They Stopped Trusting Us to Do It: The Second Reason Physicians Are Leaving
They did not just stop paying for what we do. They stopped trusting us to do it.
Last week I wrote about what they cannot code. This post is about what they decided we cannot be trusted to do anyway.
Every time physicians find margin in the schedule, the system fills it with volume. Not better care. More patients per unit of time. The reward for efficiency is more work. The penalty for working faster is a longer list. We optimized ourselves into a trap and they built the walls while we were busy seeing patients.
Prior authorizations are the clearest example of a system that has lost the plot. The infrastructure required to approve or deny one, the staff, the technology, the physician reviewer time, the appeals process, frequently costs more than the treatment being evaluated. The few thousand dollars we spend on semaglutide is considerably cheaper than a diabetic amputation. Nobody has run that actuarial table honestly because nobody in that apparatus is accountable for the result. But your physician, who has twelve more patients to see today, somehow is.
Military medicine was one of the last places this had not fully metastasized. The cancer has spread and it brought its full toolkit. As Senior Medical Officer deployed aboard my ship I have had clinical recommendations overturned by civilian non-practitioners. I have had people sent to me who do not meet entry requirements without any operational screening. I submit prior authorizations that appear to be approved and denied by technicians.
The central dysfunction of American medicine is the trust-to-expectation ratio. Physician-level judgment, accountability, emotional labor, and liability are all expected. In return we receive technician-level autonomy, clerk-level trust, and a productivity metric someone else designed for someone else's quarterly report.
The ratio is not sustainable. We did the math a long time ago. We are just finally acting on it.
The first post ended with this: the shortage is the choice the System made.
This is the mechanism. They took the margin we created and filled it with volume. They built a prior authorization apparatus that costs more to run than the care it denies, staffed it with technicians, and handed them veto power over physician judgment. They sent me patients who do not meet entry requirements and overturned my clinical recommendations from a desk stateside. Then they wondered why the people carrying disproportionate responsibility for logarithmically unequal disrespect eventually put down the chart and walked out.
We are not leaving because the work got hard. The work was always hard. We signed up for hard.
We are leaving because they made it pointless.