It wasn't long ago that physicians ran the OR, and the clinic, and the procedure rooms. Not because we needed everyone to know we were in charge, but because when something happened, we were expected to make the call. We walked in, looked at the room, and knew exactly what needed to happen. 

The anesthesiologist knew us. The circulator knew how we worked. The scrub tech knew what we were going to ask for before we even asked. And when something changed, people looked at us. We set the pace. We made the call. But somewhere along the way, that changed. 

Now, the OR runs us. The turnover time runs us. The staffing grid runs us. The block utilization report runs us. The administrator asking why the first case started 12 minutes late runs us. The inbox waiting when we finish our last case, it also runs us. And maybe the hardest part is that we're still responsible for what happens in that room. We just have a lot less control over almost everything surrounding it.

Well, hey everyone, and welcome to another episode of the Better Physician Life podcast. Thank you so much for being here today. I think a lot of us have noticed that shift that I'm talking about. We just don't talk about it a lot because saying it out loud can sound bad. It can sound like ego, like we want some old hierarchy back.

Like we're upset that patients ask questions now. Like we miss some version of medicine where the physician spoke and everyone else just listened. That's not what I'm talking about. I'm talking about something much more ordinary. We spent years becoming good at this job: medical school, residency, fellowship for some of us.

Then years in practice where the learning didn't stop just because the formal training ended. We learned which patient worried us way before the labs even came back. We learned when we could move quickly and when we couldn't. We learned what could wait and what needed our attention right now. And over time, that judgment became part of how we practiced medicine.

We didn't think a lot about it; we just knew. But increasingly, physicians are practicing inside systems that don't really know what to do with that kind of judgment. The system knows our RVUs; it knows our patient satisfaction scores; it knows how many charts we closed. It knows whether we completed our modules.

It knows about our block utilization. It knows whether we responded to our inbox within the expected timeframe. It can measure almost everything about our work, and somehow it can still know very little about the physician doing it. And that's a strange thing to experience no matter where you are in your career.

And it doesn't necessarily happen all at once. It's a hundred small things, and none of them seem like that big a deal on its own. But over time, it all adds up. A patient pulls out a phone and tells you about something they read the night before. That's fine. Patients should ask questions. But sometimes it's not really a question. It's a correction.

So you explain why you're recommending what you're recommending. You go through the evidence, you answer the questions, and somewhere in the back of your mind, you notice that you've just spent five minutes proving that you know how to do something you've done 10,000 times before. 

Then you walk out of the room. There are three messages waiting. One is about a patient you've never seen asking for medical advice through the portal. One is about a prescription you've already addressed twice, and one is from the administration about a new workflow designed to improve efficiency. And of course, that workflow adds another six clicks to your day. On its own, none of this seems like that big a deal, and that's part of the problem.

Because if something is clearly wrong, we know how to respond. We assess it, we make a decision, we do something. But this is different. No single thing feels important enough to address, so we just absorb it. And then we absorb the next thing. And after a while, that becomes the job. 

It's being told how your clinic should run by someone who has never sat through your clinic. It's finding out that your schedule changed after the change was already made. It's losing an experienced nurse and getting told the position will never be refilled. It's looking at a productivity dashboard at 9:30 at night and wondering why you're behind when you haven't stopped working all day. It's sitting at the kitchen counter answering messages because you don't want them waiting for you tomorrow morning.

And then somebody at home asks you a completely reasonable question, and you answer them like they're one more person who needs something from you. Not because of the question, because the clinic ended three hours ago, but your day didn't. That's the cost that doesn't show up on the dashboard.

I worked with a physician who had been practicing for more than three decades, employed by a very large health system, very experienced, very good at what he did, and nobody in leadership had spoken with him about his work in more than a year. He wasn't even entirely sure who he reported to anymore.

Think about that. 30-plus years of clinical experience, thousands and thousands of patient encounters, and the organization knew him primarily through his numbers. He knew exactly how quickly he could see patients without cutting corners, which visits needed another five minutes, and when something didn't fit.

The system had a target for him anyway, not because somebody had carefully evaluated his practice and concluded that his judgment was wrong. Nobody was evaluating his judgment at all. The number was simply the number. That's where I think some of the tension comes from. We are still carrying physician-level responsibility inside a system that increasingly gives us employee-level control.

Those two things do not sit particularly well together. Because when the patient has a complication, we are responsible. When something gets missed, we replay it. When the clinic is behind, we speed up. When the inbox isn't done, we finish it. When staffing is short, we compensate. And when the schedule doesn't work, we figure out how to make it work.

That's what physicians do. We're very good at closing the gap between what the system provides and what the patients actually need. The problem is that after enough years, the system starts depending on you to close that gap, and eventually, you start depending on yourself to close it, too. That's when the OR starts running you, not just while you're there.

It follows us home. I noticed this happening in myself for a long time. I started bracing before certain conversations, sometimes with patients, sometimes with administrators. Honestly, it didn't really matter. I'd walk into the conversation already preparing my argument, evidence ready, explanation ready.

I was preparing to defend a decision nobody had questioned yet. That was interesting for me to notice because there was nothing wrong with being prepared. But this wasn't just preparation. I had just gotten used to expecting that my judgment would need to be defended. And once that becomes your expectation, you carry it into rooms where nobody has actually challenged you.

You're already irritated by the email before you finish reading it. You're already anticipating the pushback before the meeting starts. You're already constructing the rebuttal while someone else is talking. That's a lot of energy, and most physicians don't notice how much we're spending. We notice that we're tired, we notice that we're more irritable, we notice Sunday afternoons feel different than they used to.

We notice ourselves calculating how many more years until retirement while we're still finishing our notes for the day. But we don't necessarily connect those things. We just assume this is medicine now, and maybe part of it is. Medicine has changed. I'm not particularly interested in pretending otherwise.

The room is different. Patients are different. Health systems are different. The economics are different. The technology is different. The expectations are different. And some of those changes are good, but some aren't. But somewhere in all of that, we've lost something too, and I don't think we talk about that very much.

We used to be trusted differently. We used to have more control over how we did our work. We used to feel that experience bought us something. And for a lot of physicians, it doesn't feel that way anymore. Maybe grief is the right word for some of this.

Not grief for some golden age of medicine. The old system wasn't perfect, and I'm certainly not arguing that physicians should have unquestioned authority. But there is something to grieve. The autonomy, being known, having 20 years of judgment actually count for something. And none of that disappears all at once.

There's no retirement party for it. Nobody sends an email saying, "Starting Monday, your professional autonomy will be reduced by 18%." It happens a little at a time. You just start noticing it. One scheduling change, one productivity report, one staffing decision, one prior authorization, one meeting where the clinical question gets discussed for 45 minutes and the physicians in the room speak for six of them. 

Then you go back to clinic because you have patients waiting. And that's part of what makes all of this so frustrating. We know we're valuable. 

We know what happens when there aren't enough physicians to cover the call schedule. We know what happens when someone leaves, and their patients have nowhere to go. We know what happens when a service line loses the person who's been holding it together for years. The system struggles to run without us, but you wouldn't always know that from the way we're treated.

I worked with a surgeon who knew what would happen if he left his hospital. The call coverage would be in trouble. Coverage would disappear. A program he'd spent years building would probably fall apart without him. He wasn't being arrogant about it; it was just math. He knew what he covered, the referral volume, and who else was available.

And none of this was a secret. He knew what he was worth to that hospital. The people around him knew it too, but you wouldn't know it from the way he was treated. Because saying something like, "Do you understand what happens if I leave?" Sounds like a threat. And what he actually wanted wasn't leverage. He just wanted his value to count for something. 

Most physicians I know aren't asking for a plaque. They don't need another physician appreciation email or a branded water bottle for Doctor's Day. They want the reality of their work to count for something. And when that doesn't happen for long enough, a lot of us do what we've always done. We work harder. And that's where the problem starts to compound because the physician's response to feeling less valued is often to become more valuable.

See another patient, take another call, cover the gap, answer the message, don't complain, and make yourself indispensable. And then one day, you realize that being indispensable didn't actually buy you more control. It bought the system more access to you. That's a really difficult realization when you've spent most of your career being the person who figures it out.

You learned early that when something is difficult, you get better at it. When the workload increases, you become more efficient. And when someone needs help, you handle it. And that works really well in medical training. It works really well in patient care, but it also has a limit because you cannot outwork a system that will accept every additional unit of work you're willing to give it.

The more capable you are, the easier it becomes for everyone, including you, to assume you'll keep absorbing the difference. At some point, you have to look at what all of this is costing you. And usually, that comes down to pretty ordinary decisions, the kind you make every day. Do I answer this tonight? Do I volunteer for this?

Am I actually responsible for fixing this staffing problem? Does an unhappy patient mean I did something wrong? Does this productivity report contain useful information, or am I using it as a weekly referendum on whether I'm still a good doctor? Those are different questions than: how do I get the old room back?

Because honestly, I don't think we're getting the old room back, and I'm not even sure that should be the goal. And maybe that's part of the shift. You stop waiting for the room to acknowledge what you bring to it. You know how you practice. You know whether you're taking good care of your patients. You know what your experience brings to the room.

You know what you've built. That doesn't mean feedback stops mattering. It doesn't mean metrics don't matter. It doesn't mean you're always right. You can look at the numbers; you can listen to the feedback. You decide what's useful, and you make adjustments when you need to. But you don't let every patient complaint, productivity report, or administrative decision become a judgment on your entire career.

That distinction has taken me some time to understand. Because if every complaint stays with you, you'll take it home with you. If every productivity number sends you back to the dashboard, you'll keep checking it. If every administrative decision feels like something you need to respond to, explain, or push back against, you'll spend a lot of energy on things you may not actually be able to change. And you stay braced.

Because after years of being the person who handles things, it gets hard to tell what you actually need to handle, what you're responsible for, what you're willing to carry, what the numbers actually mean, what they don't mean, what being a good physician requires from you now, and what you've taken on simply because you're used to being the person who handles it.

And most of the time, this comes down to pretty ordinary decisions. You leave one message until morning. You say no to one piece of coverage you didn't actually need to take. You look at the math instead of just assuming you can't afford to make a change. You run the retirement projections. You talk through what leaving would actually mean instead of thinking about it between patients.

You start figuring out which parts of medicine you still value and which parts you've just gotten used to tolerating. None of this fixes the system. But honestly, the system doesn't have to change before you start making different decisions about your own career. The hard part is that these decisions can be difficult to sort through when you're still in the middle of all of it.

The schedule, the money, the call, what it's costing you at home, the resentment that's been building for a long time, the retirement number you keep checking, and the parts of medicine you still genuinely like. That's where I think a conversation with another physician can be useful. Not because somebody else has the answer, but because sometimes you need a place to put all of it on the table and actually look at the trade-offs.

What will happen if I stay? What would actually have to change for this job to work? Can I afford to work less? What happens to my compensation if I give up call? Do I actually want to leave, or do I just want this version of the job to be different? Sometimes you don't need a five-year plan. You need one conversation where you can look at the whole thing without having to defend why it's become a problem.

And in my experience, that's what a lot of physician coaching looks like. If you've been feeling like the OR runs you now (whether that's literally the OR, your clinic, your inbox, your call schedule, or the entire system surrounding all of it), these are exactly the conversations I have with physicians. You don't need to know what you want to change before we talk.

You don't need to be ready to leave your job. You don't have to have a plan. We can look at what's happening, what it's costing you, and what options you actually have. If you're ready to have that conversation, you can learn more about working with me at betterphysicianlife.com. 

Because the OR has changed. The question is: How much of your life are you still willing to let it run?

Thank you so much for being here today, and I'll see you next time on the Better Physician Life Podcast.