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

On Closure

The chief complaint, the history and physical, the differential diagnosis, the proper testing, the treatment.

From Day 1, these are the pieces of medicine that are hammered in to young doctors' heads: the best way to treat this or that, the best drug, widget or gizmo, the latest advance. We learn which approach is better than the other, which treatment to apply when more conventional approaches can't be taken. Each of these steps are drilled over and over again in the hopes of crafting a strategy for each clinical scenario a doctor is likely to encounter. Yet while each of these steps that are learned are important in their own right, few of these steps are critical to doctors' sustainability in their profession.

Because after the treatment strategy or therapy is applied, there's another vital part of the medical care that is often under-appreciated for doctors and policy makers: the closure.

"Closure" is the time in medicine where we either revel in our success or squirm in our failure. It's where we must face the music - good or bad - with our patients. More often than not, it's the time for doctors that brings meaning to our efforts and the hours we work.

Closure can occur at different times for different doctors. For specialists (increasingly called "proceduralists" these days), closure usually occurs in the post-operative or post-procedure period. For primary care doctors, "closure" occurs during the follow-up visit after a prolonged hosptitalization or difficult illness. For both types of doctors, it's the chance to see the good they did or bad they did first-hand. It a time to validate their understanding of the patient's ailment and the caliber of their treatment plan. Importantly, it's not the end of the patient's ongoing care but rather, it's the conclusion to a particular chapter of their care. For doctors, it's the critical time we grow as professionals.

Yet sadly, these moments of closure are becoming rarer for both the patient and the doctor.

With doctors racing between facilities on productivity compensation plans who must perform more cases in less time and in more locations to offset declining payment rates, it's become harder both logistically and financially to justify excessive post-operative time with patients after their procedures. The money required to feed the our massive system of administrators, collectors, quality score counters, overheads and salaries demands a constant ever-growing source of funds, so doctors must keep moving.

To that end, specialist physicians have seen post-operative care routinely clumped together with the pre-procedure and intra-operative care as one big "encounter" that pays health systems only once. Increasingly to add "value" to health care dollars, policy makers are shifting the "risk" of caring for patients to the providers of that care. Insurers and policy makers like to call this shifting from "procedural-based" payments to "outcome-based" payments. In theory this sounds nice, but it's robbing the doctors of the closure time so critical in the valuation of their profession in favor of treating a greater quantity of healthier, lower-risk patients to assure reliable payments to the system.

For primary care doctors who now only see patients in their offices, the opporunity to see the product of a continuous care strategy has been surrendered to the hospitalist movement robbing them of closure time. And even the hospitalists who "diagnose and say 'adios'" from the confines of the hospital, the opportunity see the late consequences of their care in a non-critical environment has been lost to production quotas as well. No fractious group "medical home" care in the world can replace this loss of closure inflicted upon primary care and shift-working hospitalist physicians or the patients for whom they care.

Our health policy analysts have assured us these "closure" visits can be accomplished by ancillary care providers. Technically, they are correct. But there is no question that the loss of these post-procedure visits by the treating physician or operating surgeon robs them of a critically important opportunity for continuous self-improvement as they reflect on the quality and cailber of their work first-hand. Further, doctors lose an opportuntity after the haze of amnestic medications have subsided to educate and re-connect. Doctors need this time with their patients just like patients like this time with their doctors - maybe even more. It's what makes it worthwhile to get up and do it all again.

Despite the current push, I still try to see my patients after a procedure whenever possible. Sure, we don't get paid for this, but I still relish a patient's gentle smile or a quiet "thank you." More importantly, when things aren't perfect, I need the opportunity to reassure and console. If things really don't go well, I find there are huge benefits derived when I can explain and empathize with the patient's situation.

Still, I feel the tug. "It's not efficient," they tell me.

Perhaps.

But it's this closure that sustains me and I suspect sustains many in our profession. And honestly? If doctors' closure time continues to be parsed and devalued further, they'll look for validation of their work elsewhere.

Then what kind of closure will we have?

-Wes

The Risks of Remote-Controlled Medicine

"It is more important to know what sort of person has a disease than to know what sort of disease a person has."

- Hippocrates

Increasingly our Western world culture assumes that most things in medicine can be reduced in to a linear, data-driven, algorithmic processes. One only needs to witness the now-famously heralded article on ICU check-lists to understand the unwavering trust we have in this model. ICU medicine's complexity reinforces our trust in this approach because patients are usually too sick to contribute to their care. While there, intensivists resort to their Fourier transform of all things living, parsing our patient's life into the various frequency spectra of their organ systems. With careful tuning of these harmonics, more often than not the patient survives. And we deem this good. So good, in fact, that the notion of a predictability to medicine has spawned the development of remote controlled ICU's and even robots to replace doctors.

Yet when we consider medicine nothing more than a rational, scientific, transactional exchange between the doctor and patient we become limited. Such interactions miss medicine's sacred, intimate and intensely human, non-linear aspects. After all, people do not travel long distances to see a specialist who merely reads algorithms. Instead, they travel long distances to see highly experienced doctor who takes huge, intuitive, and often illogical leaps. The level of presence required to hear a patient on this level of broad critical thinking is not supported by quotas, checklists, little sleep, and multiple back-to-back seven-minute appointments.

Doctors and their patients are clearly sensing this shift to the omnibus, bean-counter, centralized approach to medicine. For a myriad of seemingly well-intentioned reasons, concern for the patient has shifted to concern for documentation. We see independent thought giving way to guidelines and treatment protocols. Whether these protocols really reduce errors remains to be seen, but we already see the consequences of these processes as patients say privately, "doctors don't care anymore." We should ask ourselves when they say this, are they talking about a lack of their doctor's social graces or a potentially life-threatening disconnection? In fact, if medicine is such a formulaic service-delivery model, then the natural consequence of this rote health care model implies that all doctor shift changes are risk-free and doctors are simply replaceable, rotatable and expendable.

Yet doctors offer little to correct this shifting perception. We console ourselves that centralized certification bodies will assure the maintenance of core health care delivery competencies, but do so at the expense maintaining a yearning for excellence. The results are telling. In the march toward the mirage of error-free adequacy, doctors are being worn down by the emotional withdrawal from their patients. Burnout is common. The loss of emotional connection is not what our most altruistic, bright medical students sign up for when they enter medical school. Will it be okay if our young doctors no longer see the intangible, emotional contact with patients as a necessary prerequisite for providing health care?

Humans are a study in contradictions. We yearn for the thousand points of light only to find, more often than not, they leave us in the dark. We crave the impersonal, the predictable, and the controllable. We cling to the magical thinking that if we just do what we're supposed to, eat right, exercise, and walk the proper line we'll be fine even though each of us acknowledges, eventually, our own mortality. We want the government to provide our health care, yet realize they will never return our calls. We love the glitz, the shiney, the whizbang, but first, we want to talk to the doctor.

Both doctors and patients still want and need these intangibles in medicine. Yet more and more forces threaten to dissolve them. With each new mandate, each new checklist, each new certificate, each new order set, each new performance measure, each new computer screen, we risk chipping away at this critical cornerstone of medicine. Worse, we risk losing our best and brightest in medicine in favor of nothing more than our best remote-controlled, linear, and logical promises.

-Wes

Patient Blogs Make HIPAA Unenforceable

HIPAA, the Health Insurance Portability and Accountability Act of 1996, contains privacy provisions that provide "protection" of patient's health care information to assure that health care providers, health plans, and health care clearinghouses don't leak such sensitive information in a public forum. You see, our legislature felt that doctors and health care providers might use such information to the detriment of our patients, so they made this law to allow government to reassure others that Big Brother could do a better job at protecting your privacy.

But now comes another realization: patient's family members might leak the informaton instead.

Patient blogs are now the rage at local hospitals here in Chicago, detailing play-by-play accounts of health care delivery and histories on patients themselves. You see, patients aren't covered by HIPAA. They can say what ever they want about themselves. But sometimes the patient isn't the one posting on the patient's blog, family members were, dutifully updating the daily progress of their loved one to the world.

"Many people have been inquiring about him so I would like to share some information with everyone," said the first in a series of near-daily updates posted by Nequin's wife, Dawn.

She described in detail how her husband had slipped on ice March 6 while walking the family dog, hit his head on the sidewalk and, nearly three hours later, asked to be taken to the hospital, complaining of a headache and weakness in his leg.

"Within minutes he was having a CAT scan, and in a few more minutes we knew he had a brain bleed," she wrote.

And companies providing these patient weblogs and message boards are springing up like 17-year cicadas:

TLContact Inc., the Northwest Side company that oversees CarePages, has created more than 50,000 such pages, according to a spokeswoman. CaringBridge, a competing service based near Minneapolis, and theStatus.com, a third major competitor based in Anchorage, claim roughly the same numbers of pages, most of them generated in the last few years as word has spread about their availability.

"Most people don't find out about them until a friend goes into the hospital and starts one," said theStatus founder Mark Pierson.

Such sites have been around nearly 10 years, are free, easy to use and fairly secure -- families can control access to them via passwords and invitation lists. Though the companies contract with hospitals for branding and promotional purposes, any patient anywhere can sign up and use any of the services.

They relieve family members and patients of the tedious job of telling the same story over and over, while the accompanying message areas become a forum for encouragement and prayers.

They offer an advantage for health-care professionals as well. Having the family post updates online allows them to skirt the awkwardness and even legal peril that newly stringent medical privacy regulations have added to such simple questions as "How's he doing?"

So in the future, if doctors or insurers get accused of violating the HIPAA provisions, they'll just look stupid and say, "Hey, I just read what I know about him on his patient blog!"

-Wes