Who will be your doctor when doctors quit?
A survey of 2400 physicians found that ObamaCare would cause a mass exodus of doctors, with 74% of them saying they would quit, retire early, work part-time, or switch to nonclinical work.
When Fox's Megyn Kelly discussed this, she was skeptical that so many doctors would quit after investing so many years in their education and training. I am less sanguine.
First, many doctors don't like their jobs. In my career, I've met only a handful who were thrilled to be physicians or surgeons; most continued to practice only because of their financial commitments. Making medical practice increasingly noxious, as ObamaCare will surely do, will shift the tipping point for many docs who are already fed up with the myriad hassles of medicine. Yes, doctors need money, but with a bit of help, anyone smart enough to become a doctor can figure out other ways to make just as much or even more money with less stress and less work.
Second, while many current doctors may feel trapped in their careers, making medicine more hellacious guarantees that more of the brightest students will choose others careers, leaving their places to applicants with less brainpower. This is already happening (see Why your next doctor may be cognitively impaired), thanks to the past few decades of frivolous lawsuits, declining reimbursements, and the joy of dealing with insurance company bureaucrats who would have felt right at home in Nazi Germany.
The inertia of sticking with a poor career choice is one manifestation of how people succumb to sunk costs, but relying on big mortgages and piles of student loan debt to keep doctors practicing medicine is a recipe for burnout and resentment that will inevitably degrade the quality of care.
I know what Obama and his daffy pals in Congress are thinking: When doctors tire of dealing with their crap, they'll try to fill their shoes with Physician Assistants (PAs) and Nurse Practitioners (NPs). PAs and NPs are not trained to replace doctors. They are intended to handle the easier routine cases, leaving the more complex ones to doctors. As I mentioned years ago when I was interviewed for a Men's Health article, I've worked with some excellent PAs and one that was so shockingly lazy and ignorant that I wondered if she were in cahoots with the local funeral home. Then I think of another PA who didn't know the correct term for hypokalemia, and another who'd never heard of methylmalonic acid.
If you would run away from a builder whose brain would light up into a giant question mark when asked about plywood or nails, you would run away from medical practitioners who look spiffy in their white coats but don't know the rudiments of medicine and surgery. If they don't know the basics, it's a cinch they don't know the million-and-one advanced things it takes to optimally diagnose and treat patients.
PAs are not supposed to practice independently, but I've seen cases in which their legally mandated supervision by physicians was just a perfunctory sham: instead of being seen by an ER doctor, ER patients were treated by a PA whose charts were signed the following week by a family practice physician who later became famous for his sexual escapades with patients that resulted in a self-imposed exile to Saudi Arabia after the state medical board permanently revoked his medical license and his cash-strapped wife began working as a waitress in a Mexican restaurant to supplement her income as a Wal-Mart pharmacist—yes, really. One of the involved PAs didn't know ER 101 essentials, such as how to examine a patient with a neck injury sustained in a motor vehicle accident. She had enough beauty to make my boss and the hospital administrator overlook her incompetence, but not enough brainpower and education to not endanger patients.
Just as flour, sugar, and butter can be combined to form many different foods, a smattering of signs and symptoms are the visible tip of the iceberg for a bewildering variety of diseases. While I think that well-educated and dedicated PAs and NPs are fine for treating routine cases or for following complex ones after being diagnosed by a doctor, I wonder how anyone who purports to be an expert in common maladies knows with certainty when the mélange of signs and symptoms now facing him or her add up to something other than a garden-variety problem.
Patients with difficulty breathing many have a common disease such as asthma, or they may have something uncommon, like idiopathic hypertrophic subaortic stenosis (IHSS). How much you want to bet that the PAs who were mystified by hypokalemia and methylmalonic acid wouldn't have a clue when faced with a patient with IHSS? (Unless they had a super stethoscope I invented years ago that makes such a diagnosis child's play.)
Almost all symptoms and signs are nonspecific. Even when they are combined, fever, cough, and lethargy can signal 1001 diseases, as can headache, sore throat, and chills. Let's be frank: doctors make plenty of diagnostic errors, but the way to improve this isn't to abbreviate education and training.
Less education is bound to lead to more mistakes. Years ago, one of the brightest nurses I knew approached me in the ER on a fairly slow night and asked if he could “play doctor.” That is, he'd do everything that I, as the real ER doctor, would do: take a history, examine the patient, generate a differential diagnosis, order tests, x-rays, EKGs (and interpret them), order treatment, and decide upon a final diagnosis and disposition. Since this was a slow night and I could supervise him, I had no qualms about this arrangement and gave him the OK to proceed. He looked flustered and stumbled on very basic ER cases that he'd seen ER docs handle with aplomb thousands of times. He struggled to think of a plausible diagnosis and, with no good idea of what the diagnosis was, the treatment plan was equally nebulous. He also could not perform a complete EKG interpretation even though he had far more years of ER experience than me. Most ER nurses are very good at interpreting cardiac rhythms, but I've yet to meet an RN who is skilled in interpreting a standard 12-lead EKG. Interpreting an EKG, by the way, is a very basic thing, sort of the doctor equivalent of what alphabet blocks are for preschool children.
When you watch someone do something, it is often deceptively easy to convince yourself that the activity is easier than it looks and that it'd be a piece of cake for you. I felt bad for this man because, from the hurt look on his face, it was clear he knew he had stumbled. He told me later that playing the role of a doctor had long been one of his dreams, and the dream did not turn out as he imagined. Had he obtained the same training as me, he could have been a topnotch ER doc. He had a high IQ, but not the training. Anyone who hopes to fill the shoes of a doctor obviously needs to receive just as much education.
fewer smiling doctors.
However, all of those years of working 110 hours per week memorizing unpronounceable polysyllabic words and making sacrifices that no one should have to make have a side effect: they create an understandable expectation that there is light at the end of the tunnel. When doctors find that the expected pot of gold is more like a pile of copper, and the abuse they are expected to endure changes from one form to another instead of going away, doctors are bound to feel gypped, engendering bitterness and resentment that fuels a desire to quit. Sunk costs be damned, just as they should.
Thus, when doctors quit—and they will, in droves—your healthcare practitioner might be one of the new docs who squeaked by the medical school Admissions Committee because more qualified applicants chose more rewarding careers with fewer drawbacks. Or your healthcare practitioner might be someone like the PAs whose brains are full of mush instead of facts about hypokalemia, methylmalonic acid, neck injuries, and everything from IHSS to dyshidrotic eczema.
What do you call an unqualified practitioner who plays doctor without knowing what doctors know? An unwitting walking death panel.
Perhaps this is Obama's ultimate goal: all those diabetic, hypertensive patients with heart and kidney disease along with undiagnosed nonalcoholic steatohepatitis (NASH) suck up too many healthcare dollars. The Community Organizer masquerading as President can't snuff 'em out by himself, but he can put those medically fragile patients in the care of people who frankly don't know what the hell they're doing. One gap in their knowledge and—boom!—the patient is dead so Obama can shower money on the UAW instead of that patient's future healthcare needs.
There are many ways to save healthcare dollars, and Obama is crafty enough to have found one. However, there are smart ways to save money, and then there are Obama's ways.
“The test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”
— F. Scott Fitzgerald
Reference: Imagining dialogue can boost critical thinking: Excerpt: “Examining an issue as a debate or dialogue between two sides helps people apply deeper, more sophisticated reasoning …”
