COMMENTARY

When a Physician Leaves, We All Lose

John M. Mandrola, MD

Disclosures

October 15, 2015

When Experienced Physicians Leave Patient Care, Everyone Loses

Almost nothing gets better with age. Exceptions include wine, family dogs—and doctors.

When I heard that Dr Seth Bilazarian, author of Practitioner's Corner on theheart.org on Medscape, was quitting clinical practice, I was dismayed but not surprised. Seth has spoken clearly about the increasing burden of paperwork, the farce that is electronic health records, and the toxicity of removing joy from the practice of medicine. Among the drone of healthcare jargon, Seth's candor and plainspeak have stood out.

It is distressing when experienced clinicians leave patient care before the normal time. It's bad for patients. It's bad for healthcare systems. And, it's bad for the profession.

I'm not sure many people understand the normal progress of a doctor through his or her career. Emphasis here on progress as a process—a verb, an action and one that is continuous and lifelong.

To an administrator or employer, doctors look similar. A young doctor finishes years of training; he or she is board certified and ready for the real world. A few modules on compliance and coding, and he or she is ready to produce.

Nothing could be further from the truth.

Any experienced physician knows that it takes thousands of patient encounters, the grief of mistakes, and the longevity of having practiced through history to acquire the wisdom of a master clinician. Good training is essential, but learning amasses over a career, and if nurtured, medical knowledge knows no asymptote.

When I joined a 20-physician practice nearly two decades ago, there were a handful of master clinicians. These guys may not have known logistic regression, but they knew medicine. They were your go-to guys. We even nicknamed one of them "The General."

Another had enough pride in his skills that he took the American Board of Internal Medicine board exam the year before he retired. And another had a reputation for being mean because he advocated (vigorously) for diet and exercise—in the 1990s.

A fourth clinician used to get in trouble for not micromanaging elderly patients. He didn't do enough, went the critique. I now see the elegance of that approach.

These guys hung their self-esteem on the patient-care peg. They cared. They were attached to outcomes before outcomes had its own journal.

Of course, it's normal for older doctors to retire, and others are destined for administration, industry, or research. The problem is that more and more experienced clinicians are finding a new peg—and it is not patient care.

In my hospital, one of the most respected surgeons—a woman known for her patient-care ethos, her willingness to take the toughest cases, and her tenacity—moved to administration. A master surgeon now earns her living sending emails.

Two years ago, my colleague, friend, and a master electrophysiologist, Dr David Mann, left clinical practice far earlier than he should have. His kindness and humility were legend. He was practicing electrophysiology at the highest level, but for him, the nonsense negated the joy. I'm happy my friend is enjoying retirement, but our healthcare community is lessened.

Hardly a week goes by that I don't receive an email announcing the hire of a new administrator—a quality officer, a compliance director, or a physician "leader." I spoke to a retiring internist yesterday. (One month before quitting, he called me to make sure an elderly patient did not get lost in the morass.) He said it was a hard decision, but, like David Mann felt, the joy was too little and the nonsense too great.

"All it would take is two bad days in row, and I am out," says one of my senior partners. In a recent commentary published in Forbes, Dan Diamond argued that physicians are leaving practice for the same reasons most people choose to leave work: They are aging and retiring.[1]Contrary to this opinion, I believe my colleague. And if this doctor goes, it's one fewer person in the system who understands that cardiac disease is more than a plumbing problem,[2] and that palliative care has a role in heart failure.

The underperforming US healthcare system has many symptoms—such things as wasteful, low-value care; inequality; and limited access—but one of its core problems is in the delivery of RightCare.

Wisdom comes slowly. Accurate diagnoses require time and focus. Doctors are human. (And there is human nature.) It's fantasy to talk about shared decisions, patient-centered care, and reducing low-value care when we have a system that devalues listening, thoughtfulness, and using time as a therapy. And with pay-for-performance, good doctoring is often punished.

It used to be that the best doctors (and nurses) took care of patients. Is that still the case? I'm not sure.

The smartphone and technology will surely help when you need antibiotics for otitis, or an ECG for palpitations. And I have little doubt that I could train almost anyone to implant a pacemaker. These are the easy parts of medicine.

The hard part is when you need wisdom and empathy. In these cases, you need a Seth or a David, not a joyless distracted employee tied to a computer and a checklist.

What's more, clinicians with decades of practice have earned the capital to say "no" to procedures without risk to their standing—like the internist who saved my dying mom from worthless chemotherapy, or the vascular surgeon who did not operate on my frail grandmother when she was dying of mesenteric ischemia.

Patients often ask me to refer them to a new primary care doctor. They want someone who has the time and emotional strength to listen. They want a caregiver who knows both the science and them. Sadly, these doctors are nearly gone. They are in a meeting somewhere, working a shift in a hospital, retired, or "not taking new patients."

I'm afraid healthcare policy experts are making a rookie mistake. They are treating symptoms but missing the root cause. As it is in education, if we want good medicine, we must value the human element of patient care.

Somehow, we must find a way to care more for the caregivers.

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