I’ve attended medical Grand Rounds most weeks for the past 50 years. I consider the exercise one of the grander traditions of my profession. I trace it back to the amphitheater at the University of Montpelier where the 15th C cleric, humanist, author and physician, François Rabelais, first studied and then held forth. By mid-20th C, Grand Rounds had become a focal point of training and continuing medical education in academic medical centers. A patient was presented whose illness was puzzling, informative, and/or daunting. A member of the faculty considered the clinical challenges in a fashion designed to be illuminating. The front rows of the audience were populated by silverback physicians behind whom various levels of novitiate were seated. It was incumbent on the discussant to engage the interest of all in the audience regardless of their degree of specialization and incumbent on the audience to participate in a lively exchange. By lively, I mean disagreements on points of substance were valued. There was always an element of showmanship. The result was a durable transfer of information and an hour that was memorable more often than not.
Since the 1970s, this Medical Grand Rounds grand tradition has gradually eroded. Faculty attendance dwindled as faculty aligned with their subspecialty’s minutia more than with a broader view of the experience of illness. Trainees’ tendency to find excuses for skipping had to be counterbalanced with “requirements” of the ACGME to hold “Grand Rounds” with compliance fostered by taking attendance and with a proverbial free lunch – often directly or indirectly a gift of a “benevolent” pharmaceutical firm. The presentation of a case has become quaint and unnecessary. The faculty is called on to discuss something that they are comfortable discussing with a preamble that disavows conflictual relationships with purveyors of that something. There may be clinical relevance, but that’s not required. Furthermore, neither the silverbacks nor the novitiates are primed for a lively interchange. One may ask a question but that is likely designed as a display of hubris. A question designed to call into question a premise of the discussant is likely to make many uncomfortable. Grand Rounds are no longer grand, or rounds.
That has never stopped me from the asking. I was poised to do so last week, but held back. I felt too much empathy for the speakers and the audience to rub their noses in their obvious obsequiousness. However, my colleagues deserve better. This essay is an attempt to assuage my guilt for my silence.
The topic of this grand round was “An institutional program to increase physician engagement.” There were 2 speakers: a young psychiatrist who spoke about “Awareness, assessment, and treatment of burnout” and a young internist who spoke about “Building resilience: current and future wellness programming, emerging directions for structural change.” In labeling them as “young” I am taking liberty as an Emeritus Professor; most of my colleagues seem young. These 2 are highly trained, respected and skilled mid-career faculty. They are also articulate, caring and experienced physicians.
They took us through the data that corroborates the general impression that something is rotten in the “healthcare industry.” Growing numbers of physicians and other “providers” are frustrated in their quest for career satisfaction. The resulting dissatisfaction is reflected in the trends toward career shifting and early retirement. It is associated with medical errors and diminished professionalism. It is also manifest in personal consequences: substance abuse, affective disorders, inattentiveness, disaffection, even suicide.
We were reminded that medicine in general, and patient care in particular, is a stressful undertaking. Physicians are selected and nurtured to want to “do right”; we are perfectionists on a mission. The result is a professional role that can be all consuming. Learning to walk the line between what can be accomplished and what is beyond control is an age old challenge. Physicians who can walk this line with aplomb are readily identified by their peers and often chosen by peers as their personal physicians. But even these master clinicians are falling victim to disaffection in the contemporary healthcare industry.
The explanation for this sorry state was offered as generally accepted: caring for patients has been confounded by layers of dissuasive demands. Most of these demands have the force of regulatory righteousness. Most take time, often extending the “work day” beyond daylight. Most constrain clinical judgment, thwart collegiality, and interfere with the patient-physician dialogue. And most make no clinical sense. In fact they create cognitive dissonance. For physicians who are perfectionists trying to do good, professional satisfaction is Sisyphean.
Resilience and Wellness
The grand rounds audience accepted this litany without developing indigestion while munching on their free lunch. All of this was the prelude to the real reason for this session; (drum roll) help is here and more is on the way. Our hospital, thanks to our poohbah (Dean/CEO/Vice Chancellor all rolled up into one), was tackling the “burnout epidemic”. There is the “Taking Care of Our Own Program” which provides “education, confidential support, advice, and if appropriate, professional referral for individual mental or physical help” () There is the Resident Wellness Committee which focuses on “preventing burnout, identifying burnout and providing resources to treat burnout” (.) The Committee is promoting an array of interventions that include “yoga and Zumba at work”, dietary advice, “Mindful Mondays”, mentorship, parties and picnics and….
Shanafelt and colleagues at the Mayo Clinic have taken the lead in the early identification of burnout and in promoting this sort of approach to its amelioration. Screening instruments are available designed to detect early burnout with the expectation that early intervention will provide a solution if not a cure. I envision a modern hospital where physicians and scribes and all sorts of folks take breaks from their computer terminals to participate in Zumba classes or “team building” luncheons, both facilitated by a new category of employee hired to rekindle their flame.
Blaming the Victim
My colleague and friend, Professor Dan Ariely, graced the pages of the Mayo Clinic Proceedings in 2015 with the argument that the disturbing trends in physician burnout reflect dissatisfaction with “work-life balance” . Dan is a brilliant behavioral economist. In his view, the causes of all this disaffection include loss of autonomy, asymmetrical rewards, and cognitive scarcity. These are all well-established psychological constructs. All of them support the notion that interventions that enhance coping are sensible. All of them support the proliferation of a “wellness” agenda. But that is not Dan’s conclusion, nor has it been mine for decades. We agree that “the structure we have created for practicing medicine makes taking care of patients more difficult, more stressful, and, ultimately, counterproductive…(it’s) a fixing-people production line.” We agree that this current “structure” is an exercise in iatrogenesis. We disagree as to why and what next. The why reflects the unintended consequences of seemingly sensible policies over the past century and the entropy of the status quo (). For Dan what next is a health care system that supports medical practice as a “as a research and development activity….a research and development practice.” For me the solution resides with a health care system that considers a rational, empathic patient-physician dialogue inviolate.
Blaming the System
I am not wont to point fingers at people. I believe that there are too few misanthropes to influence my worldview. But I have no compunction at pointing fingers at our “system.” Through a series of historical accidents and unintended consequences, America has fashioned the most irrational “health care delivery system” in the advantaged world. The investment moneys and personnel is astronomical but the “bang for the buck” puny relative to other resource advantaged countries. No one in our system considers himself or herself unnecessary, over paid, ineffective, redundant or, for that matter, a wastrel. Each is doing the “necessary” while tucked into a peer group doing the same. That there is folly to the peer review is never apparent within the peer group. It is not their fault if their peer group is part of a perverse system.
The “health care dollar” is a fatuous notion. It is calculated from administrative data without validating that the transfer of wealth has anything to do with health, let alone with care. It also neglects the transfers of wealth for “health” that are out-of-pocket. There is no doubt that the “health care dollar” has a great deal to do with creating and supporting our vaunted “healthcare industry.” I have amused myself playing with this Monopoly game. So, too, has Congress, even asking the National Academy of Medicine (née Institute of Medicine) to play a hand (see Figure). Is there another “industry” that could survive a 30% loss off the top? Maybe some pharmaceutical firms could. When I play this hand, I come up with >50% of the “healthcare dollar” being transferred to pockets in pants that are worn vanishingly far from the bedside.
I would venture to say that any corporation with this spread sheet would face bankruptcy unless it had a Board that “cleaned house.” The health care industry is famous for Boards stocked with individuals who are in awe of the industry and its leadership. Furthermore, the healthcare industry defies every aspect of the “free market”. If the Board won’t clean house, neither will the marketplace.
So, for now, Grand Rounds around the country will blame the doctors and other “providers” for their burning out. And their top-heavy, self-serving, iatrogenic institutions will sanctimoniously pay for a “wellness” remedy. The healthcare industry will continue to ignore all the advances of occupational medicine and human factors research that impugns administrative shortcomings in other industries for epidemics of absenteeism, presenteeism, and the disabling illness experiences that serve as surrogates for job dissatisfaction. Other industries are already more than wary regarding the utility of “wellness” programs.
But the “healthcare” industry will carry on as long as it can extort largesse from the American coffers. The “healthcare” industry knows no other way. Furthermore, teaching any bureaucracy new tricks is seldom successful. In 1620, Francis Bacon (Novum Organum) said, “The human understanding when it has once adopted an opinion (either as being the received opinion or as being agreeable to itself) draws all things else to support and agree with it. And though there be a greater number and weight of instances to be found on the other side, yet these it either neglects and despises, or else by some distinction sets aside and rejects, in order that by this great and pernicious predetermination the authority of its former conclusions may remain inviolate.” Today we’d say, “When my mind’s made up, don’t try to confuse me with the facts.”
Nortin Hadler is Emeritus Professor of Medicine, University of North Carolina – Chapel Hill.