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Physicians in Florida are more pessimistic about the future of their profession

By PL JETER

"It's prudent to keep in mind that the first reaction to seeing canaries perish in a coal mine wouldn't usually be to send out for tougher canaries." Gary Price, MD, president of The Physicians Foundation.

Three of four doctors have suffered burnout, a much higher rate than a few years ago when a perfect storm of changes rocked the healthcare industry. Compared nationwide, Florida physicians experience burnout more frequently than their counterparts.

"It's sobering," said Gary Price, MD, president of The Physicians Foundation, a nonprofit group that published the 2018 Survey of U.S. Physicians, with nearly 9,000 physicians weighing in. "The career plans and practice pattern trends revealed in this survey will likely have a significant effect on our physician workforce, and ultimately everyone's access to care."

According to the sixth biennial survey by national physician search firm Merritt Hawkins, the problem is so severe that 31 percent of Florida doctors say if they had a do-over, they wouldn't choose the same profession, and more than half say they would not recommend medicine as a career to their children. Even more disturbing: 46 percent of respondents plan to change career paths.

Much is to blame. The most frustrating problem, a vast majority of doctors say, is the inefficiency of a system created for efficiency: electronic health records (EHRs). They're unhappy about the inefficient EHR design and interoperability; nearly half the respondents said EHRs have reduced or detracted from their interaction with patients.

Other least satisfying career factors: insurance and regulatory burdens, professional liability concerns, and erosion of clinical autonomy. These problems may contribute to doctors being slow to adopt telemedicine, with only 17 percent practicing some form of it.

"The evidence points to the need for a major effort on the part of all the partners in the healthcare industry to re-examine the electronic health record as a tool for improving physician's abilities to provide care, and re-inventing it for that purpose," said Price.

Doctors also point to third party authorizations, treatment protocols, EHR design and pesky administrative tasks as adversely impacting their practice to "a great degree."

Clinical-wise, social problems - addiction, poverty, unemployment, homelessness - that make it difficult to treat patients also frustrate physicians. In fact, 81 percent of Florida doctors say their patients are impacted by a social situation that poses a serious impediment to their treatment of care.

"It's distressing that such a high number of patients are dealing with one or more social situations that are detrimental to their health," said Walker Ray, MD, who chairs the foundation's research committee. "These challenges directly impact a physician's ability to deliver effective care, and the cost implication of these issues is enormous."

Perhaps because of those circumstances, a vast majority of patients consistently don't adhere to their treatment plans; 31 percent don't follow plans at all.

"More patients with complex and chronic diseases cannot follow through on care recommendations due to limited finances and unpredictable living situations," said Dr. Russell Libby, board member of the Physician's Foundation. "Physicians like to see their patients get better. When it's diminished by social determinants, they may experience a sense of futility, failure and be more susceptible to burnout.

"It's one of the many heavy feathers accumulating on the backs of physicians and may be the one that breaks some of them."

Long hours - typically 50 to 60 weekly -also turn off physicians, with 65 percent seeing up to 30 patients daily. Eighty percent report being at full capacity or overextended. Thirty percent don't see Medicaid patients, while 15 percent don't accept Medicare patients.

These factors contribute to an overall 40 percent of doctors planning to retire or cut back on hours within the next three years. The largest group of respondents? Aged 56 to 65.

"The frustration and diminished sense of accomplishment associated with burnout almost certainly contributes to the large numbers of physicians reporting plans to diminish work hours or retire earlier than anticipated," said Price.

The accelerated growth of hospitals acquiring physicians has also taken a toll. Only 12 percent of respondents agree it's a "positive trend likely to enhance quality of care and decrease costs." To that end, 35 percent describe hospitals employing physicians in a "somewhat negative and adversarial" light.

"In our survey, 52 percent of employed physicians reported very or somewhat positive feelings about their morale in general, compared to only 37 percent of independent physicians," said Price, noting that only 31 percent of respondents are in private practice, down from 48 percent in 2014.

Libby pointed out it's important to find ways to engage physicians in the discussion about burnout.

"We need to have ways to screen, and vehicles to offer once an individual has been identified, and especially when they're reaching out for help," he said. "We need to build systems that address the myriad causes ... and build evidence-based solutions to sustain the careers and productivity of our medical professionals."

Price expressed concern about symptoms of burnout being directly related to medical errors, lower quality measurements, and lower patient satisfaction, adding that medical organizations have developed programs to provide tools for physicians to identify burnout symptoms, identify pathways to treatment, and strategies to attempt to avoid it.

"Practicing physicians are the leaders of our healthcare system, yet their voices are often not heard," noted Tim Norbeck, CEO of The Physicians Foundation.

But only partial solutions can be offered.

"If the root causes aren't addressed, the problem will not go away," said Price. "It's prudent to keep in mind that the first reaction to seeing canaries perish in a coalmine wouldn't usually be to send out for tougher canaries."

RESPONSES FROM THE STATE OF FLORIDA

Following are responses from the state of Florida to a national survey of physicians commissioned by The Physicians Foundation and conducted by Merritt Hawkins. Of 8,774 survey responses, 461 were from physicians in Florida. Responses of Florida physicians are compared to all survey responses.

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1. Which best describes your professional morale and your feelings about the current state of the medical profession?

	Florida	All
Very positive	6.4%	7.1%
Somewhat positive	34.4%	37.7%
Somewhat negative	40.3%	37.4%
Very negative	18.9%	17.9%

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2. Which best describes how you feel about the future of the medical profession?

	Florida	All
Very positive/optimistic	5.2%	6.2%
Somewhat positive/optimistic	28.0%	32.2%
Somewhat negative/pessimistic	45.7%	42.4%
Very negative/pessimistic	21.1%	19.2%

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3. What is Your Medical Specialty?

	Florida	All
Primary Care	28.8%	32.1%
Specialty	71.2%	67.9%

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4. What is Your Current Professional Status?

	Florida	All
Practice owner/partner/associate	35.0%	31.4%
Employed by a hospital	12.0%	19.1%
Employed by a hospital- owned medical group	13.4%	17.4%
Employed by a physician- owned medical group	15.5%	12.6%
Other	24.1%	19.6%

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5. If you had your career to do over, would you choose to be a physician?

	Florida	All
Yes, medicine is still rewarding	68.6%	72.6%
No, the negatives outweigh the positives	31.4%	27.4%

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6. Would you recommend medicine as a career to your children or other young people?

	Florida	All
Yes	46.7%	51.3%
No	53.3%	48.7%

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7. Do you now practice some form of telemedicine?

	Florida	All
Yes	17.3%	18.5%
No	82.7%	81.5%

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8. What percent of your patient encounters occur through telemedicine?

	Florida	All
0-10%	67.9%	73.8%
11-25%	16.7%	15.9%
26-40%	8.9%	4.8%
41-60%	2.6%	1.3%
61% or more	3.9%	4.3%

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8. What is your age?

	Florida	All
35 or under	9.4%	11.2%
36-45	20.9%	19.8%
46-55	21.8%	22.9%
56-65	31.6%	29.0%
66 or older	16.3%	17.0%

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9. What is your gender?

		Florida	All
Male		64.3%	66.1%
Female		35.7%	33.9%

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10. What TWO factors do you find MOST satisfying about medical practice?

	Florida	All
Patient relationships	72.9%	78.7%
Prestige of medicine	8.9%	9.8%
Intellectual stimulation	60.9%	55.1%
Interaction with colleagues	10.9%	14.3%
Financial rewards	22.5%	18.9%
Social/community impact	20.5%	20.9%

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11. What TWO factors do you find LEAST satisfying about medical practice?

	Florida	All
Erosion of clinical autonomy	35.6%	37.0%
Professional liability concerns	37.5%	30.2%
Regulatory/paperwork burdens	65.4%	67.7%
Lack of time with patients	11.9%	12.4%
Inefficient EHR design/interoperability	31.6%	39.2%
Income/Compensation	14.4%	13.3%

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12. In the next one to three years, do you plan to (check all that apply):

	Florida	All
Continue as I am	53.6%	54.2%
Cut back on hours	23.4%	22.3%
Retire	15.9%	17.4%
Switch to a cash/concierge practice	5.3%	4.5%
Work locum tenens	8.5%	8.4%
Sell practice to hospital/health system	3.1%	2.2%
Merge with another physician group	3.1%	2.8%
Seek a non-clinical job within healthcare	11.6%	12.4%
Seek employment with a hospital	4.2%	4.3%
Work part-time	10.1%	8.5%

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13. Hospital employment of physicians is a positive trend likely to enhance quality of care and decrease costs.

	Florida	All
Strongly agree	2.8%	2.7%
Agree	9.2%	10.6%
Neither agree nor disagree	23.5%	29.2%
Disagree	32.9%	29.6%
Strongly disagree	31.6%	27.9%

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14. Value-based compensation is likely to improve quality of care and reduce costs.

	Florida	All
Strongly agree	2.9%	2.9%
Agree	12.9%	15.1%
Neither agree nor disagree	24.5%	25.2%
Disagree	32.1%	33.1%
Strongly disagree	27.6%	23.7%

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15. What do you think is the best direction for the U.S. healthcare system?

	Florida	All
Maintain the current system	2.7%	4.5%
Move to a single payer insurance	18.2%	26.2%
Move to a two-tiered system	36.8%	35.5%
Move to a market-driven system	35.2%	27.2%
Other	7.2%	6.6%

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16. How many of your patients are affected by a social situation that poses a serious impediment to their health?

	Florida	All
All	3.4%	4.7%
Many	45.7%	51.7%
Some	35.9%	31.4%
Few	14.6%	11.1%
None	0.5%	1.1%

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18. On average, how many hours do you work per week (include all clinical and non-clinical duties)?

	Florida	All
0-20	3.9%	4.9%
21-30	5.9%	5.0%
31-40	11.6%	11.6%
41-50	23.9%	24.1%
51-60	24.2%	26.1%
61-70	16.8%	15.7%
71-80	9.6%	7.8%
81 or more	4.1%	4.7%

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19. Of these, how many hours do you work each week on NON-CLINICAL (paperwork) duties only?

	Florida	All
0-5	29.0%	25.0%
6-10	26.6%	28.6%
11-15	15.7%	18.8%
16-20	13.5%	12.3%
21-25	5.7%	6.1%
26 or more	9.4%	9.2%

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20. On average, how many patients do you see per day (include both office and hospital encounters)?

	Florida	All
0-10	18.2%	18.1%
11-20	35.0%	40.0%
21-30	29.8%	27.7%
31-40	8.3%	8.6%
41-50	4.8%	2.6%
51-60	1.5%	1.3%
61 or more	2.4%	1.8%

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21. Which of the following best describes your current practice?

	Florida	All
I am overextended and overworked	25.6%	23.9%
I am at full capacity	51.3%	55.6%
I have time to see more patients and assume more duties	23.1%	20.5%

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22. On the whole, how would you describe the current state of relations between physicians and hospitals, many of which now would employ physicians?

	Florida	All
Mostly positive and cooperative	6.3%	6.1%
Somewhat positive and cooperative	20.8%	25.6%
Neither positive nor negative	23.9%	21.8%
Somewhat negative and adversarial	34.7%	34.4%
Mostly negative and adversarial	14.3%	12.0%

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25. How has EHR affected your quality of care?

	Florida	All
Increased/Improved	23.2%	28.6%
Little to no impact	34.1%	18.9%
Reduced/Detracted from	42.7%	35.8%

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26. How has EHR affected your efficiency?

	Florida	All
Increased/Improved	22.9%	25.2%
Little to no impact	19.8%	18.9%
Reduced/Detracted from	57.3%	55.9%

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27. How has EHR affected your interaction with patients?

	Florida	All
Increased/Improved	9.1%	7.9%
Little to no impact	43.8%	26.4%
Reduced/Detracted from	47.1%	66.7%

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28. Are you a member of your:

	Florida	All
County medical society	36.6%	40.6%
State medical society	56.9%	63.2%
National specialty society	77.7%	79.4%
American Medical Association	22.1%	26.3%
American Osteopathic Association	7.9%	6.6%

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30. Approximately what percent of your patients DO NOT consistently adhere to your treatment plans?

	Florida	All
0-10%	13.8%	12.7%
11-20%	21.4%	21.3%
21-30%	25.1%	24.3%
31-40%	14.8%	15.1%
41-50%	10.1%	9.9%
51-60%	5.7%	7.1%
61-70%	3.9%	4.7%
71-80%	3.5%	3.3%
81-90%	1.2%	1.2%
91-100%	0.5%	0.4%

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31. What is your position on concierge/direct pay medicine?

	Florida	All
I now practice some form of concierge/direct pay medicine	8.9%	6.6%
I am planning to transition fully to this model	3.3%	2.4%
I am planning to transition in part to this model	12.8%	9.9%
I have no plans to transition to this model	75.0%	81.1%

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32. To what extent do you have feelings of professional burnout in your medical career?

	Florida	All
No such feelings	5.7%	5.7%
Rarely have these feelings	13.5%	16.6%
Sometimes have these feelings	39.4%	37.7%
Often have these feelings	30.7%	31.0%
Always have these feelings (significant burnout)	10.7%	9.1%

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33. How much ability do physicians have to significantly influence the healthcare system?

	Florida	All
Very little	34.1%	32.0%
Little	33.9%	30.5%
Somewhat	21.9%	26.9%
A good deal	7.6%	8.1%
A great deal	2.4%	2.5%

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34. To what degree is patient care in your practice adversely impacted by external factors such as third party authorizations, treatment protocols, EHR design, etc.?

	Florida	All
Not at all	2.4%	2.6%
Little	8.4%	8.8%
Somewhat	20.4%	26.6%
A good deal	30.8%	33.0%
A great degree	37.9%	29.0%

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35. Is any of your compensation tied to quality metrics such as patient satisfaction, following treatment guidelines, compliance, "citizenship", error rates, etc.?

	Florida	All
Yes	43.6%	47.1%
No	39.7%	39.5%
Unsure	16.8%	13.4%

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36. What percent of your TOTAL compensation is tied to such metrics?

	Florida	All
0-10	36.2%	41.9%
11-20	21.9%	22.4%
21-30	10.7%	8.4%
31-40	3.1%	2.5%
41-50	2.6%	1.8%
51 or more	6.1%	4.2%

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37. Maintenance of Certification (MOC), as required by my specialty board, accurately assesses my clinical abilities.

	Florida	All
Completely disagree	38.7%	35.7%
Disagree	28.1%	32.6%
Neither agree nor disagree	18.8%	18.0%
Agree	11.9%	11.8%
Completely agree	2.4%	1.9%

Courtesy of The Physicians Foundation and Merritt-Hawkins

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What are fellow physicians' priorities?

Which factors are most satisfying about practicing medicine? Relationships with patients and intellectual stimulation. Perhaps surprisingly, the profession's financial rewards ranked a distant third, while the prestige of medicine landed last on a list that includes interaction with colleagues and social impact on the local community.