Practices cannot survive the COVID-19 cash flow crisis
By JEFF LIVINGSTON, MD
Will doctors be able to keep their practices open during the worst pandemic in our lifetime? Our country needs every available doctor in the country to fight the challenges of Covid-19. Doctors working in independent practices face an immediate cash flow crisis threatening their ability to continue services.
The CARES Act was signed into law on Friday, March 27, 2020. The law offers much-needed help to the acute needs of hospitals and the medical supply chain. This aid will facilitate the production of critical supplies such as ventilators and PPE. The law failed to consider the needs of the doctors who will run the ventilators and wear the masks.
Cash flow crisis
Private-practice physician groups experienced an unprecedented reduction in in-office visits as they moved to provide a safe and secure environment for patients and staff. In compliance with CDC guidelines, practices suspended preventative care, nonurgent visits, nonemergent surgery, and office procedures.
These necessary practice changes help keep patients safe and slow the spread of Covid-19. The unintended consequence is an unreported and unrecognized cash flow crisis threatening the viability of physician practices.
By MIKE MAGEE, MD
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.”
By SANJ KATYAL, MD
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?
By HANS DUVEFELT, MD
I looked at a free book chapter from Harvard Businesses Review today and saw a striking graph illustrating what we’re up against in primary care today and I remembered a post I wrote eight years ago about burnout skills.
Some things we do, some challenges we overcome, energize us or even feed our souls because of how they resonate with our true selves. Think of mastering something like a challenging hobby. We feel how each success or step forward gives us more energy.
Other things we do are more like rescuing a situation that was starting to fall apart and making a heroic effort to set things right. That might feed our ego, but not really our soul, and it can exhaust us if we do this more than once in a very great while.
In medicine these days, we seem to do more rescuing difficult situations than mastering an art that inspires and rewards us: The very skills that make us good at our jobs can be the ones that make us burn out.
Doctors are so good at solving problems and handling emergencies that we often fall into a trap of doing more and more of that just because we are able to, even though it’s not always the right thing to do – even though it costs us energy and consumes a little bit of life force every time we do it. And it’s not always the case that we are asked to do this. We are pretty good at putting ourselves in such situations because of what we call our work ethic.
By HANS DUVEFELT, MD
I find myself thinking about how being a doctor has come to impact the Christmas Holiday for me over the years. I have written about working late and driving home in the snow and dark of Christmas Eve in northern Maine; I have shuffled Osler’s written words into something that speaks to physicians of our times; I have written about the angst around the Holidays I see in my addiction recovery patients.
This year, my thoughts go to the way Christmas is a time of reconnection for many people. We reconnect with family and friends we may not see as often as we would like, and many of us reconnect with secular traditions dating back to our childhood. Many people also reconnect more deeply with their Christian traditions, the ancient celebration of Hanukkah or the newer one of Kwanzaa.
As a doctor, I think Christmas is a time when individuals are more open toward others, more willing to extend “good will toward men” (Luke 2:14). It can be an opener for future relationships to form or grow, a time to share our humanity in the context of experiencing something larger than ourselves and our everyday existence. It allows us to get a little more personal by sharing something of what we all have in common – the need for togetherness with those we love.
By HANS DUVEFELT, MD
Medical researchers and their groupies – early adopters, thoughtleaders, those easily influenced or whatever you want to call them – never seem to learn that when you try to outsmart Mother Nature or Our Heavenly Father, whichever appeals more to your world view, you usually get your hand slapped.
When I was a resident (1981-1984), I got penalized if I didn’t offer postmenopausal women estrogen-progesterone replacement therapy because it seemed obvious that if women with endogenous estrogen didn’t get many strokes or heart attacks and women without estrogen did, all we needed to do was make up for God’s or Mother Nature’s oversight in not keeping the estrogen coming after age 50.
Then the Women’s Health Study in 2000, almost 20 years later, showed that women on Prempro had more strokes, blood clots and heart attacks, and more breast cancer on top of that, than women who accepted the natural order of things – menopause with all its symptoms and inconveniences.
The same things has happened with osteoporosis – more subtrochanteric femur fractures after five years of Fosamax than in untreated women.
By HANS DUVEFELT, MD
“By the way, Doc, why am I tired, what’s this lump and how do I get rid of my headaches?”
Every patient encounter is a potential deadly disease, disastrous outcome, or even a malpractice suit. As clinicians, we need to have our wits about us as we continually are asked to sort the wheat from the chaff when patients unload their concerns, big and small, on us during our fifteen minute visits.
But something is keeping us from listening to our patients with our full attention, and that something, in my opinion, is not doctor work but nurse work or even tasks for unlicensed staff: Our Public Health to-do list is choking us.
You don’t need a medical degree to encourage people to get flu and tetanus shots, Pap smears, breast, colon and lung cancer screening, to quit smoking, see their eye doctor or get some more blood pressure readings before your next appointment. But those are the pillars of individual medical providers’ performance ratings these days. We must admit that the only way you can get all that health maintenance done is through a team effort. Medical providers neither hire nor supervise their support staff, so where did the idea ever come from that this was an appropriate individual clinician performance measure?
By CHADI NABHAN, MD, MBA, FACP
thought about your own mortality?
given the frequency of seeing death and grief depicted in the media or through
real life encounters with friends, relatives, neighbors, or patients? These
incidents trigger uncomfortable and sometimes uneasy thoughts of how we might
personally deal with potential illness and disease. The same thoughts are soon
displaced by the busyness of living.
dealing with the death of his mother from a brain tumor, we learn David
Fajgenbaum was healthy, living life to its fullest, and a future doctor in the
making. He may have thought about his own mortality as he grieved the death of
his mother, but likely never imagined anything dire would happen to him.
Fajgenbaum was pushing forward on several fronts, including leading a
non-for-profit organization for grieving college students, symbolically named
“Actively Moving Forward” or “AMF” after his mother’s initials, all while first
playing college football and then attending medical school. By all accounts,
this was a vigorous young man, meticulous about his diet and physicality. When he became ill, it was a blunt reminder
that life is unpredictable.
In his book “Chasing my Cure”, Dr. Fajgenbaum takes us back to the time when he first got ill. He vividly describes his physical symptoms and various scans which detected his enlarged nodes. Interestingly, we learn how long he was in denial of these symptoms, thereby delaying medical attention in favor of studying. This neglect of self-care highlights part of his personality, but also represents the pressure and expectations placed upon a majority of medical students.
By LISE ALSCHULER, ND, FABNO
I am a naturopathic doctor, and because I operate outside of insurance-based medicine, I have, what most healthcare providers would consider, lots of time with my patients. My typical first patient appointment is 90 minutes long and my follow-up visits are 30 minutes long.
What, you may ask, do I do with all this time? I get to know my patients by listening to their stories, their concerns and their hopes. We delve into their health concerns, we review their medical records, and we explore lifestyle-based strategies to optimize their healing and wellbeing.
In short, I listen and apply what I know in partnership with each patient with the goal of empowering them towards greater wellness. Over and over, I hear from my patients how unusual this is. They speak about the 5-minute visits with their doctors that feel rushed and disconnected. They express frustration and dismay about being a diagnosis, not a person, when seeing their healthcare providers.
A recent survey conducted by the New York Times found that two-thirds of Americans support some form of change to the current healthcare system and favor moving towards greater insurance coverage for all. My experience for almost 25 years leads me to conclude that underlying this vision of healthcare is a deep-seated desire for patients to be cared for and listened to.
By HANS DUVEFELT, MD
It’s a funny world we live in. Lots of people make a handsome living, defining their work and setting their own fees and hours with little or no formal education or certification
There are personal and executive coaches, wealth advisers, marketing experts, closet organizers and all kinds of people offering to help us run our lives.
In each of these fields, the expectation is that the provider of such services has his or her own “take” or perspective and offers advice that is individual, unique and as far removed from cookie cutter dogma as possible. Why pay for something generic that lots of people offer everywhere you turn?
So why is it, in this day of paying lip service to “personalized medicine”, genetic mapping, the human biome and psychoneuroimmunology that we expect our healthcare to be standardized and utterly predictable?
And why is it that we are so willing to fragment our care, using convenient care clinics, health apps, specialists who don’t communicate with each other and so on? Does anybody believe it makes sense to have your life coach tell you to have a latte if you feel like it because it makes you happy and your financial adviser scorn you for wasting money, never mind your health coach talking about all those unnecessary calories?
In today’s world, almost all knowledge and information is available, for free, instantly and from anywhere on the planet. But this has not eliminated our need for “experts”. It used to be that we paid experts for knowing the facts, but now we pay them for sorting and making sense of them, because there are too many facts and too much data out there to make anything self explanatory.