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 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.
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.
Even this cardiologist knows why. The not so subtle evidence lies in the cloudy
lens in front of his pupils. He is
afflicted with cataracts that obstruct his vision to the point he can’t really
do his job refurbishing antique furniture safely. His other problem is that he hates doctors.
He hasn’t had reason to see one for more than a decade. He’s 68, takes no medications, smokes a pack
of cigarettes a day, and is a master of one word answers. He’s in my office because
he needs a medical evaluation prior to his cataract procedure. Someone needs to
attest to medical safety. I’m it.
He just wants to get out of here.
His annoyance of being in the office is
justified. Cataract surgery is very low
risk. Unless he’s having an acute
medical problem, there is little to do.
The problem is that in an age of high volume, super specialized care,
the eye doctor can’t attest to this, and the anesthesiologists have little
interest in finding out the morning of his procedure that Mr. Smith has been
having more frequent episodes of chest pain over the last two weeks. Perhaps the chest pain is just acid reflux,
or maybe it’s because of a pulmonary embolism related to the tobacco induced
lung malignancy no one knows about. It’s possible, and highly likely, Mr. Smith
will survive his cataract surgery even if
he has a pulmonary embolism.
Cataract surgery really is pretty low risk.
But the doctor’s ethos has never been to
‘clear a patient for a cataract’, it is to commit to the health of the
patient. Mr. Smith deserves the
opportunity to receive good medical care that isn’t made threadbare just
because of the cataract surgery on the horizon.
Surely every resident has had the experience of trying to explain to a patient or family what, exactly, a resident is. “Yes, I’m a real doctor… I just can’t do real doctor things by myself.”
In many ways, it’s a strange system we have. How come you can call yourself a doctor after medical school, but you can’t actually work as a physician until after residency? How – and why – did this system get started?
These are fundamental questions – and as we answer them, it will become apparent why some problems in the medical school-to-residency transition have been so difficult to fix.
In the beginning…
Go back to the 18th or 19th century, and medical training in the United States looked very different. Medical school graduates were not required to complete a residency – and in fact, most didn’t. The average doctor just picked up his diploma one day, and started his practice the next.
But that’s because the average doctor was a generalist. He made house calls and took care of patients in the community. In the parlance of the day, the average doctor was undistinguished. A physician who wanted to distinguish himself as being elite typically obtained some postdoctoral education abroad in Paris, Edinburgh, Vienna, or Germany.