How do physicians really feel about health care today?


If one relied mostly on social media as a barometer of the medical profession's views, one might get the impression that physicians today are a brooding and bitter lot, deeply dissatisfied with their careers and placing the blame on government, insurance companies, their own professional societies, and even their own patients. But more reliable analyses provide a more complete picture.

To illustrate the former view, a Daily Beast blog post from April 14, 2014, by internist Daniela Drake, MD, MBA, argued that medicine “has become a miserable and humiliating undertaking.” Westby G. Fisher, MD, posited on Oct. 14, 2013, on KevinMD.com that “the overriding reason doctors leave medicine” is because patients are acting like narcissistic teenagers: “The theme is like an adolescent who realizes his parents have feet of clay. In adolescence, he comes out of his childhood bubble and realizes his parents have failures and limitations because they are human beings. This results in the adolescent feeling unsafe, unprotected and vulnerable. Since this is not a pleasant feeling, narcissistic rage is triggered toward the people he needs and depends on the most.”

They are hardly alone. If you peruse KevinMD.com, SERMO, and other prominent social media sites for physicians, you can find many examples of those who are dissatisfied with their careers, are disgruntled with the advocacy they get (or feel they don't get) from ACP, the American Medical Association, and others, are angry at Obamacare, and, most disturbingly of all, are unhappy with their patients. Yet is this toxic stew of anger and angst really representative of most physicians? Not according to the available evidence from independent and statistically reliable polls of physicians, which show more nuanced views on the changes taking place in medicine.

Health information technology. A recent Commonwealth Fund/Kaiser Family Foundation poll found that 50% of physicians said that increased use of health information technology had a positive impact on their ability to provide quality care to patients, while 28% said it had a negative impact and 10% reported no impact.

However, a physician survey conducted by AmericanEHR Partners in conjunction with the American Medical Association, American College of Physicians, and American Academy of Family Physicians on use of electronic health record (EHR) systems in 2014 reported that 42% of respondents found their EHR system's ability to improve efficiency difficult or very difficult, 72% thought their EHR system's ability to decrease workload was difficult or very difficult, 54% thought their EHR system increased their total operating costs, and 43% said they had yet to overcome the productivity challenges related to their EHR system.

Similarly, ACP's own 2014 membership survey found that “Although 6 in 10 (61%) somewhat or strongly agree that their EHR improves the quality of care. ... about two-thirds agree that their EHR requires them to perform tasks that other staff could do (71%), that their EHR slows them down while providing clinical care (66%), and/or that it interferes with patient-doctor communication during face-to face clinical care (61%).”

Value-based payments. The Commonwealth/Kaiser poll cited previously also found that most primary care physicians are down on accountable care organizations (ACOs) and pay for performance and unsure about medical homes. “Physicians were more likely to view the increased prevalence of ACOs as having a negative (26%) rather than positive (14%) impact on quality of care,” the authors wrote. “Performance assessments and financial penalties tied to patients' outcomes are unpopular among providers. Half of physicians (50%) ... feel that the increased use of quality metrics to assess provider performance is having a negative impact on quality of care ... one-third (33%) of physicians ... said they believe medical homes are having a positive impact on quality of care ... while roughly 1 of 10 said the impact has been negative. About a quarter of each group said there has been no impact or they are not sure.”

Obamacare/Affordable Care Act (ACA). A different poll by the Kaiser Family Foundation found that physicians, like most voters, are split, with Democratic physicians approving of the law, Republicans disapproving, and Independents mixed. Yet more of the physicians rated the ACA as having a positive impact on access to health care and insurance in the country overall (48% positive, 12% no impact, 24% negative, and 14% not sure).

They were mixed on the quality of care their patients received (50% reported no impact, 18% reported a positive impact, 25% reported a negative impact, and 6% were not sure) and on the overall impact on their practice (31% reported no impact, 23% reported a positive impact, 36% reported a negative impact, and 9% were not sure). More reported that Medicaid expansion has had a more positive impact on patient care than a negative one. Most of the surveyed physicians said that patients' ease of getting appointments is about the same.

Career satisfaction. The same Kaiser Family Foundation poll found that “a large majority of primary care providers (83% of physicians and 93% of nurse practitioners and physician assistants)—both Republicans and Democrats—reported they are very or somewhat satisfied with their medical practice overall ... Indeed, current satisfaction levels are slightly higher than what was reported by primary care physicians before the ACA. In 2012, meanwhile, 68% of primary care physicians reported they were very satisfied or satisfied with practicing medicine.”

ACP's own membership survey found that “Seven in 10 members report that their ‘attitude today toward practicing medicine’ is ‘very’ (21%) or ‘somewhat’ (48%) satisfying.” Unlike the Kaiser poll, however, satisfaction among the College's members is trending to the negative, with “87% reporting that they were ‘somewhat’ or ‘very’ satisfied five years ago as compared to 66% currently. The shift in attitude appears to occur at the ‘very satisfying’ level; 46% describe their attitude as very satisfying five years ago and now only 20% do so.”

To recap, primary care physicians are not of 1 mind about the changes taking place in American medicine. They agree that health information technology has improved quality, yet they are dissatisfied with its effects on productivity and workload. They are skeptical about value-based payments, especially ACOs and performance measures, yet open to the potential of medical homes. They are divided along partisan lines on Obamacare, although most agree it has improved access and fewer than 1 out of 4 say that it has had a negative impact on quality. And while a large majority of primary care physicians are satisfied with their careers, there is reason to be concerned that levels of dissatisfaction may be increasing.

So rather than paying undue attention to the unrepresentative physician brooders on social media who see only the worst of everything, it would be better for policymakers to look at both the good and bad aspects of being a doctor today as seen through independent surveys of physicians and work to improve those causing the greatest concern, including reducing the adverse impact of EHRs on productivity, addressing concern about the reliability of performance measures, and making the ACA work even better for doctors and their patients, rather than seeking to repeal it.