How Threats to Health Care Professionals' Core Values Lead to Moral Injury

Introduction: Threats to Core Values

In the late 1990s, my colleagues and I started noting a rising tide of what we then called physician dissatisfaction.  One small clue was that physicians I met at meetings seemed to be responding to polite questions about their well-being with less enthusiastic responses.  In the early 2000s, publications begin appearing about health care professionals' dissatisfaction (1-3). 

To better understand what was causing this dissatisfaction, we interviewed doctors and health professionals, and found that US physicians feared their core values were under threat(4).   We postulated that several aspects of American health care dysfunction caused such threats, and set about trying to better characterize and understand them.  Since then, we have been discussing health care dysfunction and how it threatens core values on Health Care Renewal.

Health Care Professionals Whose Core Values are Threatened May be Morally Injured

We were focused on what produced threats to core values, but not so much on how these threats affected health care professionals, other than by producing dissatisfaction.

Meanwhile, others focused on that dissatisfaction, and then on health care professionals' burn-out, but not so much on its systemic causes.  In 2012, we noted the first report on burnout by Shanefelt et al(5), and we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing it. Instead, the literature often characterized burnout as a lack of health care professionals' resilience, or even the result of some sort of psychiatric disease affecting them.

However some physicians were trying to understand how health care professionals' angst derives from health care dysfunction.  In 2018, Dr Wendy Dean and Dr Simon Talbot wrote an article in StatNews entitled "Physicians' aren't 'burned out.' They're suffering from moral injury." They wrote:

Burnout is a constellation of symptoms that include exhaustion, cynicism, and decreased productivity. More than half of physicians report at least one of these. But the concept of burnout resonates poorly with physicians: it suggests a failure of resourcefulness and resilience, traits that most physicians have finely honed during decades of intense training and demanding work. Even at the Mayo Clinic, which has been tracking, investigating, and addressing burnout for more than a decade, one-third of physicians report its symptoms.

Rather than burnout, they suggested that physicians are suffering from moral injury:

The term 'moral injury' was first used to describe soldiers’ responses to their actions in war. It represents 'perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations.' Journalist Diane Silver describes it as 'a deep soul wound that pierces a person’s identity, sense of morality, and relationship to society.'

The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care.

Moral injury is a consequence not of some sort of personal failing, or lack of self care.  It is the consequence of a bad system.  They cited some aspects of health care dysfunction, including

Financial considerations — of hospitals, health care systems, insurers, patients, and sometimes of the physician himself or herself — lead to conflicts of interest. Electronic health records, which distract from patient encounters and fragment care but which are extraordinarily effective at tracking productivity and other business metrics, overwhelm busy physicians with tasks unrelated to providing outstanding face-to-face interactions. The constant specter of litigation drives physicians to over-test, over-read, and over-react to results — at times actively harming patients to avoid lawsuits.

 World War I - Battle of the Somme


Thus

Navigating an ethical path among such intensely competing drivers is emotionally and morally exhausting. Continually being caught between the Hippocratic oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand. Routinely experiencing the suffering, anguish, and loss of being unable to deliver the care that patients need is deeply painful. These routine, incessant betrayals of patient care and trust are examples of 'death by a thousand cuts.' Any one of them, delivered alone, might heal. But repeated on a daily basis, they coalesce into the moral injury of health care.

Dean and Talbot noted that instead of addressing moral injury, large health care organizations seem to blame health care professionals for their own burnout, and hence make them the targets of interventions meant to improve burnout:

The simple solution of establishing physician wellness programs or hiring corporate wellness officers won’t solve the problem. Nor will pushing the solution onto providers by switching them to team-based care; creating flexible schedules and float pools for provider emergencies; getting physicians to practice mindfulness, meditation, and relaxation techniques or participate in cognitive-behavior therapy and resilience training. We do not need a Code Lavender team that dispenses 'information on preventive and ongoing support and hands out things such as aromatherapy inhalers, healthy snacks, and water' in response to emotional distress crises. Such teams provide the same support that first responders provide in disaster zones, but the 'disaster zones' where they work are the everyday operations in many of the country’s major medical centers. None of these measures is geared to change the institutional patterns that inflict moral injuries.

The Resonance of  Moral Injury

Dean and Talbot have continued to raise the alarm about moral injury.  They have expanded on their original writing by noting that health care organizations' focus on flaws of health care professionals as causes of burn out are a kind of "gaslighting"(6)

'Gaslighting' refers to the act of psychologically manipulating someone to question their own sanity, in order to gain some advantage. Intentional or not, it carries significant repercussions for its targets, which in this case may be clinicians in our struggling healthcare system.

The term comes from the 1944 film Gaslight, in which a woman's husband regularly dims and brightens the gaslights in their home while he sneaks around in the attic, searching for hidden valuables. When she asks why the gaslights flicker, he insists that they have not changed intensity and that she is only imagining it. The woman's husband invalidates her perceptions and leads her to doubt her sanity.

Scene from Gaslight with Charles Boyer and Ingrid Bergman

They asserted:

A similar phenomenon is happening today to clinicians regarding the distress they experience as a result of the double binds imposed by the competing allegiances inherent in our healthcare system.

Health care professionals, often blamed for their own burnout, found that the concept of moral injury resonated.  By mid 2019, Dr Dean, writing again in StatNews, wrote:

we have learned that the concept of moral injury resonates powerfully, not just with doctors, but with every kind of health care professional we’ve met, from nurses and social workers to hospital administrators, personal-care assistants, first responders, and others.

The concept of moral injury allows clinicians to express what the burnout label failed to describe: the agony of being constantly locked in double binds when every choice one makes yields a compromised outcome and when each decision contravenes the reason for years of sacrifice. All of us who work in health care share, at least in the abstract, a single mission: to promote health and take care of the ill and injured. That’s what we’re trained to do.

But the business of health care — the gigantic system of administrative machinery in which health care is delivered, documented, and reimbursed — keeps us from pursuing that mission without anguish or conflict. We do our best to put patients first but constantly watch the imperatives of business trump the imperative of healing.

By early 2020, the concept of moral injury appeared in the main stream media, that is, the Washington Post, in an article that agreed that moral injury

resonates with clinicians across the country. Since they penned an op-ed in the online health news site Stat in 2018, Dean and Talbot have been flooded with emails, comments, calls and invitations to speak on the topic.

The article ended with this from an emergency department physician:

He said many people frame burnout as a character weakness, sending doctors messages like, 'Gee, Keith, you’ve just got to try harder and soldier on.' But [Dr Corl] said the term 'moral injury' correctly identifies that the problem lies with the system. 'The system is flawed,' he said. 'It’s grinding us. It’s grinding good docs and providers out of existence.'

Those further interested in understanding and addressing moral injury should see to the Fix Moral Injury website.


Discussion

In retrospect, it seems that Health Care Renewal has been trying to describe the causes of moral injury since 2004. Thus our work complements that of Dr Dean and Dr Talbot.

Our 2003 article(4) identified five aspects of health care dysfunction that threatened core values, and hence we now realize could cause moral injury:

1. domination of large organizations which do not honor these core values
2. conflicts between competing interests and demands
3.  perverse incentives
4. ill-informed, incompetent, self-interested, conflicted or even corrupt leadership
5.  attacks on the scientific basis of medicine, including manipulation and suppression of clinical research studies

Since then we have come upon many instances in which health care professionals' core values were under threat, likely generating moral injury.  We found cases in which top health care leadership took actions that ignored or directly challenged core values, that is, mission-ignorant or mission-hostile management.
 
 A major reason was the rise of  "generic managers." Increasingly, health care organizations, including hospitals, pharmaceutical companies, health insurance companies, government agencies, etc are now led by people with management training, but not necessarily with any training or background in medicine, biomedical research, epidemiology, public health, or health care policy. We began noting how such generic managers often prioritize short-term revenue over all other concerns, presumably based on the shareholder value dogma taught in business schools (look here).  Worse, generic managers may be ignorant of, misunderstand, or be frankly hostile to the core values of health care professionals. Finally, generic managers often are subject to perverse incentives that put short-term revenue and managers' self-interest ahead of core values.

In other words, health care is now in the grip of "managerialism," as characterized in   an article that in the June, 2015 issue of the Medical Journal of Australia (look here)(7) :
- businesses of all types are now largely run by generic managers, trained in management but not necessarily knowledgeable about the details of the particular firm's business
- this change was motivated by neoliberalism (also known as economism or market fundamentalism)
- managerialism now affects all kinds of organizations, including health care, educational and scientific organizations
- managerialism makes short-term revenue the first priority of all organizations
- managerialism undermines the health care mission and the values of health care professionals


We have identified breathtaking cases of mission-hostile management by managerialists leading health care organizations primarily to maximize current revenue and/or their own income and self-interest.  Some recent examples:
-  A proud teaching hospital ended up bankrupt after it was traded back and forth by for-profit hospital chains and private equity firms (look here).
- Hospitals offered better care to wealthier patients, and thus worse care to poorer one, or spent  money on achieving market dominance rather than quality patient care (look here and here)
- A pharmacy chain donated to a political organization supposedly to advocate for tax reform, but whose positions contradicted the chain's pledge of social responsibility (look here).
- A health care focused charity directed most of its revenue to a company owned by the charity's leaders (look here)
- Hospital management influenced timing of patient discharge to maximize revenue, regardless of the benefits to patients of shorter or longer stays (look here) etc, etc, etc
Here are more examples.

Dean and Talbot cited hospital systems and health insurance companies putting short-term revenue ahead of patient care as a cause of moral injury.  They also noted badly designed and implemented electronic health records and litigation risks as causes. But managerialism is rampant among health care organizations.

So we have identified shocking cases of leaders of various health care organizations who put self-interest ahead of the quality of care, or the integrity of health care education and research.  These organizations were not just hospitals and health insurance companies; but also academic medical centers, and medical schools; pharmaceutical, biotechnology and device companies; and lately, especially in the US, government and government agencies (look here).  (Also see our tag list for links to particular companies and organizations, eg, DHHS, Pfizer, UPMC, UnitedHealth, etc)

Organizational leaders enabled, directed or implemented actions like deceptive marketing and public relations, promotion of propaganda and disinformation,  manipulation and suppression of research, generation of conflicts of interest, and even crime and corrupt actions, including bribery and kickbacks, and fraud.  

And yet, despite these widespread actions generating moral injury, while health care professionals muttered under their breath about the behaviors of health care organizational leaders, there has been so little open discussion that it appears such discussion is taboo- we call this the anechoic effect.  Of course, failure to openly discuss the problem resulted in failure to craft any workable responses.

So appreciating that moral injury of health care professionals is a final common pathway of such extreme health care dysfunction adds even more urgency to our task.  To address health care dysfunction, we must address what health care professionals may see as severe problems, but which they seem afraid to talk about, much less challenge.  

As long as those with a vested interest in maintaining the current system can dismiss their critics as lacking resilience, in need of therapy, and just plain weak, their criticism will be blunted.  However, we must make those with such vested interests face the moral consequences of a dysfunctional system that has provided them with such personal advantages.


References

1. Haas JS. Physician discontent: a barometer of change and need for intervention. J Gen Intern Med 2001;16:496–7.

2. Shanafelt TD, Bradley KA, Wipf WE, Back AL. Burnout and self-reported patient care in an internal medicine residency program. Ann Intern Med 2002;136:358–67.

3. Steinbrook R. Nursing in the crossfire. N Engl J Med 2002;346:1757–66.

4. Poses RM.   A cautionary tale: the dysfunction of American health care.  Eur J Int Med 2003; 14(2): 123-130. (link here).

5.  Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012; 172(18):1377-1385. doi:10.1001/archinternmed.2012.3199 (link here)

6. Dean W, Dean AC, Talbot SG. Why 'burnout' is the wrong term for physician suffering. Medscape - Jul 23, 2019. (link here)

7.  Komesaroff PA, Kerridge IH, Isaacs D, Brooks PM.  The scourge of managerialism and the Royal Australasian College of Physicians.  Med J Aust 2015; 202: 519- 521.  Link here.

In addition to it being time for patients to refuse use of EHR's in their care, is it time for clinicians to refuse forced use of same? - "Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians"

At my Nov. 12, 2019 post "Google’s ‘Project Nightingale’ Secretly Gathers Personal Health Data on Millions of Americans - Time to Refuse Use Of EMR's In Your Healthcare?" (https://hcrenewal.blogspot.com/2019/11/googles-project-nightingale-secretly.html) on a massive clinical data project by Google and Ascension Health, I wrote:

... I believe invasive healthcare data trafficking projects like this, with potential for massive abuses, provide reasonable justification for patients to REFUSE the use of EHR's in their care.  Paper works just fine.  In fact, when the IT goes down, it's what hospitals and doctors go right back to, and the PR always claims that "patient care was not compromised."

Yale's Dr. Edward Melnick, assistant professor of emergency medicine and director of the Clinical Informatics Fellowship at Yale (I am Yale FW '94 after completing my postdoctoral fellowship in Yale's Center for Medical Informatics 1992-1994) authored an article further supporting the contention I've been expressing for many years, as have many others.  My belief is that commercial EMR's have become so complex and overwhelming that they actually impair the well-being of clinicians, and thus the very practice of medicine:

The Association Between Perceived Electronic Health Record Usability and Professional Burnout Among US Physicians
Mayo Clinic Proceedings
Edward R. Melnick, MD, et al.

https://www.mayoclinicproceedings.org/article/S0025-6196(19)30836-5/fulltext

Abstract

Objective
To describe and benchmark physician-perceived electronic health record (EHR) usability as defined by a standardized metric of technology usability and evaluate the association with professional burnout among physicians.

Participants and Methods
This cross-sectional survey of US physicians from all specialty disciplines was conducted between October 12, 2017, and March 15, 2018, using the American Medical Association Physician Masterfile. Among the 30,456 invited physicians, 5197 (17.1%) completed surveys. A random 25% (n=1250) of respondents in the primary survey received a subsurvey evaluating EHR usability, and 870 (69.6%) completed it. EHR usability was assessed using the System Usability Scale (SUS; range 0-100). SUS scores were normalized to percentile rankings across more than 1300 previous studies from other industries. Burnout was measured using the Maslach Burnout Inventory.

Results
Mean ± SD SUS score was 45.9±21.9. A score of 45.9 is in the bottom 9% of scores across previous studies and categorized in the “not acceptable” range or with a grade of F. On multivariate analysis adjusting for age, sex, medical specialty, practice setting, hours worked, and number of nights on call weekly, physician-rated EHR usability was independently associated with the odds of burnout with each 1 point more favorable SUS score associated with a 3% lower odds of burnout (odds ratio, 0.97; 95% CI, 0.97-0.98; P<.001).

Conclusion
The usability of current EHR systems received a grade of F by physician users when evaluated using a standardized metric of technology usability. A strong dose-response relationship between EHR usability and the odds of burnout was observed.

I have two observations:

1.  My January 31, 2018 Healthcare Renewal blog post "The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging" at http://hcrenewal.blogspot.com/2018/01/the-inevitable-downgrading-of.html, in which I opined that the downgrading of the clinician-facing components of EHRs was essential and inevitable, is increasingly supported by empirical research. 

Research such as this further invalidates marketing-driven  industry narratives about the benefits of today's commercial health IT, which is often bad health IT:

Bad Health IT ("BHIT") is defined as IT that is ill-suited to purpose, hard to use, unreliable, loses data or provides incorrect data, is difficult and/or prohibitively expensive to customize to the needs of different medical specialists and subspecialists, causes cognitive overload, slows rather than facilitates users, lacks appropriate alerts, creates the need for hypervigilance (i.e., towards avoiding IT-related mishaps) that increases stress, is lacking in security, compromises patient privacy, lacks evidentiary soundness, or otherwise demonstrates suboptimal design and/or implementation. (S. Silverstein/J. Patrick, 2012, http://cci.drexel.edu/faculty/ssilverstein/cases/)

and

2.  In addition to patients having increasingly good reasons to refuse the use of EHRs in their care, clinicians have increasingly good reasons to boycott the forced use of these systems as well. 

In that statement I am not even accounting for EHR malfunctions that lead to patient harm and clinician liability.

-- SS

Experts declare physician burnout ‘a public health crisis’ - and health IT a significant pathogen

I'm certain when the information technology hyperenthusiasts and non-clinical management information systems "experts" and pundits get the technology all figured out, this burnout crisis will end.

It will be about the same time as Zefram Cochrane invents the warp drive in Bozeman, Montana just prior to first contact by the Vulcans. That is in 2063 or so.

Experts declare physician burnout ‘a public health crisis’
January 22, 2019

https://www.healio.com/psychiatry/practice-management/news/online/%7B7f2124e2-d72e-4e3e-be53-6fbe41986186%7D/experts-declare-physician-burnout-a-public-health-crisis

Experts from leading U.S. health organizations deemed physician burnout “a public health crisis” in a recent report.

“Physician burnout has received some attention in recent years, but not enough. As a result, it is both poorly understood and getting worse,” Andrew R. Iliff, MA, JD, lead writer and program manager at Harvard Global Health Institute, told Healio Psychiatry.

“Like the blind man describing an elephant, people have described the challenges in front of them, including unhelpful electronic health records and a looming physician shortage,” he continued. “We believe it is important to frame this as a systems problem, requiring systemic solutions in order to avoid further adding to ballooning health care costs and undermining the provision of care.”

In their paper, experts from Harvard T.H. Chan School of Public Health, the Harvard Global Health Institute, the Massachusetts Medical Society and the Massachusetts Health and Hospital Association recommended ways to address the prevalence of burnout among physicians and other health care providers. Recommendations included:

• appointing an executive-level chief wellness officer (CWO) at every major health care organization;
• providing support for those experiencing burnout; and
• improving the efficiency of EHRs.

More on that third Pavlovian, formulaic, hackneyed, health IT amateur-proffered bullet point in a moment.

... The usability of EHRs must be addressed through reform of certification standards by the federal government; improved interoperability; use of application programming interfaces by vendors; and increased physician engagement in the records’ design, implementation and customization, according to the report.

"Certification" standards are useless towards the stated ends.  Interoperability via API's is not the major issue, either; fundamental operability and, ultimately, clinician burden is.

It is also far too late in the game for "physician engagement" to make any difference.   People in my specialty, myself included dating back to the 1990's - and me on this blog starting ca. 2004 - had been calling for clinician (and especially Medical Informatics) leadership (not merely "engagement") of health IT. 

I note that the original title for my health IT academic site, still residing here, was "Preventing Medical Errors: Medical Informatics and Leadership of Clinical Computing."  The original ca. 1999 site is partially archived at http://www.ischool.drexel.edu/faculty/ssilverstein/informaticsmd/index_org.htm.

Little has changed, and the worst predictions I'd been making about the healthcare IT bubble/experiment (see query search https://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20experiment) seem to be reaching unfortunate fruition.

Regarding the "efficiency" bullet point above:  quite seriously, from the perspective of this trained-by-the-pioneers Medical Informatics specialist, the "efficiency of EHRs" can only marginally be "improved."  This is due to both technical and political reasons.  The systems are far too complex, with far too many templates, widgets, options, "tricks", "gotchas" etc.  (with user manuals hundreds of pages long for each, that cause even my eyes to glaze over), too embedded, too protected by the industry, especially those involving legacy code, and too entrenched by politics - to name just some of the issues making major reform of the systems themselves impractical.

The situation should never have gotten this far, predicted as far back as 1969 by EHR pioneer Dr. Donald A.B. Lindberg (http://www.nlm.nih.gov/od/roster/lindberg.html), who wrote that an effect of the "over sell" even occurring then has been "the feeling that logic compels us to build total hospital information systems like military command-and-control systems ... and other grotesque concepts too numerous to mention."
  

Lindberg in 1969.  From Collen, "A History of Medical Informatics in the United States: 1950 to 1990"

What is needed is a significant downgrading of required clinician (physician/nurse) interaction with these "command-and-control systems", including data entry, and the use of clericals to perform those functions.  See my August 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at https://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html

More generally, see my numerous posts on this issue at https://hcrenewal.blogspot.com/search?q=oppression

One last quote from the Healio article:

... Burnout not only causes physicians suffering, it also can adversely impact patients. Prior research has shown that burnout may does increase the risk for medical errors.  [Fixed the academic equivocation - ed.]

Put more simply, physician and nurse burnout can kill you.

If a healthcare organization cannot afford the appropriate clerical help to avoid clinician burnout, then they cannot afford an EHR.

Finally:

Can I now say "I told you so?" without the health IT industry sockpuppets coming out of the woodwork? (http://hcrenewal.blogspot.com/2010/01/more-on-perversity-in-hit-world.html)

-- SS

And the Dander Keeps On Rising

This is número cinco in our series of attempts to shed some of this dander. But it keeps on rising. Here are two recent reports both relating to the life-on-the-ground of North American rank and file physicians, especially as that life increasingly revolves around data entry and digital madness over and above everything else.

Are physicians suffering from acute, maybe by now chronic, PTSD? In the 20 March 2018 number of the important Boston Globe-affiliated newsfeed STAT, Elizabeth Métraux, a prolific staffer and author at the eminent organization Primary Care Progress, gives us another quite useful take on physician burnout. An Iraq War veteran herself, the author gives us a provocative title that
pretty much says it all: "I experienced trauma working in Iraq. I see it now among America’s doctors." Her diagnosis is stark.

[A]s a health care advocate who has struggled with PTSD, it’s clear to me that many of our country’s health care providers are struggling with trauma, as well. And we’re doing little to support them.

Here's another snippet of conversation she recently had with a phyhsician colleague who'd also served in Iraq.

You know, I’d go back to the field any day. Beats practicing in my clinic. ... I didn’t become a doc to put up with billing codes and power struggles. I thought that PTSD would hit when I came home from Fallujah. It’s so much worse when I come home from the office. Truth is, I’ve lost my sense of purpose.

In what she terms "tiny betrayals of purpose," the death of 1000 tiny cuts, she outlines the extent to which the endless obsession by bosses with data entry and charge capture, the eight-minute patient encounter, the constant deflection of attention away from the patient all the while marketing and admin people are trumpeting "patient-centered everything" to their "customers," all of these have taken their toll.

Unfortunately, the usual caveat applies: making the diagnosis is a lot more straightforward than establishing the right therapy for the PTSD viewed by every student who rotates through a preceptor's community office: rapidly driving the best and brightest young physicians away from primary care. The author suggests the patient turn around and ask the physician how she is doing. But much more structural reform will be needed to curb these excesses and reverse these trends. Higher pay would be a fabulous start, not to mention forgiveness of medical school loans.

Less empathic but no less important: revenge of the EHR--more paper records than ever, revealing private information. A fascinating research letter published the same day in JAMA (behind paywall), out of several hospitals in Toronto, Ontario, reveals still more new--but actually, hardly new at all--issues raised by perverse effects of Electronic Health Records. More, not less, paper documents are being discarded because of the EHR. The investigators spent about half a year auditing all the recycling-bound paper from five hospitals. The results are arresting. Here are the key take-aways. Bear in mind the context: these institutions had Protected (Personal) Health Information (PHI) policies; they also had recycling bins and shredders where they needed to be.

• Nearly a ton of paper was examined including nearly 3000 discrete documents.
• The study was multi-institutional.
• Every hospital contained examples--lots of examples--of PHI discarded in both in- and out-patient settings.
• Over 2500 documents containing PHI were found, including over 1000 with highly sensitivbe information (defined as including both diagnoses and descriptions of patients' conditions).
• The vast majority of these documents were found in out-patient settings.
• The highest proportion of PHI-containing documents was found in physicina offices--not hospitals or institution-bound clinics.
• Paper records were impossible--in distinction to electronic privacy breathes--to trace with respect to identifying responsible individuals.
• The authors reported no actual harms accruing to the documents' discovery.

The biggest drawback of this study was its focus on recycling materials, as opposed to other random discards. But recycling does not means properly-disposed-of, so the data are important. Most important is the Revenge Effect, to quote from Edward Tenner's important analysis of technology's impact, of the EHR.

To any of those of us who've lived this scenario, it all sounds drearily familiar. EHR allows managerialism to run rampant in terms of up-coding and adherent to more often than not perverse incentives around Meaningful Use of EHRs. Not to mention outright abuse. But it actually produces all sorts of other perverse effects. One near and dear to our hearts is the "credit" for printed "Clinical Summaries cited as "performed" in EHR databases, but actually abandoned on printers. And, when retried, lacking any information on the clinical plan--essentially only listing medication lists that are often dangerously erroneous.

Now, from Toronto, but we already knew this, we're reminded that EHR didn't do away with paper. Because so much paper comes in and gets scanned to EHR, it is rather more pervasive--but now discarded in the wrong palce--than ever.

The inevitable downgrading of burdensome, destructive EHRs back to paper & document imaging

In recent days, I've posted about current articles on the destructive nature of today's vastly over-complex, burdensome EHR technology.  These posts included "Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records" at http://hcrenewal.blogspot.com/2018/01/physicians-harassed-by-onerwhelming.html
and "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html.

There are many other earlier articles of a similar nature discussed on this blog, e.g., the May 2017 post  "Death By A Thousand Clicks: Leading Boston Doctors Decry Electronic Medical Records" at http://hcrenewal.blogspot.com/2017/05/death-by-thousand-clicks-leading-boston.html for one, and others retrievable by query links http://hcrenewal.blogspot.com/search/label/healthcare%20IT%20dissatisfaction, http://hcrenewal.blogspot.com/search/label/Healthcare%20IT%20failure and similar.

Here's another recent article along the same lines that just appeared in the prestigious New England Journal of Medicine:

Perspective
Beyond Burnout — Redesigning Care to Restore Meaning and Sanity for Physicians
Alexi A. Wright, M.D., M.P.H., and Ingrid T. Katz, M.D., M.H.S.
January 25, 2018
N Engl J Med 2018; 378:309-311
http://www.nejm.org/doi/full/10.1056/NEJMp1716845

In late 2016, a primary care physician with a thriving practice decided it was time to shut her doors. She felt her retirement was forced on her after she’d spent a year in the grips of her health care system’s new electronic health record (EHR). It was her fourth EHR over her years of doctoring, but this transition felt different. Instead of improving her efficiency, the new system took time away from her patients, added hours of clerical work to each day, and supplanted her clinical judgment with the government’s metrics for “meaningful use” of information technology in health care.

I note that, unlike this primary care physician, many physicians have to learn numerous EHR's and use them simultaneously if they provide services at different healthcare systems. 

Channeling the satirical medical internship novel "House of God" and its "law #11" (https://en.wikipedia.org/wiki/The_House_of_God, full movie at https://www.youtube.com/watch?v=bPllfH9YREA), these poor souls are probably constantly thinking "find me the EHR that only triples my work and I'll kiss your feet."

“We’re spending our days doing the wrong work,” argues Christine Sinsky, a practicing internist and vice president for professional satisfaction at the American Medical Association, who has conducted several studies tracking how doctors spend their time. “At the highest level, we are disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

That is a prescription for suboptimal performance and increased risk of harm, on its face.  There is little to argue on that point.  I personally would not want an airline pilot, let alone a physician, providing me services who is "disconnected from our purpose and have lost touch with the things that give joy and meaning to our work.”

Increasing clerical burden is one of the biggest drivers of burnout in medicine. Time-motion studies show that for every hour physicians spend with patients, they spend one to two more hours finishing notes, documenting phone calls, ordering tests, reviewing results, responding to patient requests, prescribing medications, and communicating with staff.¹ Little of this work is currently reimbursed. Instead, it is done in the interstices of life, during time often referred to as “work after work” — at night, on weekends, even on vacation.

That is, quite frankly, an absurd workload deleterious to provider AND patient well-being.

“EHRs can be a double-edged sword, because they give you more flexibility about where you work, enabling physicians to get home for dinner,” argues Tait Shanafelt, professor of medicine at Stanford University and a leading researcher on physician burnout. “But physicians are working a staggering number of hours at night, and this has enabled organizations to continuously increase productivity targets without changing the infrastructure or support system, effectively adding a whole extra workweek hidden within a month.”

Imagine trying to force "a whole (uncompensated) extra workweek hidden within a month" to the workload of a union member of, say, the Transport Worker's Union.  It would result in an instant labor strike ... or worse.

... Beyond the financial toll physician burnout takes on institutions, there are human costs to both doctors and patients. Studies over the past decade have shown that burnout can undermine a physician’s sense of purpose and altruism and lead to higher rates of substance use, depression, and suicidality. Physicians with symptoms of burnout are more likely to report having made a major medical error in the past 3 months and to receive lower patient-satisfaction scores.³

I rest my case on the increased-risk-of-harm issue.

I seem to be one of the first to recognize, or at least start writing openly about, the bad leadership of the health IT field and the dangers of the bad health IT produced as a result.  My observational skills and critical thinking capabilities led me to start writing on these issues circa 1999, after my experiences as postdoc and faculty in Medical Informatics at Yale School of Medicine/Yale-New Haven Hospital and then as CMIO at the Christiana Care Health System in Delaware. 

That writing is largely retained at http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases, in a website I have not updated in several years due to time constraints related to the EHR forensics work I have been doing in the legal and law enforcement sectors.

It is clear my concerns are now proven correct and are now being echoed by large sectors of the physician and nursing communities.   My concerns were obvious, I opine, to anyone of reasonable critical thinking and observational skills, who were not affected by conflict of interest.  That is, those without profitable connections to the health IT industry.

I now make a prediction for the future that, once again, seems obvious to me:

Today's EHRs, especially the sections for narrative clinician documentation, will be downgraded from their "template madness" time-wasting design to document imaging retrieval interfaces to notes written by clinicians on paper.  Perhaps domain-specialized paper forms as I created for invasive cardiology in the late 1990s' as at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html, but paper nonetheless.  Data extraction of these notes for financial purposes will be done, once again, by coders.

A small sample of why physicians and nurses burn out from EHRs.

Debate if you will, but that is my prediction for the future.  I feel it inevitable considering the unintended/unexpected terrible consequences and realities of this technology.  "New curtains" (that is, tidying up the user interfaces) will not suffice.  This is a prediction from one of the first Medical Informatics professionals to start openly writing about EHR difficulties almost two decades ago. 

-- SS

Physicians Harassed by Overwhelming Levels of Messaging From Electronic Medical Records

In yet another example of the clerical overload caused by bad health IT, physicians find themselves drinking from a fire hose through cybernetics.  This, in the field of dermatology, let alone critical care specialties:

Physicians Overwhelmed by Messaging From Electronic Medical Records
MedicalResearch.com Interview with: Matilda W. Nicholas, MD, PhD
Duke Dermatology
January 29, 2018
https://medicalresearch.com/author-interviews/physicians-overwhelmed-by-messaging-from-electronic-medical-records/39671/

MedicalResearch.com: What is the background for this study?
Response: I have found many physicians overwhelmed by the electronic messaging feature in Electronic Health Record systems (EHRs). I found there was very little published about this phenomenon, particularly for specialists. So, we set out to take a look at the volume and effect these systems have. 

MedicalResearch.com: What are the main findings?
 Response: We found that, on average, clinicians receive 3.24 messages per patient visit, for an average of about 50 messages per full day of clinic. The number of messages also correlated with poor reported work life balance for dermatologists.

Those 50 messages are in addition to whatever messages physicians receive through their other, personal accounts.  The number is likely far higher in more generalized and more critical care subspecialties such as internal medicine on the one hand, and, say, ICU medicine on the other.

MedicalResearch.com: What should readers take away from your report?
 Response: As previous studies have shown, physicians are spending much more time in non-direct patient care and less time with patients. This is bad for everyone involved. Targeting methods to decrease this burden would be important in improving patient care and physician wellbeing ... We are planning on examining the messages sent directly from patients more closely, hoping to target higher risk patients to decrease post and inter-visit messaging.

As at my Jan. 28, 2018 post "Medical Economics: Highly experienced physicians lost to medicine over bad health IT" at http://hcrenewal.blogspot.com/2018/01/medical-economics-highly-experienced.html and many, many others, cybernetics are proving a distraction from - and actually a deterrent to - the practice of good medicine.

With the increasing outcry of physicians and nurses against EHRs and the oppressive demands the systems place on them, and the burnout these systems cause (see the numerous posts on burnout at query link http://hcrenewal.blogspot.com/search/label/burnout), I'm increasingly of the opinion these systems are not fixable.

There is only so much that can be accomplished with surface changes to user interfaces, without substantive changes to physicians' work expectations. 

The true problem that nobody seems to want to deal with - the proverbial elephant in the living room -  is expectations of clinicians doing oppressive amounts of clerical work, in addition to their patient care responsibilities.

(Note that in this essay I am not addressing other critical drawbacks to this technology such as crashes, lack of security including growing record theft, ransomware attacks on EHR's, and so forth.)

In my view, the only solution to these problems are separation of clinicians from clerical duties (see my August 9, 2016 essay "More on uncoupling clinicians from EHR clerical oppression" at http://hcrenewal.blogspot.com/2016/08/more-on-uncoupling-clinicians-from-ehr_91.html), and the use of data-entry personnel, as I set up in the Invasive Cardiology Clinical Database at Christiana Care Health System in Delaware (http://cci.drexel.edu/faculty/ssilverstein/cases/?loc=cases&sloc=Cardiology%20story) so many years ago. 

Of course this will likely never happen, because it's an expensive labor proposition.

Based upon my EHR forensics/expert witness work since 2010, I also believe physicians can expect no help from the public or the government on this.  The issues seem above the public's heads (with the exception of those injured or killed by bad health IT, who - or whose heirs - seem to learn very fast about the drawbacks), and conflict with the bureaucratic goals for control of medical finance.

Physicians need to take control of their occupations, for there is no help coming from government or the public regarding cybernetic oppression. The only way repair of the profession can happen is through unionization, such as I saw in my work in the public transit industry.

If physicians are unwilling to take that step, then they will have to accept being servants to the bureaucracy, and being endlessly stressed, distracted and harassed by their cybernetic overlords.

-- SS

Part of the Solution, or Part of the Problem? - Health Care Corporate CEOs on Physician Burnout

Physician burnout is in the news again.  Late in 2015, an article by Shaneyfelt and colleagues in the Mayo Clinic Proceedings showed an increase in the proportion of physicians reporting at least one symptom of burnout to 54.4% in 2014(1), up from the 45.5% they reported in 2012(2).  A March 28, 2017, post in the Health Affairs blog based on the latest article warning about burnout and suggesting how to address it got considerable attention.

Background - Physician Burnout

However, physician burnout is hardly new.  As we wrote in 2012 about the predecessor the 2012 Shaneyfelt article, this is just the latest in a long series of studies showing physicians' growing angst, dissatisfaction, burnout, or whatever one calls it. In 1987, in an AMA survey of physicians over 40, 44% replied that were they given chances to do it all over again, they would not go into medicine.(3)  In a 2001 survey of Massachusetts physicians, 62.3% were dissatisfied with the practice environment.(4)  In 2002, a national survey by the Kaiser Family Foundation showed that 45% of physicians would not recommend that a young person should go into medicine.(5)   In a survey of primary care physicians in 2007, 38.7% were somewhat or very dissatisfied.(6)  I have a 6 inch thick set of paper files containing articles on the subject, although it is remarkable how many research studies reported only average scores on instruments, and hence did not report proportions of physicians who were burned out or dissatisfied. Yet the 2017 Health Affairs post garnered headlines  declaring physician burnout to now be a crisis.

Whether the current attention to burnout will lead to any real improvements is doubtful.  In particular, I am concerned that the Health Affairs blog post that sparked all the attention was at best misdirected. It avoided discussing more than a few of the most immediate, proximate causes of burnout.  It seemed more motivated more by concerns about money than about patients and the physicians that try to serve them.  It read like a top down diktat uninfomed by the concerns of physicians or patients, maybe because all of its authors were CEOs of large health care organizations, all but one large hospital systems.

I will venture to go through the issues point by point in the hope of sparking a discussion more focused on the physicians subject to or at risk of burnout, and ultimately the effects of their burnout on their patients.


For the Love of Money


While the blog post began with a nod towards improving the quality of, lowering the cost of, and improving access to health care, there was a subtext.  Consider some quotes, first, stating that one cause of burnout is,

profound inefficiencies in the practice environment

Also,

The experience from Atrius Health suggests that replacing a physician who retires early or leaves to pursue other career opportunities can cost between $500,000 and $1 million due to recruitment, training, and lost revenue during this time.

Also,

Professional satisfaction for physicians is primarily driven by the ability to provide high-quality care to patients in an efficient manner.

Also,

As leaders, we must recognize burnout in physicians and other health care workers as a serious problem and respond vigorously. This is especially true if we want to maximize the effectiveness, productivity, and longevity of clinicians.

Also,

More than words are needed. Leaders of health care delivery organizations must embrace physician well-being as a critical factor in the long-term clinical and financial success of our organizations. We must make both the prevention of burnout and the restoration of the joy of a career in medicine core priorities, and address this issue with the same urgent methods we would use to solve any other important business problem: commit to measurement, develop strategy and tactics, and allocate the resources necessary to achieve success.

To interpret these passages, note that the authors of the blog post were John Noseworthy, James Madara, Delos Cosgrove, Mitchell Edgeworth, Ed Ellison, Sarah Krevans, Paul Rothman, Kevin Sowers, Steven Strongwater, David Torchiana, and Dean Harrison (links are those supplied by the post.)  All but Dr Madara are CEOs of large, nominally non-profit corporate hospital systems.  Dr Madara is the CEO of the American Medical Association (AMA). 

I would suggest that to a business CEO, efficiency refers to a state in which goods and services are produced with a minimum of costs.  Furthermore, many business managers follow the business dogma first called the shareholder value theory, which seems mainly to be interpreted to mean managers should maximize short-term revenue as their first priority (look here).  This is part of the larger financialization of all spheres of life, including hospital systems.

The focus on relentless revenue maximization may be reinforced by large incentives for top managers, particularly CEOs, based on revenue and other financial, not clinical outcomes.  Such perverse incentives have resulted in huge increases in executive compensation for hospital CEOs.  For example, as we recently discussed,  author Dr John Noseworthy, CEO of the Mayo Clinic, received more than $2.3 million in total compensation in 2013, and was just reported to have received more than $2.5 million in 2015. Author Dr Delos (Toby) Cosgrove, CEO of the Cleveland Clinic, received more than $4.8 million in 2015 (look here). 

Thus, too a hospital CEO, efficiency might mean the ability to provide services as cheaply as possible, and such efficiency is likely to be a top priority.  The quotes above suggest that hospital CEOs mainly want to combat burnout to increase efficiency.  One quote above refers directly to the monetary costs, again presumably to the hospital, of losing physicians to burnout. One quote refers to burnout as hampering physician productivity, which to a hospital CEO might mean the ability to produce maximum billing, that is revenue, in the minimum amount of time.  Finally, one quote suggests that to the authors, burnout is a business problem, not a human problem, or a clinical problem.

Even stranger, two quotes suggest that the CEO authors believe  inefficiency might cause burnout. That would appear very strange to employed physicians who may be increasingly pressured by top management to be more efficient, and thus to increase revenue.  I would guess that many employed physicians would attribute their burnout to this relentless push for productivity and efficiency by top management. 


So reading not between the lines, but the lines themselves suggests that the CEO authors might be more interested in reducing burnout to increase hospital revenues, and thus their total compensation, rather  than to make physicians happier or more fulfilled, much to less improve patient care.  Such a focus on revenue might not be reassuring to burned out physicians, especially those who feel forced to shortchange time spent with individual patients to fuel revenue.  The repetitive discussion of efficiency and productivity in the Health Affairs blog post should worry any physician who feels his or her first responsbility is to take the best care of each individual patient. 


Hear No Evil,...

Proximal Versus Organizational, Leadership and Governance Causes of Burnout

Here is what the blog post said about the causes of burnout:

The spike in reported burnout is directly attributable to loss of control over work, increased performance measurement (quality, cost, patient experience), the increasing complexity of medical care, the implementation of electronic health records (EHRs), and profound inefficiencies in the practice environment, all of which have altered work flows and patient interactions.

We dealt with the curious citation of inefficiencies as a cause of burnout above.
 
The rest of the items seem more plausible.  However absent from the post is consideration of why physicians lost control over work, have been subject to performance measurement (often without good evidence that it improves performance, and particularly patients' outcomes), and have been forced to use often badly designed, poorly implemented EHRs.  Particularly absent was any consideration of whether the nature or actions of large organizations, such as those led by the authors of the blog post, could have had anything to do with physician burnout.

Contrast this discusion with how we on Health Care Renewal have discussed burnout in the past. In 2012, we noted the first report on burnout by Shanefelt et al(2).  At that time we observed that the already voluminous literature on burnout often did not attend to the external forces and influences on physicians that are likely to be producing burnout. Instead, burnout etc has been addressed as if it were lack of resilience, or even some sort of psychiatric disease of physicians. 

In fact, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes.  Our first crude qualitative research(8) suggested  hypotheses that physicians' angst was due to perceived threats to their core values, and that these threats arose from the issues this blog discusses: concentration and abuse of power, leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting this viewpoint.

We found some corroboration of these hypotheses from other research.  Written comments from the 2001 Massachusetts survey made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line.  Taken over by large corporations.  Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(4)  Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(9)  (Also, see our comments on this paper.)(10)  Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(11)   We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(12)

Yet at best most studies of physicians' burnout, angst, or dissatisfaction only vaguely allude to "system factors" and not greedy, money-focused, preversely incentivized, self-interested, or corrupt leadership, etc as its causes. "System factors" such as bad EHRs and performance measures suggested by the Health Affairs bloggers were more likely to have been imposed on physicians by bad organizational leadership than by the physicians themselves.  Of course, the CEO authors of the post likely would be made very uncomfortable with the notion that  bad health care leadership, including of hospital systems like their own, might be a major cause of burnout.

Furthermore, there clearly have been leadership problems at many of the blog post authors' institutions that could have made them more uncomfortable.  Cases involving some of the authors' institutions have appeared on Health Care Renewal.

Most recently we noted that Mayo Clinic CEO Dr Noseworthy had raised questions of mission-hostile management by suggesting that the Mayo Clinic should give some patients with commercial health care insurance priority over those with less well paying government health insurance (look here).   Not long ago we noted the controversy generated by Cleveland Clinic CEO Dr Cosgrove's lukewarm approach to the Trump administration's "Muslim ban," even though that ban had affected one of the Clinic's own house-staff, while the Clinic was planning a fund raising event at Mr Trump's Mar a Lago resort, raising yet more conflict of interest questions (look here).

We have also disccused issues occurring at the American Medical Assocation, and particularly its RBRVS Update Committee (RUC) (CEO Dr Madara), Sutter Health (CEO Ms Krevans), Johns Hopkins (CEO Dr Rothman),  Duke (CEO Mr Sowers), Partners (CEO Dr Torchiana), and Northwestern (CEO Mr Harrison).

Finally, several of the Health Affairs authors have "board level" conflicts of interest.  In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]

Two Health Affairs blog authors have such conflicts.  Dr Paul Rothman is on the boards of Merck and of Cancer Genetics, a biotechnology company specializing in DNA based testing. Dean M Harrison is on the board of Northern Trust, a wealth management firm. He was on the board of Ikaria Inc, a biotechnology company now part of Mallinckrodt, and incidentally is a special advisor to Merrick Ventures, a private equity firm (look here).

Thus, how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?


Corporate Employment as a Cause of Burnout

Finally, the Health Affairs post mention of "loss of control over work" deserves special attention.  It could represent a catch-all of more "system factors" as noted above.  However, the biggest cause of physicians' loss of control over work may be the rising power of large health care organizations, in particular the large hospital systems that now increasingly employ physicians, turning them into corporate physicians.

In the US, home of the most commercialized health care system among developed countries, physicians increasingly practice as employees of large organizations, usually hospitals and hospital systems, sometimes for-profit corporations.  The leaders of such systems meanwhile are now often generic managers, people trained as managers without specific training or experience in medicine or health care, and "managerialists" who apply generic management theory and dogma to medicine and health care just as it might be applied to building widgets or selling soap.

We have also frequently posted about what we have called generic management, the manager's coup d'etat, and mission-hostile management.  Managerialism wraps these concepts up into a single package.  The idea is that all organizations, including health care organizations, ought to be run people with generic management training and background, not necessarily by people with specific backgrounds or training in the organizations' areas of operation.  Thus, for example, hospitals ought to be run by MBAs, not doctors, nurses, or public health experts.  Furthermore, all organizations ought to be run according to the same basic principles of business management.  These principles in turn ought to be based on current neoliberal dogma, with the prime directive that short-term revenue is the primary goal.

Again, the authors of the Health Affaris post included some generic managers:  Mr Edgeworth, whose highest degree was an MBA, and who had a long career as a hospital manager; Ms Krevans, and MBA with an MPH, who also had a long career as a hospital manager; and Mr Harrison, an MBA, who also had a career in hospital management.  Doubtless all of the authors lead organizations whose upper management is frequently generic and managerialist.  It is likely that the hospital systems they lead increasingly employ physicians, who thus have become corporate.  So the Health Affairs blog authors might not be comfortable with the notion that a major cause of burnout may  physicians' new status as hired employees sometimes of their own hospital systems, rather than autonomous practitioners.

To repeat,  how can one regard as credible an article on physician burnout which ignores how large organizations' nature or actions might be the major cause of such burnout, and which was written by the top leaders of such organizations?


Summary

I am glad that physician burnout is getting less anechoic.  However, in my humble opinion, the last thing physicians at risk of or suffering burnout need is a top down diktat from CEOs of large health care organizations.  The CEOs who wrote the Health Affairs post may not have any personal responsibility for any particular physician's burnout.  However, the transformation of medical practice by the influence of large health care organizations run by the authors' fellow CEOs, particularly huge hospital systems, often resulting in physicians practicing as hired employees of such corporations likely is a major cause of burnout.  If the leaders of such large organizations really want to reduce burnout, they should first listen to their own physicians.  But this might lead them to realize that reducing burnout might require them to divest themselves of considerable authority, power, and hence remuneration.  True health care reform in this sphere will require the breakup of concentrations of power, and the transformation of leadership to make it well-informed, supportive of and willing to be accountable for the health care mission, honest and unconflicted.

Physicians need to join up with other health care professionals and concerned member  of the public to push for such reform, which may seem radical in our current era.  Such reform may be made more difficult because it clearly would threaten the financial status of some people who have gotten very rich from the status quo, and can use their wealth and power to resist reform.

Despite the fact that the current US president has stated he is for the "forgotten people" rather than the elites, do not expect such reform from him.  He has sought advice on health care policy from the same people who wrote the Health Affairs post, as per the Washington Post, December 28, 2016:

On Wednesday, his guests were health-care executives, many of whom represent companies or institutions that have a big stake in the outcome of Trump’s ambitions to dismantle the Affordable Care Act. According to a pool report, the group, all men, met with him at 11 a.m. at the Mar-a-Lago estate in Palm Beach, Fla. They included John Noseworthy of the Mayo Clinic, Paul Rothman of Johns Hopkins Medicine, David Torchiana of Partners HealthCare and Toby Cosgrove of the Cleveland Clinic.

We truly live in interesting times. 


References

1.  Shanafelt TD et al.   Changes in Burnout and Satisfaction With Work-Life Balance in Physicians and the General US Working Population Between 2011 and 2014. Mayo Clin Proc 2015; 90: 1600-1613. Link here.
2.  Shanafelt TD, Boone S, Tan et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population.  Arch Intern Med 2012; available online here
3.    cited in Schroeder SA. The troubled profession: is medicine's glass half full or half empty? Ann Intern Med 1992; 116:583-592.
4. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
6.  Kaiser Family Foundation. National survey of physicians - part III: doctors' opinions about their profession.  Link here.
7.  Merritt Hawkins & Associates. 2007 survey of primary care physicians.  Link here.
8. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
9.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
10. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
11. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
12. Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182. Link here.

Musical Diversion

"For the Love of Money" by the O'Jays, used as the opening theme for (now President) Donald Trump's Celebrity Apprentice

Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institute for Medical Humanities at University of Texas - Medical Branch at Galveston, and blogger at Hooked: Ethics, Medicine and Pharma. 

Danielle Ofri, a prominent internist/author at Bellevue in New York, started a recent op-ed piece, “Last week I was ready to quit medicine."

She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.

Ofri’s plaint caught my attention because I had recently put up a guest post on Health Care Renewal about another highly skilled, caring physician who was seriously considering quitting practice. This led me to write a column for some of our local newspapers about demoralized doctors

In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.

We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.

There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.

Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports either quality care or efficient resource use?

If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look here - Ed]  . And we know that at least at the high end, these managers are paid munificent sums, and are lauded for their supposed genius (look here for example). 

So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.

All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.

This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I explained some time ago, most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or economism. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look here.)

Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look here), or "financialization." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this generic management. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now.

Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "learned helplessness." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.

After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, “when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”

Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means? 

Dr Howard Brody