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.
Call it what you want, white privilege and health disparity appear to be two sides of the same coin. We used to consider ethnic or genetic variants as risk factors, prognostic to health conditions. However, the social determinants of health (SDOH) have increasingly become more relevant as causes of disease prevalence and complexity in health care.
As a pediatric hospitalist in the San Joaquin Valley region, I encounter these social determinants daily. They were particularly evident as I treated a 12-year old Hispanic boy who was admitted with a ruptured appendix and developed a complicated abscess, requiring an extensive hospitalization due to his complication. Why? Did he have the genetic propensity for this adverse outcome? Was it because he was non-compliant with his antibiotic regimen? No.
Rather, circumstances due to his social context presented major hurdles to his care. He had trouble getting to a hospital or clinic. He did not want to burden his parents—migrant workers with erratic long hours—further delaying his evaluation. And his Spanish-speaking mother never wondered why, despite surgery and drainage, he was not healing per the usual expectation.
When he was first hospitalized, his mother bounced around in silent desperation from their rural clinic to the emergency room more than 20 miles from their home and back to the clinic, only to be referred again to that same emergency room. By the time he was admitted 2 days later, he was profoundly ill. The surgeon had to be called in the middle of the night for an emergency open surgical appendectomy and drainage. Even after post-operative care, while he was on broad-spectrum intravenous antibiotics, his fevers, chills and pain persisted. To avoid worrying his mother, he continued to deny his symptoms. Five days after his operation, he required another procedure for complex abscess drainage.
In learning my third EMR, I am again a little disappointed. I am again, still, finding it hard to document and retrieve the thread of my patient’s life and disease story. I think many EMRs were created for episodic, rather than continued medical care.
One thing that can make working with an EMR difficult is finding the chronologyin office visits (seen for sore throat and started on an antibiotic), phone calls (starting to feel itchy, is it an allergic reaction?) and outside reports (emergency room visit for anaphylactic reaction).
I have never understood the logic of storing phone calls in a separate portion of the EMR, the way some systems do. In one of my systems, calls were listed separately by date without “headlines” like “?allergic reaction” in the case above.
In my new system, which I’m still learning, they seem to be stored in a bigger bucket for all kinds of “tasks” (refills, phone calls, orders and referrals made during office visits etc.)
Both these systems seem to give me the option of creating, in a more or less cumbersome way, “non-billable encounters” to document things like phone calls and ER visits, in chronological order, in the same part of the record as the office notes. That may be what IT people disparagingly call “workarounds”, but listen, I need the right information at the right time (and in a place that makes sense to me) to make safe medical decisions.
We’re pretty proud of
modern medicine. We’ve accumulated a very intricate understanding of how
our body works, what can go wrong with it, and what are options are for
tinkering with it to improve its health. We’ve got all sorts of tests,
treatments, and pills for it, with more on the way all the time.
However, there has been
increasing awareness of the impact our microbiota has on our health, and I
think modern medicine is reaching the point classical physics did when quantum
physics came along.
pictured the atom as kind of a miniature solar system, with well-defined
particles revolving in definite orbits around the solid nucleus. In
quantum physics, though, particles don’t have specific positions or exact
orbits, combine/recombine, get entangled, and pop in and out of
existence. At the quantum level everything is kind of fuzzy, but quantum
theory itself is astoundingly predictive. We’re fooled into thinking our
macro view of the universe is true, but our perceptions are wrong.
So it may be with modern
medicine. Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of
Designing a functional lamp is simple. Building the Mars Rover is complex. Getting a doctor to ask the right questions so that a patient feels confident about their care in a highly regulated and time constrained environment? That’s complicated.
Healthcare is filled with complicated challenges. Increasingly, healthcare companies and institutions are attacking these challenges with cross-disciplinary teams — doctors, data scientists, marketers, quality officers, financial experts, information technologists, and more. An often missing member of these teams are design leaders. Designers can provide an invaluable role in healthcare, but too often healthcare does not take advantage of all that design can offer.
Good design is invisible. Think about the last time you obtained or purchased something that was well designed. When you get a new blender, you plug it in and turn it on without looking at the user manual, and it works. You don’t necessarily think “Wow, they put that on button right where I thought it would be.” You use it and get on with your day. And every day you use that blender, putting in new mixtures of fruits and vegetables. Sometimes you get a delicious jackpot mix and think this is the best blender ever. Sometimes you get something brown and sticky and you make a mental note never to try that one again, even as you choke it down.
I’ve had several telephone calls in the last two weeks from a 40-year-old woman with abdominal pain and changed bowel habits. She obviously needs a colonoscopy, which is what I told her when I saw her.
If she needed an MRI to rule out a brain tumor I think she would accept that there would be co-pays or deductibles, because the seriousness of our concern for her symptoms would make her want the testing.
But because in the inscrutable wisdom of the Obama Affordable Care Act, it was decided that screening colonoscopies done on people with no symptoms whatsoever are a freebie, whereas colonoscopies done when patients have symptoms of colon cancer are subject to severe financial penalties.
So, because there’s so much talk about free screening colonoscopies, patients who have symptoms and need a diagnostic colonoscopy are often frustrated, confused and downright angry that they have to pay out-of-pocket to get what other people get for free when they don’t even represent a high risk for life-threatening disease.
But, a free screening colonoscopy turns into an expensive diagnostic one if it shows you have a polyp and the doctor does a biopsy – that’s how the law was written. If that polyp turns out to be benign, or hyperplastic, there is no increased cancer risk associated with it, but you still have to pay your part of a diagnostic colonoscopy bill because they found something.