee-for-service and managed care, Americans want lower health costs when the issue is tax increases and all possible care and interventions when they are talking to their physicians about their health problems. Physician discontent appears to be inextricably linked to an unwillingness of America to come to grips with these two conflicting values.

Few expect the next President or Congress or the states to come up with any far-reaching, comprehensive proposals to deal with the problems of the health care system. The failure of the Clinton health care plan and the polarization of the Republicans and the Democrats that was evident during the impeachment process both argue that only incremental piecemeal solutions applied to the current competitive model of delivering and financing health care are possible for the next several years.

The Robert Wood Johnson Foundation-sponsored Institute for the Future's forecast of health care in America predicts in the next ten years incremental legislative reform, continued business strategies to repress cost increases, increased HMO involvement in the commercial and Medicare market, an oversupply of physicians, and unresolved conflict between providers and intermediaries over who will control patient and provider behavior. (13)

The brave new world 

Is there a relationship between physician anger and the changes that the Information Age is causing for all industries and all peoples? Many have pointed out that the ready availability of vast amounts of information associated with personal computers and the Internet is changing our lives. Some call this process a transformation; others call it a revolution; It has been described as a divide and a new age.

Few would argue with Peter Drucker's assessment in Post-Capitalist Society that we are living through a period where, within a few short decades, society has rearranged its worldview, basic values, social and political structures, arts, and key institutions. (14) I believe this transformation is contributing to physician anger by unleashing trends that are unstoppable and that will change medicine for better and for worse in the coming years. Globalization of world markets, diffusion of power, value fragmentation, and a decrease in face-to-face human contact are all consequences of this change. (15)

Thomas Friedman's The Lexis and the Olive Tree examines how the integration of free markets enables individuals, corporations, and countries to communicate faster and cheaper than ever before. (16) He describes how this integration produces winners who can operate in this new world and losers who do not have the knowledge or inclination to participate in this process. Lester Thurow makes the same point by writing, "Those with third world skills will earn third world wages because anything can be made anywhere on the face of the earth and sold everywhere else on the face of the earth." (17) Although most physicians do not realize it, the use of telemedicine and sensors to monitor patients at great distances will change medicine in ways barely imagined today.

Charles Dwyer in The Shifting Sources of Power and Influence discusses how information that used to be restricted to physicians is now readily available to patients, nurses, third-party payers, and others. (18) Many physicians are treating patients who come into the office with long lists of questions gleaned from extensive research on the Internet. While some physicians welcome a well-informed, aggressive, empowered patient, others find it threatening when a patient asks questions about a therapy or a drug the doctor has never even heard of. Americans are also visiting alternative medicine providers in numbers that in some studies are larger than visits to primary care physicians. (19)

This diffusion of power away from physicians and other professionals is a trend that will Increase. Dwyer's fragmentation of values refers to people having to deal with others who do not share their fundamental belief systems. Previously disenfranchised groups have chat rooms where they can find support from others around the world. The positive aspects must be balanced against the negative possibilities of subcultures refusing to understand different perspectives and having tolerance for those who disagree with us.

This new technology allows people to communicate with others around the world, order books, submit articles, and pay bills without ever leaving their computer and home. Edward Hallowell, writing in the Harvard Business Review, describes patients who are actively involved in this new computer age who have what he calls toxic worry. (20) It stems from a lack of face-to-face contact in a business world where travel, voice mail, faxes, and email allow us to conduct business without ever being in the same room as our colleagues and customers. Earl Shorris in A Nation of Salesmen believes "the global village predicted by the seers of the 1960s is being replaced by electronic cottages populated by isolated dreamers.... We are a nation of lonely molecules." (21)

Conclusion

Much of physician discontent is related to uneasiness about where we fit into this new world that has not yet emerged, but that clearly will change our jobs as physicians, our relationships with our patients, the problems our patients bring in, the financial arrangements that pay our bills. In the new environment, some physicians will become losers and others winners.

Physician discontent is widespread and is harming our health care system. It is linked to managed care, the debate about constraints on health care costs, and the Information Revolution. Physician discontent will not go away until we emerge from the past we cannot preserve and the future that remains frightening, seductive, challenging, and uncertain.

References

(1.) Kassirer, J.P. Doctor Discontent. New England Journal of Medicine. 1998;339: 1543-1545.

(2.) Squillacote, D.C. Letter to the Editor. New England Journal of Medicine. 1999;340: 650.

(3.) Kendrich, R.A. Letter to the Editor. New England Journal of Medicine. 1999;340: 650.

(4.) Cleaveland, R. Letter to the Editor. New England Journal of Medicine. 1999;340: 651.

(5.) "The 1998 Med Stat Quality Catalyst Physician Study." Ann Arbor. Michigan: Med Stat Group. 1998.

(6.) Simon, SR., Pan, R.J.D. Sullivan, A.M., Clark-Chlarelll, N., Connelly. M.T.. Peters, A.S., Singer. J.D., Inut, T.S., Block, S.D. Views of Managed Care: A Survey of Students. Residents, Faculty, and Deans at Medical Schools in the United States. New England Journal of Medicine. 1999; 340:928-36.

(7.) Feldman. D.S., Novack. D.H., Gracely. E. Effects of Managed Care on Physician-Patient Relationships, Quality of Care, and the Ethical Practice of Medicine: A Physician Survey. Archives of Internal Medicine. 1998; 158:1626-1632.

(8.) Klint, R.B. A Dance in Anger: Physician Responses to Changes in Practice. The Physician Executive. 1999; 25:18-22.

(9.) Pincus, C.R. Have Doctors Lost their Work Ethic? Physician Disability Claims Increase. Medical Economics. 1995; 72:24.

(10.) Daugird, A., Spencer. D. Physician Reaction to the Health Care Revolution: A Grief Model Approach. Archives of Family Practice. 1996; 34:497-501.

(11.) Bodenhelmer, T. The American Health Care System; Physicians and the Changing Medical Marketplace. New England Journal of Medicine. 1999; 340:584-588.

(12.) Raune, T.J. Letter to the Editor. New England Journal of Medicine. 1999; 340:651.

(13.) Institute for the Future. "A Forecast of Health and Healthcare in America." Princeton, New Jersey: The Robert Wood Johnson Foundation, 1998.

(14.) Drucker PP. Post Capitalist Society New York. New York: HarperBusiness, 1994.

(15.) Bottles, K. The Information Revolution: Opportunities and Pitfalls for Patients and Providers. The Physician Executive. 2000; 26:20-31.

(16.) Friedman, T.F. The Lexus and the Olive Tree. New York. New York: Farrar Straus Giroux. 1999.

(17.) Thurow, L.C. Building Wealth: The Alew Rules for Individuals, Companies, and Nations. New York, New York: HarperCollins, 1999.

(18.) Dwyer, C.E. The Shifting Sources of Power and Influence. Tampa, Florida: American College of Physician Executives, 1991.

(19.) Elsenberg. D.M., Davis, R.B., Ettner. S.L., et al. Trends in Alternative Medicine Use in the United States 1990-1997. Journal of the American Medical Association. 1998; 280:1565-75.

(20.) Hallowell, E.M. The Human Moment at Work. Harvard Business Re view. 1999; 78(1)

(21.) Shorris, E. A Nation of Salesmen: The Tyranny of the Market and the Subversion of Culture. New York, New York: WW Norton and Company, 1994.

Kent Bottles, MD, is President of the Genomics Repository of Genomics Collaborative, Inc., in Cambridge. Massachusetts. He can be reached by calling 617/661-2400 ext. 254 or via email at [e-mail].