The Healthcare System Has Become a Dysfunctional Game

Nowadays it can require luck and connections to get decent care.

“Is this how the medical system is supposed to work?”

My friend’s husband sounded both baffled and angry when he asked me this question. We were standing outside in the January cold chatting, while their pajama’d kids ran around inside their house.

His frustration was well-justified. His wife was suffering in a local emergency room for the second time in as many days. It looked like it was going to be a long night for her, and for her husband, who had to stay home with their three small children.

I was headed to the hospital to bring her some things, like a warm sweatshirt, decent food… and maybe also, as a former clinician, to help ensure that she got the care she needed.

A painful experience

Without divulging identifying details, I can share that she was in great pain with a serious orthopedic issue, and had been unable to reach her own doctor. Actually, no one from her doctor’s office even called her back.

She had already endured one long, awful emergency room visit, and had been discharged without an accurate diagnosis, nor an adequate plan. Predictably, she had bounced back, still in massive pain.

Knowing that I was a doctor, she had reached out to me.

This was not the first time I’d found myself in this situation.

What was fascinating about the entire ordeal was that a few years prior, a different friend — I’ll call her friend #2 — had had almost the exact same orthopedic issue and a similar series of ineffective interactions with the healthcare system.

She had also had no help from her own doctor, sat in an emergency room while suffering with 10/10 pain, waited forever, and was discharged without an accurate diagnosis nor plan for management.

In that case, when friend #2 had reached out to me, I had been able to work the system — my system, the hospital where I had been practicing for over a decade — to get her the diagnostic imaging and urgent surgical consultation that she needed.

But that was then, and friend #1’s situation was now.

Unfortunately I didn’t have any connections at the hospital where friend #1 was. In fact, I had already quit primary care and had no hospital affiliation whatsoever.

My medical advice was peppered with many caveats, like:

“Here is what I would be thinking if I was still in practice, keeping in mind that I’ve been out for over a year…”

And

“This is what next steps should look like based on my past experience, though I have no power over this process anymore…”

In both cases, it’s true that their primary care doctors could have helped.

It didn’t need to be me, and in fact some may consider my involvement in my friends’ medical care a little ethically borderline.

After all, we had no pre-existing doctor-patient relationship. There are privacy concerns. And there was potential for my clinical judgment to be clouded by all sorts of socio-emotional factors… It’s a medicolegal grey area for sure.

If I had to defend my involvement in either of these cases, I’d say honestly, if I’m ever languishing in an emergency room and someone I know is in a position to step in to help, I won’t care if it’s a friend’s neighbor’s babysitter’s uncle. I’ll take whatever help I can get, and I’ll be thankful. Connections can really help.

The fact is, both of my friends’ own primary care doctors were effectively absent.

But why?

The way the system is supposed to work, it’s the primary care provider’s job to at least respond to a call from a patient who has an acute medical issue.

Ideally, they’re supposed to do some preliminary assessment over the phone, and maybe even make few suggestions, even if ultimately the patient is better served by going to the emergency room. If that’s the case, the doctor still can answer the patient’s questions, help coordinate care, and then maybe follow up afterwards.

But, there was none of that for my two friends.

I don’t know what happened to their doctors, but I do know better than to judge them.

Before I walked away from clinical care, it was becoming more and more difficult to be a “the way the system is supposed to work” kind of doctor. My panel of active patients was so large (just under a thousand patients!) and my time so crunched (split between patient care, teaching, and research), that if I went out of my way for one patient, it took time away from another patient. And it was getting worse: Upper management wanted us to have larger panels and see more patients, in less time.

It had become a complex game of Whac-A-Mole: for every peg I knocked down — like, to make the extra phone calls to help a patient in an emergency room — two more popped up.

It wasn’t in my imagination that my clinical workload exceeded the number of hours in a day.

A Forbes article titled “Physicians would need almost 27 hours per day to provide optimal patient care“ describes a 2022 study looking at the time required for a primary care doctor to provide guideline-recommended preventative care, manage chronic diseases, address acute medical issues, as well as complete minimal documentation and respond to inbox messages every workday.

The researchers found that on average, a doctor trying to handle all these things on their own would need 27 hours per day to meet the passing standard. A doctor who was adequately staffed would only need 9 hours per day — though in reality, it’s rare that a doctor’s office is adequately staffed. Mine never was.

Very notably, the study did not take into account all the other stuff doctors have to do, like chasing down radiology reports, reading through specialists’ communications, managing prior authorizations, completing all the hospital’s or the medical specialty board’s required trainings, or God forbid look at a body fluid sample under the microscope to help make a diagnosis, or take the time to thoughtfully research a case in order to provide better care.

And the study most definitely didn’t factor in the phone calls that can make all the difference when a patient is languishing in an emergency room somewhere.

No, the way our healthcare system is nowadays, doctors who want to practice in a “the way the system is supposed to work” kind of way — which means being able to provide optimal patient care — just can’t.

COVID-19 made it worse

Then add the substantial stressor of the pandemic and they really just can’t. A survey of over 20,000 healthcare providers looking at the impact of COVID-19 on work intentions found that 1 in 5 physicians and 2 in 5 nurses planned to leave clinical medicine within the next 2 years. The word “burnout” is often used to describe this phenomenon but “demoralized” is probably more accurate.

There already was a shortage of primary care physicians, and now it’s getting worse, way worse — to the tune of a shortage of almost 100,000 by 2026 per the American Association of Medical Colleges. Fewer providers means more work for those who are left, and then probably only a matter of time before they leave as well, and patients will require even more luck and connections to get decent care.

So what happened to friend #1?

In answer to my friend’s husband’s frustrated question, No, the medical system is not supposed to work this way. And it felt so, so lame when I explained:

“Yeah, the healthcare system as a whole is so dysfunctional and everywhere is so understaffed that it either requires strong connections or a lucky break to get adequate care.”

With that, I headed into the emergency room to see what I could do. In the end, with some coaching from me, friend #1 was able to advocate for herself. She fended off the ER’s attempt at a second inappropriate discharge, was admitted to the hospital, had the diagnostic imaging she needed, plus an urgent surgical consultation while in-house. (That the hospital had open beds and the surgical team was available was, well, lucky.)

Indeed, “U.S. healthcare is increasingly like a casino”, states one longtime health writer in Axios, “Having insurance is only the first step toward receiving quality care.” The rest requires luck, and connections.

A version of this article was originally posted on Medium. An earlier version of this article was published on my personal blog in March 2023.