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

-Wes

More Questions About Donald Berwick Surface

With the unvetted recess appointment of Donald Berwick to the Centers for Medicare and Medicaid Services (CMS), some interesting questions that would have been asked at his Senate confirmation hearing were skuttled, like this one:

Beyond that, the GOP is especially curious about a nonprofit organization Berwick founded, the Institute for Healthcare Improvement. A 501(c)(3) tax-exempt organization, the institute reported receiving $12.2 million in contributions and grants, among other revenues, in 2008 (the most recent year for which figures are publicly available). Given all the money that has flown around in the health care debate, Republicans wanted to know where the $12.2 million came from. The recess appointment meant that Berwick didn't have to answer.

The institute has also been very good to Berwick personally. He received $2.3 million in compensation in 2008 (a figure that included retirement funds), and was paid $637,006 in 2007 and $585,008 in 2006. On top of that, investigators discovered a little-noticed paragraph in an audit report revealing that in 2003 the institute's board of directors gave Berwick and his wife health coverage "from retirement until death."

This is no small issue since this man now controls nearly half of the half the US health care budget. I can assure you, doctors did not contribute that kind of money to Mr. Berwick's coffers.

So it begs the question: who did?

-Wes

The End of "Rescue Medicine"

Like many others, I am still reeling from the "recess appointment" of Dr. Donald Berwick as the new Director of the Center for Medicare and Medicaid Services (CMS). But unlike others who feel his appointment was a "sneeky move," I would have to admit that it was brilliant political display of "The Chicago Way."

You see in Chicago, if you hold a position of great stature politically, you don't have to ask permission from anyone to do things. You just do them.

Don't like an airport and want it closed? Just call The Boys and have them go out and rip up its runway under the cover of darkness. You just have to have some forward-looking perspective: like a cool $1.4 million a year in revenues that can be gained from the amphitheatre The Boys build there.

Problem handled.

When things like this happen here, people kick and scream and fuss and fume, but they're ultimately left powerless to do anything about it, so they just take some money and move on.

And so it is likely to be with medicine.

For quite a while.

Oh sure, we can all kick and scream and fuss and fume, but it would be far better for us understand what we've really just gained.

It is not just the shift from "rescue care" to the philosophy of a "redistribution of wealth" as Mr. Berwick has espoused earlier:

"You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any healthcare funding plan that is just, equitable, civilized and humane must -- must -- redistribute wealth from the richer among us to the poorer and less fortunate," Berwick said in a 2008 speech in London on the virtues of the British healthcare system. "Excellent healthcare is by definition redistribution. Britain, you chose well."

No, it is far more sinister.

My concern is that rather than achieving a overt means of health care rationing vetted by the populous, the covert nature of health care rationing will continue via administrative fiat. As such, people and large health care institutions will continue to be given their government payments to "play nice" by the many, many new "rules," or else. In effect, our health care system has the potential to evolve into a macabre reenactment of bloated, bureaucratic system that defines "The Chicago Way."

After all, since Mr. Berwick won't insist on his own appointment be publicly vetted before our elected representatives, what will that mean for the health care decisions that come from his office and costs of the bureaucracy behind it all?

-Wes