Tuesday, March 31, 2015

Medicine, like air travel, once was fun

A Wall Street Journal blog about a reunion of employees of American Airlines lamented the good old days of air travel. Here's an excerpt:

"They came together to celebrate the days when flight attendants in white gloves hustled to serve you, gate agents doled out upgrades and arranged seating so families could be together, and managers worked flights with the single mission of ensuring excellent customer service."

The employees told tales of the fun they had and the camaraderie they shared. The passengers had fun too.

One retiree said of today's airline employees, "They don't look like they are having any fun at all."

Certainly the same can be said of today's passengers.

I'm usually not a fan of the airline-medicine analogy, but I'm going to make an exception here.

Back in the day, those of us in medicine had fun too. Don't get me wrong. It wasn't at the expense of the patients.

We always approached our patients with a proper attitude of respect. But it was OK to enjoy those encounters and also the fellowship of colleagues. We helped each other out, and we did it with spirit and camaraderie.

Not anymore.

All we read about now is how doctors are burned out, stressed, depressed. We battle with electronic records, hospital administrators, clipboard carriers, third-party payers, the government and just about everyone else.

What happened to the fun? It's all about the money.

David Shaywitz in Forbes: "The view from the front lines suggests that hospitals and care delivery systems are obsessing like never before on doing whatever they possibly can to maximize their revenue. They are consumed, utterly consumed, by this objective."

He added: "Many (I’d say most) providers and provider groups feel that they are locked in a deadly battle with payors (and increasingly, other providers) for their livelihoods; many feel they are having to work harder and harder to bring in the same (or less) money then doctors a generation ago. Many feel that the profession has lost the autonomy and respect it used to enjoy, and that providers are now viewed as mechanized assembly line workers, held to strict quantitative “quality” metrics that rarely capture the complexity, or essence, of the patient experience."

I believe what Shaywitz said is true. Can anything be done or is it hopeless?


SeaSpray said...

It is both sad and troubling to hear of these things. I know the days of Dr. Welby are gone and I miss when doctors could really visit with a patient. My doctors are terrific but then I do feel guilty if we end up chatting about other than health care. I also worry about them when I read these articles and hope that they take care of themselves. We all need you and your fellow physicians and you deserve much respect.

If you could wave a magic wand to fix the problems ..or what you see as the main problem ...what would you eradicate or improve?

I've thought it would be great if there was a way to obliterate all the regulations but the most important for safety/integrity within the system. And regarding EMRs - only keep the truly efficient aspects and obliterate the inane and redundant. Government out of health care and open up the free markets. But ...I'm just a lay person and so I'm not sure if those are feasible. Well ...free market is.

And then finally and I'm sorry this is off track, but I heard an investigative reporter on the radio talking about how there is a plan to cluster patient health care in the future and not that far off. That sounds disastrous! It would also give doctors less autonomy with their patients. The government could say that based on x, y and z studies we believe you have to treat this class of patients with this treatment. Scary stuff!

Skeptical Scalpel said...

There are so many things wrong that I don't think they could be fixed. The whole system needs to be reworked from the ground up. I don't think that will happen because of politics, corporations, self-interest and other factors.

Clustering patient care? I got off the bus at medical homes.

The Sex MD said...

This will be quite difficult to fix and doesn't have a chance as long as decision-making stems from insurance companies' demands/refusals. It seems quite criminal to me that between pharma charging so much more for treatments in this country compared to other countries & insurance companies continuing to take more from the consumer and delivering less and less, that the two principal players in this tragedy - the providers and the patients - are the ones really suffering.

Anonymous said...

SeaSpray, you said, "Government out of health care and open up the free markets."

I wonder if this is really for the best. Government certainly is expert at bollixing things up, but free market interests tend to be all about the bottom line (i.e., maximizing revenue). Corporate entities have what amounts to a moral imperative to make their shareholders money. I admit I don't have the answer, but I'm highly skeptical of the idea that the free market will solve these health care woes.

Anonymous said...

Anonymous Europe: The problem with health care is money and lawyers, mostly..... It is not centered about the people taking part in it (doctors, nurses, patients, etc) anymore, but around the money and that ruins everything. The other thing: you have to work immense hours and they are not what they used to be. What I mean: we do now during the working hours more than even 10 years ago (more patients, more operations, etc)... Besides that, our workplaces do not care about what happens to their employees as long as the quotas are fulfilled. They do not care that we also have families, private life, etc... We may die of a heart attack in the middle of the night and they would not lift a finger to help us.
What the system should understand but it never will is that we are not service industry, we are a provider industry and we are not about money but helping the people....

Anonymous said...

I think there are a combination of things that could be done between patients and doctors. The first step? Dump 1/2 the lawyers and administration from healthcare. Admin of each hospital must make less than the top 3 doctors employed or contracted by the hospital. Then we can go from there, like hiring more floor nurses, and paying doctors for the EHR time.

Skeptical Scalpel said...

I agree it will be difficult to fix. There's no way to get rid of the administrators and lawyers. In fact, I see more and more of them as the rules and regulations proliferate. I'm not sure the government can do it. I'm not sure the government can do anything right.

Anonymous said...

One action we can all take to address part of the problem - give this letter to your chief of staff.

Dear Chief of Staff:

The physicians of your hospital consider you uniquely positioned to resolve the some major shared complaints of your entire medical staff. Namely:

1) Non-clinical obligations substantially obstruct clinician workflow and erode staff morale. Patient care suffers as a result.

2) Clinicians are powerless to address such ever-growing obligations.

We ask that you advocate on our behalf in the following ways:

1) Help our administration recognize the value of staff who function happily at top-of-license - as clinicians - instead of resentfully as data entry clerks. A staff functioning efficiently at top-of-license is critical to our hospital's bottom line.

2) Begin a local initiative to unburden clinicians from non-clinical obligations. Return clerical work to clerical staff. Cull universal training mandates (HIPAA training, etc.) without strong evidence supporting their utility.

3) Create a position for a workflow advocate who will shadow clinicians, observe the common, cross-departmental workflow obstructions they face, and work to reduce them.

4) Empower clinicians to just say no the next time a new non-clinical mandate or required text field appears.

Thank you for your support. We look forward to your progress on this initiative, and to better serving our patients.

Your staff.

Anonymous said...

Chris Porter, lot of good you put in there. Lots in there many patients would and could get behind. May I make a few suggestions?

HIPAA is not one you want to drop. Seriously. Think about it this way: would you want your medical information plastered on the internet? Your home address? Not everyone posts TMI on FB, Twitter, etc.

The problem with the EHR entry? If a mistake happens because the scribe doesn't have medical knowledge, guess who's butt is on the line? It aint theirs. The other is that see the first issue, not everyone wants to advertise their info to a non medical person. If voice transcription worked better than what I've seen in some of my notes, I'd be cool with it. I mean some of my records that were dictated are ones for the funny farm. That doesn't help the doctors (and maybe you might be one one day) who come after.

PS You forgot one obscenity: MOC. Now that I've said it, its time for anti nausea medication ...

Skeptical Scalpel said...

Chris, great suggestions but unless your chief of staff is an outlier, it's not going to happen. Most chiefs of staff, chief medical officers, VPs of medical affairs have drunk the kool-aid. They are agents of the hospital.

HIPAA doesn't need to be dropped. It needs to be clarified and simplified. It is a major hindrance to care in many places. I've written about scribes on my Physician's Weekly blog [http://www.physiciansweekly.com/attack-scribes/] The ED docs attacked me vigorously on that issue. Don't get me started on MOC.

Anonymous said...


Agreed about chiefs. Currently they have zero motivation to advocate broadly for physicians and other clinicians. Nor do I think our professional organizations are positioned to put the fun back in medicine.

I believe the solution lies in some kind of group action, though. I forget how Network ends, but some kind of 'mad as hell' moment or initiative must come to pass to empower us.

Clerical, bureaucratic, and compliance obligations appear in every thread on burnout and provider job dissatisfaction. Because these obligations originate from varying sources (payers, admin, joint commission, the dean, etc.) there is no natural interface for group negotiations. We have no agency.

We need to somehow create an interface between clinicians and the disparate collective of annoyances. The closest thing to that interface I can identify is the chief of staff - but how to motivate him/her?

Create a mandate via mass action: Henceforth, physicians nationwide expect advocacy.

Hold them accountable: Query them on progress, report on their action or inaction.

Help me brainstorm please, how to take arms against a sea of troubles? Can physicians be empowered? Presently, I feel all members of the system take advantage of our docility and lack or coordination.

Skeptical Scalpel said...

The only thing that has galvanized physicians lately is the firestorm of protest about maintenance of certification. Unfortunately, it does not look like there will be much building on the momentum that protest has generated.

Surgeons have been strangely quiet about MOC. It's not my problem because I'm retired, but I don't understand why those of you still needing to stay board-certified aren't more vocal about it.

I certainly haven't seen any Wes Fishers amongst the surgeons on social media. If MOC can't rile up the troops, I don't know what will.

Anonymous said...

Disparate collective of annoyances? That is what I am to a few boards. You guys just don't know how to effectively discuss your issues. :) I'm on several hit lists, I'd say most notably for suggesting that 1/2 the admin staff, risk management, and admin salaries no higher than the avg. of the top 3 docs' salaries, with the $$$ being used to pay docs for some EHR time and floor nurses, didn't go over well.

The rest of my suggestions are being used along with my photo for a dartboard and chain saw competition.

Skeptical Scalpel said...

With that attitude, you may not be asked to serve on committees in the future.

Anonymous said...

I'm fine with that. Sometimes a dose of the truth helps people to understand. After doctors get hit up, the only ones to go after is the administration.

Stoich91 said...

This is a very insightful post. I believe the future of medicine will be dependent on the ever-growing disparity between high-paid specialists who can afford the ever growing monetary and financial cost of medical schooling and lower-paid, general PA's, DO's, etc. who work in groups reminiscent of private practices.

Not everyone in this country needs and/or deserves the quality of care they receive - many poor and undeserved would greatly benefit from the redistribution of the pricey, superfluous medical effort that so many rich receive (instead of ridiculous plans included in ACA that propose the government will PAY for poorer people to receive this same superfluous, pricey medical care! That is literally the worst "plan" to rescue this situation!).

As you mentioned, from education to lawsuits to every new drug on the market, it is and will become even more "all about the money." But if physicians play their cards right (in a "grounds up" restructuring of the medical care system), parents of kids with gastroenteritis will get reassured, cancer will be screened earlier and more efficiently, and Nobody (Uncle Sam or the Rich Guy Next Door - same person?) will be paying more for it. My two cents, anyways. Not a physician, yet! ;)

Skeptical Scalpel said...

Stoich91, thanks for the comments. It's a brave new world out there. Your vision may be correct. Who knows?

artiger said...

Stoich91, I doubt it, but seriously hope you are right. Pardon my cynicism.

Anonymous said...

Nothing will improve unless the corporate mentality of healthcare is tamed and placed on strict regulatory control.With no transparency, a huge inefficient administration and immunity gained by political lobbying, the healthcare industrial complex along with big Pharma will continue to wield their power over physicians.The average person will continue to pay more and more for a mediocre product.
I have practiced in both Canada and the USA.
At least in Canada I could take off for a vacation when I became burned out.As an employed doc in the US, that was next to impossible.
A single payer system strictly regulated by the government would help physicians regain some professional autonomy.
I would really like to see more of your posts on the current precarious state of healthcare in the USA.Thanks,

Gabe MD

Skeptical Scalpel said...

Gabe, I agree with you that a single-payer system might be better, but based on other existing programs, I think many people would not trust US government to run the entire health care system. Also, the insurance lobby is very powerful and would undoubtedly oppose the establishment of any single-payer system.

Anonymous said...

Gabe MD has it on the nose. SS you also have the right points for here.

PS I don't care about not being on committees. Lets just say that I think I've gotten a few things done by simply getting their attention.

Skeptical Scalpel said...

The direct approach is usually better. Hospital committees are mostly useless for getting things done.

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