Physician As Journeyman

Like many other physicians, I am continuing to struggle with our future in the evolving healthcare field in the United States. I know that I have talked about physician burnout before and we have all been inundated by both commentary and scholarly discussions on the cause of burnout amongst physicians and what to do about it. I think it’s safe to say that none of us have a good answer.

Several recent blogs I have read seem to point to the idea that we are working too hard and there are not enough of us to meet the demands of the aging population. A natural solution, like many skilled trades is to unionize. This certainly has its advantages in terms of collective bargaining for certain minimum rights and to counteract the ever increasing regulatory burden that we all suffer with individually.

But there are several major flaws to the idea that physicians as a group should unionize. First, for many specialties, we do not have a shortage. What we have is a distribution problem. For example, the density of urologists in Michigan is relatively high in Southeast Michigan which includes Metro Detroit. However, go North of Lansing and we have sparse urologic coverage especially when you get to the upper peninsula. I see a lot of people for high level urologic oncology care from across the State but most urologic problems should not require a 6-12 hour round trip car ride to address. I suspect that outside of primary care specialties, mental health, and pediatric specialties, distribution and not supply are the issue.

And this naturally flows into my second point. Physicians are not a single monolithic group. What drives burnout and frustration in one group is entirely different than in another specialty. Hospitalists, ER physicians, Anesthesiologists, Radiologists, and Pathologists have different drivers from each other that markedly differ from surgeons, OB/GYN, and primary care physicians. Hence unionizing by health system or hospital which would make sense from a bargaining standpoint may be challenging because of the varied needs of different specialties.

Finally, there are legal and logistic challenges. Are we able to unionize? What is the law around this? And even if we do choose to unionize, right to work laws don’t require a physician in a hospital to be part of the union. Also, who do we bargain with- the hospital, the health system, the payers? For many surgeons, our interests are aligned with the hospital we operate out of and care for patients post-operatively and in many rural hospital, their margin is very tight so extracting better compensation or benefits may win the battle but lose the war.

An obvious solution is to try to turn back the clock where most physicians were in partnerships and many current large single specialty groups promote this as a way for physicians to extricate from the mess we are in. There are many problems with this model that are equally troublesome to the employed model that most of us find ourselves in currently. First, there is a need for critical mass to provide leverage for these groups with payers and health systems. While some large groups are attempting to franchise themselves across State lines to smaller practices often in partnership with venture capital, this cannot cover every group. There has to be a positive ROI for this to make sense to the big group. Communities are less concerned with ROIs and more concerned with care but doing the right thing is often not the driver of the equation when investors and shareholders are involved. Ultimately, the bigger problem is whether you are part of the mothership or the franchise, you are still employed by someone who expects productivity, margin, and adherence to regulations and metrics to cover the same types of overhead that health systems must cover. Sure, the practice supports ancillary income streams that support the bottom line but does not solve any of the other issues that are factors in burnout.

There is a third way that could help some physicians and address the lack of access to healthcare in rural areas. But to describe it, I have to pick up a few historical threads.

Kidney and bladder stones have burdened humanity throughout much of recorded history. The first descriptions of cutting for stone come from ancient Egypt and Hippocrates called out this care specifically beseeching physicians to leave this work to specialists. As such, a group of surgeons known as lithotomists arose to fill this need. They would travel from town to town cutting for bladder and urethral stones through the perineum or suprapubically. Outcomes were often poor and while specialized instruments and techniques were developed, the practice was barbaric due to the lack of anesthetic and often failure to appreciate the anatomy. For patients that did survive, they often lived with fistulas that left them debilitated.

However, the concept of itinerant surgeon traveling to meet the needs of patients rather than patients traveling especially for common disease processes makes sense. A patient really should not have to leave their locally community hospital to have a kidney stone treated or safely have their bladder drained when they are in retention or stabilize someone with gross hematuria. But for many patients, sometimes there is no other option but to travel to receive care.

While rural or underserved health systems try to recruit surgeons often at great expense, when they do find them, they often cannot keep them. Initial income guarantees are unsustainable, there is often no connection to the community to encourage someone to settle down, and being on a island leads to professional stress and isolation. I personally take lots of calls from solo urologists bouncing cases off of me where they know the right answer but just need to discuss with a colleague for confirmation. We take these interactions for granted in our big groups. Locums is the epitome of the itinerant doctor and solves the problems created by trying to recruit a permant clinicians but leads to lack of continuity of care and sometimes lack of quality control. In addition, this constant cycle is costly to patients and health systems.

Yet the idea can be modified and there are historical models that can be used to guide us. Guilds developed in medieval Europe as a way to ensure that certain skilled trades met certain standards. Traditionally, an apprentice would train with a master craftsman for seven years. Sure, it was not great-their pay was often in the form of room or board and they were essentially indentured to their mentor during that time. Eventually, however, these apprentices would graduate to journeymen who were employed and paid. They would work for a master craftsman but could leave and find other employment if they chose. While many never rose to Master craftsman, there was the opportunity to do so based on the rules of the particular guild.

Many journeymen would travel to work with different masters for three years before settling down. This allowed them to hone their skills and also carry new ways of doing things to other areas.

If this sounds familiar, that was the intention. Internship and residency mirrors apprenticeship while fellowship and many doctors’ first positions approximate the journeyman role. Lastly, established clinicians and academic faculty serve as master craftsman that keep the system afloat and transfer knowledge and expertise.

What if we could take pieces of the traveling specialist and the guild model of apprentice, journeyman, and master craftsman and create a model that would serve the needs of our patients and help fight some of the aspects of burnout that are afflicting practicing clinicians?

I still believe that one of the greatest factors in burnout is lack of autonomy for physicians. But I have been toying with another model that I call the Law of Addition without Subtraction. While physicians are the most skilled and highest paid employees of a health system, our time is not truly valued. More work gets piled on our plates and nothing is ever removed even if what we are doing no longer makes sense. The cutting and pasting of labs and other results into notes that are present in the electronic medical record and (un)meaningful use are two simple examples. But what about mandatory learning modules taken year after year or the countless mounds of emails and metrics we are exposed to? We need a system for physicians that values our time through appropriate compensation and decreased burden, meets the needs of patients, and battles burnout.

Instead of unionizing, different specialties should form guilds. You may argue that we have this already but national specialty societies are too removed and unfocused to serve the needs of their members. Regional or State specialty societies don’t seem to serve this role either. Guilds could be formed on a number of levels- a county, town, or logical region depending on the density of clinicians and the needs of the area. These guilds could then negotiate to provide services to underserved hospitals at an agreed on market rate that would appropriately compensate and support the clinician but free the doctor from billing issues. In exchange, these guilds would guarantee quality and ensure physicians are practicing to current standards. One way that this would fight burnout is that physicians could choose to take blocks of time off and still be compensated. The guild would ensure coverage and continuity of care. Some physicians could remain journeymen their whole career working part of the year and spending the rest of the time with family or pursuing other meaningful activities while others might choose to make a position permanent and graduate to a master craftsman getting the periodic support from a traveling journeyman. Fundamentally, this model could help re-establish the autonomy that many of us feel we have lost while serving the needs of patients and communities.

The cynic out there will say that this model cuts out the locums companies as middlemen but there are several distinct differences. First, a guild would establish quality standards for admission and ensure that members maintain this to remain in the guild. This self-policing strategy brings autonomy back to the clinician. Second, it creates a sustainable coverage model for underserved communities that locums cannot. A contract with a guild would guarantee service even when the covering physician gets sick because those in the guild who are not working at that time could cover. There are credentialing, privileging, and licensure issues to this type of coverage but potentially if a guild could attest to certain standards and outcomes, these processes could be shortened.

Ultimately, even if you do not like this idea, our current system is not sustainable for anyone. Burnout is taking our best clinicians out or leading them to become disengaged in change. Decisions are increasingly being driven by overly bureaucratic organizations based on metrics and margin statements without contemplating the physical and emotional toll on physicians, nurses, other clinicians, staff, and most importantly patients. The good will model of relying on the sense of obligation of professional to do more with less with the failed promise of improved efficiency through technology or process is running the ship to ground. Something has to change and a guild model might work for certain segments of physicians.

Thanks

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