Recent medical news has focused on the need to recruit more health care workers because of the departure of many from the field. Although the COVID-19 pandemic certainly added stress to the work, there were difficulties that preceded the pandemic.

When I began practicing pediatrics about 40 years ago, the ratio of help needed to support me was 3:1 – or essentially nursing, secretarial and billing positions. Now the ratio is 16:1. That’s a lot of salaries for one provider to support, despite some being new and essential, such as an IT person. However, the offloading of some tasks of past smaller practices has been replaced by other burdens.

Primary care has historically been the most poorly reimbursed of medical fields. Now these are often the empty positions. I found it shameful that insurance would reimburse more for procedures as minor as freezing warts than for an hour spent resuscitating a newborn or counseling a suicidal teen.

My eight years of college and medical school, which cost $30,000 in the 1970s, now costs $600,000 for tuition only. This pushes young doctors away from primary care in order to pay back school loans using the higher salaries that come with subspecialty and surgical care.

There are many well described challenges for those currently providing health care. Insurance companies routinely challenge charges, limit reimbursement and also change coverage rules. Drug companies frequently deny prescriptions, something that necessitates time to respond and negotiate – and often re-prescribe.

The electronic medical record may offer clarity of notes but also requires mastery of every program change, a shameful lack of eye contact with the patient, and the skill for rapid data entry, primarily for the purpose of billing. Our patients’ mental health needs have soared, and can now rarely be addressed in compressed office visits.


We need to acknowledge that health care has become a business.

As medical practices and hospitals have been taken over by the corporate world, decisions are made by non-health care individuals and are based on economics. The emphasis is on revenue, and that means seeing more patients faster, despite the complexity of or lack of familiarity with their problems. It means closing and consolidating hospitals and practices. It also means hiring less expensive and therefore less qualified people to answer phones, screen patients and even provide care. Less overhead, more visits, more procedures, more “billable moments.”

At some point, most of us who entered medicine for altruistic reasons find ourselves providing a declining quality of care. We find that we have become a high-speed data entry person for the various corporations that decide how we practice medicine – the insurance companies, the drugmakers, even the corporations that run the practices and hospitals. Some of these corporations can use the label nonprofit because they pour the revenue into administrative salaries. In response to our feedback and calls for change, we are told that we must be more “resilient.”

Until we turn some of health care management back to those who are providing the care, we will continue to see a loss of qualified nurses and doctors. The problem is not only burnout with multiple demands and clerical work, but also what has aptly been labeled “moral injury.” We cannot provide the level of care that we know to be best and that we aspired to provide.

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