Dissatisfaction with Medical Practice
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Zuger's article (Jan. 1 issue)1 about physicians' dissatisfaction is fascinating but does not mention that health care is increasingly dominated by large organizations whose leaders may sometimes be incompetent, self-interested, and even corrupt. As power is concentrated in larger organizations, the ability of their leaders to do good or ill also increases.2 Zuger quotes Ludmerer, but not his concern about "medical school and hospital officials [who] approached academic medical centers much as if those institutions were making cars or breakfast cereals."3
Multiple anecdotes about bad leadership have appeared in the local news media but are rarely mentioned in the medical and health research and policy literature. Consider the example of the ultimately bankrupt Allegheny Health, Education, and Research Foundation, assembled by a chief executive officer who paid huge management salaries, covered up increasing debt, and wound up convicted of misapplying charitable funds.2
Physicians who must deal with such leadership cannot help but be demoralized and even despairing. It is time for the clinical, health care research, and health policy communities to address these issues.
Roy M. Poses, M.D.
Brown University Center for Primary Care and Prevention
Pawtucket, RI 02860
roy_poses@brown.edu
References
Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004;350:69-75.
Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Intern Med 2003;14:123-130.
Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. Oxford, England: Oxford University Press, 1999:367.
To the Editor: Dr. Zuger mentions that "the recent interest in identifying and preventing medical errors has magnified feelings of insecurity." This is actually the tip of an iceberg: the beating we regularly take from within the medical establishment. Regarding issues such as racial disparities in care, sexual disparities, noncompliance with medications, or adherence to guidelines, our "colleagues" in academe tell us we are racists, sexists, ignoramuses who never read a journal, or lousy communicators. Meanwhile, the "noncompliant patient" is an evil construct born of paternalism. In short, everything that is not ideal is directly our fault, and this in an age when we have less control than ever over patients' behavior. Ergo, patients have authority and no responsibility, whereas we are assigned responsibility and no authority. This is a nightmare straight out of "Dilbert" and a sure recipe for stress and burnout on the part of physicians.
Stephen M. Sokolyk, M.D.
2286 Kensington Way
New Braunfels, TX 78130
ssokolyk@aol.com
To the Editor: Dr. Zuger confirms that doctors making $250,000 or more are happier than doctors making less money. The only solutions I could find in the article were exercise, more family time, and so forth. I was surprised that the author does not say that better reimbursement for our services would reflect society's value of our services and thereby relieve many of the difficulties of private practice and lead to a happier and more satisfied medical community.
Richard S. Margolis, M.D.
Shady Grove Adventist Hospital
Rockville, MD 20852
rsmargolis@hotmail.com
To the Editor: Although Zuger provides a thorough review of the literature on physicians' dissatisfaction with medical practice, I am troubled by her dismissive tone and appalled by her list of possible solutions. Suggesting that physicians respond to the brokenness of the American health care system by improving diet and exercise or lowering expectations makes as much sense as treating the fever of bacterial sepsis with a cold cloth to the forehead.
Zuger asserts that the root causes of physicians' dissatisfaction are malpractice and managed care. Why not address them head on? There are credible efforts under way at both the state and federal level to seek reasonable resolutions of the malpractice crisis. Abandoning or reforming managed care would decrease dissatisfaction by more than 50 percent.1 One interim step along that path would entail the use of information technology at the point of care to result in administrative simplification.2,3
Medicine has progressed by attempting to define and then treat the causes of disease, and not simply masking the symptoms. We should address our ailing health care system with no less courage or rigor.
Peter Basch, M.D.
MedStar Health
Washington, DC 20003
peter.basch@medstar.net
References
Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians' view. Health Aff (Millwood) 1997;16:139-148.
Sox HC. Saving office practice. Ann Intern Med 2003;139:227-228.
Basch P. Quality of health care delivered to adults in the United States. N Engl J Med 2003;349:1867-1867.
The author replies: An overview of physicians' dissatisfaction could be written in millions of different ways — one for every doctor in the world. Any single attempt will necessarily seem incomplete to some readers and wrongheaded to others.
Poses and Sokolyk bring valuable additional points to the discussion. Misguided corporate leadership can certainly exacerbate physicians' feelings of powerlessness and lack of control, as can rifts between the policy-setters of medical academia and ordinary doctors in the trenches.
Margolis suggests that better reimbursement would improve doctors' spirits. Although some studies indicate that doctors with high earnings are happy doctors, others do not.1 The philosophical and ethical assumptions behind such an equation are troubling, and one wonders whether better reimbursement might not simply exacerbate the societal ill will that saddens many doctors today.
Basch erroneously states that I endorse "lowering expectations" among physicians. In fact, the phrase used in the article is "more accurate expectations"— not necessarily the same thing. He uses a 1995 survey documenting twice as much physician dissatisfaction in states with high health-maintenance-organization penetration2 to argue that abandoning managed care would cut overall national rates of professional dissatisfaction in half. The validity of such a calculation is dubious, and the considerable professional unhappiness evinced by many physicians in countries without managed care suggests that the problem transcends this particular solution.
Finally, both Margolis and Basch misunderstand when they assume that the list of proposed solutions to the problems of physicians' dissatisfaction at the article's conclusion are my personal recommendations. Far from it: like the rest of my article, my conclusion aimed to summarize the relevant literature as comprehensively and impartially as possible, with citations for the sources for all the recommendations. My own personal set of solutions to the substantial problems facing our profession has yet to be written. When it is, I can assure readers that exercise and diet advice will not be part of it.
Abigail Zuger, M.D.
Albert Einstein College of Medicine
Bronx, NY 10467
Abzug@panix.com
References
Williams ES, Konrad TR, Linzer M, et al. Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health Serv Res 2002;37:121-143.
Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians' view. Health Aff (Millwood) 1997;16:139-148.
Multiple anecdotes about bad leadership have appeared in the local news media but are rarely mentioned in the medical and health research and policy literature. Consider the example of the ultimately bankrupt Allegheny Health, Education, and Research Foundation, assembled by a chief executive officer who paid huge management salaries, covered up increasing debt, and wound up convicted of misapplying charitable funds.2
Physicians who must deal with such leadership cannot help but be demoralized and even despairing. It is time for the clinical, health care research, and health policy communities to address these issues.
Roy M. Poses, M.D.
Brown University Center for Primary Care and Prevention
Pawtucket, RI 02860
roy_poses@brown.edu
References
Zuger A. Dissatisfaction with medical practice. N Engl J Med 2004;350:69-75.
Poses RM. A cautionary tale: the dysfunction of American health care. Eur J Intern Med 2003;14:123-130.
Ludmerer KM. Time to heal: American medical education from the turn of the century to the era of managed care. Oxford, England: Oxford University Press, 1999:367.
To the Editor: Dr. Zuger mentions that "the recent interest in identifying and preventing medical errors has magnified feelings of insecurity." This is actually the tip of an iceberg: the beating we regularly take from within the medical establishment. Regarding issues such as racial disparities in care, sexual disparities, noncompliance with medications, or adherence to guidelines, our "colleagues" in academe tell us we are racists, sexists, ignoramuses who never read a journal, or lousy communicators. Meanwhile, the "noncompliant patient" is an evil construct born of paternalism. In short, everything that is not ideal is directly our fault, and this in an age when we have less control than ever over patients' behavior. Ergo, patients have authority and no responsibility, whereas we are assigned responsibility and no authority. This is a nightmare straight out of "Dilbert" and a sure recipe for stress and burnout on the part of physicians.
Stephen M. Sokolyk, M.D.
2286 Kensington Way
New Braunfels, TX 78130
ssokolyk@aol.com
To the Editor: Dr. Zuger confirms that doctors making $250,000 or more are happier than doctors making less money. The only solutions I could find in the article were exercise, more family time, and so forth. I was surprised that the author does not say that better reimbursement for our services would reflect society's value of our services and thereby relieve many of the difficulties of private practice and lead to a happier and more satisfied medical community.
Richard S. Margolis, M.D.
Shady Grove Adventist Hospital
Rockville, MD 20852
rsmargolis@hotmail.com
To the Editor: Although Zuger provides a thorough review of the literature on physicians' dissatisfaction with medical practice, I am troubled by her dismissive tone and appalled by her list of possible solutions. Suggesting that physicians respond to the brokenness of the American health care system by improving diet and exercise or lowering expectations makes as much sense as treating the fever of bacterial sepsis with a cold cloth to the forehead.
Zuger asserts that the root causes of physicians' dissatisfaction are malpractice and managed care. Why not address them head on? There are credible efforts under way at both the state and federal level to seek reasonable resolutions of the malpractice crisis. Abandoning or reforming managed care would decrease dissatisfaction by more than 50 percent.1 One interim step along that path would entail the use of information technology at the point of care to result in administrative simplification.2,3
Medicine has progressed by attempting to define and then treat the causes of disease, and not simply masking the symptoms. We should address our ailing health care system with no less courage or rigor.
Peter Basch, M.D.
MedStar Health
Washington, DC 20003
peter.basch@medstar.net
References
Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians' view. Health Aff (Millwood) 1997;16:139-148.
Sox HC. Saving office practice. Ann Intern Med 2003;139:227-228.
Basch P. Quality of health care delivered to adults in the United States. N Engl J Med 2003;349:1867-1867.
The author replies: An overview of physicians' dissatisfaction could be written in millions of different ways — one for every doctor in the world. Any single attempt will necessarily seem incomplete to some readers and wrongheaded to others.
Poses and Sokolyk bring valuable additional points to the discussion. Misguided corporate leadership can certainly exacerbate physicians' feelings of powerlessness and lack of control, as can rifts between the policy-setters of medical academia and ordinary doctors in the trenches.
Margolis suggests that better reimbursement would improve doctors' spirits. Although some studies indicate that doctors with high earnings are happy doctors, others do not.1 The philosophical and ethical assumptions behind such an equation are troubling, and one wonders whether better reimbursement might not simply exacerbate the societal ill will that saddens many doctors today.
Basch erroneously states that I endorse "lowering expectations" among physicians. In fact, the phrase used in the article is "more accurate expectations"— not necessarily the same thing. He uses a 1995 survey documenting twice as much physician dissatisfaction in states with high health-maintenance-organization penetration2 to argue that abandoning managed care would cut overall national rates of professional dissatisfaction in half. The validity of such a calculation is dubious, and the considerable professional unhappiness evinced by many physicians in countries without managed care suggests that the problem transcends this particular solution.
Finally, both Margolis and Basch misunderstand when they assume that the list of proposed solutions to the problems of physicians' dissatisfaction at the article's conclusion are my personal recommendations. Far from it: like the rest of my article, my conclusion aimed to summarize the relevant literature as comprehensively and impartially as possible, with citations for the sources for all the recommendations. My own personal set of solutions to the substantial problems facing our profession has yet to be written. When it is, I can assure readers that exercise and diet advice will not be part of it.
Abigail Zuger, M.D.
Albert Einstein College of Medicine
Bronx, NY 10467
Abzug@panix.com
References
Williams ES, Konrad TR, Linzer M, et al. Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health Serv Res 2002;37:121-143.
Donelan K, Blendon RJ, Lundberg GD, et al. The new medical marketplace: physicians' view. Health Aff (Millwood) 1997;16:139-148.