What Are Organizations’ Responsibilities When Surgeons Experience Regret?

Organizations and Regret

As more physicians have become employees of large health systems, responsibility to address environmental factors that contribute to clinicians’ feelings of regret should be shared by organizations. Health care environments, for example, can contribute to surgeons’ regret about not being able to adequately treat patients and can be noticeable to patients.¹ Organizations also play roles in surgeons’ experiences of career regret, especially when surgeons bear individual responsibility for key actions and decisions over years. Holding organizations accountable should be done with nuanced understanding of many players’ contributions to surgical care environments.

Financial Regret

Focusing on their education, high-stakes examinations, continuing education, and recertification requirements instead of business operations, many surgeons have found themselves woefully unprepared for the business of running a practice. Financial and administrative demands of running a practice have prompted many surgeons to relinquish control of their practices to professional health care administrators and business operations experts. The American Medical Association’s Physician Practice Benchmark Survey noted that, between 2012 and 2022, the share of physicians who work in private practices dropped from 60.1% to 46.7%.² Physicians are now employees and fall under the rules of engagement in business. The organizations in which physicians work are responsible to all parties, not just them. These organizations must provide a service to the consumer (the patient), follow the rules (state and federal laws), make a profit (for shareholders), create the best deals (with hospitals and insurance companies), get the most out of their investments (assets, including employees), and treat their employees well to keep the competition from taking their lifeblood.

Business practice includes the exchange of value for money, and physicians’ inadequate understanding of the key business operations in health care organizations can lead to financial regret. When physicians are viewed as employees, organizations are not held to an obligation outside of contracts that are built to protect them, not physicians. Physicians are offered standard corporate contracts based on statistics not available to them and unfavorable non-compete clauses without adequate leverage to strongly negotiate in their favor, as increasingly larger health systems have the competitive advantage. Although physicians’ annual salaries are higher compared to many professions,³ few professions require as long a duration and as steep an expense of training. Patients, administrators, the government, and physicians themselves forget that physicians’ income only begins after deferring income and accumulating debt for more than a decade. Financial regret can be mitigated by reminding everyone involved about deferred income and that the amount of money surgeons will receive is based on the value of their training and experience, not the exchange of time for money. Creating more opportunities for residents and attending physicians to understand the business that they are joining is crucial to preventing financial regret.

Financial Literacy

Although remembering the motivations behind their career choice and appreciating their contributions to patient care is an excellent first step every surgeon can take without additional work or training, gaining a better understanding of the business aspects of health care can allow for more effective negotiations and the ability to advocate for changes that prioritize quality over mere performance metrics.

Many physicians finish residency without understanding how they get paid. The lack of financial literacy is exacerbated by the hesitance to discuss income, as physicians believe they should only think about their patients, not themselves. Traditional, simple fee-for-service payment has evolved into an increasingly complex system. Inquiries into how much income surgeons bring to the hospital for the services they provide are met with concerns about violations of the Stark Law and insurance nondisclosure limitations.⁴ The Stark Law is an evolving federal statute intended to prevent conflicts of interest by imposing significant financial penalties for physicians’ referral of patients to entities with which they have a financial relationship.⁵ Many physicians are not aware of the details of the law or how it could be used against them. When the organization allows financial details of reimbursement to remain opaque, it can lead to physicians’ financial regret over their loss of control of how they are reimbursed for their time and expertise from over a decade of deferred income and accumulated debt. If surgeons understood the details of how much their services are worth to the system based on their professional fees and the resources they bring to the system, as well as on the financial health of the organization, then feelings of regret would be far less likely.

Career Regret

As surgeons realize they are limited not only in the income they can make based on the value they have gained at personal sacrifice, but also in the care of patients who are uninsured, underinsured, or unable to get approval for services from insurance companies, they might experience career regret. Physicians frequently encounter the disheartening reality of being unable to provide care to patients lacking adequate insurance, a situation that starkly contrasts with their primary motivation to help those in need. This inability to act due to financial or policy constraints not only limits patient care but also leads to career regret for many surgeons, who find themselves determining treatment based on coverage rather than medical necessity. If surgeons are ultimately forced to work for free to provide care for their patients, the working conditions become unsustainable and lead to a loss of the most talented surgeons in communities. In cases where the working conditions are unsustainable, making the difficult decision to leave may be necessary to preserve personal well-being and professional integrity. This power to leave their current position or even the profession as whole is the ultimate control exerted by practicing surgeons to manage overwhelming regret.

Inability to act due to financial or policy constraints not only limits patient care but also leads to career regret for many surgeons. 

Another source of career regret is that physicians are perceived as interchangeable (or optional) cogs in an increasingly large wheel. Health care was the third largest industry facing cuts in the workforce in 2023. According to an analysis by consulting firm Challenger, Gray & Christmas, the health care sector cut 58 560 jobs in 2023, a 91% increase over the previous year, trailing the technology and retail industries.⁶ Physicians facing layoffs experience significant regret while grappling with noncompete clauses, which restrict their employment opportunities within a geographical area and a specified time frame, thereby requiring them to relocate. The high costs of tail coverage insurance and the tedious, time-consuming process of recredentialing with insurance providers can also present formidable barriers to relocation, as each state and hospital will have different requirements. The alternative to an employment model is setting up a small surgical practice, although it has become increasingly difficult for private practices to compete against larger health entities that monopolize the market through stringent contracts and expansive insurance arrangements.

Another reason for career regret is overwork. A recent poll of 2600 physicians found that 81% were overworked.⁷ The poll noted heavy workloads and high administrative burden as so problematic that many physicians were either considering accepting lower compensation for more work-life balance or leaving clinical practice altogether. The betrayal of physicians’ time and effort, acknowledged as a limited resource, has played into deepening the regret already prevalent among physicians operating in the high-stakes practice of medicine.

Responsibilities for Managing Regret

Organizations. To mitigate possible career regret, health care organizations can advocate for more inclusive insurance policies and work to reduce the bureaucratic barriers that contribute to health care disparities. Additional support for surgeons who choose to care for indigent patients at their own financial risk would decrease regret.

Another way to reduce career regret would be to address physician discontent over scope-of-practice creep. Health businesses have sought to balance the moral obligation to provide affordable, accessible, unbiased, and high-quality care to patients with cost control measures, including employing mid-level clinicians like nurse practitioners and physician assistants instead of physicians. Although these advanced practice clinicians were meant to augment the medical team, the recent trend has been for them to replace physicians. In addition to the augmented tasks of rounds, order writing, and postoperative follow-ups, nonphysicians are performing procedures.⁸ Nearly all specialties have seen nonphysicians gain more ground on tasks that were traditionally physician-only jobs. A cooperative approach to the division of labor could improve the accessibility and affordability of health care without diminishing the invaluable contributions of highly trained physicians, which can contribute to the feeling of regret for becoming a doctor if clinicians with alternative degrees are allowed to fill the same roles.

Wellness programs might also help reduce regret over outcomes, as they markedly improve physician well-being and reduce burnout by enabling participants to recognize that feelings are not determined by the environment set by organizations.^9,10,11 Peer coaching, in particular, provides a supportive framework whereby physicians can discuss challenges and regrets associated with daily practice.⁹ These relationships provide a nonpunitive environment, thereby promoting healing and learning rather than blame. Professional coaching programs provide effective frameworks and safety outside of peer interactions, with randomized controlled trials supporting this strategy.^9,10,11 Beyond providing and supporting coaching initiatives, organizations can create a culture that facilitates open discussion of failures and complications without stigma, often through peer review, professional enhancement committees, or nonpunitive debriefing sessions that can help normalize these experiences and reduce feelings of isolation and guilt.

Self-care, mindfulness, and strategies for dealing with difficult emotions like regret often need a multifaceted approach. The effectiveness of these programs hinges significantly on the voluntary participation and genuine engagement of physicians themselves. It also depends on a cultural shift within the medical community to destigmatize seeking help, particularly among older generations of surgeons. Such a shift would encourage openness and acknowledge the human aspects of practicing medicine, thereby fostering a more supportive and sustainable professional environment.

Surgeons. Although organizations create environments where feelings of regret could develop, surgeons play a crucial role in managing and mitigating their own feelings of regret, a responsibility that extends beyond availing themselves of organizational support. As employment dynamics have changed, it can feel tempting to indulge in feelings of helplessness, powerlessness, and financial dependence. These feelings can lead to a victim mentality, allowing systemic issues to diminish one’s sense of self-worth. Surgeons can empower themselves through proactive measures and by engaging actively in shaping a health care environment that values and supports their critical work. Specifically, surgeons can address “scope creep” by nonphysicians by clearly defining and asserting their unique roles within the health care team. Surgeons should be treated as empowered and valued members of the organization and be able to employ the problem-solving skills and intelligence that they honed in their medical training.

Conclusion

In transferring the business aspect of medicine to the organization, physicians made assumptions about how the relationship would be conducted. The perception that organizations have not adequately valued surgeons’ training, experience, and expertise led to feelings of betrayal, as the organization seemed to renege on the deal that was never really clarified. Over time, as the betrayal set in, financial and career regret ensued. After a long lead time, doctors were now stuck with large debt, time lost for earning income, and financially insecure environments without the resources to succeed, all of which ultimately affect patients if regret leads surgeons to leave medicine.