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General Medicine

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Nurse Practitioners' Substitution for Physicians
National Health Expenditures: The Past, Present, Future and Solutions
Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative
   Case Study of Physician-Faculty Perspectives
Special Article: Physician Burnout-The Experience of Three Physicians
Brief Review: Dangers of the Electronic Medical Record
Finding a Mentor: The Complete Examination of an Online Academic 
   Matchmaking Tool for Physician-Faculty
Make Your Own Mistakes
Professionalism: Capacity, Empathy, Humility and Overall Attitude
Professionalism: Secondary Goals 
Professionalism: Definition and Qualities
Professionalism: Introduction
The Unfulfilled Promise of the Quality Movement
A Comparison Between Hospital Rankings and Outcomes Data
Profiles in Medical Courage: John Snow and the Courage of
Comparisons between Medicare Mortality, Readmission and 
In Vitro Versus In Vivo Culture Sensitivities:
   An Unchecked Assumption?
Profiles in Medical Courage: Thomas Kummet and the Courage to
   Fight Bureaucracy
Profiles in Medical Courage: The Courage to Serve
   and Jamie Garcia
Profiles in Medical Courage: Women’s Rights and Sima Samar
Profiles in Medical Courage: Causation and Austin Bradford Hill
Profiles in Medical Courage: Evidence-Based 
   Medicine and Archie Cochrane
Profiles of Medical Courage: The Courage to Experiment and 
   Barry Marshall
Profiles in Medical Courage: Joseph Goldberger,
   the Sharecropper’s Plague, Science and Prejudice
Profiles in Medical Courage: Peter Wilmshurst,
   the Physician Fugitive
Correlation between Patient Outcomes and Clinical Costs
   in the VA Healthcare System
Profiles in Medical Courage: Of Mice, Maggots 
   and Steve Klotz
Profiles in Medical Courage: Michael Wilkins
   and the Willowbrook School
Relationship Between The Veterans Healthcare Administration
   Hospital Performance Measures And Outcomes 


Although the Southwest Journal of Pulmonary and Critical Care was started as a pulmonary/critical care/sleep journal, we have received and continue to receive submissions that are of general medical interest. For this reason, a new section entitled General Medicine was created on 3/14/12. Some articles were moved from pulmonary to this new section since it was felt they fit better into this category.



Nurse Practitioners' Substitution for Physicians

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ USA



Background: To deal with a physician shortage and reduce salary costs, nurse practitioners (NPs) are seeing increasing numbers of patients especially in primary care. In Arizona, SB1473 has been introduced in the state legislature which would expand the scope of practice for NPs and nurse anesthetists to be fully independent practitioners. However, whether nurses provide equal quality of care at similar costs is unclear.

Methods: Relevant literature was reviewed and physician and nurse practitioner education and care were compared. Included were study design and metrics, quality of care, and efficiency of care.

Results: NP and physicians differ in the length of education. Most clinical studies comparing NP and physician care were poorly designed often comparing metrics such as patient satisfaction. While increased care provided by NPs has the potential to reduce direct healthcare costs, achieving such reductions depends on the particular context of care. In a minority of clinical situations, NPs appear to have increased costs compared to physicians. Savings in cost depend on the magnitude of the salary differential between doctors and NPs, and may be offset by lower productivity and more extensive testing by NPs compared to physicians.

Conclusions: The findings suggest that in most primary care situations NPs can produce as high quality care as primary care physicians. However, this conclusion should be viewed with caution given that studies to assess equivalence of care were poor and many studies had methodological limitations.

Physician Compared to NP Education

Physicians have a longer training process than NPs which is based in large part on history. In 1908 the American Medical Association asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote a reformist agenda and hasten the elimination of medical schools that failed to meet minimum standards (1). Abraham Flexner was chosen to prepare a report. Flexner was not a physician, scientist, or a medical educator but operated a for-profit school in Louisville, KY. At that time, there were 155 medical schools in North America that differed greatly in their curricula, methods of assessment, and requirements for admission and graduation.

Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated."

At the time of Flexner's survey many American medical schools were small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. Only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training often left something to be desired. A medical degree was typically awarded after only two years of study.

Flexner used the Johns Hopkins School of Medicine as a model. His 1910 report, known as the Flexner report, issued the following recommendations:

  • Reduce the number of medical schools (from 155 to 31);
  • Reduce the number of poorly trained physicians;
  • Increase the prerequisites to enter medical training;
  • Train physicians to practice in a scientific manner and engage medical faculty in research;
  • Give medical schools control of clinical instruction in hospitals;
  • Strengthen state regulation of medical licensure.

Flexner recommended that admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. He also argued that the length of medical education should be four years, and its content should be to recommendations made by the American Medical Association in 1905. Flexner recommended that the proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even financially.

By and large medical schools followed Flexner's recommendations. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations. As a result the following consequences occurred (2):

  • Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving MD-granting institutions in 1935, 57 were part of a university.
  • Physicians receive at least six, and usually eight, years of post-secondary formal instruction, nearly always in a university setting;
  • Medical training adhered closely to the scientific method and was grounded in human physiology and biochemistry;
  • Medical research adhered to the protocols of scientific research;
  • Average physician quality increased significantly.

The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day.

Today, physicians usually have a college degree, 4 years of medical school and at least 3 years of residency. This totals 11 years after high school.

The history of NP education is much more recent. A Master of Science in Nursing (MSN) is the minimum degree requirement for becoming a NP (3). This usually requires a bachelor of science in nursing and approximately 18 to 24 months of full-time study.  Nearly all programs are University-affiliated and most faculty are full-time. The curricula are standardized.

NPs have a Bachelor of Science in Nursing followed by 1 1/2 to 2 years of full-time study. This totals 5 1/2 to 6 years of education after high school.

Differences and Similarities Between Physician and NP Education

Curricula for both physicians and nurses are standardized and scientifically based. The length of time is considerably longer for physicians (about 11 years compared to 5 1/2-6 years). There are also likely differences in clinical exposure. Minimal time for a NP is 500 hours of supervised, direct patient care (3). Physicians have considerably more clinical time. All physicians are required to do at least 3 years of post-graduate education after medical school. Time is now limited to 70 hours per week but older physicians can remember when 100+ hour weeks were common. Given a conservative estimate of 50 hours/week for 48 weeks/year this would give physicians a total of 7200 hours over 3 years at a minimum.

Hours of Education and Outcomes

The critical question is whether the number of hours NPs spend in education is sufficient. No studies were identified examining the effect of number of hours of NP education on outcomes. However, the impact of recent resident duty hour restrictions may be relevant.

Resident Duty Hour Regulations

There are concerns about the reduction in resident duty hours. The idea between the duty hour restriction was that well rested physicians would make fewer mistakes and spend more time studying. These regulations resulted in large part from the infamous Libby Zion case, who died in New York at the age of 18 under the care a resident and intern physician because of a drug-drug reaction resulting in serotonin syndrome (4). It was alleged that physician fatigue contributed to Zion's death. In response, New York state initially limited resident duty hours to 80 per week and this was followed in July 2003 by the Accreditation Council for Graduate Medical Education adopted similar regulations for all accredited medical training institutions in the United States. Subsequently, duty hours were shortened to 70 hours/week in 2011.

The duty hour regulations were adopted despite a lack of studies on their impact and studies are just beginning to emerge. A recent meta-analysis of 27 studies on duty hour restriction, demonstrated no improvements in patient care or resident well-being and a possible negative impact on resident education (5). Similarly, an analysis of 135 articles also concluded here was no overall improvement in patient outcomes as a result of resident duty hour restrictions; however, some studies suggest increased complication rates in high-acuity patients (6). There was no improvement in education, and performance on certification examinations has declined in some specialties (5,6). Survey studies revealed a perception of worsened education and patient safety but there were improvements in resident wellness (5,6).

Although the reasons for the lack of improvement (and perhaps decline) in outcomes with the resident duty hour restriction are unclear, several have speculated that the lack of continuity of care resulting from different physicians caring for a patient may be responsible (7). If this is true, it may be that the reduction in duty hours has little to do with medical education or experience but the duty hour resulted in fragmentation which caused poorer care.

Comparison Between Physician and NP Care In Primary Care

A meta-analysis by Laurant et al. (8) in 2005 assessed physician compared to NP primary care. In five studies the nurse assumed responsibility for first contact care for patients wanting urgent outpatient visits. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care. Nurses tended to provide longer consultations, give more information to patients and recall patients more frequently than doctors. The impact on physician workload and direct cost of care was variable. In four studies the nurse took responsibility for the ongoing management of patients with particular chronic conditions. In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource utilization or cost.

However, Laurant et al. (8) advised caution since only one study was powered to assess equivalence of care, many studies had methodological limitations, and patient follow-up was generally 12 months or less. Noted was a lower NP productivity compared to physicians (Figure 1).


Figure 1. Median ambulatory encounters per year (9).

The lower number of visits by NPs implies that cost savings would depend on the magnitude of the salary differential between physicians and nurses, and might be offset by the lower productivity of nurses compared to physicians.

More recent reviews and meta-analysis have come to similar conclusions (10-13). However, consistent with Laurant et al's. (8) warning studies tend to be underpowered, poor quality and often biased.

Despite the overall similarity in results, some studies have reported to show a difference in utilization. Hermani et al. (14) reported increased resource utilization by NPs compared to resident physicians and attending physicians in primary care at a Veterans Affairs hospital. The increase in utilization was mostly explained by increased referrals to specialists and increased hospitalizations. A recent study by Hughes et al. (15) using 2010-2011 Medicare claims found that NPs and physician assistants (PAs) ordered imaging in 2.8% episodes of care compared to 1.9% for physicians. This was especially true as the diagnosis codes became more uncommon. In other words, the more uncommon the disease, the more NPs and PAs ordered imaging tests.

NPs Outside of Primary Care

Although studies of patient outcomes in NP-directed care in the outpatient setting were few and many had methodological limitations, even fewer studies have examined NPs outside the primary care clinic. Nevertheless, NPs and PAs have long practiced in both specialty care and the inpatient setting. My personal experience goes back into the 1980s with both NPs and PAs in the outpatient pulmonary and sleep clinics, the inpatient pulmonary setting and the ICU setting. Although most articles are descriptive, nearly all articles describe a benefit to physician extenders in these areas as well as other specialty areas.

More recently NPs may have hired to fill “hospitalist” roles with scant attention as to whether the educational preparation of the NP is consistent with the role (16). According to Arizona law, a NP "shall only provide health care services within the NP's scope of practice for which the NP is educationally prepared and for which competency has been established and maintained” (A.A.C. R4-19-508 C). The Department of Veterans Affairs conducted a study a number of years ago examining nurse practitioner inpatient care compared to resident physicians care (17). Outcomes were similar although 47% of the patients randomized to nurse practitioner care were actually admitted to housestaff wards, largely because of attending physicians and NP requests. A recent article examined also NP-delivered critical care compared to resident teams in the ICU (18). Mortality and length of stay were similar.


NP have less education and training than physicians. It would appear that the scientific basis of the curricula are similar and there is no evidence that the aptitude of nurses and physicians differ. Therefore, the data that nurses care for patients the same as physicians most of the time is not surprising, especially for common chronic diseases. However, care may be divergent for less common diseases where lack of NP training and experience may play a role.

Physicians have undergone increased training and certification over the past few decades, nurses are now doing the same. The American Association of Colleges of Nursing seems to be endorsing further education for nurses encouraging either a PhD or a Doctor of Nurse Practice degree (19). However, the trend in medicine has been contradictory requirements for increasing training and certification for physicians while substituting practitioners with less education, training and experience for those same physicians. An extension of this concept has been that traditional nursing roles are increasingly being filled by medical assistants or nursing assistants (20). The future will likely be more of the same. NPs will be substituted for physicians; nurses without advanced training will be hired to substitute for NPs and PAs; and medical assistants will increasingly be substituted for nurses all to reduce personnel costs. It is likely that studies will be designed to support these substitutions but will frequently be underpowered, use rather meaningless metrics or have other methodology flaws to justify the substitution of less qualified healthcare providers.

Much of this "dummying down" has been driven by shortage of physicians and/or nurses. The justification has always been that substitution of cheaper providers will solve the labor shortage while saving money. However, experience over the past few decades in the US has shown that as education and certification requirements increase, compensation has decreased for physicians (21). NPs can likely expect the same.

Some are asking whether physicians should abandon primary care. After years of politicians, bureaucrats and healthcare administrators promising increasing compensation for primary care, most medical students and resident physicians have realized that this is unlikely. Furthermore, the increasing intrusion of regulatory agencies and insurance companies mandating an array of bureaucratic tasks, has led to increasing dissatisfaction with primary care (22). Consequently, most young physicians are seeking training in subspecialty care. It seems apparent that it is less of a question of whether physicians will be making a choice to abandon primary care in the future, but without a dramatic change, the decision has already been made.

Arizona SB1473, the bill that would essentially make NPs equivalent to physicians in the eyes of the law, is an expected extension of the current trends in medicine. Although physicians might object, supporters of the legislation will likely accuse physicians of merely protecting their turf. Personally, I am disheartened by these trends. The current trends seem a throwback to pre-Flexner report days. The poor studies that support these trends will do little more than allow the unscrupulous to line their pockets by substituting a practitioner with less education, experience and training for a well-trained, experienced physicians or nurses.


  1. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. New York, NY: The Carnegie Foundation for the Advancement of Teaching; 1910. Available at: (accessed 2/6/16).
  2. Barzansky B; Gevitz N. Beyond Flexner. Medical Education in the Twentieth Century. New York, NY: Greenwood Press; 1992.
  3. National Task Force on Quality Nurse Practitioner Education. Criteria for evaluation of nurse practitioner programs. Washington, DC: National Organization of Nurse Practitioner Faculties; 2012. Available at: (accessed 2/6/16).
  4. Lerner BH. A case that shook medicine. Washington Post. November 28, 2006. Available at: (accessed 2/9/16).
  5. Bolster L, Rourke L. The effect of restricting residents' duty hours on patient safety, resident well-being, and resident education: an updated systematic review. J Grad Med Educ. 2015;7(3):349-63. [CrossRef] [PubMed]
  6. Ahmed N, Devitt KS, Keshet I, et al. A systematic review of the effects of resident duty hour restrictions in surgery: impact on resident wellness, training, and patient outcomes. Ann Surg. 2014;259(6):1041-53. [CrossRef] [PubMed]
  7. Denson JL, McCarty M, Fang Y, Uppal A, Evans L. Increased mortality rates during resident handoff periods and the effect of ACGME duty hour regulations. Am J Med. 2015;128(9):994-1000. [CrossRef] [PubMed]
  8. Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271. [CrossRef]
  9. Medical Group Management Association. NPP utilization in the future of US healthcare. March 2014. Available at: (accessed 2/17/16).
  10. Tappenden P, Campbell F, Rawdin A, Wong R, Kalita N. The clinical effectiveness and cost-effectiveness of home-based, nurse-led health promotion for older people: a systematic review. Health Technol Assess. 2012;16(20):1-72. [CrossRef] [PubMed]
  11. Donald F, Kilpatrick K, Reid K, et al. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract. 2014;2014:896587. [CrossRef] [PubMed]
  12. Bryant-Lukosius D, Carter N, Reid K, et al. The clinical effectiveness and cost-effectiveness of clinical nurse specialist-led hospital to home transitional care: a systematic review. J Eval Clin Pract. 2015;21(5):763-81. [CrossRef] [PubMed]
  13. Kilpatrick K, Reid K, Carter N, et al. A systematic review of the cost-effectiveness of clinical nurse specialists and nurse practitioners in inpatient roles. Nurs Leadersh (Tor Ont). 2015;28(3):56-76. [PubMed]
  14. Hemani A, Rastegar DA, Hill C, al-Ibrahim MS. A comparison of resource utilization in nurse practitioners and physicians. Eff Clin Pract. 1999;2(6):258-65. [PubMed]
  15. Hughes DR, Jiang M, Duszak R Jr. A comparison of diagnostic imaging ordering patterns between advanced practice clinicians and primary care physicians following office-based evaluation and management visits. JAMA Intern Med. 2015;175(1):101-7. [CrossRef] [PubMed]
  16. Arizona Board of Nursing. Registered nurse practitioner (rnp) practicing in an acute care setting. Available at: (accessed 2/12/16).
  17. Pioro MH, Landefeld CS, Brennan PF, Daly B, Fortinsky RH, Kim U, Rosenthal GE. Outcomes-based trial of an inpatient nurse practitioner service for general medical patients. J Eval Clin Pract. 2001;7(1):21-33. [CrossRef] [PubMed]
  18. Landsperger JS, Semler MW, Wang L, Byrne DW, Wheeler AP. Outcomes of nurse practitioner-delivered critical care: a prospective cohort study. Chest. 2015;148(6):1530-5. [CrossRef] [PubMed]
  19. American Association of Colleges of Nursing. DNP fact sheet. June 2015. Available at: (accessed 2/13/16).
  20. Bureau of Labor Statitistics. Occupational outlook handbook: medical assistants. December 17, 2015. Available at: (accessed 2/13/16).
  21. Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. [CrossRef]
  22. Peckham C. Physician burnout: it just keeps getting worse. Medscape. January 26, 2015. Available at: (accessed 2/13/16).

Cite as: Robbins RA. Nurse pactitioners' substitution for physicians. Southwest J Pulm Crit Care. 2016;12(2):64-71. doi: PDF 


National Health Expenditures: The Past, Present, Future and Solutions

Richard A. Robbins, MD

Phoenix Pulmonary and Critical Care Research and Education Foundation

Gilbert, AZ

"[T]he US health care system … defies the laws of economics, and of gravity. Once the price is high, it just stays there."- Dr. Naoki Ikegami


The costs of health care in the US have been increasing for many years and the US now spends more on health care than other developed country. The cost of health care is higher in the US in nearly every category. However, the dramatic rise in health care costs over the past 35 years occurs during the time when pharmaceutical costs and administrative costs have also dramatically risen. It seems likely that these costs may account for much of the increase in health care. However, neither is dealt with by the Affordable Care Act (ACA). Until a system of oversight is enacted on medical costs, it seems likely that US health care costs will continue to rise.

The Past

In comparison to other economically developed countries health care costs have risen dramatically in the US over the past 35 years (Figure 1) (1).

Figure 1. Rise in health care spending in the US and selected other countries.

Myths. The reasons for this rise in spending have been shrouded in myths and accusations. It has been argued that high costs is the price for the best health-care system in the world. However, patient outcomes in the US are mixed. In a 2011 report by the Organization for Economic Co-operation and Development (OECD), the United States ranked 25th in life expectancy (1). Although we do better in cancer survival rates, we are more likely to die of heart disease and we do not have a good track record on treating chronic diseases such as asthma.

Health care rationing. An argument has been made that because health care is heavily rationed in other countries, Americans use more health-care services in comparison. We do rank high in the use of some expensive tests and procedures (more on this later), but overall the OECD reports that the US is well below other developed countries in number of average doctor visits per year, hospitalizations and hospital length of stay (1). Americans have better-than-average access to specialists, but we lag compared to other countries in getting immediate access to a primary care doctor when we're sick and we are much more likely forgo heath care because of costs (2).

Bad patients. Some have claimed that the US has to spend more on health care because we are fat and lazy. Although this may be true, it does not explain the gap in health care spending between the US and other countries. Obesity rates are higher in the US but the US compares well to other countries in smoking and drinking (1). We also have a younger population compared to many other OECD countries which should actually lower costs (1).

Tort reform. The US has more lawyers and more lawsuits of doctors but this does not seem to be a major factor in health care costs. Tort reform would probably not go far in bringing down US health-care costs. A 2009 study by the nonpartisan Congressional Budget Office (CBO) found that implementing tort reform would reduce US health care spending by only 2 percent (3).

Government inefficiency. There is also speculation that US Government inefficiency and spending that drives up health care costs. Health care administrative costs in the Veterans Administration (VA) are estimated to be lower than private insurance according to the CBO (4). However, as recently discovered in the patient wait times scandal, VA data may be suspect. The Centers for Medicare and Medicaid Service's (CMS) administrative costs are reported to be about 2 percent of claims costs, while private insurance companies’ administrative costs are in the 20 to 25 percent range. The argument is that private industry with costs for advertising, collection, and profit are eliminated by CMS resulting in lower costs. However, this concept has also been challenged. CMS’s administrative costs are often hidden or completely ignored by the complex and bureaucratic reporting and tracking systems used by CMS (5). Furthermore, the estimates completely ignore the inefficiencies created by CMS's mandates requiring an increasingly heavy paperwork burden for physicians and hospitals.

Physician income. Some think that greedy physicians making too much money explain the rising costs in health care. Physician compensation varies widely between specialty, health care setting and region. Laugesen and Glied (6) concluded that higher physician fees were the main drivers of higher US spending. However, in 1970, the average inflation-adjusted income of general practitioners was $185,000. In 2010, it was $161,000, despite a near doubling of the number of patients that doctors see a day. Furthermore, during the boom years of the 1990's physician incomes remained relatively stagnant with an actual decline in the early 2000's (7-9). Although physician income is higher in the US than other countries, it would not appear to explain increasing health care costs since physician income was predominately stagnant or decreasing while health care costs rose.

Drug costs. Pharmaceutical costs have been increasing in the US (Figure 2) (10).



Figure 2. Total prescription drug spending 1980-2012.

Some have blamed these costs in increasing health care costs in the US. Although the rate of growth appears to be leveling off when adjusted for inflation (Figure 2), pharmaceutical costs remain high in the US.

Administrative costs. In ground-breaking work published in 1991 Woolhandler and Himmelstein (11) found that US administrative health care costs increased 37% between 1983 and 1987. They estimated these costs accounted for nearly a quarter of all health care expenditures. In Canada the administrative costs were about half as much and declined over the same period. They followed their 83-87 report by examining data from 1999 (12). US administrative costs had risen to 31% of US health care expenditures.

The trend is perhaps best illustrated by the graph below (Figure 3) (13).  

Figure 3. Growth in administrators and physicians 1970-2010 (used with permission of David Himmelstein).

The growth in administrative costs may not limited to the private sector. CMS' administrative costs are very difficult to determine. Similarly, the VA also has hidden costs. However, during my 30 years at the VA, I saw a disturbing growth in the front office. New assistant directors were continually hired, sometimes during a hiring freeze when needed doctors and nurses were not hired (Robbins RA, unpublished observations). The growth in VA administration has been staggering at some levels. Regional Veterans Integrated Service Network (VISN) offices were founded in the mid 1990's. However, these VISNs provide no healthcare and now number nearly 5000 employees (14). VA central office in Washington grew from about 800 employees to 11,000 in the last 15 years (14). This represents a staggering 20-fold increase over the past 15 years.

The Present

High Costs. Nearly everyone agrees that health care costs are too high and have continued to rise albeit more slowly during the Obama administration (1,15). At $8713 per person the US outspent every other OECD country for a number of years including 2015 (Figure 4) (1,15).

Figure 4. Current expenditure on health, per capita, US$ purchasing power parities. OECD average in green and United States in red.

The next closest was Switzerland at $6325. The US is a very rich country, but even so, it has devoted an increasing percentage of its gross domestic product (GDP) to health than any other country for a number of years including 2015 (Figure 5).

Figure 5. Current expenditure on health as a % of gross domestic product (GDP). OECD average in green and United States in red.

Switzerland is the next highest, at 11.1% of GDP, and the average among economically developed countries was almost half that of the US, at 8.9%.

High Numbers of Expensive Procedures. There is plenty of blame to spread for the increased cost of health care in the US. Spending on almost every area of health care is higher (Figure 6) (1,2).

Figure 6. Health spending by category in US dollars 2010 or latest year available.    

Because the spending is higher in nearly every category, the reasons for the high costs in the US are likely multifactorial. US health care has a long-standing reputation for excessive numbers of procedures at high costs. The data would seem to back that impression. The numbers of some expensive procedures or operations appear to be higher in the US compared to other countries (Table 1) (1).

Table 1. Numbers of exams or procedures in the US with OECD rank and average.

High Cost per Procedure. Furthermore, the costs of procedures in the US are high compared to other countries (1,16). (Table 2).

Table 2. Cost of common procedures. Highest cost in red.

The average price for a wide range of both medical and surgical services in the US is 85 percent higher than other OECD countries (16). Both the numbers of expensive procedures and the high cost of procedures undoubtedly contribute to the high cost of health care in the US.

Administrative Costs. In 1999 the administrative costs of health care were estimated to be about 1/3 of all costs and were rapidly rising. There appears to have been little slow down in the rapid rise of administrative costs. Himmelstein and Woolhandler (17) estimated that administration costs could be as much as 45% of health care costs in 2014. There is no line for administrative costs on a medical bill but these costs are factored into all categories of medical spending.

The Future

As both Niels Bohr and Yogi Berra have said, "it's tough to make predictions, especially about the future". Now that King vs. Burwell has been settled, it is apparent that American health care will be directed by the ACA for the foreseeable future. Each year an official National Health Expenditure Projections for the next 10 years is released by the Centers for Medicare and Medicaid Services (CMS)’ Office of the Actuary. By examining these projections (which may be overly optimistic) as well as some observational studies, a rough prediction for the costs of health care can be made.

Economies of Scale. A principle in medical economics central to the Affordable Care Act (ACA) is economies of scale (18). The theory is that larger insurers will have lower prices because they are more administratively efficient. However, a recent study found that the largest insurer in each of the US states served by raised their prices in 2015 by an average of over 10% compared to smaller competitors in the same market (19). Those steeper price hikes for monthly premiums did not seem warranted by the level of health claims which did not significantly differ as a percentage of premiums in 2014.

Provider-Owned Health Plans. Another principle of the ACA in controlling health care costs is establishment of provider-owned (usually hospital) health plans. The theory is that substitution of provider-owned health plans will lower costs by controlling doctors over charging in a fee-for-service model. Although temptingly simple, a recent study concludes that this theory is not supported by the evidence. Comparing provider-owned to nonprovider-owned plans within twelve counties across the US was on average 12% more expensive compared to traditional insurers (20).

Drug Costs. Although drug prices remain consistently high in the US compared to other economically developed countries, competition to reduce these prices for CMS patients has been limited by Congress. Most health care plans have focused on formularies to control prices. Under this system, contracts with pharmaceutical manufacturers establish preferred drugs for use by their clients and their contracted physician prescribers. Although this strategy has been in place for some time, it appears to be ineffectual in controlling drug costs (Figure 6). Most countries place price controls on drugs, a strategy that seems to lack political will in the US (21). There appears to be little in the ACA that will control drug costs.

Administrative Costs. Himmelstein and Woolhandler (22) calculated new overhead costs from the official National Health Expenditure Projections for 2012-2022 released by the Centers for Medicare and Medicaid Services (CMS)’ Office of the Actuary in July 2014. Between 2014 and 2022, CMS projects $2.757 trillion in spending for private insurance overhead and administering government health programs (mostly Medicare and Medicaid), including $273.6 billion in new administrative costs attributable to the ACA. Nearly two-thirds of this new overhead—$172.2 billion—will go for increased private insurance overhead.

Most of this soaring private insurance overhead is attributable to rising enrollment in private plans which carry high costs for administration and profits. The rest reflects the costs of running the ACA exchanges.

Insuring the 25 million additional Americans, as the ACA is projected to do, is surely worthwhile, but the administrative cost is enormous. The ACA isn’t the first time we’ve seen bloated administrative costs from a federal program that subcontracts for coverage through private insurers. Medicare Advantage plans’ overhead averaged 13.7 percent in 2011, about $1,355 per enrollee. However, both Congress and the White House seem intent on sending more federal dollars to private insurers. Indeed, the House Republican’s initial budget proposal would have "voucherized" Medicare, eventually diverting almost the entire Medicare budget to private insurers. Fortunately, the measure passed by the House on April 30, 2015 dropped the voucher scheme.


The difficulty with the ACA is that it does not appear to control the two major causes of the rise in health care spending - pharmaceutical costs and more importantly administrative costs. Himmelstein and Woolhandler (22) have long advocated a national single-payer system for health care similar to Canada's. They cite the low overhead for Medicare and Medicaid and the VA as demonstrating that such a system can work in the US. Despite the obfuscation of the overhead data by both US government agencies such as CMS and the VA, it seems likely that a single payer system would be more efficient than a private system. As Himmelstein and Woolhandler (22) have stated "public insurance gives much more bang for each buck".

However, a caveat must be added. A lesson that should be learned from the recent VA scandal is that public officials are no more honest that private companies in reporting data. Any system devised will need close oversight by knowledgeable patient care advocates. If not, the dollars intended for health care will be diverted into administrative pockets. It seems most likely that this should be on a local level by health care providers not employed or appointed by the administrators they oversee. Otherwise, there would be no real oversight. The ACA seems to encourage "provider-owned" health plans. These plans should be overseen not by the business cronies or administratively appointed physicians and nurses, but by independent health care providers who will look at administrative costs with a suspicious eye and question the costs at a local level. Otherwise the present system of less care at higher prices will persist.


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Cite as: Robbins RA. National health expenditures: the past, present, future and solutions. Southwest J Pulm Crit Care. 2015;11(4):176-85. doi: PDF


Credibility and (Dis)Use of Feedback to Inform Teaching : A Qualitative Case Study of Physician-Faculty Perspectives

Tara F. Carr, MD

Guadalupe F. Martinez, PhD


Division of Pulmonary/Critical Care, Sleep and Adult Allergy

Departments of Medicine and Otolaryngology

University of Arizona College of Medicine

Tucson, AZ



Evaluation plays a central role in teaching in that physician-faculty theoretically use evaluations from clinical learners to inform their teaching. Knowledge about how physician-faculty access and internalize feedback from learners is sparse and concerning given its importance in medical training. This study aims to broaden our understanding. Using multiple data sources, this cross-sectional qualitative case study conducted in Spring of 2014 explored the internalization of learner feedback among physician-faculty teaching medical students, residents and fellows at a southwest academic medical center. Twelve one-on-one interviews were triangulated with observation notes and a national survey. Thematic and document analysis was conducted. Results revealed that the majority accessed and reviewed evaluations about their teaching. Most admitted not using learner feedback to inform teaching while a quarter did use them. Factors influencing participants use or disuse of learner feedback were the a) reporting metrics and mechanisms, and b) physician-faculty perception of learner credibility. Physician-faculty did not regard learners’ ability to assess and recognize effective teaching skills highly. To refine feedback for one-on-one teaching in the clinical setting, recommendations by study participants include: a) redesigning of evaluation reporting metrics and narrative sections, and b) feedback rubric training for learners.


Teaching is at the heart of academic medicine. Evaluation plays a central role in teaching in that clinical teachers, theoretically use evaluations from learners to inform their teaching (1,2) Feedback has been identified as a critical component of evaluation, and by extension, medical education training (3-6). National accreditation agencies emphasize the need for the ongoing meaningful exchange of feedback between learners and physician-faculty (7,8)

The learner perspective has dominated feedback research (9-14). These studies examine how physician-faculty deliver feedback, and how learners absorb the content and delivery of feedback. Physician-faculty also assume the role of learner when medical students and trainees serve as evaluators and provide feedback about physician-faculty teaching. In response, physician-faculty develop perceptions about the quality and context of feedback from learners that shape their receptiveness of that feedback, and teacher self-efficacy (15-18). Yet, only four studies consider context and explore factors that influence feedback receptiveness of physician-faculty (15, 19-21).   Only one study examines how physician-faculty respond to learner feedback to make adjustments to their teaching (15). Previous studies have also uncovered the important idea of “source credibility." (11,14,20,22).  They find that the impetus for both effective learning and teaching adjustment comes from the feedback recipient’s trust in the evaluators’ credibility. A limitation of these studies is the lack of attention to the feedback reporting mechanisms used by their institutions, leaner-teacher contact time, the establishment of relationships, and the various factors that go into trusting or valuing learner feedback. These perceptions play an essential role in how we understand educational exchanges between teacher and learner. As such, the purpose of this study is to recognize physician-faculty perceptions about the feedback process in relationship to their teaching practice.

Knowledge about how physician-faculty access and internalize feedback from learners is sparse (22), much less faculty recommendations for improving the process. This is concerning given the important role feedback plays in clinical training. This study aims at broadening the understanding of how physician-faculty access and internalize written feedback from learners while considering contextual factors that shape the overall feedback experience for physician-faculty. We qualitatively examine if and how learner feedback influences physician-faculty receptivity and incorporation of feedback critiques into their teaching practice. In supporting inquiries, we ask: To what extent do physician-faculty access and use feedback and why (or why not)? What factors shape their decisions to incorporate (or not incorporate) learner feedback into their teaching practice?


Exempt from human research approval by the site’s Institutional Review Board, this cross-sectional case study explored feedback internalization among medicine physician-faculty at a southwest academic medical center (23). The ethical conduct to maintain anonymity and inhibit coercion was exercised and articulated to participants. Participation was voluntary and without monetary compensation.

Case study research in the social science calls for the use of multiple data sources to gain understanding of an issue using a bounded group (24,25). As such, three data sources were included in analysis and to triangulate findings. First, purposeful selection was used to identify physician-faculty whose lived experiences in the department would assist us in understand the issue (26). Physician-faculty were introduced to the study’s purpose at a routine faculty meeting where voluntary participation was elicited.

Twelve of 15 (80%) full-time medicine subspecialists participated. Sometimes mistaken as a limitation of qualitative case study design is the relative small sample size; our interview numbers not only meet the general qualitative research sample size criterion of five to 30 interviews (27-30) but focuses on obtaining information-richness in the form of quality, length and depth of interview data and supporting evidence from additional sources that answer the research question. (Table 1).

Table 1. Sample Demographics.

Original interview questions were created (Appendix A). Individual semi-structured open ended interviews were conducted during the Spring of 2014. Follow-up interviews on two participants were conducted in early February of 2015 once promoted from mid-level to full professor. The same interview protocol was used to capture changes in perspective from full professors in the effort to expand the insight pool of senior professors.

During the preceding three years, all physician-faculty in the department received e-feedback at the end of rotations from learners that includes evaluation of their individual teaching. E-feedback was designed by the college’s medical education program directors. Forms were 9-point Likert scale with an optional written comments section after each question. To gather information regarding the internalization of feedback, we asked physician-faculty to recollect past e-feedback through their tenure at the study site. Interview questions asked participants to describe their access to evaluations, and internalizations of feedback. Interviews lasted between 30-60 minutes, were audio recorded, and transcribed. Transcripts were de-identified, and demographic information reported was limited. Reporting of narratives was truncated to capture central points and stay within the word count limitation. Participants from outside institutions and departments were not included in this study as evaluation tools may include different reporting mechanisms. Additionally, we wanted to capture and understand the current subculture that exists regarding feedback and teaching that is particular to one local clinical department.

Secondary data were: observation notes, and annual ACGME trainee survey results. Observation notes were taken by the principal investigator to memorialize each interview exchange, physician-faculty education meetings (e.g. faculty meetings, clinical competency committee meetings), and clinic exchanges also during Spring of 2014 (31). Given that the principal investigator is also a physician-faculty member, an insider researcher approach (32) allows the design to include her notations as she is acutely attuned to the daily lived experiences of the participating physician-faculty. The advantage of implementing this approach is that the principal investigator understands the participants’ academic values, current work environment, insider language and cues for accurate and trustworthy behavioral notes. Observation notes were taken to document behavior at education meetings where program evaluation and physician-faculty development was discussed. Disadvantages of being an insider could lead to bias, assumptions about meanings, and overlooking of routine behaviors that could be important. A quasi-outside researcher and non-physician-faculty member in the department served as a collaborator to counter insider researcher assumptions and bias.

Physician-faculty interviewed also partook in the 2013-2014 annual ACGME anonymous online trainee survey in the Spring of 2014. Trainee ratings of physician-faculty commitment to GME programs, and perceived satisfaction the program’s perceived use of evaluations to improve rotations could further validate whether or not physician-faculty use evaluations to inform their teaching. (Appendix B).

Data were analyzed using qualitative software, QSR Nvivo10©. Using a holistic and cross-case analysis approach (25), thematic coding was used to identify patterns in access to feedback, and receptiveness on interview data and observation notes. Axial coding was then used to hone in on specific challenges/strengths in feedback from learners. Once identified, selective coding was conducted to detect themes and redundant assertions so as to ensure that no new information was emerging. Last, document analysis of the ACGME survey results was conducted. Implementing the In-between-triangulation method (33), codes from observation notes and the ACGME survey results were linked through memos to interview data. Member checking between the principal investigator and co-investigator regarding themes, terms, and categorizations occurred to ensure data trustworthiness as defined by Guba (34) (Appendix C).


Access, review, and (dis)use

A significant proportion of physician-faculty accessed and reviewed feedback about them when available (10/12: 83%). The majority of physician-faculty revealed that they do not use learner feedback to make adjustments to their teaching (9/12; 75%). One physician-faculty member summarized the group’s sentiments and disclosed, 

“Not at all. The verbal feedback from my colleagues and boss makes me more cognizant of my behavior and I modify it appropriately; whether it was a success, I’ll let them judge. The written eval[uation]s from [learners] has never changed [my teaching] because they go from horrible to great and they are not useful.”-S11

Only a quarter, all of whom were junior faculty, reported utilizing learner feedback to alter teaching (3/12; 25%). Evidence that the majority of physician-faculty may not be using learner feedback to adjust teaching is broadly, but further corroborated by the ACGME survey data. Although 100% of trainees in this GME program reported having the opportunity to evaluate physician-faculty, less than 70% (which was very close to the national average) reported satisfaction with the program and physician-faculty using learner evaluations to improve. Despite this rating, these learners also reported that physician-faculty were interested in the educational program, and created an environment of inquiry at the rate of 100% (Appendix B). Furthermore, from observation notes taken during daily clinical discussions, it was noted that physician-faculty did not discuss their weaknesses with each other; especially regarding their teaching skills. Finally, when conversations regarding national conferences arose in physician-faculty education meetings or informal social settings, physician-faculty did not dialogue about attending conferences for the specific reason of improving or learning new teaching skills.

Factors influencing (dis)use

Physician-faculty identified several factors shaping their decisions to incorporate learner feedback into their teaching. To begin, just over half (7/12; 58%) reported that the metric used was problematic. When asked what they found valuable or disposable in reporting mechanisms, physician-faculty attested: 

 “A one-to-one evaluation rather than [the software we use] would be more valuable because…the numerical feedback is not very good. They need directed questions. There are non-substantive comments.” - S11

 “The numbers are worthless. I’d rather get comments that say,’ the bedside teaching was excellent, but he should work on his didactic session and change the graphics on that PowerPoint,’ but I never get that.” - S04

Second, differences in the perception of the learners emerged. Observation notes documenting contact time, relationship establishment and perspectives on fellows, specifically, revealed that physician-faculty tended to label learners in “good/bad” categories based on a combination of professional conduct, and medical knowledge base. “Good fellows” were the desired learner in the clinical setting. These learners were discussed and seen frequently in the company of physician-faculty at grand rounds, academic half days and departmental social gatherings. From observation, five physician-faculty had a following of learners who were similar to them in personality traits, interests or career aspirations. These physician-faculty and learners had a relationship, and it was evident at both social and academic gatherings as evident by the quality, duration and topic of verbal engagement, and physical proximity. Not all physician-faculty observed had this type of following and engagement.

Expanding on the observation of categorization and relationship establishment, physician-faculty reflected on their overall experience with learners and reported a general concern with the learners serving as evaluators. As a result, they cited this as a major reason for the disuse of feedback to inform their teaching (9/12; 75%). Concerns were grounded in the context of a) inadequate contact time, b) learners’ teaching fund of knowledge, and c) feedback being foregrounded in whether or not the learner takes a personal liking to the attending. When asked what their visceral reaction was to learner feedback, physician-faculty stated,

“I think you should limit it to somebody who has prolonged exposure to you. Most [learners] are only exposed to you for a few days…I think it’s more about the person doing the eval[uation] than the faculty member’s teaching ability. So I don’t hold learner feedback in high regard.” - S07

“I don’t think they know what a good teacher is….most [learners] just anchor their eval[uation] based on whether they like someone or not, so there’s not a rigorous evaluation of teaching methods.”- S04

These issues relate to physician-faculty skepticism about learners’ abilities to assess the teaching skills of their attending. There was a perception that learners were either: a) not knowledgeable about teaching methods and feedback, or b) scared to give honest feedback to physician-faculty because of the fear of retaliation. Nearly all physician-faculty reporting concerns with learner feedback knowledge recommended they receive a rubric as a tool to not only guide their feedback, but educate them about the evaluation process, and help identify “teaching moments” (7/9; 78%). Physician-faculty remarked,

“They might not know when the teaching is happening… I don’t think they know how that works and what that standard is... they don’t notice it…a lot of the teaching can be seen as unconventional. A rubric for them might be helpful…they need to be educated on evaluation.“- S10

Conversely, only two physician-faculty reported using learner feedback to adjust their teaching (2/9; 22%). They noted,

“[Learners] have been exposed to a lot of teaching and have a sense of what is effective and works for them. So part of our job is to be an effective teacher for different learners so if we’re not an effective teacher for certain learners we need to know about that…in a sense everyone is qualified… It doesn’t mean that one person who says you are not an effective educator is correct. We can’t please everyone, but we can work towards it.”- S11

 “…I try to establish relationships with the residents and fellows, and unfortunately or fortunately, it is easier for me to talk to them that way.”- S01

Learners’ experiences with numerous teachers and styles throughout their physician training were valued by the latter example. They perceived that learners had enough knowledge and experience to provide valid and competent feedback. Additionally, they saw it as their responsibility to adjust teachings and approach the teacher-learner construct as a bidirectional relationship. This is consistent with teacher-learner relationships noted in the observation settings.


The implications surrounding learner feedback and how physician-faculty internalize and use feedback to inform their teaching practices are substantial. In sum, physician-faculty in our study did not hold learner feedback in high regard. Extending the work identifying the issue of “source credibility” in feedback (3,11,14,20,22), a key finding that adds dimension to this concept is that physician-faculty in our study use learner feedback to adjust teaching practices based on the specific value they placed on learners’ past education experiences and competency regarding teaching skills and assessment. Results suggested that source credibility is further shaped by communication and existence of a relationship between the two parties given that study participants discussed viewing the dyad as “relationship”. Supporting a recent framework, “educational alliance” introduced by Telio and colleagues (3), this idea of a relationship implies an investment, and value in each other’s roles and contributions. The quality of the relationship and communication matters as it appears to play a role in the development of physician-faculty perceptions about their learner and by extension, receptiveness to learner feedback. If such an alliance is developed, physician-faculty could then draw more informed conclusions about learner credibility that could subsequently shape their use of learner feedback. When considering the context of resident and fellow learners, this underscores the importance of national Resident-as -Teachers programs as the intent of these programs is to build a teaching fund of knowledge for trainees. Research examining their effectiveness from the perspective of seasoned physician-faculty is needed. Additionally, future studies assessing correlations between faculty who place high value on learner feedback and credibility with increased recognition as effective teachers would greatly add to our understanding of this complex issue.

Findings also highlighted the importance of appropriate feedback metrics and mechanisms. Physician-faculty reported dissatisfaction with the metrics of the institution’s online evaluation system, and their corresponding narrative sections. They recommended rubric training for the learners to refine feedback for one-on-one teaching. Looking to our results, we support and propose a feedback rubric that is deployed via a purposeful training. To set the stage for feedback to occur as a process, rubric training could require learners to undergo brief training at their respective orientations on both the use of the rubric and importance of quality narrative feedback for program improvement and physician-faculty development. Rubric for each metric that incorporates rich descriptions could scaffold and improve the critical thinking process involved in writing constructive feedback narratives for learners. Moreover, comment boxes on evaluation reporting mechanisms with either prompts or ideal substantive comment examples could help learners’ better articulate meaningful feedback for physician-faculty and make connections with rubric scoring guides. This approach forces a reconceptualization of the role of learner feedback that is different. With the training and implementation of feedback rubric for learners, this places them in the role of teacher and expert evaluator. This alters the traditional paradigm and forces physician-faculty to expect more of learners and facilitates a system to further train learners in teaching and evaluation skills.

Finally, rubrics could include moderate tailoring to address abbreviated contact time, ensure anonymity, and review institutional safeguards against physician-faculty retaliation against the learner. A limitation of current feedback frameworks (3) is the lack of attention to how limited duration of contact time, and desire for anonymity, could impact quality communication and the establishment of a relationship. Consequently, physician-faculty being evaluated should undergo parallel training to understand context in which learners have been instructed to reflect and formatively evaluate their teaching practices given a varied set of learning/teaching conditions that consider the aforementioned obstacles. We encourage the development and testing of such tools as a next step.


A limitation of our study is the restriction to one department and over-representation of junior faculty. Physician-faculty were not asked to disaggregate feedback by the type of learner. Differences between physician-faculty perceptions of medical students versus residents versus fellows may have emerged. Despite these limitations, findings provide critical insight into what gives rise to the receptiveness of learner feedback while providing an honest report on why physician-faculty use or disuse evaluations to inform their teaching.  


Our study evaluates the value physician-faculty place on individual learner feedback about their teaching in the clinical setting. Despite the centrality of feedback in medical education training, physician-faculty predominantly accessed, reviewed, but disused feedback from learners to inform their teaching. This is due to the reporting mechanisms and concern over credibility of the learner; specifically, their ability to assess and recognize effective teaching skills. The introduction of feedback rubric training for learners could advance learning and contribute to sound evaluation as they are important sources of information for identifying and improving teaching and evaluation skills.35 Physician-faculty need to be able to trust and value the feedback they receive. Credible feedback shapes the decisions they make when selecting appropriate professional development opportunities, thus, shaping the quality of our medical training programs.


We would like to thank Karen Spear Ellinwood, PhD, JD and Gail T. Pritchard, PhD for the Academy of Medical Education Scholars (AMES) Teaching Scholars Program for providing a platform from which to design and conduct the study. We also wish to thank the faculty members who participated in this study, for their time and candor.

Declaration of Interest

No declarations of interest.



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Reference as: Carr TF, Martinez GF. Credibility and (dis)use of feedback to inform teaching : a qualitative case study of physician-faculty perspectives. Southwest J Pulm Crit Care. 2015;10(6):352-64. doi: PDF


Special Article: Physician Burnout-The Experience of Three Physicians

Robert A. Raschke, MD

University Banner Good Samaritan Medical Center

Phoenix, AZ

Our fellowship held a discussion on physician burnout which was facilitated by Kris Cooper PhD, a psychologist who has long experience working with struggling physicians. We were joined by three physicians who volunteered to share their personal experiences regarding burnout. Each of these three physicians are exceptional in their devotion to their profession, high self-expectation, and level of professional achievement. Yet the commendable personal characteristics they share may have actually set them up to ultimately suffer burnout. Each of them responded to burnout in a different way.

The first physician is an intensivist who left work suddenly 6 months ago, likely never to return. Over a long career, this physician had earned the respect of his colleagues and was beloved by the nurses for seeming to always knowing the right thing to do and dedicating himself fully to the care of the sickest patients and their families. For most of his career he rarely experienced anxiety even under the most stressful situations - “I did not even know really what it meant to be anxious”. He typically slept soundly 8 hours a night no matter what had happened at work. But nearing the end of his career he felt he had been floundering, essentially “propped-up” by the housestaff and his partners as he became progressively unable to function. At the time of his sudden departure, he was suffering unremitting insomnia, anxiety, and low self-confidence. He routinely avoided taking the sickest patients. His anxiety became so severe that he suffered anticipatory nausea even when simply accepting hand-off of the ICU service by phone.   

He relates the beginning of his professional difficulties to seven years previously when his wife of 20 years unexpectedly announced her intention to divorce him. This was emotionally highly traumatic and essentially caused a situation of unremitting stress both at work and at home. He recalled often having to deal with divorce lawyers even while at work – once having been called by a lawyer while was trying to run a code. He was not able to remediate his marriage. The process was frustrating and costly, however, he was able to seemingly recover over a prolonged course. He continued functioning at a high level at work during this process and for a number of years afterwards however he found himself socially isolated and with new financial worries.

Several years later a series of complaints were lodged against him at work. In one case, he was reprimanded for publically berating a colleague regarding an inappropriate patient transfer to the ICU. Several of his patients suffered bad outcomes and were submitted for peer review. However, the reviewers were not intensivists, and he felt were not truly “peers” in the sense that they couldn’t relate to the types of decisions required in ICU emergencies. In one case, a hematologist criticized his decision to give activated factor VII to a patient who was coding from uncontrollable obstetrical hemorrhage after the blood bank was unable to provide plasma. It was decided that his action in this case was outside the standard of care, although the reviewer did not offer any therapeutic alternative. In another incident, the physician extubated a patient who was subsequently unable to maintain independent breathing. Attempts to reintubate were unsuccessful and consequently fatal. In each case, the physician knew he had done the best he possibly could for the patient, but this chain of events cumulatively resulted in enduring workplace anxiety and a loss of self-confidence. Although he continued to provide good patient care, he felt he was “faking it”, by avoiding the sickest patients and leaning heavily on residents and fellows. He sometimes asked as many as three physicians (a critical care colleague, surgeon, and anesthesiologist) to back him up when one of his patients required endotracheal intubation, although his airway skill level demonstrated over the long course of his career was excellent.

A tremor which he had suffered with for several years worsened, making it even more difficult to perform procedures. He complained of neck pain and arm weakness but a neurological evaluation was unrevealing. He was repeatedly sick with the stomach flu and upper respiratory tract infections. He was diagnosed with depression, anxiety and post-traumatic stress disorder (PTSD), but prescription medications provided no benefit and seemed to worsen somatic complaints. Insomnia became unremitting. He would go for weeks on end, sleeping only a few hours per night, or not at all. Although he was overcome by anxiety, he became detached from more situationally-appropriate emotions – relating that he could run a code, watch the patient die, then “go right to the doctor’s lounge and eat a cheeseburger”- as though his feelings about things that were happening around him were irrelevant. The realization that he could no longer go on this way hit him suddenly and somewhat expectedly, although in retrospect it should have been obvious much sooner.

Up to 50% of physicians and nurses experience “burnout” at some point in their career – the highest incidence is in critical care (1). Burnout is characterized by the triad of emotional exhaustion, depersonalization, and a loss of any satisfaction in doing your job. It is caused by long term exposure to emotionally demanding situations in an environment of high responsibility and low control. Physicians with high empathy and high self-expectation and introspection are particularly at risk. It is associated with having made mistakes, perceptions of unreasonable work demands, feeling unsupported by the organization, and interpersonal conflicts. Symptoms include somatic complaints, frequent minor illnesses, social withdrawal, cynicism, exhaustion, and feeling underappreciated and overworked. Burnout may overlap with compassion fatigue, PTSD, depression, anxiety, alcoholism and drug abuse in some providers. The risk of suicide is increased by 600% for physicians, particularly female physicians.

The first physician said that he had a number of strikes against him, and took a number of wrong turns along the way. He recalled coming home from work exhausted many nights, and having no one to talk to, but at the same time, turning down opportunities to socialize more with friends. He felt he sometimes created more workplace stress than necessary by futilely resisting the hospital administration on a number of trivial issues. His partners were supportive, but really did not understand enough about what he was going through to effectively help him. He waited too long to get himself out of the environment.

But since removing himself from the ICU, he has been slowly improving under professional guidance. At this point, he has been away from work for about six months. [Many of the ICU staff – nurses and physicians alike – consider him the finest doctor they have ever worked with, and often ask when he can return.] But he is fairly certain that he will ever be able to return to work in the ICU.

The second physician is a highly respected intensivist who retired about a year ago, unrelated to burnout. He was described by the first physician as “the best intensivist that I ever met over the course of my career”. However, the second physician suffered significant setbacks and frustration that greatly reduced enjoyment of his career. He distinguished himself as being “fed-up” vs. being burned-out by saying that if we asked him to come into the ICU tomorrow to cover a shift, he would be eager to chip-in.

He also distinguished himself from the first physician by acknowledging that his wife of 42 years had been a huge source of support throughout the course of his many professional setbacks.

In the 1980s, in an era long before the practice of palliative care was accepted, he recalled being approached by several families of patients with end-stage COPD. At the time such patients often suffered through prolonged courses of futile ventilatory support before dying. He made a personal decision to instead offer these patients the option of morphine palliation. This was of clear benefit to his patients, but was considered well outside the standard of care at the time. He was accused of performing euthanasia, and his medical license was threatened. He was offered a deal to continue practicing medicine if he would desist and admit that what he had been doing was wrong. But his wife reassured him that he was doing the right thing and advised him not to give in. He successfully fought the complaint and continued practice. He earned a reputation for being one of the hardest-working, dedicated, and experienced physicians in the city.

In the 1990s, at the peak of his career, he diagnosed a patient with Miller Fisher variant of Guillain Barré, and placed a subclavian line to accomplish therapeutic plasmapheresis. He had previously placed perhaps thousands of subclavian lines over the course of his career. This time however, he lacerated the subclavian artery during the procedure. The patient suffered a life-threatening hemothorax requiring emergent surgical repair. The patient slowly recovered over a month-long ICU stay, during which the physician rarely left the hospital. But despite the eventual favorable outcome, he was sued, and a settlement was not reached. The case went to trial. He recalls that his wife sat in court with him every day. Ultimately he was exonerated by the jury, and he feels his wife’s constancy at his side was likely favorable in their eyes. But the cumulative stress of the traumatic and prolonged legal process changed how he felt about coming to work in the ICU. He tried to return, but his partner convinced him that he needed a break from patient care. He became a successful researcher for a few years. Then he tried his hand at general internal medicine “which was terrible – unless you enjoy writing Percocet scripts for everyone”. He even did a stint as an administrator, which he felt was a mistake in retrospect “you can't make yourself into something you are not”. Eventually, he found his way back to critical care, which he still says is “in my DNA”. Although now retired, he enthusiastically volunteers to do locums work in the ICU (but only with his wife’s approval) and remains a highly effective bedside intensivist and great favorite of the entire ICU staff.

This physician felt several things helped explain his ability to survive the difficult tribulations of his career. He credits his wife being by his side, and his work partner for actively intervening when he was floundering but did not see that he needed a break from patient care. He also thinks his personal philosophy helped him deal with setbacks. “Essentially, bad things happen in the ICU. If you gave it all that you could, you ought to be able to live with yourself, no matter how things turn out. If you cannot do that, you won’t last long in the ICU”.

The third physician pioneered his specialty in the state of Arizona. When he went into single practice in the 1980s, he estimates that he went at least three years without having a single night that wasn’t interrupted by a pages or phone calls. On top of his rapidly growing patient practice, he travelled around the state, lecturing at dozens of venues to establish his specialty in the state. As his practice grew, physicians started to refer him their most complicated patients, many of whom already had complicated medical-legal issues before he was involved. This resulted in his being included in multiple law suits. At one point he was named in over two dozen open suits. Even though he was not found guilty of malpractice in a single case, the cumulative stress of repeated medical legal conflicts took a heavy toll on him. He felt that there was absolutely no support available from the hospitals he worked at, or from professional societies of that time period. He became irritable, angry, and increasingly disengaged. “If you want to know if you’re burned-out, just ask your wife”. He began suffering a series of physical complaints including headaches, palpitations, blepharospasm, and symptoms of irritable bowel for which extensive medical workups were negative. Finally one day he snapped. His pager went off for the ten-thousandth time, and he put his fist through the wall, and told his wife “that’s it – I’m though with (expletive deleted) medicine”.

Fortunately his partners supported his decision to step back from patient care, but advised him to concentrate his considerable experience and interpersonal and organizational skills into the administrative side of their practice. He subsequently achieved a high level of accomplishment and job satisfaction, and currently runs the national professional society of his specialty.

This physician subsequently became a strong advocate for recognition of physician burnout, within his practice, and within his specialty on a national level. He offered some good advice for the audience: Learn what burnout is. If you have the symptoms, you have to stop pretending you’re not burned-out and get professional help. If you notice behaviors of burnout in a colleague, reach out and talk to them.

He pointed out a number of ways to resist the effects of burnout:

  • Maintain harmony in your life. It’s not all about work. Family, community, your personal needs, and your spirituality should all be integrated into a healthy lifestyle.
  • Do something non-medical that you love to do every day – whether that is walking your dog, playing guitar or reading a good (non-medical) book.
  • Get some control of your work schedule and how many hours you are working. Overwork will ultimately ruin both your productivity and the quality of your care. Remember why you went into medicine.
  • Don’t build a lifestyle that fosters greed. Studies have shown that once a relatively modest income is achieved, more money does not make life more satisfying or happy. Be altruistic.
  • The best way to feel good about yourself is by helping others.
  • Meditate each day about the good things that happened and people that you helped, rather than allow your mind to ruminate on negative events and worries.
  • If you have interpersonal stress, talk to the person who is the source. Except for the occasional adversary with a personality disorder, open communication usually relieves interpersonal tensions.
  • Exercise regularly - Your brain and body are connected.
  • Don’t accept a job in which you are routinely asked to sacrifice important life experiences, such as being with your children as they grow up. These experiences cannot later be replaced by or compensated for by job promotions or greater financial income.


  1. Embriaco N, Papazian L, Kentish-Barnes N, Pochard F, Azoulay E. Burnout syndrome among critical care healthcare workers. Curr Opin Crit Care. 2007;13(5):482-8. [CrossRef] [PubMed]

Reference as: Special article: physician burnout-the experience of three physicians. Southwest J Pulm Crit Care. 2015;10(4):190-4. doi: PDF


Brief Review: Dangers of the Electronic Medical Record

Richard A. Robbins, MD

Southwest Journal of Pulmonary and Critical Care

Gilbert, AZ

In 2009 then president-elect Barack Obama said he planned to continue the Bush administration's push for the federal government to invest in electronic medical records (EMR) so all were digitized within five years. "This will cut waste, eliminate red tape, and reduce the need to repeat expensive medical tests," he said, adding that the switch also would "save lives by reducing the number of errors in medicine"(1). Now over 5 years on, it might be time to examine how EMR has impacted medicine.

Historically, similar arguments were made by Dr. Ken Kizer, then Undersecretary for Veterans Healthcare Administration (VHA), 20 years ago (2). As a physician who practiced the VA at the time, my colleagues and I welcomed EMR. It had to be better than a system where neither the chart nor the x-rays were available for pulmonary clinic most of the time (Robbins RA, unpublished observations). EMR improved this. In general, x-rays and records were available and I have little doubt that this improved healthcare. However, it came at a price. It's the later that is discussed in this review.

Waste and Red Tape

Elimination of waste and red tape are good things. However, does the EMR eliminate either? Most articles have been similar to Buntin et al. (3) who point out that "92 percent of the recent articles on health information technology reached conclusions that were positive overall". However, most represent a series of opinions, usually of healthcare administrators, rather than data. Studies which have examined efficiency data have not found such an improvement (4).

My experience suggests that EMR actually creates waste of practioners' time and increases red tape. The collection of the required superfluous information detracts from patient care. Asking every patient at every visit a family history, review of systems and reentering past medical history and surgical history is very unlikely to produce any new clinically useful information and detracts from practioners focusing on the patient's problem. The recent VA scandal resulted from a performance-measurement system through the EMR that had become bloated and unfocused requiring the recording of multiple measures (often tied to administrative bonuses) of dubious or meaningless significance (5,6). These additional clerical tasks contributed to too few physicians being unable to care for too many patients. The private setting has become similarly afflicted. Performing the ever increasing meaningless measures required for reimbursement by Centers for Medicare and Medicaid Services (CMS) or other third party carries is resulting in similar detriments in care and will likely result in outcomes similar to the VA.

In addition, the data must now be recorded on a template that is easily electronically retrievable. This saves third party clerical time because the clinic notes do not have to be abstracted. However, the clerical burden now falls onto the physician or office staff. It usually means the data is entered at least twice-once on the clinic note and once on the template. Everything from smoking to electronic prescriptions must be entered on a template. Sometimes this actually saves time but at others it is horribly detrimental. For example, yesterday my practice administrator and I spent 15 minutes trying to electronically send prescriptions to a local Walgreens pharmacy mostly because we could not electronically locate the store although we had the address and phone number. With the addition of these requirements, it now takes longer, in many cases much longer, to type the note and enter the data than it does to see the patient. This is driven by a requirement for the data to be entered in an EMR in order to receive reimbursement.

There are multiple commercially available EMRs. Each system may have its some unique issues and problems. The fact that institutions may decide to change from one EMR system to another, based on a number of factors, can have significant stress on the providers and may impact overall quality of care and safety during the “learning curve” to adapt to a new EMR. Even if the system stays with one product, there are frequent “upgrades” that require learning new processes. There is a limit to how many updates and changes can be effectively learned by physicians and other providers while maintaining efficiency. These issues need to be understood by health care administrators.

Duplicate Testing

It makes some sense that if results are available electronically that duplicate testing could be reduced. Unfortunately, the reality is that although the data might be recorded electronically, it is often not available. The various computers do not necessarily "talk" to each other and even when the do, retrieving the data can be problematic because of the multiple security hoops that need to be jumped through (remember HIPPA). Furthermore, sometimes the data is substandard. Yesterday, I saw a patient with COPD from smoking, a recurrent rectal carcinoma and a CT-PET scan positive for a 1 cm enhancing mass in the right upper lobe according to the radiologist. Yet, I could see no lesion on the small image that I could view on our computer. I decided the safest course of action was to repeat the test in 3-6 months. Had I been able to review an adequate image, the need to repeat the test might have been avoided. Similarly, other x-ray, laboratory and other data is frequently inaccessible.

CMS is largely responsible for this oversight. Although the federal government has spent over 30 billion in tax dollars since 2009 implementing EMRs, they are not standardized across facilities (7). Similar problems occurred at the VA. Although it was one computer system, multiple vendors who supplied radiology, pulmonary function, and other equipment were electronically incompatible with the VA system.

Save Lives By Reducing the Number of Errors in Medicine

This may eventually prove to be true, but the available data suggest that at least initially the opposite may be true at least for computerized physician order entry (CPOE). For example, a survey of the house staff at the University of Pennsylvania found that a widely used CPOE system facilitated 22 types of medication errors (8). More disturbing is data that mortality increased from 2.8% to 6.6% after CPOE implementation in one pediatric intensive care unit (9). Other studies have failed to demonstrate such an increase in mortality (10).

Unavailability of the EMR

It seems rather obvious but EMRs have to be as dependable as other electronic records such as banks. Unfortunately, this is usually not the case. For example, the VA system would periodically crash. Trying to care for a patient when no data is available and no orders can be written is problematic. Incidentally, the problem of the periodic crashes was because local administrators refused to increase the server capacity at the Veterans Integrated Service Network level (EMRs can utilize huge amounts of memory) until the system did crash. There seemed no consequences to those responsible when the EMR was unavailable.

Unauthorized Access to Patient Information

Equally obvious is data stored in EMRs is vulnerable to unauthorized access just as computers from the Pentagon, banks, Target and even Sony pictures have all been hacked. It seems unlikely that the data in the EMR is as well protected as military or financial data especially given the large numbers with access to the data and the need to access the data sometimes quickly in emergency situations. Interestingly, large breeches in EMRs at the VA seemed to have occurred not through healthcare professionals but through information technology (IT) or administrative personnel (11).

Rarely, medical computers are hacked with the intent of extorting money. The hacker encrypts the files and then demands money to unencrypt the data (12). Some physicians' offices who have been hacked now keep two sets of data, one electronic and another paper not only cancelling most of EMR's advantages but resulting in the time and effort of keeping two record systems.

Health Care Professionals Spending Less Time with the Patient

Although physicians complain about the time required to complete various aspects of the EMR (in my view justifiably), observations in the hospital suggest nurses may be even more affected. A never ending list of documentation facilitated by the EMR have robbed many nurses of what they found most satisfying about their profession, bedside nursing (13).

Poor Understanding of the Medical Record

Poor understanding of patient data remains a significant problem for everyone from the patient who may find the record confusing and frightening to the healthcare administrator who is not trained or skilled in the practice of medicine. A number of medical practices are utilizing “patient portals” in their EMRs that allow patients to review their records online. The knowledge that a patient will be able to review all information entered in their record seems likely to have an effect on physician documentation, particularly in certain areas such as potential substance abuse, mental health issues, or malingering. Review of the record by the patient may also create challenges in patient care. For example, a patient who has read a radiology report that states “malignancy cannot be excluded” may question a decision by the clinician not to do a biopsy because the risks of further testing or biopsy are not justified by what may be a very low likelihood of malignance. Confusion can result in numerous bad outcomes, but usually for the patient and/or the practioner. These are all new issues and the impact overall on patient care and the doctor-patient relationship are not clear.


This might be the largest potential danger and most contentious aspect of the EMR. It revolves around who owns the medical record. Some believe patients should own their record, and similarly, administrators, CMS, insurance companies and practioners all believe that the EMR should be theirs, at least in part (14). Consequently, there are conflicts regarding what should and should not be recorded. Although this argument is far beyond this brief review, the implications are far-reaching and important.

Regardless of who is the ultimate owner of the medical record, it is quite clear that administrators in the hospital and large clinics and CMS and insurance companies can dictate both the content and form. Furthermore, it is quite easy to place requirements to complete the records or receive reimbursement. For example, completion of CMS' most recent "meaningful use" measures can be required for reimbursement, and similarly, information might be required before a document can be signed. This might be reasonable unless the requests are busywork or for predominately useless information. This can detract from the usefulness of the medical record. For example, at one hospital where I practiced there was an excellent gastroenterology department. They used a computer generated report for their procedures that usually resulted in about 5 typed pages. It satisfied all CMS, insurance company, JCAHO, and professional standards. However, it was difficult (some of my colleagues said impossible) to read and interpret timely and efficiently. Increasingly, we see office reports, consults, history and physicals, radiology reports, laboratory reports, and discharge summaries which approach the length of a Dostoyevsky novel and have little utility in conveying information useful in patient care. Furthermore, should any part of the medical tome be missing (remember bundles), CMS and insurance companies will gleefully deny payment while healthcare administrators will harass both nurses and physicians to complete the medical record according to CMS and the insurance company mandates. This results in practioner inefficiency. However, the solution is usually to hire more administrative personnel to make sure that the practioners work even harder and longer further decreasing efficiency both medical and administrative inefficiency.

Not usually mentioned as a danger, although it should be, is that the EMR can be alerted by the unscrupulous who may control the EMR. For example, Sam Foote told me a story that while at the Phoenix VA, he could place a request for back magnetic resonance imaging (MRI) but would later find that the order removed. At the time the hospital had overspent its fee basis budget and was actively discouraging the ordering of MRIs. Furthermore, we have seen radiology reports altered when a misreading was discovered without evidence of the original misreading present (Robbins RA, unpublished observations).


EMRs represent a potential boon to patient care and providers, but to date that potential has been unfulfilled. Data suggest that in some instances EMRs may even produce adverse outcomes. This result probably has occurred because lack of provider input and familiarity with EMRs resulting in the medical records becoming less a tool for patient care and more of a tool for documentation and reimbursement.


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  11. van Rosse F, Maat B, Rademaker CM, van Vught AJ, Egberts AC, Bollen CW. The effect of computerized physician order entry on medication prescription errors and clinical outcome in pediatric and intensive care: a systematic review. Pediatrics. 2009;123(4):1184-90. [CrossRef] [PubMed]
  12. Office of Inspector General. Report No. 06-02238-163. Review of issues related to the loss of VA information involving the identity of millions of veterans. Available at: (accessed 3/5/15).
  13. Murphy T, Bailey B. Is your doctor's office the most dangerous place for data? Associated Press. February 9, 2015. Available at: (accessed 3/6/15). Thompson D, Johnston P, Spurr C. The impact of electronic medical records on nursing efficiency. J Nurs Adm. 2009;39(10):444-51. [CrossRef] [PubMed]
  14. N Chesanow. Who should own a medical record -- the doctor or the patient? Medscape. January 13, 2015. Available at: (requires subscription, accessed 3/6/15).

Reference as: Robbins RA. Brief review: dangers of the electronic medical record. Southwest J Pulm Crit Care. 2015;10(4):184-9. doi: PDF