Doctor’s Are Living The Good Life … Aren’t They?
General

Doctor’s Are Living The Good Life … Aren’t They?

In this third and final part in our series on Healthcare Workers, we focus on the way being a doctor in America has changed, and try to clear up some myths about physicians.

Physician Burnout: Feeling the Squeeze

The final piece of the physician burnout puzzle concerns time and money. We touched on these a little in Part 2 of our series when discussing the complex billing in managed care and the pay disparity between hospital administrators and doctors. That was just the beginning.

Doctors contend with numerous assaults on their incomes as well as their time that pile on stress and sap their job satisfaction. Burnout is closely related to threats to doctors’ incomes and ever-increasing, often unnecessary job demands. Thirty-nine percent of doctors cite, “too many work hours” as a prime culprit, and one-quarter feel they are not paid fairly.  Many feel corporate healthcare puts “profits over patients,” and one in eight feels that maintenance of certification requirements are too onerous.

Living The Good Life?  Let’s Look Deeper.

Let’s start with how much doctors earn. Everyone assumes that doctors are “rolling in dough” and “living the good life,” but that’s not simply not true. The lowest paid doctors are primary care physicians and pediatricians, who make, on average, $200,000-225,000 each year. At the other end of the spectrum are Orthopedic and plastic surgeons averaging in the $400,000 range. Given these numbers, it’s no wonder most people see doctors as rich. I mean, that is way above the average American worker’s salary, right? But what most people are not aware of is that is only part of the story.

Despite making what seem at first like, “the big bucks,” doctors have a lot of strains on their income throughout their careers. The heftiest cost is their training, both the price of medical school and the years of income they forego from not choosing a different occupation. Even though doctors’ incomes are a lot higher than the national median income, that only comes after four years of undergraduate college, then four years of medical school, and finally three to eight years of residency.  During college and medical school they are not earning any money and are accumulate debt for high tuition, living expenses, and more. That is eight years of lost potential income, and growing debt before a doctor earns their first dollar. So doctor’s begin their careers already in the hole.

Opportunity Cost

If, instead of medicine, doctors had gone into business, finance, law, or any other career that their college peers had chosen, they could have started making money many years earlier.  This is called “opportunity cost.” It represents all the possibilities that are given up when you follow one path and not another.

Life is full of opportunity costs. Every choice you make has them. The choice to become a doctor costs, at minimum, 11 years of education beyond high school and several hundred thousand dollars of income from another potential profession. And that’s in addition to the several hundred thousand dollars of debt from both undergraduate and medical school.

Doctors do earn money during residency, the period of specialized training that takes place after they graduate from medical school.  However, the amount they are paid is a pittance relative to the number of hours they work and what they could be making if they were already four years into another career. Residents make just over $61,000 a year on average, but they are working up to 80 hours a week and sometimes more. If you do the math, that comes out to $15 an hour for a high-pressure job where peoples’ lives are literally in their hands.

Money Worries

By the time they have completed four years of college, four years of medical school, and three to eight years of residency, most doctors don’t really start earning their professional-level salaries time until they are into their 30’s. They are years behind their peers in buying a home, investing, saving for their kids’ college educations, and putting away money for retirement.

In fact, retirement is a major concern for doctors because they have fewer years of high income and several hundred thousand dollars more of debt. Imagine being 60 years old and still putting in 60 hours of work per week, but not being close to retiring.

Dr. Mike Stern, a trauma surgeon with Central Maine Healthcare, confirmed this sentiment.  “Retirement savings is super postponed, income ‘looks good on paper,’ but then you take away a ton in taxes, try to buy a house, etc. By the time you realize that all those years are gone that could have been spent saving from a traditional job, someone with a much less paying job can actually have a way better retirement.”

The Skyrocketing Price of Medical School

Speaking of cost, let’s spend a bit of time on the truly ridiculous cost of medical school in America. Since 1990, the cost of a private medical school education has tripled, and the cost of a public medical school education has quadrupled. The average medical student now graduates with six times the debt they would have three decades ago.

How could this possibly happen? Has the human body become three times more complex? Did our organs suddenly multiply in number and intricacy? There are certainly more medicines and technology available, but that hardly explains this gross increase in cost.

Graduating doctors certainly hate their skyrocketing debt. Many ultimately pay close to half a million dollars to enter the profession. How do you attract the best and brightest when these intelligent young people could easily go into business, finance, or almost any other profession, with way less initial investment and subsequent financial and personal stress? It just doesn’t make sense.

While the cost to become a doctor has far outpaced inflation, physician salaries have only barely kept up with it. It’s no wonder many medical students plan to avoid the lower paying specialties.

Mountains of Debt

Let’s get into some raw, painful numbers. The average medical school debt is over $230,000. Almost one in five medical students borrow over $300,000. Loans from undergraduate school tack on at least another $20,000. The usual time to pay off these enormous sums is over 13 years.

Dr. Stern remarked he carried double the average debt, adding, “I don’t really feel like it’s worth it financially.” Dr. Michael Pang, a hospitalist in Scottsdale, AZ, had a different take, noting that he attended medical school in the 1990s when it was much less costly. “For me it was worth it, but I had scholarships to med school (tuition and books paid for) and so didn’t come out of med school with a huge debt.” This gaping divide in their experiences demonstrates the massive increase in cost.

Making Payments

Many residents don’t make any payments on their loans during residency; however, interest gets added on to the original part of the loan. Ultimately, doctors must pay interest on their interest, which adds an average of $58,000 in interest during residency alone.

You might be thinking, “Why not just start making payments during residency?” Well, $58,000 in interest during residency works out to about $1,000 in interest each month. To a resident who has finally started making money after eight years of higher education, the idea of putting $1,000 each month, one-quarter of their income, towards interest is just too much to bear.

After residency, this increasing interest doesn’t let up. Because paying off the loans takes so much time (up to 20 years in many cases), the total cost of repaying the loan actually costs from $400,000 to half a million dollars. If you combine this debt with the missed income (the opportunity cost we talked about earlier) from years of medical school and the years of terrible pay in residency, doctors come out of residency about $1 million poorer than if that had pursued other careers.

We could do better, though. America spent $3.6 trillion on healthcare in 2018. It would cost less than 0.1% of that to make all medical schools tuition-free. This would take the pressure off medical students when considering which specialty to choose and make it more affordable to become a primary care doctor, one of the fields with the lowest income. This would also certainly help address the growing doctor deficit in America. If we’re really serious about producing more doctors, especially primary care doctors, we need to do a better job of supporting that goal by making it more attainable and attractive to intelligent young people.

Working Fools

Now, let’s talk about how much doctors work – because they work A LOT.  One in four work more than 60 hours a week, and just as many work at least 50 hours a week. Only a few work less than full time.[xx]

Dr. Stern reported averaging around 60 hours a week. He said “of course” he would like to work less, but it was simply not a financial option.

Long hours by themselves are no stranger to professional people in many fields other than medicine.  But the difference here lies in these ugly facts: Physicians are learned professional who have completed years of training,  overcome many hurdles, and passed extremely difficult tests at many steps along the way to prove themselves. After making all the personal sacrifices needed to achieve the goal of becoming a full- fledged physician, they once carried status and respect both professionally and socially. Their work was gratifying because they could apply their acumen to make responsible decisions, form trusting relationships with patients and families, and help people through illness and suffering. 

In today’s American healthcare system, doctors have become like factory workers. Most are employed by big healthcare corporations and have little autonomy to practice medicine the way they desire. They still carry all the emotional and legal liability if something goes wrong, yet they do not have authority or autonomy to decide how to practice and how much time to give individual patients. Working 60 or more hours a week is much more difficult under such circumstances.

Residency Hours

These long hours start in residency. There is a long backstory to the fight over resident hours, but the short of it is that 75 years ago, residents routinely worked over 100 hours a week. They actually lived at the hospitals where they worked, hence, the term “residents.”

Resident strikes, patient deaths, and threats of action by Congress have led residency programs and the organization that oversees them (the Accreditation Council for Graduate Medical Education) to reduce resident hours to a maximum of 80 hours per week.

Forced to Lie

Unfortunately, there are numerous incentives for residents to under-report their work hours. A residency program that repeatedly exceeds duty hours can lose its official status. When this happens, it forces the residents there to find another program to take them, a terrifying and difficult proposition for them.

They could also be punished by their program directors or other residents for putting their program in jeopardy. Dr. Stern said he never felt forced to lie about hours in his residency. However, he did state, “There are people who force you to do too much, and that’s where [a work hour limit] is mildly helpful. I do think there are a ton of places lying about it based on what I hear.”[xxv] Sixty percent of residents under-report their work hours, making the regulations all but useless. This is how the unhealthy culture of overworking starts early in doctors’ careers.

Living to Work

You’d think things would get better after finishing training, but they don’t. The long hours never let up, and some doctors are getting sick of this culture. More than half of doctors want to work fewer hours. Specialists who work fewer hours have higher job satisfaction, while those who work longer hours are much less happy.

The proliferation of technology and electronic health records now allows work to follow doctors home. Doctors do one to two hours of extra paperwork every day from home, often lying in their beds at night during what’s called “pajama time.” This serves as a daily reminder to doctors that they spend twice as much time on paperwork as they do with patients.

Dr. Stern reported that he tries “to finish work at work,” but that’s not a hard and fast rule. “On my days where I’m not seeing patients, sometimes I will follow up labs, etc… from home.”

Doctors with the highest volume of patients get hit the hardest with this extra work. These are mostly primary care physicians, who are among the lowest-paid doctors and serves as yet another insult to them. Ultimately, medical students see these crazy hours, late nights, and mountains of unpaid paperwork and choose to chase the highest-paying specialties with the best hours. No wonder America has so few family and primary care doctors.

The “Maintenance of Certification” Scam

Despite working so hard, doctors work in a system that seems to doubt their expertise on several levels, one of the sorest points for burned-out doctors. At the end of residency, newly minted doctors take their “board” exams, which certify them as being competent in their profession in the eyes of the American Board of their chosen specialty.

While the board organizations that require these exams insist they are necessary because they improve patient care, not everyone is convinced. If these exams were so important, you would expect the rules around them to apply equally to all doctors; however, they do not. In fact, older doctors who became board certified before 1990 are certified for life, while those certified after that year must retake the exams every seven to ten years.

The practice might pass muster in other industries, but in a job where people’s lives are at stake, it undermines the legitimacy and alleged necessity of retaking these exams periodically. If these exams are so important and the safety of patients is truly at stake, then everyone, no matter how long ago they graduated from residency, should have to take them regularly. So, is there something special about these older doctors who are able to practice medicine without retaking the exams?

This unexplained exception makes it seem like this is nothing more than a money-making scheme at worst or, at best, a poorly organized and inconsistently implemented attempt to ensure competency. And this discrepancy is not lost on doctors today who are frustrated with the system, to say the least. The science is with them, too. A study looking at health outcomes in 68,000 Veterans Affairs patients found no difference between those treated by younger doctors who retook certification exams regularly and older doctors who did not.

A Drain on Time and Money

What’s even more insulting is the ridiculous price tag for these exams. Written exam fees run over $1800, and the oral exams are not far behind that. Many specialties require a third exam with a similar cost. Doctors also have to pay yearly fees for things like organization dues which can be another few hundred dollars. If they don’t pay this, they risk losing their certification status even though they took and passed the tests.

Beyond these eye-popping numbers, there’s the time doctors have to make to study for these exams and the special preparation materials that they have to buy. Study courses and practice tests can cost thousands of dollars. Preparation time comes out of doctors’ free time as well as from time they would normally be at work. When they work less to study, they miss out on income. All of these extreme costs add yet another drain on their finances and are a headache to their busy lives.

You might think doctors should be able to just walk right into a test and take it without preparing since they “do this stuff” every day. However, the tests are actually full of obscure details that have little relevance to everyday practice. Two-thirds of doctors say the recertifications and other requirements do not help their daily practice of medicine at all. And for many older doctors, these tests are so onerous that they would rather retire early rather than take another one just so they can practice for a couple more years.

Big Profits for a Non-Profit

These high test costs serve to line the pockets of the supposedly non-profit organizations that administer the board exams. A 2017 study confirmed that these “non-profit” groups had actually been raking in huge profits in recent years. The board organizations reported $25 million in profit and $264 million in total income. The vast majority of that income comes from testing fees; however, they only spend a fraction of that income actually administering the tests.  In fact, they spend much more just running their organizations.

There is no justification for these organizations to take in four and a half times as much money from these fees as they spend to administer the tests. They are failing the only responsibility they have tasked themselves with. Most of their income goes to propping up bloated bureaucracies, while much less goes to the only real service they actually provide.

Running a Racket

These organizations hold a monopoly on this testing and have created a system that essentially makes it mandatory. They claim that the testing is not mandatory; that it is just extra proof of a doctor’s capability. But in reality, it essentially is. Doctors have lost admitting privileges at hospitals and been refused payment by insurance companies for not keeping up with these certifications.

The American Board of Medical Specialties (the overarching group that includes all of these specialty board organizations) actively promotes the necessity of certification to patients. They even set up a service called “Certification Matters” and a website that allows patients to investigate whether their doctors are board certified. As a result, they have convinced 95% of Americans that their doctor should keep up with this arbitrary certification.

This organization also collects vast amounts of data on physician practices, which they don’t just keep to themselves. They sell it. To pharmaceutical companies, biotech firms, and anyone else in the industry. This scheme makes money for them from doctors desperate to stay employed as well as medical corporations looking to profit.

What makes all this even worse is that it is redundant: There is already a system in place for ensuring that doctors keep up to date. This is called Continuing Medical Education (CME), and it is required by state licensing boards in order for doctors to maintain their legal right to practice medicine. Doctors have to pay for this, too, of course; but it has existed far longer than the Maintenance of Certification requirements, which add no value in most doctors’ eyes. This whole scheme is just one more reminder that the job doctors love doesn’t always love them back.

Pharmacy Benefit Managers

It seems that American healthcare is one huge pie, and a whole array of interest groups are trying to get their slice. This includes Pharmacy Benefit Managers, middleman-style corporations that negotiate drug prices between pharmaceutical companies and insurance groups. Years ago, this arrangement helped keep drug prices down. The collective power of many insurers working through a manager could demand a lower drug cost from a manufacturer.

Over time, many of these pharmacy benefit manager companies have merged and, unfortunately, they have focused more on boosting their profits and less on controlling costs. Their income is based in part on drug prices, so they have an incentive to promote more expensive drugs. These companies have also become more powerful. They now often determine which drugs are “preferred” and whether a patient should even receive a drug their own doctor prescribed. They do this via a process called “prior authorization.”

The Prior Authorization Headache

Prior authorization is another way that physicians’ expertise is second-guessed by a bureaucracy focused on maximizing profit. When a doctor prescribes a medication that the insurance company doesn’t prefer (because of the cost), the company the insurance company will not pay and will block the pharmacy from filling that prescription. They then require the prescribing doctor to complete a “prior authorization request.”  Such request consist of the doctor either getting on the telephone or filling out forms – taking their time away from patients.

The questions asked seem designed for the sole purpose of taking up the doctor’s time. They are asked for their full name, address, telephone and fax numbers, tax ID number, patient’s name, address, telephone number, date of birth, member ID number, all information the insurers already have in their databases. Once the doctor answers all of these questions they may be placed on hold to be transferred to another clerk who will ask “clinical questions.”  The so-called clinical questions are very often redundant and nonsensical. For example, the patient’s date of birth was provided earlier but a questions might ask, “is the patient 6 years of age or older?”

It appears that this process exists only to discourage doctors from prescribing medicine that the insurer thinks are too expensive and cajole them into prescribing cheaper alternatives in order to save themselves hassle.  Many practices have to employ extra staff to help handle all of these extra demands, so doctors must choose between losing time or money. Insurers claim they do this in the interest of the patient. This claim is suspect, however when it is the insurer who stands to profit from this practice. No one cares more about patients than their doctors; this is simply not up for debate.

If anything, the prior authorization procedure hurts patients. Ninety-one percent of doctors believe it delays access to necessary care and creates additional medical risk. More than a quarter of doctors reported that the delay led to an unnecessary medical consequence in at least one of their patients. These delays are usually at least one full day and often up to three days. If you really need a medication, which you obviously do since your doctor prescribed it, that wait can make the difference between getting well and getting sicker.

The process is cumbersome and extremely time-consuming. It costs the average medical practice 16 hours per week for doctors, nurses, and clerical staff to process these applications. This extra time costs the American medical system billions of dollars a year. Dr. Stern and Dr. Pang both noted the hospitals they work in have multiple employees dedicated just to dealing with prior authorizations.

Worse yet, it undermines the doctors’ authority and damages patients’ respect for them by placing treatment decisions in the hands of faceless bureaucrats. This set up is a daily nightmare for doctors who have no way around it and patients who must nervously wait, just hoping to get their medications on time.

It All Adds Up

There is no single cause of doctor burnout. No obvious target, no solitary culprit. Instead, burnout creeps insidiously into doctors’ lives. Like a death by a thousand cuts, a myriad of insults every day builds throughout their career and slowly saps their energy, enthusiasm, and love for their job. Gradual changes throughout American healthcare over the past several decades have combined to make the job more stressful and less satisfying.

Doctors have less control over their time, which has become more spent on paperwork than patient care. Weighing down upon them is an ever-growing bureaucracy of hospital administrators, insurance companies, certification programs, pharmacy benefit managers, pharmaceutical companies, and medical device corporations. Burdensome electronic health records slow them down on the job and let busywork follow them home, invading their free time.

The year 2020 has brought COVID crashing down on top of all of this. The pandemic has exacerbated all the failings of American healthcare, as hospitals from coast to coast are stretched to capacity. Despite all the death and sickness, a vocal minority continues to downplay the danger, insulting physicians’ expertise.

Moving Forward

Despite all this negativity, there is a bright side. Discussing burnout is “not taboo [and] more people are becoming comfortable talking about it,” Dr. Stern commented.[lxi] With the elephant in the room recognized, groups like the American Medical Association have dedicated themselves to combating it.

Strategies focus on addressing physician complaints about job stresses. Dr. Pang cited “patient load” as a prime source of stress, and many doctors agree.[lxii] Distributing work load, especially office work, over a team including scribes, pharmacists, and assistants, reduces pressure and increases job satisfaction. Other fixes include optimizing electronic health records and improving workflow. The key is to make the systems that doctors use daily work for them rather than against them.

The other half of addressing burnout involves “networks [that] support mental and physical health,” as Dr. Stern put it. Healthcare organizations need to proactively address burnout by offering resources to help doctors create a better work-life balance. Doctors have invested a lot to get where they are. Now it’s time the healthcare system invests in them.

Resources

[i]     Medscape National Physician Burnout & Depression Report 2018. (2018). Retrieved from https://www.medscape.com/slideshow/2018-lifestyle-burnout-depression-6009235#13. [Citation is on slide 13]
[ii]    Medscape Physician Compensation Report 2019. (2019). Retrieved from https://www.medscape.com/slideshow/2019-compensation-overview-6011286#3 on 11/10/20. [Citation on bar graph]
[iii]   Shane Tenny, C. (2020). 7 Reasons Why Financial Stress is Contributing to Physician Depression. Retrieved from https://www.sdtplanning.com/blog/financial-stress-physician-depression on 11/15/20. [Citation is in Physicians are Behind Their Peers’ Careers]
[iv]   Shane Tenny, C. (2020). 7 Reasons Why Financial Stress is Contributing to Physician Depression. Retrieved from https://www.sdtplanning.com/blog/financial-stress-physician-depression on 11/15/20. [Citation is in Physicians are Behind Their Peers’ Careers]
[v]    Shane Tenny, C. (2020). 7 Reasons Why Financial Stress is Contributing to Physician Depression. Retrieved from https://www.sdtplanning.com/blog/financial-stress-physician-depression on 11/15/20. [Citation is in 6 Figure Student Debt Burden]
[vi]   Park, R. (2017). The Atlantic. Atlantic. Retrieved from https://www.theatlantic.com/business/archive/2017/02/doctors-long-hours-schedules/516639 on 10/28/20. [Citation is in paragraph 4]
[vii]  Shane Tenny, C. (2020, November 01). 7 Reasons Why Financial Stress is Contributing to Physician Depression. Retrieved from https://www.sdtplanning.com/blog/financial-stress-physician-depression on 11/3/20. [Citation is in Physicians are Behind Their Peers’ Careers]
[viii] Stern, Mike. (2020, Dec). Personal communication (email).
[ix]   Daughtridge, G., and Vapiwala, N. (2017, March 14). To prevent physician burnout and depression, tackle financial stress.  Retrieved from https://www.statnews.com/2017/03/14/depression-burnout-doctors-debt on 10/15/20. [Citation is in paragraph 2]
[x]    Hughes, J. F. (2020, November 09). Is It Better to Be a Doctor Now Than It Was 50 Years Ago? Retrieved from https://www.mdlinx.com/physiciansense/is-it-better-to-be-a-doctor-now-than-it-was-50-years-ago/  on 11/9/20. [Citation is under Physician Salaries]
[xi]   Carter, M. (2020). Average Student Loan Debt for Medical School. Credible. Retrieved from https://www.credible.com/blog/statistics/average-medical-school-debt/#extreme-medical-school-debt on 10/10/20. [Citation is in paragraphs 1,2]
[xii]  Stern, Mike. (2020, Dec). Personal communication (email).
[xiii] Pang, Michael. (2020, Dec). Personal communication (email).
[xiv] What is interest capitalization on a student loan? (2020). Retrieved from https://studentaid.gov/help-center/answers/article/what-is-loan-capitalized-interest on 10/10/20. [Citation is on paragraph 1]
[xv]  Carter, M. (2020). Average Student Loan Debt for Medical School. Credible. Retrieved from https://www.credible.com/blog/statistics/average-medical-school-debt/#extreme-medical-school-debt on 10/10/20. [Citation is on How interest piles up during residency]
[xvi] Carter, M. (2020). Average Student Loan Debt for Medical School. Credible. Retrieved from https://www.credible.com/blog/statistics/average-medical-school-debt/#extreme-medical-school-debt on 10/10/20. [Citation is on How interest piles up during residency]
[xvii] Carter, M. (2020). Average Student Loan Debt for Medical School. Credible. Retrieved from https://www.credible.com/blog/statistics/average-medical-school-debt/#extreme-medical-school-debt on 10/10/20. [Citation is on Average time to repay medical school loans]
[xviii]      Daughtridge, G., and Vapiwala, N.To prevent physician burnout and depression, tackle financial stress. (2017, March 13). Retrieved from https://www.statnews.com/2017/03/14/depression-burnout-doctors-debt on 11/1/20. [Citation on paragraph 13]
[xix] Wofford, B. (2020, April 13). We’re Devastatingly Short on Doctors. Why Doesn’t the US Just Make More?  Retrieved from https://www.washingtonian.com/2020/04/13/were-short-on-healthcare-workers-why-doesnt-the-u-s-just-make-more-doctors on 11/17/20. [Citation is in paragraph 7]
[xx]  How many hours are in the average physician workweek? (2015). Retrieved from https://www.ama-assn.org/practice-management/physician-health/how-many-hours-are-average-physician-workweek on 10/10/20. [Citation is on paragraph 2]
[xxi] Stern, Mike. (2020, Dec). Personal communication (email).
[xxii] Imrie, K. R., Frank, J. R., & Parshuram, C. S. (2014). Resident duty hours: past, present, and future. BMC Med. Educ., 14(Suppl 1), S1. [Citation is in A brief history of duty hour regulations]
[xxiii]      Imrie, K. R., Frank, J. R., & Parshuram, C. S. (2014). Resident duty hours: past, present, and future. BMC Med. Educ., 14(Suppl 1), S1. [Citation is in A brief history of duty hour regulations]
[xxiv]      Fargen, K. M., & Rosen, C. L. (2013). Are Duty Hour Regulations Promoting a Culture of Dishonesty Among Resident Physicians? J. Grad. Med. Educ., 5(4), 553. [Citation is on paragraph 6]
[xxv] Stern, Mike. (2020, Dec). Personal communication (email).
[xxvi]      Fargen, K. M., & Rosen, C. L. (2013). Are Duty Hour Regulations Promoting a Culture of Dishonesty Among Resident Physicians? J. Grad. Med. Educ., 5(4), 553. [Citation is on paragraph 6]
[xxvii]     How many hours are in the average physician workweek? (2015). Retrieved from https://www.ama-assn.org/practice-management/physician-health/how-many-hours-are-average-physician-workweek on 11/1/20. [Citation is on paragraph 4]
[xxviii]    Cryts, A. (2018). After Hours EHR Time is a Problem for Physicians.  Retrieved from https://www.physicianspractice.com/view/after-hours-ehr-time-problem-physicians on 11/5/20. [Citation is in paragraph 5]
[xxix]      Downing, N. L., Bates, D. W., & Longhurst, C. A. (2018). Physician Burnout in the Electronic Health Record Era: Are We Ignoring the Real Cause? Ann. Intern. Med., 169(1). [Citation is on
[xxx] Drummond, D. (2020). Physician Burnout and EMR – it’s the Keystrokes, Silly. Documentation Overload and Four Ways Forward. Retrieved from https://www.thehappymd.com/blog/physician-burnout-emr-ehr-keystrokes-silly-documentation-overload on 11/1/20. [Citation is in paragraph 2]
[xxxi]      Stern, Mike. (2020, Dec). Personal communication (email).
[xxxii]     White, B., & Twiddy, D. (2017). The State of Family Medicine: 2017. Fam. Pract. Manag., 24(1), 26–33. Retrieved from https://www.aafp.org/fpm/2017/0100/p26.html on 11/9/20. [Citation is on Patient Panel Size]
[xxxiii]    Dalen, J. E., Ryan, K. J., & Alpert, J. S. (2017). Where have the generalists gone? They became specialists, then subspecialists. The American journal of medicine, 130(7), 766-768. [Citation is in Table 2]
[xxxiv]    Torie S. Sepah, M. D. (2020). How MOC is contributing to the demise of physicians. Retrieved from https://www.kevinmd.com/blog/2020/06/how-moc-is-contributing-to-the-demise-of-physicians.html on 11/24/20. [Citation is on paragraph 1]
[xxxv]     Murphy, B. (2019). Licensing and board certification: What residents need to know.  Retrieved from https://www.ama-assn.org/residents-students/transition-practice/licensing-and-board-certification-what-residents-need-know on 11/24/20. [Citation is under section Passing Your Boards, paragraph 2]
[xxxvi]    Gilman, D., Miller, B., and Goldstein, B. (2017). Board Certification: A Dose of Competition. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20171121.748789/full on 11/24/20. [Citation is on Lack Of Quality Benefits From Certification]
[xxxvii]   Rabin, R. C. (2014). Docs Slam Recertification Rules They Call A Waste Of Time. Kaiser Health News. Retrieved from https://khn.org/news/docs-slam-recertification-rules-they-call-a-waste-of-time on 11/24/20. [Citation is on paragraph 12]
[xxxviii]  John Hayes, M. D. (2014). Association Between Physician Time-Unlimited vs Time-Limited Internal Medicine Board Certification and. JAMA, 312(22), 2358–2363. [Citation is in section Discussion, paragraph 1]
[xxxix]    Drolet, B. C., & Tandon, V. J. (2017). Fees for Certification and Finances of Medical Specialty Boards. JAMA, 318(5), 477. [Citation is in Results, paragraph 1]
[xl]   Sepah, T. (2020). How MOC is contributing to the demise of physicians. Retrieved from https://www.kevinmd.com/blog/2020/06/how-moc-is-contributing-to-the-demise-of-physicians.html on 11/26/20. [Citation is on paragraph 4]
[xli]  Gilman, D., Miller, B., and Goldstein, B. (2017). Board Certification: A Dose of Competition. Retrieved from https://www.healthaffairs.org/do/10.1377/hblog20171121.748789/full on 11/24/20. [Citation is on High Costs, Limited Competition, paragraph 3]
[xlii] Wood, D. (2011). Physician Recertifications Adding to Early Retirement? Retrieved from https://www.amnhealthcare.com/latest-healthcare-news/455/1033 on 11/24/20. [Citation is on paragraphs 8,9,10]
[xliii] Hughes, J. F. (2018). Doctors Tell Us How They Really Feel about Maintenance of Certification. Retrieved from https://www.mdlinx.com/physiciansense/doctors-tell-us-how-they-really-feel-about-maintenance-of-certification/ on 11/24/20. [Citation is on paragraph 5]
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