22 February 2019
Dear Interested Readers
Professionalism In Difficult Times
It is no longer news that many doctors and nurses, as well as the healthcare professionals who provide the business and operational support for healthcare, are struggling in the current environment. Taking care of others has always been associated with personal stress, and a sense of “professionalism” has been a resource and a reminder of why we are willing to take on difficult challenges. Teachers, the clergy, social workers, lawyers who work in government or defend and aid the poor, and public servants like the military, the police, firefighters, and other first responders have always shared with medical professionals the idea that their calling was to something greater than just a way to put food on the table for their families, and they have also been vulnerable to “burnout” from the stresses of their responsibilities and the hostile circumstances that they are often forced to tolerate. Most professionals in any of these activities will tell you that what they do is more than just a job, it is a choice to be a servant of others.
Perhaps some physicians chose medicine as a career with the idea of becoming wealthy, and indeed compared with the economic experience of the majority of our neighbors we do well, but practicing medicine has never been a terrific strategy for getting rich. I do not think that I have ever met the doctor who said,“I became a doctor because I wanted to have enough money to buy a yacht.” What I do frequently hear is, “I became a doctor because I wanted to help people, but then things changed.” It is true that the external pressures of healthcare finance, the demands of payers for documentation, the ever growing number of bureaucratic and regulatory demands to assure quality, and the frustrations of patients with poor access, depersonalized systems, and the high out of pocket costs all converge to make caring for patients seem increasingly difficult.
Patients are angry that they now pay more for what seems like less attention from their care providers. Their anger is exacerbated by sitting in an exam room and watching their doctor type on a keyboard while asking them questions without turning their eyes from their computer screen. Patients do not schedule their appointments with the idea that they will spend their time in the office watching the doctor work from behind when what they really wanted was an experience more like the Norman Rockwell painting of “The Doctor and Doll.” What is sad is that both the doctor and the patient are longing for something more.
We live in times that confuse us. We are told that collectively we have never been smarter, never been richer, never had fewer people in poverty, and never had so many live for so long, but when it comes to either the experience of giving care or receiving care there has never been a time when more people on either side of the transaction have felt that there is something that is terribly wrong. The irony of the moment is that surely there has never been a moment in time when we have known more about disease and the effective ways to treat disease than we do now, but at the same time it feels like we have never been more inept than we are now in our ability to equitably distribute the benefits of our knowledge to the patients that need it. It is hard to escape the conclusion that something is terribly wrong, and that while we have gained important scientific understanding and technical skill, we have lost something from the recipe for a satisfying experience of care for both the provider and the patient. Medical journals, publications of medical societies, and the lay press have written at length about what is wrong with healthcare and what we might do to make things better.
As important as universal coverage is, whether we provide Medicare for all, a reworked ACA with a public option, or immediately switch from fee for service payment to value based reimbursement, the problems in the delivery of care that frustrate patients and clinicians alike are unlikely to improve if the focus is just to get everyone covered and pay for it. Over the years I have been in many many meetings that were deep dives into the problems of satisfaction with practice or the experience of receiving care in situations where everyone was covered, and there were more than adequate resources.
There are many who bemoan the transformation of practice that has been wrought by the introduction of the EMR. I recently heard that doctors now spend 50% of their time typing into computers and only about 25% of their time talking with patients. I do not doubt that this is true, and I also do not believe that EMRs are the only cause of the sense of loss and dissatisfaction that patients, doctors, and nurses feel. There is no question that the demand that we do more, do it better, and do it for more people for relatively fewer dollars in less time per patient will continue and intensify into the future. I am also certain that the sense that something is wrong would persist if we suddenly had more resources per patient.
Don Berwick’s call for a “third era,” a new “moral era,” of healthcare attempts to address many components of the malaise that we sense in what we do. I would refer you to a previous post from last February if you need a reminder about Don’s Era 3. But here are his bare bones suggestions of the things we should stop doing , and the things that we should begin to do, if we want to improve the experience of giving and receiving care.
- Stop Excessive Measurement
- Abandon Complex Incentives
- Decrease Focus on Finance
- Avoid Professional Prerogative at the Expense of the Whole
- Recommit to Improvement Science
- Embrace Transparency
- Protect Civility
- Listen. Really Listen
- Reject Greed
Even though I am arguing that there is not one “silver bullet” solution to the lack of satisfaction with the process of giving and receiving care, I do believe that any of the points that Don makes and the actions he suggests will move us in the right direction.
There is much talk about what is wrong in politics these days. No one ever quite says it, but there seems to me to be some consensus that something has changed about the “professionalism” of politicians. I think there may be some observations that are transferable from those feelings to the discomforts and dissatisfactions with current practice that we hear from patients and clinicians alike. We say that politicians are interested only in themselves and the interests of their donors, and the result is that no one is addressing the needs of “the American people.” We say that politicians have abandoned “norms” of behavior. We have lost any trust that they are interested in doing the “business of the people.” In essence we are questioning their “professionalism.”
I do not think that medical professionals have abandoned the traditional principles of professionalism, but in the stress of the moment we may have lost site of them, or we may be finding that living up to them is increasingly difficult. I think that there would be benefit in talking about the components of medical professionalism and how they are challenged in the current climate. Are they a fixed truth that can’t be changed? What is missing when we compare what we do with what we know we should do? Why has our professionalism not been sufficient to guide us through our current challenges?
The good new is that the people at the American Board of Internal Medicine Foundation have been thinking about professionalism for a long time, and have recognized the need to renew our sense of professionalism. The “Choosing Wisely” Program is a product of some of that thinking. I wrote about the work of the ABIM Foundation last fall, and their internationally accepted physician charter on professionalism in our times. You might remember reading:
In 2002, the ABIM Foundation, in conjunction with the ACP Foundation and the European Federation of Internal Medicine, authored “Medical Professionalism in the New Millennium: A Physician Charter.” The fundamental principles of the Charter are the primacy of patient welfare, patient autonomy and social justice. The Charter also articulates the professional commitments of physicians and health care professionals in the modern era. This seminal document has since been endorsed by more than 108 organizations and over 100,000 copies have been distributed.
That was an introduction but I think a deeper dive is indicated. If you go to the American Board of Internal Medicine’s website you will read:
Trust. Respect. Honesty. Ethical use of resources. Social Justice. These are core tenants that medical professionals embrace when serving patients. Professionalism is the force that drives doctors to do right by their patients no matter what.
Those are inspiring words that remind me of the “Scout Law” that so many boys learned when Scouting was popular.
A Scout is Trustworthy, Loyal, Helpful, Friendly, Courteous, Kind, Obedient, Cheerful, Thrifty, Brave, Clean, and Reverent.
You may think that words like those are quaint, but I hope that you will click on the last link and read the expanded version of the 12 points of the Scout Law. it may be humorous to think about medical professionals behaving like Boy Scouts, but the values aligned with the scouting movement are foundational to all manifestations of professionalism as are most of the the other brief expressions of human behavior which we learn as children such as “Do unto others as you would have others do unto you.”
I would not think that you were a cynic if you asked where all of the Boy Scouts have gone. I know that there are still boys who are memorizing the Scout Law, and I know that there are tens of millions of men who might have once known it, promised to live by it, and have now forgotten it. The Boy Scouts have fallen on hard times. Like so many of our institutions, the Scouts are struggling to be relevant in changing times. Are physicians also struggling with their ideals? Does professionalism mean the same thing now that it did in times that seemed simpler? Are we victims or have we abandoned the responsibilities and behavior that are the core of the expectations of professionals.
I was attending a dinner of healthcare professionals and board members recently where about fifty percent of the people in the group were physicians. I was sitting at a table with a little cluster of six doctors who were were at various stages in their careers with the oldest graduating from med school in the early 80s and the youngest about 2005. We were talking about the issues that concern physicians, and the impact of those issues on the practice choices and satisfaction of individual physicians, and the collective impact of the problems of individual physicians on the culture and stability of the organizations where they work. The youngest member of the group felt like the biggest barrier was the debt load physicians now carry as they choose a specialty and enter practice. This physician thought that educational debt and lifestyle choices drive physicians toward specialties where they have greater earning power and greater control over their time off. Her analysis was that the self serving choices of her colleagues were the causes of much of the pressure felt in primary care as the number of medical graduates going into primary care dwindles.
All the doctors at the table with me had some sort of institutional responsibility and they were all in practice. I am happy to say that from my own observations, all of them were excellent matches for the ABIMs statement on professionalism, but as I listened to them talk about the challenges that they faced I was concerned that it was highly likely that there were many other doctors that they knew and cared about who were not doing so well, and for whom they had concerns. The ABIM document sites many of the challenges to medical professionalism in its summary of the new charter on medical professionalism:
The practice of medicine in the modern era is beset with unprecedented challenges in virtually all cultures and societies. These challenges center on increasing disparities among the legitimate needs of patients, the available resources to meet those needs, the increasing dependence on market forces to transform health care systems, and the temptation for physicians to forsake their traditional commitment to the primacy of patients’ interests.
The preamble of the charter stresses the importance of professionalism:
Professionalism is the basis of medicine’s contract with society. It demands placing the interests of patients above those of the physician, setting and maintaining standards of competence and integrity, and providing expert advice to society on matters of health. The principles and responsibilities of medical professionalism must be clearly understood by both the profession and society. Essential to this contract is public trust in physicians, which depends on the integrity of both individual physicians and the whole profession.
The fundamental principles articulated in the charter are:
- Principle of primacy of patient welfare.
- Principle of patient autonomy.
- Principle of social justice.
Our professional responsibilities are:
- Commitment to professional competence.
- Commitment to honesty with patients.
- Commitment to patient confidentiality.
- Commitment to maintaining appropriate relations with patients.
- Commitment to improving quality of care.
- Commitment to a just distribution of finite resources.
- Commitment to scientific knowledge.
- Commitment to maintaining trust by managing conflicts of interest.
- Commitment to professional responsibilities.
I am somewhat reluctant to just copy lists for people to read and forget. I do not think that lists solve anything if they are not discussed and used to evolve solutions. The lists are just the bare bones of what you will find if you follow the links to the output of the ABIM Foundation. I would hope that physician leaders, both formal and informal, might recognize that part of their responsibility is to explore how to promote an examination and renewal of professionalism among their colleagues. I would love to learn that in many places doctors are gathering together with nurses and other professionals to discuss both Don Berwick’s Era 3 suggestions and the ABIM’s description of professionalism in our times. Years ago in my first few years of practice at the Harvard Community Health Plan, I was part of a “Balint” group of doctors and nurses that gathered weekly over lunch to discuss issues of practice, professionalism, and the stresses that we felt as professionals. My participation in that Balint group was one of the most significant experiences in my development as a professional with a sense of social responsibility. It was also a huge “vaccination” against the threat of “burnout.”
The issues we face will not just fade away if they are neglected. The issues have crescendoed over the last decade and there is no reason to expect that they will not continue to increase if they go unaddressed. As professionals we have an obligation to monitor our performance and professionalism and endeavor to improve. There is no way we can ever expect to achieve a goal as important as the Triple Aim without a renewed sense of professionalism.
Clear, Bright Days
Don’t you love a sky with no clouds? The picture in today’s header was taken on Tuesday from the southern end of Main Street in my little town. It is the view of Mount Kearsage looking across open fields under a pristine blanket of snow under a sunny, cloudless sky. Tuesday was one of those days when the sky was so high, so clear, and such a beautiful blue that I felt like the lid had been lifted on my little corner of the world. It was very cold, but the air was dry after the front went through that had given us another three or four inches of snow on Monday. I was out and about doing errands and attending a few meetings at various times during the day when I was overcome by the beauty that surrounded me. The clouds stayed away after sunset, and the full moon was almost as bright as the midday sun. It was quite a day.
Monday and Tuesday were like a gift that made up for what I had missed the week before. I had been disappointed to miss the snow that had fallen while I was in Florida. Everywhere I went in Florida people asked me, “Aren’t you happy to be missing the cold and snowy weather back in New Hampshire?” My answer was a consistent “No, I wish I was there to enjoy it!”
People who live in Florida for the winter want everyone to tell them how lucky and smart they are to have avoided the cold and slush of winter in New England. They really don’t like it when you do not envy them and credit them with the good sense of having left winter behind. I guess I got a little perverse pleasure out of expressing a point of view that was an anathema to them. Don’t get me wrong. I do enjoy walking on the beach in Florida, but I have no use for the traffic. I can’t abide the endless six and eight lane highways crowded with traffic, and I am repulsed by the grunge of their urban sprawl. Big box stores, chain fast food joints, acres of trailer parks, multiple square miles of cookie cutter condos, and a billboard every 100 yards with an advertisement for another personal injury lawyer do not jive with my idea of nirvana.
I am hopelessly drawn to the simple life of the small town. I like meeting neighbors at the post office and the hardware store. Where we live the world sometimes comes to us, at least candidates for the Democratic Party’s nomination for president come by regularly to shake hands and ask for our support. It’s always good and even better when the sky is high and clear and you can see all the way to Vermont or half the way to Boston from Main Street. On most days the worries of the world seem far away enabling a focus on the individuals near you whom you can get to know. Neighbors help neighbors. There is great reciprocity of good feeling. A small town is a good place to find help and enjoy the satisfaction of helping others.
It amazes me that even though the lake is frozen with two feet of ice, and that for most of the winter there has been a foot of snow or more on the ground, Opening Day for baseball is only about five weeks away. Even better, I will catch my first rainbow trout of the year on April 15th, which means that there are less than two more months of winter to enjoy. I am hoping for at least three more big nor’easters followed by crystal clear days to enjoy this year before the ice melts, the Sox begin their march toward their next pennant, and I catch that first “big one” of the season.
Whether you are in Florida or Maine, Washington or California, I hope that your sky will be clear, high, and blue this weekend and that you will be out and about with the best antidote for burnout which is to work up a sweat doing something in the great outdoors with a friend.
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
