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Diagnosis: Burnout

Doctors on corporate interference and insurance burdens

There was a time when the average local doctor could confidently dictate a patient’s future tests or course of treatment without having their directive ping-ponged through the administrative maze of a large corporation. Now, in a country where less than half of doctors work in a physician-owned practice, they say the process has become unnecessarily confusing, diminishing their autonomy as health care providers. 

Physicians are increasingly classified as employees, with 75 percent now working out of hospitals or major health systems. The result, according to some, is that they are incentivized to focus on meeting organization-wide financial targets instead of on the best medical next steps for a patient. This target pressure can be triggered by mergers and acquisitions, like UnitedHealth’s frantic race to buy as many medical practices as possible, or the debt spiral that happens when a private equity group takes over a local emergency room. It can also occur when employers are overly focused on Medicaid reimbursements, hoping to hit a certain number of, say, colonoscopies, regardless of patient needs.

But there is another side to the rise in doctors as employees: the possibility for unionization, despite a pervasive myth that the profession is not allowed to do so, a holdover from the era when doctors tended to own their own businesses and were more often self-employed. The movement is still very much in its infancy — just over 7 percent of practicing doctors belonged to a union as of 2019 — but it is steadily gaining ground. Last year, around six hundred Allina Health clinic doctors, nurse practitioners, and physician assistants successfully organized with Doctors Council SEIU, becoming the largest private sector doctors’ bargaining unit in the country. They were helped by the Doctors Council SEIU, a physician’s union that represents unionized doctors across the country. It’s not a coincidence that this push comes on the heels of the height of the Covid-19 pandemic. Many doctors say that Covid, in combination with disruptive changes to the structure of the medical industry, has pushed them to a state of emotional and physical burnout.

What follows is a series of interviews with doctors across the United States about their current working conditions. Their responses have been condensed and edited for clarity.

Matt, Allina Health family medicine doctor, Minnesota

I see primarily geriatric patients, people who are over sixty-five with a lot of health problems. It’s just a real challenge, because often they are not safe in their homes; they have dementia; they’re not safe to drive. There’s a ton of these social issues around [their health]. Do they have the resources to be able to move to assisted living? Are the family members living with them able to really care for them?

For a lot of us, where the burnout happens is not from physically working so much—although some people are—but from the work itself being emotionally draining and exhausting, because you’re dealing with multiple serious medical problems in patients, and then on top of that, you have these social issues.

I’m being forced into practicing medicine according to what an insurance company or a health care corporation wants.

We are also increasingly losing power as doctors in terms of our ability to make the decisions that affect our patients. Our health care corporations and insurance companies are getting more powerful in terms of dictating care, from limiting what medicines are available to patients, to denying tests that doctors think patients should get, like CT scans. Our company gets paid money for meeting certain quality metrics. One metric would be that we get people on Medicare, so those over sixty-five, in for a Medicare Wellness Exam, which is like a yearly checkup. Or the hospital will get paid if patients get colon cancer screening with a colonoscopy, or a mammogram, or immunizations.

Which, in theory, is a good thing: you are getting people in for their general checkup. But when companies start saying, Okay, we are going to pay you to do these things, and we’re going to see what percentage of patients get these done, and then reimburse you based on that, what happens is that power is taken away from the doctor to determine what is the best use of their time. It’s like, Is it more valuable for me to maybe talk about this patient’s mental health, or to talk about them getting a colonoscopy? I think that decision should be made by me! But when companies put pressure to meet these metrics, there’s a disconnect between what the doctor thinks is most important and what the company thinks is most important. It increasingly feels like the cards are stacked against me, and I’m being forced into practicing medicine according to what an insurance company or a health care corporation wants.

Nobody can escape for-profit medicine. Losing control, losing the ability to care for your patients, and not being able to provide the care for your patients because services don’t exist in terms of social services, mental health services: that to me is the big thing. I can’t speak for every doctor, but I would say those are the big things that led us to unionize [at Allina Health].

Our company made it clear that they were not going to be investing in primary care, so one of my colleagues circulated a letter which I signed. We started a WhatsApp group, and anyone who seemed like they were upset about this or open to working together, who signed onto that letter, I reached out to them basically to help them see that unionizing would be a solution to this. Then we started working with an organizer at the Doctor’s Council. It was just building unity across our sixty-one clinics.

If you complained, our company used to be like, Wow, you’re the only one that we’re hearing this from. But this is not a problem just in my brain, my clinic, or in Minnesota. This is a problem everywhere. It’s powerful to say, we can have more control in our lives, more power in our system. It’s a pretty simple message that resonated with people, I guess.

I talked to people who were like, I didn’t even know we could unionize. I think, historically, a lot of doctors owned their own practices, and it’s more recent that doctors have been employed by corporations. When you own your own practice, you can’t unionize.

Our company hired Littler Mendelson, which is one of the biggest antiunion law firms, the same one that Starbucks hired. They were very aggressive with trying to stop us, sending out tons of emails with misinformation, trying to scare people, saying you will lose control of your schedules, or you won’t get vacation. Ultimately, we were successful. We voted 325 to 200. But they are still fighting us.

Sorana, OB-GYN at a public hospital, New York

My work week is divided between covering clinic panels, where I have panels of patients that I see by myself, and also days when I cover labor and delivery, and then days when I have scheduled surgical cases in operating rooms. About once a week, I’m on call overnight, so I do twenty-four-hour shifts. A lot of the time is spent teaching residents.

A big issue in bargaining is that there is no benefit to being an experienced physician in this hospital system.

With the influx of migrants in New York, the majority of patients at our hospital are not fluent English speakers. They require interpreter services and have multiple medical and social issues that impact their health. In addition to having traveled from places like South America or the Caribbean, some of them have not sought care for many years. [I found myself] having to explain to one of my patients how medication refills work—how, when you finish taking the medication, you need to go back to the pharmacy and just ask for your refill. The concept is so foreign, but it’s something that we take for granted. A lot of times, we get double-booked in the clinic, where in one slot you have two patients scheduled. Then the patients show up, and they are some of the most vulnerable patients in New York City.

Patients might be there for two to three hours at a time. After they wait a while to see me, then maybe they need to do bloodwork, or we need to do a procedure, or they need a medication or vaccine. Then they have to wait for the nurse, they have to wait maybe for a social worker or another provider in the office, so their visit can be very lengthy.

Sometimes you see patients in their most vulnerable state, and a lot of times we have discussions and conversations about topics that are very hard to share, whether it’s physical abuse or sexual abuse, or what they endured in their migration story, or the responsibilities at home with other children, or domestic violence, or problems with addiction. It’s so much more than letting me take their blood pressure and giving them medication; it is really getting to know my patients and understanding who they are as a human, and where they are in this journey.

I am pretty active in my hospital’s union, and one of the major reasons why I’m at this job is because it has a union and has that representation. We are in the middle of collective bargaining with our employer for a fair contract and dealing with specific issues. A big issue in bargaining is that there is no benefit to being an experienced physician in this hospital system. In every other hospital system, physicians age like fine wine; we get better at what we do, and years of experience accumulates into more knowledge, and more ability to teach, and lots of improvements. But there’s no compensation for that. I have the same base salary as somebody who just finished residency.

Amber, hospitalist at a private hospital, Minnesota

Hospitalists are responsible for admitting the patients who are too sick to discharge from the emergency department. Each day, we meet with patients and their families to discuss the patient’s current status and form patient-centered plans, involving our specialist colleagues as needed. When they are discharged, we ensure they have good follow-up plans.

On a daily basis [at my hospital], we struggle with lack of beds and boarding, and frustrated patients. We are asked to work faster and do more, with decreasing resources and support staff. Misinformation accelerated by social media has exacerbated distrust in medicine, while others harbor overzealous expectations of modern medicine’s curative powers. Private equity groups, which should have no place in medicine, are spreading across the country, leading to worse health care access and worse care for patients.

Reimbursement rates are often lagging inflation, while at the same time, insurance companies are requiring frequent time-consuming prior authorizations, readily denying claims (a recent study showed 15 percent of claims are initially denied), all while recording record profits. These changes are choking hospital systems, which make radical adjustments to stay afloat. Also, there is anti-patient and anti-provider legislation. Luckily, Minnesota is a very friendly state when it comes to this, but certain states are creating health care deserts due to their legislation, something that is so sad to see in this country.

Frankly, I’ve been burnt out since the beginning of the Covid pandemic, when we put our lives on hold to serve our patients and communities. There was no break “after Covid.” Instead, we have ongoing challenges, as noted above, and we spend our free time advocating for our patients at a higher level, because there are so many serious issues in health care these days. All of this, while trying to hold together my family with four young kids, leaves me feeling drained. I know I’m not alone when I say that there just aren’t enough hours in the day to get it all done.