[music]

Brian Lehrer: It’s Brian Lehrer on WNYC. Now a call-in for doctors on the state of our health system as seen through your stethoscope. Did you see the New York Times op-ed that said doctors aren't burnt out, they are demoralized by the system. Doctors, help us report this story and tell us if that's true for you. (212) 433-WNYC. The op-ed says, “Demoralization and disillusionment with a for-profit healthcare system is driving many physicians to leave the profession and not enough new physicians are entering the field to make up the difference.”

Doctors, are you leaving medicine? Did you recently do so, that's why you can listen at this time of day? Or are you tempted to do so? Is the profit motive in the health system and how that's evolving driving you to the brink? (212) 433-WNYC, (212) 433-9692. You want to make a good living too, as an MD, right, after all that medical school training and the cost of it I'm sure. But maybe the corporatization of everything is having effects on you and your patients that you would like to describe. You are invited to help us report this story, or react to that op-ed if you read it, and if you're a doctor at (212) 433-WNYC, (212) 433-9692, or tweet @BrianLehrer.

With us now is Dr. Eric Reinhart, political anthropologist of law and public health, psychoanalyst, and physician at Northwestern University in Chicago. His op-ed in The Times is titled Doctors Aren’t Burned Out From Overwork. We’re Demoralized by Our Health System. Dr. Reinhart, thanks for continuing the conversation here. Welcome to WNYC.

Dr. Reinhart: Thank you. Thanks for having me.

Brian Lehrer: What about the healthcare system do you find is most demoralizing doctors?

Dr. Reinhart: It's a combination of many factors. Writers don't choose the titles of their op-eds in these newspapers. My editor was wonderful, and I think the title is reasonable enough, but it downplays the effect of overwork. We are overworked. I myself just got off a night shift. I work about 80 clinical hours a week right now and then on top of that, during the days, I'm doing my research, so I work well over 100 hours and I'm burnt out from overwork. But there are other factors that are also involved.

In almost all the reporting that we've had around burnout over the last few years in the US, in the healthcare sector particularly, it's been about working conditions, it's been about wellness, mental health, and what's really gone by the wayside are the systems level perversions and corruptions that are really disheartening to work within. One of the main reasons this is so disheartening is because it affects our patients. As a doctor, you want to have effects. You want to see your patients do well. When you don't have functional systems to enable that, it takes away your motivation to continue working.

I think this is the primary driver of burnout, that our health care systems and their interconnection with basic social service systems are so ineffective in this country that we have rapidly declining, relative to other nations life expectancy. We have huge health care costs. We spend far more per person on health care in the US with far worse health outcomes relative to peer nations. This isn't a system that's particularly energizing to work within when that's what you're facing every day.

Brian Lehrer: Is there a doctor shortage in this country? We've talked a lot on this show about a nurses’ shortage throughout the pandemic and put an additional spotlight on it recently when there was a nurses’ strike at some New York hospitals. Is there a doctor shortage in the United States?

Dr. Reinhart: There is, and there has been for over 50 years. This was recognized by Congress when they passed legislation for Medicare and Medicaid in the 1960s. At that time, they recognized we didn't have nearly the number of healthcare workers, including doctors, that we would need in order to provide care to the American population. Their short-term solution that was arrived at at that time was, we'll change our immigration policy and use immigration policy to target recruitment of doctors trained in foreign nations, who are wonderful doctors, but they're often recruited from places where there's far greater unmet health need in the US, for example, India, Pakistan, the Philippines, and nurses are also recruited from these places in very large numbers.

The US, with this short-term solution, pushed off the long-term structural changes they needed to make, which is a major investment in the medical education system, and used this Band Aid, and they've used it over and over again for the last 50 years. We've had a chronic physician shortage. The AAMC, the governing body for medical education in the US, they estimate that we're going to have a shortage of about 130,000 doctors by 2032, I believe it is, so about 10 years away.

We already have a very significant shortage and it's getting worse. It's not just about getting people to want to be doctors. We don't have enough training spots. We don't have enough medical school spots. If 120,000 doctors leave the workforce, this is what happened a couple of years ago, and you are only training 40,000 to enter that year, you're operating at a deficit. You got a problem.

Brian Lehrer: Is that piece of it a manufactured shortage? Because certainly more people apply to med school every year than get accepted. Is that a decision that the educational establishment make, or maybe the medical establishment is making for the sake of doctors making a good living? Maybe that's too cynical but is it a manufactured shortage?

Dr. Reinhart: It is, and it's manufactured by multiple parties. Your cynical judgment just then is actually correct. Historically, after the Flexner Report over 110 years ago, the medical profession in the US consolidated power and really tries to use market dynamics to enhance its status, its political influence, and its capacity to command high compensation rates. One of the ways that you do that is to regulate supply, so supply of physicians and medical care. Historically, there has been a force that the medical profession itself has exerted to manufacture something of a shortage.

The bigger driver of it now is Congress. Congress has refused, even though they've been petitioned, including by the medical profession to do this many times, they've refused to expand funding, federal funding for graduate medical education to enable more residency positions and fellowships to be opened. This is something that actually happened under Clinton. There was a cap put on this that has really not budged significantly since. There have been requests to Congress to expand the number of training spots significantly.

Most recently, they just made a minor adjustment where they increased residency spots by 200 per year, funding for them. That's not even a drop in the bucket in terms of what we need.

Brian Lehrer: This is WNYC HD FM and AM New York, WNJT-FM 88.1 Trenton, WNJP 88.5 Sussex, WNJY 89.3 Netcong, and WNJO 90.3 Toms River. We are New York and New Jersey Public Radio and livestreaming at wnyc.org with Dr. Eric Reinhart now, author of the New York Times op-ed that ran this week called Doctors Aren't Burned Out From Overwork. We're Demoralized by Our Health System, and we have doctors calling in. Laura in Warren, New Jersey. You're on WNYC. Hello, Dr. Laura.

Dr. Laura: [laughs] Thank you. Not that, Doctor Laura.

Brian Lehrer: Yes, I guess that’s a talk radio reference that not a lot of people will like, but go ahead.

Dr. Laura: Anyway, I just recently retired and a general internist, mostly hospital practice recently, and I retired after 40 years last month. It was multifactorial, obviously, but I've been progressively demoralized by the increasing influence of money in this profession. It's been just so disappointing. Our hospital and health system would get us together periodically for what I always called how to increase the cost of medical care without really trying. It's sort of like, “Use these words and get these diagnoses on somebody's diagnosis list so we can charge more, and it actually won't cost you any time to do that.”

It is literally what doctors are being taught to do, and it's useful from both the hospital, and the health system, and the insurance companies to get more that way from usually the government or other payers.

Lehrer: Does that spent money move around or does it hurt the patients in some way?

Dr. Laura: If they have a copay or I pay 20% of this or whatever it is, it hurts the patient as well. The other thing that it really got my goat from being inpatient medicine was most inpatient care is paid for through what's called a DRG or a diagnosis related group system. If somebody comes in with pneumonia, the hospital gets paid so much and if you say, “Oh, they have pneumonia plus they have cancer,” they get paid so much. It doesn't matter how long they're there or what drugs you use- -to treat them.

If something comes up and somebody needs, or you think that the patient needs in the hospital a particularly expensive drug, usually a cancer chemotherapy is the one that comes up the most, what the hospital will tell you is, "You need to get this person out of the hospital so they can go get this expensive drug as an outpatient because we won't get paid any more for it if they get it as an inpatient but the outpatient insurance will pay for it."

Obviously, if anything, it costs the overall society more to do that, and it's not in the best interest of the patient to have a delay in this necessary drug. It only helps powerful players in the health system to do this-

Brian Lehrer: To make money. Those are such-

Dr. Laura: -stuff, and it just makes you sick.

Brian Lehrer: -such clear examples. Thank you so much for calling in. We really appreciate it. Melissa in the Bronx, you're on WNYC. Hello, Dr. Melissa.

Dr. Melissa: Hello. Thank you for taking my call. I totally agree with Dr. Laura. I'm also a general internist. I practice in an outpatient setting, treating mostly people with addiction-related problems, but also doing their primary care. In some ways, because of the setting I practice in, I'm protected from some of these issues, but I have to say, I've been doing this for a long time. The volume of paper that comes across my desk is extraordinary to me.

Just suggestions about using this brand instead of that brand and getting prior authorization for this drug that the patient has been on to control their HIV for the past five years, that I have to spend 40 minutes talking on the phone to someone about to get approval for. The amount of time, paper, other people's time, and money that's now being spent by insurance companies in the name of saving money, I recognize I only have a very particular viewpoint, but I can't see how it's saving money. It just makes me crazy.

Brian Lehrer: Do you want to get in on that Dr. Reinhart? Were you able to hear the caller?

Dr. Reinhart: I missed the last little part, unfortunately. I'm sorry. I don't want to interject and say something incorrect.

Dr. Melissa: Just that the amount of approvals, prior authorizations, please change the prescription to this brand instead of that brand, it's extraordinary.

Brian Lehrer: It takes so much insurance company staff time. Are they even making more money by pushing the doctors around that much? Dr. Reinhart, any thought?

Dr. Reinhart: Yes, people are making money in all of this. The amount of money spent on healthcare in the US is now about $4.6 trillion. I believe there's a recent study in Health Affairs, a health policy journal that estimated by 2030, that amount is going to increase to $6.8 trillion per year. To give you a point of reference, this is more than double the next closest nation in terms of per capita healthcare spending. That spending isn't just being pushed in circles. People are extracting it. Money is being made through inefficiencies.

Efficiency is not a priority of our healthcare system if we look at it in the way that it's constructed. This, I think is very-- it's not just that it's a waste, it is very disheartening and demoralizing for physicians to work in this context. Because every single day, the caller before this one for example, mentioned the coding system, the billing system. In residency training programs, it's a very common thing now to have a module specifically on upcoding. How do you write your billing documents in such a way that you could bill for the maximum amount of money?

Rather than spending time training people to think about, how can you care for your patients in the best possible way, they're using training time to think about how can you bill so as to generate maximum income and revenue for the hospital system for which you work. This ethos permeates every part of our daily work. It's not just the bureaucratic paperwork burden. It's also what that does in terms of our sense of meaning and value in relation to what we're doing.

Brian Lehrer: Jack in San Francisco, you're on WNYC. Hello, Dr. Jack.

Dr. Jack: Hi, Brian. Long time listener now in San Francisco. I am a 62-year-old pediatric hospitalist and I absolutely love what I do. Like some of the other callers, I'm protected from some of the administrative burden in the care that I provide. When a kid comes into the hospital, I do what's right for the kid. They're almost no financial or paperwork barriers other than now trying to find the medications that we need if there's a manufacturing shortage so I'm in a very fortunate position.

I think that inspector Reinhart has hit a nerve but it's much more complex and it's not affecting everybody the same. They're different situations. I think that the physician shortage is more of a distribution issue. I would say that we don't need more plastic surgeons and dermatologists in New York City and San Francisco. We need more primary care providers, both physicians, physician assistants, and nurse practitioners in rural areas. Those people have very difficult jobs, lots of paperwork, high patient volumes.

I think one of the things that medical schools can do is try and admit students who really have a sincere interest in service to the community. They don't need to have the top MCAT scores. They don't need to be researchers, but they need to go out and serve. It's interesting to see what NYU is doing with free tuition. Are they able to select and identify future physicians who will go out and really serve the public?

Brian Lehrer: Is it free tuition for med students who promise to practice in a certain way?

Dr. Jack: I would be in favor of that and I think a state legislature like California could look at that. NYU has done it and some other schools just as a matter of principle, but I think with that, one can make a very conscious decision. Do you then try and develop a class of students who are all future bench researchers who will add academic prestige and publications to your medical school, or do you look for people who come from maybe traditionally underserved areas who will go back and do that basic healthcare work? I think that's a policy decision state legislatures need to look at.

Brian Lehrer: Jack, thank you for so many good points. As we start to run out of time, related to that, a couple of callers who are not going to have time to get. One says explicitly that student debt leads to specialization, where the money is in medicine and the shortage of general practitioners. We have another caller. We see you Garrett in Stanford, Oakland, I have time for you, talking about how nurse practitioners are taking on so much primary care because of doctors not going into it.

Dr. Reinhart, to conclude, you wrap up your op-ed by saying, “Regardless of whether we act through unions or other means, the fact remains that until doctors join together to call for a fundamental reorganization of our medical system, our work ‌won’t do what ‌we were promised it would do.” Do you see doctors joining together, whether it's unionization or something else?

Dr. Reinhart: Honestly, no, I don't see that, but what I see is a growing interest in doing that. The medical profession has organized for a very long time. We have our professional organizations that function in many ways like unions, except for they're not focused on working conditions, they are focused on maintaining professional autonomy and high compensation. They're certainly historically not focused on helping patients. Dr. Eric Topol has an excellent essay several years ago in The New Yorker called Why Doctors Should Organize where he covers that history.

I think the most important thing that doctors can do is not just join together with one another, but join with community members, join with their patients, join with broader labor organizations to push for fundamental change, because we don't just need to change our working conditions or all of these perverse incentives that the callers have mentioned, but also where it is we allocate our resources as a nation in terms of care, because healthcare should be secondary to basic social services and welfare systems that are essential for prevention.

What we have instead done is chronically underfund all of those essential services and dump trillions of dollars into healthcare that is fundamentally reactive. It's about treatment after disease has already arisen. That is what clinical medicine is largely organized around, certainly in the US. It doesn't work. That's why we have such poor health outcomes. If we want to make our work effective and valuable as physicians, we need to focus a lot of our energy on investing resources in non-professional care systems, in lay care systems, in community health worker systems, in peer support systems.

I think to do that effectively, we have to broaden our base, our movement base. It can't just be about doctors organizing together. It has to be doctors organizing with all healthcare workers, with all workers at large. This might sound unrealistic in the US labor context but I think this is what's really, really important in order for us to move towards the changes we need to see, a de-professionalization of care.

Brian Lehrer: Dr. Eric Reinhart is the very interesting combination of a political anthropologist and a physician at Northwestern University. His op-ed in the New York Times is called Doctors Aren't Burned Out From Overwork. We're Demoralized by Our Health System. Thank you so much for sharing your thoughts with us and talking to other MDs out there.

Dr. Reinhart: Thank you, Brian.

Copyright © 2023 New York Public Radio. All rights reserved. Visit our website terms of use at www.wnyc.org for further information.

New York Public Radio transcripts are created on a rush deadline, often by contractors. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of New York Public Radio’s programming is the audio record.