Monday, February 18, 2013

Physician Burnout: Meet Patient Safety

The majority of doctors in America today care deeply about their patients.  After all, they're the ones that have personal relationships with them.  They're the ones who sit with them, speak with them eye to eye, feel their pain, and witness first-hand the scourge of disease on the human body and psyche.

But you'd never know this from the Patient Safety Movement.  From day one when the Institute of Medicine report entitled "To Err is Human" was published in 1999,  the nebulous "98,000 preventable deaths" number was circulated far and wide by media outlets.  Strangely, this important publication was never made available free to physicians for review.   But instantly, the media took notice of this sound bite.  Breathless outrage ensued.  Hospitals took notice.  Even doctors and doctors' associations noticed.  Worse yet, we were still told by the media and their self-appointed safety enthusiasts that "medical errors kill enough people to fill four jumbo jets a week."  But to everyone's credit, we all did some real soul-searching.

So change came to our industry.  Overnight, enough bureaucrats to bury the number of doctors in America three-fold were hired as patient safety do-gooders.  Entire new organizations hell-bent on imposing their vision for the future of patient safety sprang up to guide large hospital organizations to their vision of patient safety nirvana.  None were as influential as the organization called the Institute for Hospital Improvement (IHI) run by the soon-to-be knighted-as-acting-CMS-directorship, Donald Berwick, MD who made a cozy sum from the safety scare.  This is the same "institute" that still provides mandated safety training to hospital systems across the US even today.

But a strange thing has happened.  Despite their best intentions, after ten years of trying with more administrative hires and scores of new imperatives thrust on doctors and nurses with hours of carefully-constructed safety courses, and scores of white papers and media stories, not much has changed.   To be fair, not all efforts have been worthless, but self-reflection on the negative consequences of this movement have been limited.

And in its place, physician burnout has exploded.

But this morning, I saw a glimmer of hope.  People might be starting to do some introspection.

Take a minute and read Bob Wachter's post.  It is a prescient view of the problems created by well-intentioned (but misguided) initiatives that ultimately fall on America's physicians and nurses to implement:

The lack of evidence that all our hard work is paying off is also contributing to burnout. Several influential papers (such as here and here), using the IHI’s Global Trigger Tool methodology, have documented continued high rates of harm; one study of 10 hospitals in North Carolina showed no evidence of improvement between 2002 and 2007. On top of that, a steady drumbeat of studies (beautifully chronicled by Brad Flansbaum) demonstrates that nearly every policy intervention that we thought would work (readmission penalties, “no pay for errors,” pay for performance, promotion of IT, resident duty-hour reductions) has either failed to work, or has led to negative unanticipated consequences. For people who have given their hearts and souls to making the system work better for patients, the result is more demoralization. 
My second major concern about patient safety stems from the Affordable Care Act (ACA), one of whose main goals, paradoxically, is to place a premium on value over volume. You’d think that the patient safety field would benefit from such a law (which also includes significant new spending on safety), and perhaps it will… eventually. But in the short term, the ACA is yet another speed bump on the road to a safe system. 
Just as physicians are overwhelmed and distracted, so too are hospital CEOs and boards. As the healthcare system lurches from its dysfunctional model to a (God willing) better place, healthcare leaders are scrambling to be sure that their organizations have seats when the music stops. The C-suite and boardroom conversations that, a few years ago, were focused on how to make systems better and safer now center on whether to become Accountable Care Organizations, how to achieve alignment with the medical staff, what the insurance exchange will mean for our reimbursement, and the like. To the degree that people remain interested in improved value, here too the emphasis has shifted from the numerator of the value equation (quality, safety, patient experience) to the denominator: cutting costs.

Read the whole thing again and think about what he's saying and what's coming unless real change that improves the burden these safety initiatives have on doctors and nurses occurs.
"Don't it always seem to go, that you don't know what you've got 'til it's gone.  They paved paradise, and put up a parking lot." 
- from"Big Yellow Taxi" by Joni Mitchell


Anonymous said...

Dr. Wachter is part of the inner circle of "thought leaders" who have destroyed the hearts and minds of America's physicians. I guess it's good he's having some second thoughts, but he continues to do lots of damage (head of the ABIM and other activities).

Anonymous said...


You're getting downright scary...
Quit the hospital and go concierge.

And "In all fairness" is quite a joke.

Here's another opinion:

DrWes said...

Anony -

I appreciate you directing me to that anecdotal commentary, but it misses my point completely.

Have reductions in medical errors occured as a result of "time-outs," forcing doctors to obtain consent, declaring the side of surgery, requiring another H&P be performed because one was 31 days old instead of 30, etc?


But then again, perhaps not.

I dare say there is not a doctor out there that does not regret when a medical error on one of their patients occurs, be they preventable or not. After all, they're the one that must face the consequences with the patient directly. No one else.

But there seems to be an almost magical belief that patients can have care that is error free when doctors are pulled in so many directions in the name of safety. From documentation demands required by the EMR, pay for performance required for payment, seeing more people with less help than before, and the need to see more people in less time to satisfy our employers' bottom line as many more patients enter our health care system expecting immediate state-of-the-art care -- the collision of fantasy and reality was inevitable. As we continue to see in the links provided in this post, little has changed with patient safety (when we look objectively at the system as a whole rather than anecdotal accounts).

This is not to say that patient safety is not important. It is. But unless and until people appreciate the negative effects of all of these well-intentioned but ineffective means of changing physician and caregiver behavior, the potential for additional harm to patients caused by experienced and caring physicians exiting the system should be considered as well.

Sadly for you, my mission with this blog is clear: insights to real (not sugar-coated) doctor experiences need to be told as dramatic changes to our health care system continue - many of which are difficult to appreciate any other way.

Anonymous said...


You have a tough job and I don't doubt you care deeply about your patients. But I tire of your unrelenting attacks on any health care reform - from Berwick, to Obama, EMR, FDA, and whatever those tracking devices are called. And I cannot work up any fiscal sympathy for specialists (most especially cardio) who make $500K.
I do worry over the 30M PEOPLE who had no insurance, and those with pre-existing conditions that would have forever left them uninsurable while some damn company is marketing devices enabling robo-removal hysterectomies and we are the only developed western country (and Most Exceptional, right?) without universal health care.
My link was anecdotal (however it hit 100% of that family!) but your view also seems limited especially in comparison to those 30M. And yes, dramatic changes are taking place in our health care system. It is no longer 1990 - or whatever date you assign as a much better time for healthcare. But please consider the burden that millions of Americans face who are without health care or are facing bankruptcy for soaring medical bills. Their problems should not be sugar-coated either. In fact, it would help if you would acknowledge they, too, face formidable health care problames without resorting to the "zombie" defense that soon we will have no physicians at all.

Art Fougner MD said...

"The nine most terrifying words in the English language are: 'I'm from the government and I'm here to help.'" Ronald Wilson Reagan

Anonymous said...

This is what health reform would look like if physicians were given the autonomy rather than bringing in overpaid bureaucrats like Berwick and politicians like Obama.

Anonymous said...

I found both case histories in the NYT, even though presented by an MD, as pretty hard to believe.

Anonymous said...


Dr. Wes says not one word on the Time cover story...

Anonymous said...

I am on Page 8 of the Time cover story. I will never again question the "stingyness" of Medicare payments to a hospital! Hospitals are worse than Somali pirates. Dr. Wes, if you do not offer an essay in response to this article I will lose all respect for you and your blog.

A word for all readers to learn: CHARGEMASTER.

What a disgusting health care system. The mafia is more ethical than this gang.

DrWes said...

Anonys 1:03:00 pm and 04:04:00 -

If you don't like what you read here on this blog, I will not be offended if you chose to look elsewhere. Really.

But while you were away, I've been posting on the issue of cost in health care for years.

The breathless Time article you both reference appears to have been written by someone who's finally pulled their head out of the sand and entered the health care reform discussion. Seriously, where has this author been all these years? Why the high prices? Really? This author's asking this NOW?

Here are just a few posts I've written previously on this issue:

Show Me the Money

Who's Performing Your Walletectomy?

Our Healthcare Hindenburg

The Challenge of Health Care Reform

Hospitals Building for the Woo-Factor

Are Large Health Care Systems Gouging Patients?

Believe me, there's many posts in these pages on health care pricing. And no, I don't need to post another right now to fan your outrage with our system.

Just remember all the players responsible (including you, me, and our society's unfettered expectations of state-of-the-art care for everyone at little to no direct cost to ourselves) that have helped make it so. This didn't happen over night. It's just gotten so expensive that people (including main stream media) are finally pulling their head out of the sand.