by Dr. Kenneth H. Cohn

I heartily recommend Abigail Zuger’s provocative article on Dissatisfaction with Medical Practice (Zuger A. 2004. "Dissatisfaction with Medical Practice."New Engl J Med 350(1):69-75). I learn more each time I reread it.

In the article, Dr. Zuger points out that the golden age of health care, which lasted approximately two decades after the passage of Medicare in 1965, was an anomaly. For example, she mentions that in 1913, the American Medical Association estimated that no more than 10 percent of physicians were able to earn a comfortable living.

She also quoted Dr. Kenneth Ludmerer from Washington University as saying, "One of the virtues of medicine...is its self-critical nature...Intrinsic dissatisfaction can lead to significant social good." As a nurse executive counseled me, "It's the sand in the oyster that creates the pearl."

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I presume that this audience is only too familiar with the sources of and reasons for physician dissatisfaction. The question is, what can we do about it that will improve care for our communities? As part of the economic stimulus package, we can consider asking President Obama and Tom Daschle on the MyPolicy website to:

• Provide partial forgiveness of medical school debt to physicians who practice in shortage areas throughout the U.S., not just primary care practitioners, but also specialists like intensivists, gastroenterologists, and general surgeons who are aging and in demand. By partial, I mean for each year of service, debt forgiveness is granted; if the average medical school debt is approximately $140,000 and, for example, $15,000 of debt forgiveness is granted annually, physicians could be free of a substantial burden of debt within a decade.

• Make it easier for physicians to use electronic medical records, subsidizing not only the cost of the hardware and software, but also the training and the loss in productivity as physicians learn a new system and input relevant data into blank fields.

• Subsidize a group of traveling physicians to provide coverage for physicians in inner-city and rural hospitals to travel to conferences to learn new skills.

• Provide assistance to physicians who want to obtain additional training in management, communication, and leadership skills.

I know that these items are but a few of what we could do to improve care for our communities. I encourage readers to submit their ideas re: "what we can do to improve care" not only to this site, but also to President Obama on his MyPolicy website.

In "Mending the Gap Between Physicians and Hospital Executives," Deane Waldman and I wrote that:

• Physicians and hospital executives agree on the "who" because they generally live in the same communities and care for the same patients.

• They agree on the "why" because both groups were attracted to healthcare to make a difference in patients’ and families’ lives (Cohn KH, Hough D, eds. The Business of Healthcare. Westport. Praeger. 2007, v.2:27-57).

• The "how" is a life-long learning journey. In "Before Alignment," I alluded to a three-step process of transparency, engagement and co-mentoring that needs to take place for our goals and values to become more synchronous. In the meantime, we can strive to create environments in which it is safe to reflect, admit uncertainty and learn from one another.

Whenever I feel frustrated by health care hassles, I try to recall Drs. Leonard Marcus and Barry Dorn’s inspiring words from "Beyond the Malaise of American Medicine" that I quoted in Collaborative Fairness:

"Listen to patients talk about what was good about their healthcare experience. They will often express it in terms that describe how much someone paid attention to them, really cared for them, listened to them, or improved their life on a very personal level. There is no machine that can replicate that sensation.

"The pendulum has swung far from the center. What forces will it take to push it back toward a more balanced future for medicine and medical practice?

"This is a time of opportunity, one in which we define a new mission and role for ourselves...Consumers want us to remain key to the workings of the healthcare system.

"When our patients are facing a frightening procedure or a discouraging diagnosis, it is common for us to comfort them by offering a course of action, something that can be done to offer them a sense of hope, and with it, a future. This formula is what good medicine is about, and it is time we do the same for ourselves and for our profession."
(Marcus LJ, Dorn BC. 2001. Beyond the malaise of American medicine. J Medical Practice Management;16(5):227-230.)

What do you think?

• What hassles and frustrations do you experience providing or receiving care?

• What are your hopes and concerns for the coming year?

• Are you willing to share your healthcare improvement ideas with President-elect Obama on the MyPolicy website?

I welcome your input.

Ken is a practicing general surgeon/MBA who divides his time between providing general surgical coverage and speaking, writing, teaching, and consulting on physician-hospital relations. Learn more about what he does by visiting http://healthcarecollaboration.com.