By Deane Waldman, M.D.
The United States has a critical shortage of health care professionals: nurses, mental health therapists, and especially physicians.
Burnout among these clinicians is the proximate cause of the shortage. Maximum wait times to see a primary care doctor can exceed four months, resulting in death by queue.
“Death by queue” was coined for Great Britain’s vaunted National Health Service (NHS), where Britons die waiting for life-saving medical care. The NHS is also experiencing an exodus of burned-out physicians, especially senior ones, similar to the United States, with catastrophic consequences. In addition to worse delays in caring for current patients, where will we get experienced physicians to teach the next generation of doctors how to care for future patients?
Missing ‘Psychic Reward’
Proposed solutions for burnout include AI-assisted documentation, immigration of caregivers, virtual caregivers, online toolkits, and recommendations to rest/eat well/exercise/ask for help. As these solutions do not address the causes of burnout, such fixes will fail and could make things worse. A review of the common causes of burnout unveils a common theme.
Physicians cannot exercise their best judgment when making care recommendations to patients. They must follow clinical guidelines, crisis standards of care, pharmacy benefits managers’ drug limitations, federal advisories, CDC mandates, and FDA prohibitions. All this advice and guidance are effectively orders. They seem designed to protect the patient from the doctor, replacing his/her judgment with government authoritarianism. Doctors feel the weight of responsibility for the patient but are denied the appropriate authority. Physicians always get the blame but rarely any praise.
Clinical caregivers endure years of school and training along with long hours and great emotional as well as physical stress for one reason above all others: the psychic reward. Maslow described it as the highest of human needs—self-actualization, discovering the meaning of one’s life and achieving it. As one nurse described the psychic reward, “When my babies [her patients] do well, it feeds my soul.”
The current health care system disconnects patients from physicians emotionally. The depersonalization patients rightly resent is felt equally by care providers. My former personal physician had an assigned list of more than 900 patients. Surgeons often first learn the patient’s name from that day’s operating schedule. The lack of psychic reward combined with overwork, especially from BARRCOME (explained below), leads to burnout.
Underlying Cause
When Washington regulates the health care system, guides care, and establishes insurance rules, it does so through bureaucracy, administration, rules, regulations, compliance, oversight, mandates, and enforcement (BARRCOME). BARRCOME manifests in health care as third-party decision-making by Washington directly through Medicare, Medicaid, and Tricare (171 million Americans) and indirectly through federal rules and regulations governing employer-supported private insurance (134 million Americans).
Third-party decision-making producing bureaucratic diversion and disconnection is the ultimate cause of physician burnout.
Bureaucratic diversion refers to inefficient health care spending that produces no medical care. In 2022, the United States expended $4.3 trillion on its health care system, an amount greater than the gross domestic product of Germany. Half of that spending was diverted from patient care to pay for BARRCOME or 2 trillion dollars’ worth of care Washington denied people to pay itself.
As Medicare and Medicaid repeatedly lower allowable reimbursement schedules—aka payments to physicians—wait times get longer, patients die waiting, and physicians burn out, feeling frustrated and devalued (see related article).
Third-Party Disconnect
BARRCOME’s third-party decision-making “disconnects” patients from their money, and doctors from their patients emotionally (along with financially).
Health care expenditures for the average American family of four is $31,065 in 2023. More than 80 percent will go to an insurance company where unaccountable, faceless bureaucrats decide how to spend family funds. As most families are healthy and have low medical expenses, they get no value from their share of the cost.
Disconnecting patients from their money indirectly promotes physician burnout. Patients see massive spending on health care, and intolerable wait times despite exorbitant physician charges (not payments, which are generally a small fraction of charges), and direct their anger at physicians. Doctors quickly burn out if they get up at 3 a.m. to see a patient, and are rewarded with disdain and physical violence.
A fiduciary connection is the key to a successful therapeutic relationship: it is also a preventative for burnout. In medicine, fiduciary means one person (the patient) gives up medical autonomy—control of body and/or mind—to another person (the physician) to be used exclusively for the benefit of the first person. This is an intimate, emotionally intense relationship between two people. When the patient and physician are disconnected by the third party, there cannot be a true fiduciary relationship. Without such a connection there is no trust and no psychic reward. The result is burnout.
Direct Pay, the Answer
The cure for physician burnout follows from the root cause. Eliminate third-party/federal government decision-making from health care, and health and care will reconnect.
Reconnect the patient with his/her money, so the patient, not the third party, makes spending decisions.
Reconnect the patient directly with their chosen physician, with no third party making medical (or financial) decisions (see related article, page 14).
This reestablishes both medical freedom and the fiduciary relationship, which can cure the problem of physician burnout and its consequent M.D. shortage.
Deane Waldman, M.D., MBA (dw@deanewaldman.com) is professor emeritus of pediatrics, pathology, and decision science, University of New Mexico; former director of the Center for Healthcare Policy at Texas Public Policy Foundation; and former director, New Mexico Health Insurance Exchange. A version of this article appeared in Real Clear Health on December 1, 2023. Reprinted with permission.
