Why I Left
Today is June 30th in the US, the last day of residency for this year’s graduates. Tomorrow a new group will begin their training.
When I left my position in North Carolina at the beginning of April, one of the hardest things I faced was how to explain what I was doing to the residents and students I was helping to train in the art of medicine. How do I communicate the brokenness of the healthcare system without instilling pessimism and exacerbating burnout? How can I be honest about my frustrations and failings without deflating hope and idealism?
I had many heartfelt conversations with colleagues, residents, and students about my decision to undertake this journey. Inspired by these conversations, I shared a letter with the program in which I tried to explain why exactly I had chosen to leave a place and group of people that were so special to me. I have often said that I doubt I could have found a position in the US that fit me better than what I had at Cone, with the combination of adult and pediatric practice, the supportive learning environment, the small residency programs that felt like family, the amazing array of colleagues and staff, the endlessly fascinating patients.
And yet, I felt drawn to this adventure in Aotearoa. US medicine is in crisis, and I simply couldn’t continue as if everything was alright. Below is the letter I wrote for my students and residents. I share it now for the same reason I shared it then: in the hope that my experience might plant the seed of possibility we need to help transform what is to what might be.
To my dear residents and students,
As you know by now, in a few short days I will leave to take a position as a physician in New Zealand. I have cherished the opportunity to talk with many of you about the impetus behind the move and my hopes for life and practice there.
The first and most important thing to say is it is not because of you. My chief joy in my work over the past three and half years has been watching you growing into compassionate, curious, independent physicians. Your questions probe the limits of my knowledge, help me relearn what I thought I already knew, and question my assumptions. I come to work every day excited to learn along with you.
Neither are the patients the source of my deepening disillusionment, though I admit to often feeling exhausted trying to care for them. Our patients are suffering, and there is often little we can do. And yet the time we spend in the company of these singular people and their families is often the most uplifting part of our days.
Indeed, I still love the practice of medicine. It’s just that we get to do so little of it.
I don’t need to tell you that we spend the majority of our day doing clerical tasks that contribute little to—or even detract from—the patient’s well-being. Many of the clerical tasks that divert us from our patients and our purpose derive from the EMR. The EMR was introduced with the promise to bring increased portability and interconnectivity to healthcare, to reduce medication errors and collate patient data, but the product we got was built primarily to codify billing. The EMR reflects the healthcare system it was built for, a system that extracts profit from disease. The financial transaction occurs between the customer (insurance payers) and the seller (healthcare corporations), each motivated by market pressures to maximize their own slice of the financial pie. Incidental in this transaction are the patient and physician, who are each left to navigate increasingly byzantine bureaucracies in pursuit of the care nominally at the center of this relationship.
This is why it feels like we spend more time documenting the presence of diseases than treating them, why we are continually interrupted by requests to “clarify documentation” to enable “accurate coding”, why when you are trying to order a medication or a test for a patient, you have to stop and document a diagnosis with multiple, sometimes dozens, of subcategories, before you can actually get back to helping your patient. How many hours have we wasted in prior authorization calls and “peer-to-peers” where we grovel before someone who has never met our patient and often seems to have little clinical understanding of their situation while we beg for the care we know our patient needs?
Meanwhile, our patients without insurance are treated as undeserving burdens on the system, relegated to a lower caste of care, separate and unequal. When they can’t afford their medications, when specialists are unwilling to see them unless they can pay out of pocket, when no nursing facility will take them for rehabilitation, our protestations are met with shrugs of indifference. I once received a message from one of our social workers asking if a disabled patient was medically ready for discharge “because he can always return to the street, LOL, I’ve got no other options for him.” Here was a social worker I knew to be caring and compassionate reflecting the values of the system, dismissing this patient with callous disregard for the impact on his life.
The hammer shapes the hand, and I worry what kind of clinicians we are becoming in this broken system, how calloused we have already become to the suffering of our patients and colleagues.
Your training is already warped by this system. It pains me every time we have to pause learning medicine to review the latest coding flowsheet or billing guideline. Even continuing medical education (CME)—which should help us maintain and develop our knowledge and skills in patient care—increasingly offers coding retreats and documentation seminars that contribute to no one’s well-being, other than the bottom line. There are entire departments dedicated to coding and billing, employing nurses who used to care for patients and now spend their days massaging the charts (and interrupting patient care) to maximize billing revenue. On the insurance side, physicians have traded in their stethoscopes and scalpels for a rejection button, denying care to pad the profits of their employers. Since 1990, workforce growth in health care has overwhelmingly occurred at the administrative level, with 10 new administrators to every 1 new doctor actually seeing patients.
No wonder burnout is prevalent. No wonder we struggle to help our patients stay well and out of the hospital. And no wonder patients are distrustful of the health care system, never certain if we are acting in their best interest or to further some profit motive.
That you should feel exhausted or disheartened or burned out by this experience does not testify to your fragility but to the inhumanity of the system in which you work. Never forget that. We are not broken. To be demoralized in this system is not weakness, nor is the solution more “self-care”. This much I know.
What I do not know is how to make it better. Rather, I don’t know how to make it better without massive, systemic reformation of the payment structure, incentives, organization, and culture of medicine. That is, in part, why I am going.
I am going because I want to experience the practice of medicine within a system that guarantees access to care, is built around health rather than profits, and is embedded in a culture that has thrived in this pandemic by acknowledging that we are stronger when we look out for each other, that we are more free when we honor our responsibility to our community.
What can I learn when my days are not consumed with the busywork and workarounds required to figure out how to pay for the care my patients need? What kind of doctor can I become? What kind of person?
Perhaps having the time and space to connect with patients and colleagues and actually dedicate myself to the practice of medicine can rekindle the joy and passion in my work and refine my understanding of how our system could be better.
And so, though this move was born in the dark days of the pandemic after a long gestation of growing disenchantment, I am really embarking on a journey guided by hope. Not the false optimism that it will all work out in the end, but that deeper “orientation of the spirit” Vaclav Havel spoke of that can take us from the world that is to the world that might be, that must be.
I don’t pretend that my adventure will change the world or even have any meaningful impact on our national or local healthcare system. I don’t have that kind of influence. I simply know we need a change. The pandemic has unmasked our broken system, laid bare its bloated, rotten core that fails patients and physicians alike.
Excising the rot will require collective action of clinicians across the nation to reorient the health care system around the relationship at its heart, between the patient and physician. That might mean asking for more time with patients and less focus on RVUs in contract negotiations, or taking leadership roles in local or national organizations to push for systemic change, or perhaps working with colleagues to form a union to increase the bargaining power of physicians.
Perhaps most important is to insist on practicing medicine in a way that is purposeful and centered around the patient’s well-being, taking each individual patient encounter and finding what you can do to help the person in front of you thrive.
In three weeks, this desk will be wiped clean, my diplomas packed away, my office plants hopefully adopted by a sympathetic colleague. Like all endings, it will also be a beginning. I eagerly anticipate my new adventures while grieving those I will have left behind. Some of you will graduate this spring, and I am sorry I will not be present to mark your own endings and beginnings. I hope that I may return to this program rejuvenated in a year or two, though if I am honest, I cannot be sure. I am not even sure our democracy will stand that long. So much is endangered now.
I worry this letter will leave you disheartened, but I owe you my truth as best as I can tell it. If it resonates in a time of frustration or exhaustion, I hope that echo reminds you that you are not alone in your yearning for the profession you thought you signed up for. Remember, we are not broken. We work in a broken system that puts profits and productivity above patients and practitioners.
As you trace your own path to joyful and fulfilling medical practice, I hope our trails may join again so we can learn alongside each other once more.
Sincerely,
Alex Raines
