This has been manipulated since roughly the eighties to increase HMO profit. There was a thesis that most physicians are not trying to maximize revenue, but trying to hit a target upper middle class lifestyle. If you cut FFS reimbursement down by 20%, they'd increase the amount of patients they pack into a waiting room by 20% (rather than taking a 20% pay-cut by seeing the same number of patients, or saying "fuck you" and no longer accepting patients from that insurer). And that's precisely what happened. That has driven the ongoing trend since in which revenue falls, number of patients per hour increases, and the result is physician income that hasn't kept up with cost in education or changes in purchasing power. You, too, would be very upset if you were being asked to work more and make less.

This also makes physicians a target for every spending adjustment measure. Physicians are not the primary driver of cost growth in america: new procedures and changes in drug prices are (when was the last time an internist raised his prices 5000%? Never, because his reimbursement is set by Medicare). But they do write the prescriptions and orders and referrals. This means that the entire system converges on controlling physician activity.

This plays directly into government willingness to expand on training positions. The government has a budget to hit; in fact, CMS is required to do studies showing that any changes they make will ultimately be budget-neutral, because they're legally obligated to protect the Medicare Trust Fund. As you see above, healthcare costs for the nation scale linearly with the number of physicians: if a doctor's total revenue for the year is capped at available time * service unit revenue/time, well, CMS' costs are that plus the cost of whatever service or drug he prescribes in that unit time. Double the docs, you double manpower costs, and double the opportunities for prescribing, in the context of trying to minimize healthcare cost.

So why are physicians burning out? Why are fewer and fewer "best and brightest" applying to medical school?

- Increased accountability with decreased authority. As the centerpoint for changes in documentation and prescription patterns, everyone is twisting physicians' arms to act in very precise ways, whether or not those ways are what the physician believe is good for the patient. Physicians get the scoldings, the pay decreases, the public scrutiny -"why don't doctors X?!" "why are doctors doing Y?!" - and none of the power to actually decide any of this.

- Decreased authority in the hospital. Hospitals are suffering the invasion of the MBAs (and MPHs, and MHAs), and have more and more people with zero clinical knowledge setting policy. The big trend has been in nurses getting MBAs (and MHAs and MPHs) and going into administration, combining "I saw what doctors do from the side, I must totally know what's going on in their heads, right?" with MBA acumen. It's deeply problematic. "This patient has depression, and you didn't give them an SSRI! Malpractice! What's wrong with you?"

"This patient has multiple comorbidities that are more serious than their depression. I have them on medications for those comorbidities, and those drugs are all second-line therapies for depression. Time has shown that this combination has been effective for controlling their depression, and as a bonus, I avoided risking the side-effects of putting this patient on a third medication."

You cannot imagine the absolute pleasure of being regularly second-guessed by someone with a tiny fraction of your training. I imagine it's rather like a senior engineer having their code regularly criticized by someone that just finished "learn python in one week!". And they will then go to the EMR folks and have them add an alert, so that I can never place an order w/o SSRIs for a patient w/ depression without going through a whole Alert! rigamarole. There are so, so many alerts that alert fatigue is ubiquitous.

Additionally, in (fair) response to bad behavior of physicians in the past, nursing and other auxiliary services have moved into parallel reporting structures.

So, when patients are mad at something that has happened in the hospital, they call the doctor and yell at them! How could the hospital have done such a thing! I have no authority over the nurses that did it, or the nurse MBAs that made the policy, but I will get to take the scolding, the risk of malpractice suit (because patients don't sue over errors - they don't know enough medicine to identify errors - they sue over breakdowns in relationships with physicians), have zero authority to change or fix anything, and if I say a word, it's outside of my operational stovepipe and I will be both ignored and ultimately ignored by nurses. The latter means that my future care orders will be ignored or given low priority, and I can rely on that ultimately affecting my patients. So I have to keep my mouth shut over anything less than egregious problems.

- Increased time doing things unrelated to patient care. There's a myth that somehow all this new documentation is meant to improve patient care. It does not. The three major reasons have absolutely nothing to do with patient care:

---Many of the increases in documentation have to do with increasing specificity that strictly increases opportunities for error, and thus reimbursement denials.

---CMS wants increasing information on practice patterns, and wants to extract this from EMRs. Because they can't spend any money to collect this information (as I said above, they are required to be budget neutral), they shift this cost onto hospitals, which shift it onto physicians (it's worthwhile for hospitals to comply, because otherwise CMS brings out the reimbursement stick.)

---EMRs make billing more reliable, and reporting data to CMS more easy, and are required now as part of the ACA. EMRs are slow as fuck, because the end-user is not the customer. Their UIs are just fucking atrocious. There aren't words enough to relate how bad they are. Most can't even present lab results in a decent way.

The result is more documentation, done more slowly, for reasons unrelated to taking care of the patient in front of me - but that none the less take time away from seeing the patient in front of me.

And there is a constant media barrage about how terrible physicians are, which studiously ignores that 99% of the things they are describing and criticizing are systems-level issues physicians have no control over.

On top of all this, I have only rarely met a physician without a real sense of professional pride. That we are ordering tests we don't want to order, creating delays we don't want to create, hiring shitty front desk staff we don't want to hire, creating massively packed waiting rooms we'd rather not have, while patients are being bled dry by their pharmaceutical companies, all while working our asses off, getting scolded for it, and having trouble paying off our ever-growing student loans is... it's fucking heart-breaking.

It's heart breaking.

You have no idea what a tide of idealism enters medical school, and what a shambling army of heart-broken zombies is left by "mid-career." If anyone was willing to pay me my current salary to see a dozen patients a day rather than thirty, to give every single one of them the extended visit to collect a rigorous history and give them the scrutiny they deserve, I'd take it in a heartbeat.

You want me to be that doctor. I want to be that doctor. The delta between that, and what the system allows me to be, hurts us both.