For Physicians; The Cheese Has Moved


At last month’s American Medical Association (AMA) House of Delegates  Interim meeting in Dallas, attendees approved a resolution to study the  impact of physician unionization based on the growing concern about  physician employment arrangements by hospitals and health insurers.

While it’s not likely physician unions will sweep the country, it’s certain physicians aren’t happy. Their reasons are understandable:

Their clinical autonomy is being challenged.

Physicians train 11 to 15 years after high school to hone their skills. They are taught to be the patient’s advocate. They believe their opinion alone is the patient’s best path to health or recovery. Buoyed by patient trust and the complexity of their field, they plow ahead with diagnoses and recommendations based on their experiences as a practitioner. They “practice” medicine because it’s an ever-changing field. Most dismiss report cards that provide laypersons “data” about their clinical performance reasoning the underlying data is not valid or reliable. But the spotlight on their medical decisions is shining more brightly than ever. Powerful statistical tools are readily available to compare and contrast their accuracy in diagnosis and adherence to scientific
evidence of necessity. And employers, the media, and consumers are watching closely.

Their income is threatened.

The profession of medicine is the highest paid job out of 100 job classifications as tracked by the U.S. Bureau of Labor Statistics: this hasn’t changed for decades. Relative to the rest of the population, physician income per capita is 5.8:1 for the average
physician and much higher in some specialties. The compensation of U.S. physicians using per capita comparisons is second only to the Netherlands of 192 countries on the planet. While income per capita in the U.S. shrank during the recent economic downturn, physician income improved.  Malpractice costs are down, but overhead is going up. Nonetheless, physicians believe their income will be lower going forward as a result of three forces: 1) the added cost of compliance with government mandates (e.g. meaningful use, Physician Quality Reporting System, et al.); 2) decreased payments from Medicare, Medicaid and private insurers,  and; 3) increased operating costs for their practices. It’s a tsunami physicians fear. And the make-good—working
harder and doing more—is  not an option for many who already face questions about the appropriateness of the tests and procedures they do and the conflicts of interest that might influence these decisions.

Their profession is under attack.

Referencing a recent determination by the U.K.’s National Health Service that it is safer for women with uncomplicated pregnancies to give birth under a mid-wife’s care compared to a hospital setting run by physicians, the New York Times editorial
board asked “Are Midwives better than Doctors?”. Three days later, it headlined its editorial “Tortured by Psychologists and Doctors” criticizing the ethicality of their complicity into the use of “enhanced interrogation techniques” and their application of “learned helplessness” in the design of the CIA’s intelligence program. Everyday, it seems, there’s more information about doctors on page one, and much that’s not flattering. It’s about business dealings and conflicts of interest. And as statisticians sort thru newly released data from the CMS Physician Compare, the Physician Sunshine Act, the Medicare Physician database and others, it’s certain the prevalence of unflattering storylines will increase. Last week, Time Magazine named as its “Person of the Year” the Ebola virus fighters—healthcare workers who risk their lives to care for the thousands in West Africa afflicted by
the virus. This story is about the profession to which most physicians and nurses aspired as they started their professional journey. But regrettably, the public’s trust in the profession has slipped—much the result of self-inflicted wounds.

Spencer Johnson’s “Who Moved My Cheese? An Amazing Way to Deal with Change in Your Work and in Your Life” was published 1998 and has sold 26 million copies in 37 languages. It’s a story about handling change: two mice, Sniff and Scurry, that navigate a maze from Cheese Station C to Cheese Station N as the cheese supply dwindles, and two humans, Hem and
Haw, who are annoyed, angered and ill-prepared to address the cheese shortage at Cheese Station C. Haw sets out to find a new source; Hem, defiant, asks “Who Moved my Cheese?” and refuses to join Haw’s search.

Haw eventually finds Cheese Station N and, upon reflection, pens lessons he hopes Hem will learn when and if he arrives:

*  Get ready for the Cheese to move
*  The quicker you let go of old Cheese, the sooner you will enjoy
the new Cheese
*  Move with the Cheese

For physicians, the cheese has moved. Cost reduction, shared risk arrangements with payers, team-based care coordination, adherence to evidence-based guidelines, stricter controls of conflicts of interest and self-referral, increased transparency, increased investment in information technologies, the convergence of allopathic and alternative therapies, and an orientation toward shared decision-making with patients are here to stay.

Some physicians are like Hem: fiercely committed to defend the status quo and dismissive of peers who search the maze. Having M.D. or D.O. after their name, they reason, entitles them to practice as they choose as much as they choose. They’re hoping the cheese supply at Station C doesn’t run out.

Others, like Haw, navigate the maze and find Cheese Station N. They learn new skills, find new ways to engage with peers and patients, and identify roles that acquit them to leadership capably.

None will survive at Cheese Station C long-term. The cheese moved.