As a Petersdorf Scholar-in-Residence at the Association of American Medical Colleges (AAMC) in 2002, Dr. Thomas S. Inui opened his mind and heart to try to understand whether and how professionalism could be taught to medical students and residents. His seminal piece, “A Flag In The Wind: Educating For Professionalism In Medicine”, seems written for today.
Nearly two decades ago, Inui keyed in on words. In our modern world of “fake news”, concrete actions carry far greater weight than words ever did, and the caring environments we are exposed to in training are “formative”—that is, they shape our future capacity to express trust, compassion, understanding and partnership.
Inui reflected on the varied definitions or lists of characteristics of professionalism that had been compiled by multiple organizations and experts, commenting:
my own perspective, I have no reservations about accepting any, or all of the
foregoing articulations of various qualities, attitudes, and activities of the
physician as legitimate representations of important attributes for the
trustworthy professional. In fact, I find it difficult to choose one list over
others, since they each in turn seem to refer largely to the same general set
of admirable qualities. While we in medicine might see these as our lists of
the desirable attributes of professionalism in the physician, as the father of
an Eagle Scout I know that Boy Scout leaders use a very similar list to
describe the important qualities of scouts: ‘A Scout is trustworthy, loyal,
helpful, friendly, courteous, kind, obedient, cheerful, thrifty, brave, clean,
reverent (respecting everyone’s beliefs).’ I make this observation not to
descend into parody, but to make a point. These various descriptions are so
similar because when we examine the field of medicine as a profession, a field
of work in which the workers must be implicitly trustworthy, we end by
realizing and asserting that they must pursue their work as a virtuous
activity, a moral undertaking.”
Tesla is now, by market cap, the second largest auto manufacturer (after Toyota). Its market cap exceeds U.S. auto makers Ford, G.M., and Fiat/Chrysler — combined. This despite selling less than 400,000 vehicles in 2019, a figure that is more than the prior two years combined.
Tesla has made its bet on the future of electric cars. It didn’t invent them. It isn’t the only auto manufacturer selling them. But, as The Wall Street Journalrecently said:
Investors increasingly see the future of the car as electric—even if most car buyers haven’t yet. And lately, those investors are placing bets on Tesla Inc. to bring about that future versus auto makers with deeper pockets and generations of experience.
A recent analysis
suggested a big reason why, and its findings should give those in healthcare
some pause. Tesla’s advantage may come, in large part, from its supply
In the 1970s, Jean Whitehorse, a member of the Navajo Nation, went to a hospital in New Mexico for acute appendicitis. Years later, she found out the procedure performed was not just an appendectomy – she had been sterilized via tubal ligation. Around the same time, a Northern Cheyenne woman was told by a doctor that a hysterectomy would cure her headaches. After the procedure, her headaches persisted. Later, she found out a brain tumor was causing her pain, not a uterine problem. Like Whitehorse and the Northern Cheyenne woman, thousands of Native American women have suffered irreversible changes to their bodies and psychological trauma that continues to this day. Most medical providers are unaware of our own profession’s role in implementing these racists policies that have direct links to the Eugenics movement.
Eugenics was a “movement that is aimed at improving the genetic composition of the human race” through breeding. From its origin in 1883, eugenics became the driving rationale behind using sterilization as a tool to breed out unwanted members of society in the United States. With the 1927 Supreme Court case Buck v. Bell permitting eugenic sterilization, 32 states followed suit and passed eugenic-sterilization laws. Although the outward use of sterilization declined after World War II because of its association with Nazi practices, sterilization rates in poor communities of color remained high throughout the United States.
Burnout among healthcare professionals is at an all-time
high. Its drivers include longer work hours, the push to see more patients,
more scrutiny by administrators, and loss of control over our practice. We seem
to spend more time with the electronic medical record and less time
face-to-face with our patients.
I have faced burnout personally. My son passed away at the
age of 29, which was beyond painful. At the same time, I felt burdened by the
growing number and complexity of metrics by which I was judged at work. Days in
the operating room and intensive care unit seemed more and more exhausting, and
my patience was becoming shorter and shorter. I was fortunate to have had a long-standing
meditation practice as well as sabbatical time that I used to decompress and
re-evaluate my career. Many of us are not so lucky. More than half of
physicians have serious signs of burnout, and more than one physician commits
suicide every day.
So many of us feel burned out these days because in our
rapidly changing profession we are asked to do more for less and with
inadequate resources. We suffer from exhaustion, self-criticism, and worry
about what will happen next to our practice, our families, and ourselves. If we
want to save our practices, patients, marriages- even our lives, we must
acquire personal resilience.
Fortunately, we can increase our resilience and happiness and reverse burnout by embracing a few simple principles—Gratitude, Acceptance, Intention, and Nonjudgment (GAIN)—that we can put into motion in our everyday lives at the hospital, at home, or wherever we are.
The United States Medical Licensing Examination (USMLE) Step
1, a test co-sponsored by the Federation of State Medical Boards (FSMB) and the
National Board of Medical Examiners (NBME), has been the exam that people love
to hate. For many years, blogs, Twitter feeds, and opinion pieces have been
accumulating urging the presidents of the FSMB/NBME to stop reporting a 3-digit
score and instead report a pass/fail score. This animosity towards the Step 1
exam originates from the reality that medical schools have increasingly focused
their curriculum on teaching what the Step 1 wants you to learn – medical
trivia that almost always has no bearing on how to approach a clinical problem.
This “Step 1 Madness” is unhealthy. The reasons for its
existence are many: residency and fellowship programs allow it to exist by
idolizing higher scores, some believe it is a metric that can predict future
quality of care, board pass rates, etc. And some are naïve enough to think that
what is tested on the Step 1 is actually useful medical knowledge! It may be
due to a combination of the above that the Step 1 has found itself in such a
peculiar spot. However, the emphasis on the Step 1 score means that medical
students’ fate is being determined by a single test. Nobody wants their fate to
be so unmalleable.
The term “moral
injury” is a term originally applied to soldiers as a way to help explain
PTSD and, more recently, to physicians as a way to help explain physician burnout.
The concept is that moral injury is what can happen to people when “perpetrating,
failing to prevent, or bearing witness to acts that transgress deeply held
moral beliefs and expectations.”
I think healthcare
generally has a bad case of moral injury.
Melissa Bailey, writing for Kaiser Health News, looked at moral injury from the standpoint of emergency room physicians. One physician decried how “the real priority is speed and money and not our patients’ care.” Another made a broader charge: “The health system is not set up to help patients. It’s set up to make money.” He urged that physicians seek to understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”
If you are like most doctors, you are sick of hearing about burnout. I know I am. There is a big debate on whether burnout is real or whether physicians are suffering from something more sinister like moral injury or human rights violations. That doesn’t matter. In the end, no matter what name we give the problem, the real issue is that physicians are in fact suffering. We are suffering a lot. Some of us—around one physician per day—are forced to alleviate their suffering by taking their own life. Each year, a million patients lose their physicians to suicide. Many more physicians suffer in silence and self-medicate with drugs or alcohol in order to function.
We are losing more physicians each year to early retirement or alternate careers. There are an increasing number of coaches and businesses whose single purpose is to help doctors find their side gigs and transition out of medicine. This loss comes at a time of an already depleted workforce that will contribute to massive physician shortages in the future. Perhaps even more troubling is that those physicians who remain in medicine are often desperate to get out. It is the rare physician these days that recommends a career in medicine to their own children. We now have a brain drain of the brightest students who would rather work on Wall Street than in a hospital.
As a physician trained in positive psychology, I have been committed to helping other physicians and students improve their well-being. The focus on well-being is a welcome change in medicine. But is it enough?
In April 2019, the Centers for Medicare & Medicaid Services (CMS) announced the Primary Cares Initiative, which is expected to reduce administrative burdens and improve patient care while decreasing health care costs. Learn more about the Primary Cares Initiative and its proposed value-based payment models in part one of this two-part blog series.
While the health care landscape has never been static,
rarely has it seen such radical changes as it has within recent decades. The
population of the United States continues to age, and the prevalence of chronic
conditions such as obesity, diabetes, heart disease, and anxiety or depression contribute
to a substantially increased demand for care. These factors are pushing a shift
from a provider-centric model toward more efficient outcome-based models that
put the patient at the center and heavily rely on primary care as the steward
of patient care.
Primary care is a vital resource in dealing with the many factors altering the health care landscape. A 2019 study published in JAMA Internal Medicine found that for every 10 additional primary care physicians (PCPs) per 100,000 people, patients saw a 51.5-day increased life expectancy.
To promote further adoption of primary care-based models, the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) recently announced a set of payment models meant to further transform primary care through value-based options under the new Primary Cares Initiative. This voluntary initiative will test financial risk and payment arrangements for primary care physicians (PCPs) based on performance and efficiency, including five new payment models under two paths: Primary Care First (PCF) and Direct Contracting (DC). These models, slated to hit 20 states in 2020, seek to address the many difficulties in paying for, and incentivizing, valuable primary care within current payment models.
By JOHN JAMES, ROBERT R. SCULLY, CASEY QUINLAN, BILL ADAMS, HELEN HASKELL, and POPPY ARFORD
Political forces trying to shape and reshape American healthcare without hearing the voice of patients provided the rationale for this work. Our experiences as patients, caregivers, and users of media sources cause us to worry. The Patient Council of the Right Care Alliance developed 6 questions to form a national survey of Americans to guide policy makers. The questions and our rationale were as follows:
3) I will get an infection while receiving treatment. Healthcare-associated infections have dropped somewhat in the past decade, yet there are still about 720,000 infections and 75,000 deaths per year from healthcare-associated infections. Many of these are becoming nearly impossible to effectively treat. The improper use of ordinary antibiotics continues to be a problem in clinical settings.