14 June 2019
Dear Interested Readers,
It’s Not All About Us
An interested reader contacted me this week for some advice about an inspirational speaker for her medical group. They are celebrating practice values as a part of an effort to fight burnout and improve morale in their practice. I confirmed that the proposed speaker would be a good choice and offered some alternatives, if the first speaker was not available. On her return email she wrote:
Thanks for the feedback and suggestions. I’ll be sure to keep you posted. BTW, did you see this Op-ed in the NYT? It’s been circulating, of course, among all of my colleagues:
https://www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html
Sigh–I worry that things will get worse before they get better. I disagree with the conclusion of the article (blaming administrators), but completely understand the sentiment.
The article that you find if you click on the link is an op ed piece from The New York Times entitled, “The Business of Health Care Depends on Exploiting Doctors and Nurses: One resource seems infinite and free: the professionalism of caregivers” by Dr. Danielle Ofri, who works at Bellevue Hospital. That is a very provocative title. My friend is right about two things. The article is very popular. It is still on the Times “Most Emailed List,” as of this writing, almost a week after it was published last Saturday. She is also right about her disagreement with the conclusion, blaming administrators.
Dr. Ofri is a well known and respected author and speaker. She has written five books. Her most recent book is What Patients Say, What Doctors Hear (2017). It is an examination of communication in the doctor-patient relationship. As the review in the Washington Post by Libby Copeland states:
...Ofri makes a compelling case that patient-doctor communication in the exam room is as crucial to diagnosis and treatment as expensive tests and procedures. Offering empathy, asking open-ended questions, involving the patient in a treatment plan and checking again and again to make sure patients understand are all key to making the sick better…
Her recent “Ted Talk” was also impressive. In it she talks about being honest about ours fears in practice and being willing to ask for help. She references Dr. Francis Peabody’s famous speech that includes the phrase “…the secret in the care of the patient is in caring for the patient.” She asks us to take that one step further and say “the next step in caring for the patient is in caring for the caregiver.” She comes across as sincere, and I am sure that her motives are pure. In the op ed piece her observations are accurate, but like my reader I disagree with her ultimate conclusions. Let’s look at the article.
She begins with a series of vignettes that many clinicians can relate to:
You are at your daughter’s recital and you get a call that your elderly patient’s son needs to talk to you urgently. A colleague has a family emergency and the hospital needs you to work a double shift. Your patient’s M.R.I. isn’t covered and the only option is for you to call the insurance company and argue it out. You’re only allotted 15 minutes for a visit, but your patient’s medical needs require 45.
These quandaries are standard issue for doctors and nurses. Luckily, the response is usually standard issue as well: An overwhelming majority do the right thing for their patients, even at a high personal cost.
Her next statement connects these realities which we have all experienced to what she considers to be their “root causes.”
…I’ve come to the uncomfortable realization that this ethic that I hold so dear is being cynically manipulated. By now, corporate medicine has milked just about all the “efficiency” it can out of the system. With mergers and streamlining, it has pushed the productivity numbers about as far as they can go. But one resource that seems endless — and free — is the professional ethic of medical staff members.
She is describing the outcome that she feels. I don’t think that she is describing a conscious intention on the part of “corporate” medicine and although she sounds cynical with her reference to efforts to introduce efficiency, I am sure that she would agree that a focus on efficiency and associated innovation are key components of our hope of improving the patient experience in a way that lowers the cost of care, improves quality, and potentially benefits patients by creating the possibility of more time with their providers. Her next comment has the truth of gospel until she returns to comments about “the system.”
This ethic holds the entire enterprise together. If doctors and nurses clocked out when their paid hours were finished, the effect on patients would be calamitous. Doctors and nurses know this, which is why they don’t shirk. The system knows it, too, and takes advantage.
Perhaps my perspective varies from hers because I never considered myself to be an hourly worker who “clocks in and out” of my responsibilities to patients. At this point in the article Dr. Ofri does a brief review of how EMRs create burnout, and on this subject she is not wrong, but she does not have insight to the root cause.
By far the biggest culprit of the mushrooming workload is the electronic medical record, or E.M.R. It has burrowed its tentacles into every aspect of the health care system. There are many salutary aspects of the E.M.R., and no one wants to go back to the old days of chasing down lost charts and deciphering inscrutable handwriting. But the data entry is mind-numbing and voluminous. Primary-care doctors spend nearly two hours typing into the E.M.R. for every one hour of direct patient care. Most of us are now putting in hours of additional time each day for the same number of patients…The E.M.R. is now “conveniently available” to log into from home…
On the first day on my office practice at Harvard Community Health Plan in 1975 I had an EMR. It was rudimentary compared to the tools we now have, but it was an asset, not a burden, because its primary function was clinical. What has turned the EMR into a nightmare is the fact that its primary function now is to document all of the components of care for reimbursement in a fee for service finance system. Your note determines the RVU value of the encounter. Quality data from the EMR determines pay for performance bonuses. The information that is recorded that adds value to the clinical management of the patient is often obscured by long lists of clinical negatives inserted to justify billing out an encounter as an L4 or L5, rather than an L3. One could argue that we have devalued the EMR as a clinical tool by making it a tool of finance. We have made pursuit of payment a central focus of our activity, and the result is the EMR is now a burden that threatens the health of both the clinician and the patient.
Near the end of the article Dr. Ofri backs off a little on her condemnation of “administration and the system.” An insinuation of management’s nefarious intent and malfeasance is replaced by an observation that perhaps the abuse of clinicans is just the result of management’s incompetence, insentsitivity, and misplaced attention which she calls “administrative creep.”
I stop short of accusing the system of drawing up a premeditated business plan to manipulate medical professionalism into free labor. Rather, I see it as a result of administrative creep. One additional task after another is piled onto the clinical staff members, who can’t — and won’t — say no. Patients keep getting their medications and their surgeries and their office visits. From an administrative perspective, all seems to be purring along just fine…But it’s not fine.
She is right that “it’s not fine.” Burnout does compromise care by its probable association with more medical errors and compromised patient safety. Both patients and caregivers are damaged by a system that is obsessed with the generation of revenue. She is also right when she states:
This status quo is not sustainable — not for medical professionals and not for our patients.
And she continues to be correct when she writes:
Health care is by no means perfect, but what good exists is because of individuals who strive to do the right thing.
We would have been hopelessly lost long ago without what is left of the professionalism and commitment to the care of the patient that moved most caregivers to devote many years to the training necessary to be of use to patients. But, I think that she goes too far when she says:
It is this very ethic that is being exploited every day to keep the enterprise afloat.
Her statement is an example of the failure to ask a very important question of me, you, her colleagues, and herself. That question is: “What part of the problem am I, are we?
I hesitate to lay the blame for all of what is wrong with healthcare on the shoulders of administration and “the system.” That negates the reality of the role that physicians have played either actively or passively in creating the environment that now creates burnout and fatigue for physicians and nurses, suffering from medical errors and the reality of an expensive and dysfunctional care experience for patients, and a downhill slide toward unsustainable medical costs for all of us.
Her reductive reasoning and misuse of “the data” presented in the next to last paragraph feels more like an attempt to excite passions and stimulate discontent than as a first step in a genuine attempt to stimulate a positive collective response to a shared problem. The increase in “administrators” is an unfortunate outcome of the pursuit of revenue and the increasing complexity of care. She is right when she implies that things must change. Robert Ebert told us more than fifty years ago that the answer to better care was not more money, more facilities, and more personnel, it was in finding a better operating system and finance mechanism to support care. To improve care and direct more resources to the support of the practice we must accurately understand how we got to where we are. Our days are filled with documenting care that often adds no value with a focus on individual encounters rather than developing longitudinal care pathways supported by a team primarily because we have carried the admonition of “no margin, no mission” too far and the mission has been lost in the pursuit of margin.
The health care system needs to be restructured to reflect the realities of patient care. From 1975 to 2010, the number of health care administrators increased 3,200 percent. There are now roughly 10 administrators for every doctor. If we converted even half of those salary lines to additional nurses and doctors, we might have enough clinical staff members to handle the work. Health care is about taking care of patients, not paperwork.
The affect in the last paragraph suggests an attitude on the part of management and the system that I have never witnessed. The insinuations that I read into her words are highly unlikely to lead to improvement of the realities of practice as currently experienced. Misplaced affect and unfair accusations are not a starting point in the search for relief for patients or clinicians.
Those at the top need to think about the ramifications of their decisions. Counting on nurses and doctors to suck it up because you know they won’t walk away from their patients is not just bad strategy. It’s bad medicine.
Clinicians must be in collaboration with those “at the top.” There must be shared goals that begin with a shared commitment to the principles of the Triple Aim, the pursuit of which will insure what we now call the Quadruple Aim. I have been both a physician and an administrator, although when someone asks me what I did in life, I answer that I was a doctor. Sometimes I mention that after over thirty years of full time practice I accepted some administrative responsibilities during the last few years of my professional life. If they push, I say that in mid career I decided that I would try to improve the care my patients received by getting involved in the governance of the group where I worked for my entire career.
Sometimes I say that after several years of trying to participate in practice improvement I realized that I was “bilingual.” My “mother tongue” was practice, but I had learned to “speak business” or at least understood what management was trying to say. I tried to be a “connector” and the longer I stayed engaged with both sides the more I became convinced that clinicians and the other healthcare professionals that Dr. Ofri lumps together as “the system” arrived at this moment in time hand in hand. If there is to be improvement without the whole system being essentially put into receivership by the public through the elective process after costs become unsustainable and patients become dismissive of what we consider evidence based medicine, then as clinicians we must recognize own our part of the problem we helped to create. What Dr. Ofri calls “the “system” must also understand that the pursuit of greater revenue through greater volume is not an effective strategy. It is a recipe for failure, and threatens our collective contributions to the well being of the nation.
I first recognized this bilateral reality when I heard Jack Silversin speak in the mid nineties while I was in the midst of the chaos created by the merger of Harvard Community Health Plan with Pilgrim Healthcare. I discussed this experience in a note last December entitled “Physicians and the Wicked Problems of Healthcare.” These days Jack works with Mary Jane Kornacki in a small consultancy, Amicus. The essence of the note last December was an attempt at transmission of their concept that the relationship between clinicians and management should be renegotiated.
Jack and Mary Jane note that doctors and the organizations within which they work have evolved in different directions, and need to renegotiate their “contracts” with one another. Doctors believe their “implicit contract” gives them:
- Autonomy
- Protection
- Entitlement.
As Dr. Ofri’s op ed demonstrates, these concepts or values often collide with the challenges that face healthcare organizations like:
- Coordinate care across intra- and inter- organizational boundaries
- Reduce cost
- Eliminate waste
- Deliver evidence-based medicine following protocols
- Implement medical records
- Move care to less expensive settings
Silversin and Kornacki counsel organizations where the concerns of clinicians seem to discount the problems of management, and management points the finger at the practice, and both ignore the real issues that matter to patients while they blame one another for problems they should share jointly.
I hear elements of the desire for autonomy, entitlement, and protection in Dr. Ofri’s analysis. I also hear an analysis that suggests that clinicians are victims. Clinicians are professionals. All professionals are expected to extend themselves for their clients. School teachers, social workers, ministers, our police, first responders, and all those who seek to serve are vulnerable to fatigue and burnout, and few of them expect a generous six figure compensation.
Our objective as clinicians should be to recognize that we are capable of being leaders for real improvement within the system of care. Our focus should not be on how we perceive that we are abused by administration and the system, but rather on how we can fulfill our professional responsibilities to patients by using our knowledge to reform the system.
When I get focused on “my needs” and how I am shortchanged in our relationship, my wife is adept at reminding me, “It’s not all about you, Gene!” Together we have objectives that neither of us could reach alone. Dr. Ofri missed the opportunity to use her clinical skill and power as a communicator to present us with suggestions that would leverage the wisdom of clinicians in the creation of a better service for patients through a more effective partnership with administrators.
The doctor whose note began this ramble is one of the doctors who “gets it.” She is a specialist who understands and values the role of primary care and has accepted a leadership role in her group practice. She is at the table as a partner with the administrative leaders of her organization. She understands their problems and she informs them of the concerns of the practice. Together they have put the needs of their larger community and of the individual patients who come to them at the center of their collaboration. They have a commitment to improving the experience of care and the experience of practice.
I can understand her disappointment with Dr. Orfi’s article because it undermines her efforts to move the doctors and nurses she leads from burnout and a sense that they are victims to being the architects and co creators of a better system of care. She is committed to a partnership for improvement built on the reality that we are professionals who have the reponsiblity to focus first on the needs of others with the knowledge and deeply held belief that if we put the care of the patient first, our needs will also be met. The other way around we will all eventually fail.
Up On One of Fifty Two With A View
The header in today’s post was taken from the top of Mount Cardigan which lies between my home in New London and the White Mountains which you can see in the distance beyond a line of windmills. Cardigan is not one of New Hampshire’s famous “48 over 4000” which may need to change as new technology is used to measure just how tall the mountains really are. If you clicked on the link you know that some mountains, like 4004 foot Mount Tecumseh, home of most of the Waterville Valley ski trails, may fall off the list. The new data suggests that it is 5 feet short of 4000 feet at 3995 feet.
We all know that politics redefines facts and data, so it is likely that “for tradition” the list of 4000 footers will remain the same. Another theoretical possibility might be that our governor, Chris Sununu, whose family owns a controlling interest in the Waterville Valley Ski Resort, will have an additional five or six feet of dirt and stone transported to the top of the mountain. That is what happened in the 1995 movie starring Hugh Grant, “The Englishman Who Went Up a Hill But Came Down a Mountain. The plot of the movie was that the residents of a small Welsh town were outraged to learn that their “mountain” was going to be downgraded from a “mountain” to a “hill” because the official definition of a mountain was 1000 feet. Two cartographers had determined that their “mountain” was only a 995 feet high “hill.” You guessed it. They pushed enough dirt up the hill to make it a mountain. People get passionate about their mountains.
At 3,155 feet, Mount Cardigan is not on New Hampshire’s 48 over 4000 list, but I was there because of the list. My friend and former colleague, Tom Congoran, wants us to climb the 4000 footers. Another friend, Steve Allenby wisely advised us to “warm up” to the challenge. Cardigan is also on a list, the 52 With a View list, aka The Over the Hill Hikers list. Those 52 mountains are all over 2500 feet. That does not mean that these ‘hills” are easy, but the views from the top are worth the effort as the picture shows. The West Trail up Cardigan is a challenge. It is steep and very rocky. The last quarter mile is across a steep granite sheet. After Cardigan, my old legs were tired, but we are setting our sites on Mount Moosilauke, a real 4000 footer, next. You can see Moosilauke just under the “th” in the Healthcare Musings banner.
I hope that you have some outdoor plans for this Father’s Day weekend. A walk in a park with no change in elevation can be a “mountain top” experience, if you are walking with a good friend. Summer is short. There are only twelve weekends to go before Labor Day. Make them all count.
Be well, take good care of yourself, let me hear from you often, and don’t let anything keep you from doing the good that you can do every day,
Gene
