Healthcare professionals find both joy and sorrow in their work. Many of us carry scars. I think it helps to tell the stories we carry with us from our experiences in the present system, even when they are not feel-good stories. It gives us ways to think about transforming healthcare delivery for the future.
Recently I had the pleasure of some long conversations reflecting on the healthcare system with my former colleague and friend of 30 years, Dr. Doug Beers. Doug and his wife Leslie had come from Portland, Oregon to visit my wife Nancy and me at our home in Lake Sunapee. My blog posts for the next couple of weeks will pass along some important stories Doug told me as we talked about our many years as internists.
Doug has worked for the last 31 years at Emanuel Hospital and Legacy Healthcare in Portland, where he has taught and supervised housestaff. His practice has been primarily a medical home for patients with HIV, Hep C, drug abuse, and all of the chronic manifestations of disease associated with socioeconomic dysfunction. Founded by Lutherans, Emanuel provides care to a disproportional share of the underserved in Portland.
Most of Doug’s patients come from the population that lives around the fringe of society in any large metropolitan area. They have sought care from the charity of Emanuel because there is nowhere else for them to go. A few of Doug’s patients are quite successful, however, and a couple who are known internationally in their fields have chosen to see him because of the reputation he has for high quality personalized management of complex medical issues.
Knowing the intensity of Doug’s practice and knowing how so many of our colleagues are jaded and feel burned out I was eager to ask Doug whether he ever felt “burned out”. When I did he looked a little puzzled and then answered, “No”. He would admit to being frustrated and at times feeling abused. Performance was never an issue for him. He is a master user of “Dragon” and Epic and even when he sees a heavy schedule with residents he is out of the office with records closed and an empty “in box” within an hour of his last visit.
He is frustrated by “systems issues” but has adopted a stance of acceptance. His concern about his patients and his commitment to teaching seem to ameliorate for him most of the mundane frustrations that plague many practitioners. He earns large performance bonuses but is not motivated by them and actually does not seem to care that much about his total compensation. His “supervisor” is someone whom he trained when she was an intern and resident. He respects her and tries to comply with the managerial programs that come down to him, but in essence the standard that he sets for himself far exceeds corporate expectations and therefore he is immune to the corporate attempts at manipulation.
I asked Doug about Lean in his organization and was interested to know that something management referred to as “Lean” was being used. I was also not surprised that he was unimpressed with the process because, when I described how it should work, he said that in his experience the management arrived with a set of solutions to a problem that they had developed and were “installing.” Solutions had not arisen through anything like a collaborative process that respected those doing the work, nor did the management ask the team to participate in the discovery of solutions. I wondered just how many physicians experience Lean in this same “directed way” rather than as a participatory process where their ideas and experience are tapped for solutions.
What has emerged over the years is that Doug has worked hard within a system as an exceptional teacher and as an example of a talented and committed physician who treats every patient as the most important patient in his practice. He cannot abide the concept of a concierge practice because it is exclusionary, but ironically he is so gifted that what his patients get is a higher level of care than most concierge physicians deliver for a much smaller and wealthier population.
I can think of no physician I have ever met who is more patient-centered than Doug. The one area where we had the greatest alignment of thought was our agreement about the negative impact of revenue-driven practice. We both agreed that Gawande was right about a culture of “overkill” or over-processing in healthcare, and that healthcare remained driven by individual and corporate concerns about maintaining income and revenues.
Next week I will recount one of Doug’s stories about the terrible results in one instance of “overkill.”
