Last week I introduced you to Donna and how my interactions with her bothered me.  Were you also bothered by her not wanting to be healthier?  By her accepting herself as she was?  By my judging her?  By my wanting something she had: self-acceptance?  I hope something in that post bothered you.

Being bothered is an invitation to dig deeper, not only to enrich our own life experience and understand ourselves better, but to better identify and define problems worth solving and solutions worth going after.

Here’s what I’m bothered by today: my family physician salary being tied to my patient’s health metrics. It’s called “pay for performance” (PFP).

I am bothered by this because it is a driver of primary care physician burnout and an often over-looked one at that.    

According to Christina Maslach, a psychologist known for her work in occupational burnout, the three key dimensions of burnout are overwhelming exhaustion, feelings of cynicism and detachment from the job, and a sense of ineffectiveness and lack of accomplishment.

What I am bothered by today drives all three of those components of burnout. 

I am all for individual autonomy.  I’ve had patients not want to treat their diabetes as they believe nature should take its course without intervention.  I’ve had countless patients decline colonoscopy and mammogram believing the risks outweigh the benefits.  I’ve had multiple patients tell me they fully understand the risks of smoking but will never quit, believing their quality of life now would be so poor without cigarettes it’s worth the trade off of fewer years on the planet or respiratory problems later in life.  

Doctors are confronted with such on a daily basis: evidence-based standard of care medical advice given to patient, advice rejected by patient.  There are innumerable other examples of patients making decisions that go against the grain of standard medical recommendations.

I am all for this.  You be you and do you.  I’ll be me and do me.  It’s one of the tenets of this free country we live, right?

In a vacuum that’s the end of the story:  I’m satisfied in doing my job in the way I see fit, giving evidence-based recommendations and answering clarifying questions as needed.  Patients are satisfied in getting the information they want and need to make an informed decision and are satisfied with their choices.  Everyone wins, life goes on, all is well.

Except we aren’t in a vacuum and in a PFP system my salary is dependent on their choices.  I’m not talking losing out on a bonus, I’m talking losing chunks of my agreed upon salary with my employer.  When patients make decisions that go against generally accepted medical advice I don’t meet my quality metric goals and my salary goes down. 

In PFP my salary drops when patients opt out of mammogram and colonoscopy; when my patients are non-compliant with diabetes and blood pressure treatment and their numbers reflect that; when my diabetic patient won’t come in for their annual urine test; when my diabetic patient doesn’t go to their eye doctor for their annual diabetic eye exam; when my patient refuses tobacco cessation counseling.  

Most primary care physicians went into this profession to have a tangible way of helping others, of making a difference in the world, of using evidence to guide health and well-being.  The desire to be a doctor is often born from kindness and compassion and love of science.

The PFP system crushes this spirit by encouraging us to see patients as quality metric numbers, as a means to a desired end. 

It takes some serious mental gymnastics to not feel anger, contempt and resentment toward the patients who’s decisions go against your recommendations.   It takes some serious mental gymnastics to not fall prey to feeling helpless and developing victim-mentality working in a system in which we are held responsible for things we can’t be responsible for.  It takes some serious mental gymnastics to find an appealing solution to moral dilemmas we never imagined facing in medicine: as long as I give medical recommendations based on my patient’s actual blood pressure reading, is fudging the number in their chart by 2 points to avoid losing part of my salary unethical? What about 4 points? 6? Where is the cutoff? Should I still click the button that says I counseled on smoking cessation for 3-10 minutes if the patient made it clear in 20 seconds they weren’t interested?  And for the natural salesmen and women among us, it may take some mental gymnastics to not resort to distasteful fear-mongering and coercive tactics to try to get patients to do what we want them to do. 

These are but a few of the dilemmas, feelings and questions physicians are grappling with day in and day out under the PFP model.  Meanwhile, we’re contending with numerous other morale busters that contribute to burnout while still digging to find the good-intentions in us that brought us to medicine in the first place so that we can live in integrity with ourselves. 

It’s an exhausting dance.

What can be done about it?  Should we all go to business school and gain some sales acumen?  Read more books on getting people to do what we want them to do?  Relinquish the patients of their power to choose and no longer tout individual autonomy? Stop caring about losing a percentage of my salary? Primary care physicians all leave the insurance-driven healthcare system in lieu of a DPC style practice? Keep doing all the mental gymnastics it takes to stay out of burnout and still be able to live with ourselves doctoring in this environment?

What about dropping the primary care PFP model? I haven’t seen evidence showing it leads to better patient outcomes. I certainly have, though anecdotal, evidence of it contributing to burnout which comes at a high cost to physician well-being, patient care and to the economy.

What do you think? Who are the winners in the current PFP system in primary care? Who are the losers? What do we have to gain by dropping it? What do we stand to lose by doing so?