The train sped along from Seattle to Portland on a spectacular summer morning, following the track along the waterways of the lower Puget Sound. One of my daughters lived in Portland at the time, so I found myself on the train frequently. Like most of us, I don’t seek out conversations with strangers while traveling, which is unfortunate, as I have had transformative moments when I decide to engage and treat fellow passengers as fellow humans.
That day the train was crowded, and I didn’t have the option of keeping my distance. I found myself at a table with two women—both physicians and both of whom had left the conventional healthcare system because the chaos had disgusted and beaten them down. They didn’t know one another before that crowded train ride but weren’t surprised when they’d so quickly found common ground.
I asked them what piece of our healthcare system was most broken? They both immediately answered, speaking at the same time: “How we die. End of Life.” This was in 2012, and how we die in America was not front-page news. (Atul Gawande’s Being
Mortal wasn’t published until two years later.) I was taken aback and asked for more information. I quickly learned two devastating statistics: that end-of-life care is the number-one factor in American bankruptcies and that although 80 percent of Americans want to die at home, only 20 percent do.
On a sunny New England morning at a secluded guest house with a perfectly manicured lawn, medical residents, each with their own brightly colored yoga mat, were getting ready to assume the downward dog position. They were on an annual retreat organized by their residency program to promote wellness. One embraced the opportunity with delight, smiling through every pose. Another grimaced as his back spasmed. And yet another wandered off towards a lake to find his own kind of respite.
Physician wellness has become something of a buzzword in recent years, and rightfully so considering that the rates of burnout and suicide within medicine are rising. Individual residency programs have found burnout rates between 55% and 76%. Such burnout erodes well-being over time and may be contributing to suicide, which is now the second leading cause of death among residents nationwide. In 2014, the suicides of two medical interns in New York prompted the American College of Graduate Medical Education to take action. A series of initiatives to combat burnout were rolled out, including the consideration of wellness in its review of residency programs during site visits. In 2017, emergency medicine physicians convened the first Residency Wellness Consensus Summit to devise a module-based curriculum on wellness. Hospital systems have attempted to respond as well, through the hiring of chief wellness officers.
It is unsurprising that the medical community has taken such an analytical approach towards diagnosing burnout, much as we do with other diseases, in search for a cure. But perhaps such a prescriptive approach fails to capture the highly individualized and somewhat abstract concept of wellness. The reasons for resident burnout are personal and vast. Decreased wellness has been attributed to the lack of time for self-care, inadequate sleep, social isolation, negative work environments, excessive paperwork, long work hours, poor relationships with colleagues, and insufficient mentorship, among others in a lengthy list. Any attempt to standardize the definition of wellness should be met with caution.
So how do we as a society go forward in ensuring our resident physicians are well?Continue reading…
There is lots of talk of disruption in healthcare particularly involving new entrants and weird combinations such as the CVS-Aetna merger, CIGNA and Express Scripts, Amazon Berkshire Hathaway and J.P. Morgan, and now Wal-Mart and Humana all claiming to transform healthcare. At the same time, we are seeing continued consolidation in the traditional healthcare industry with hospital systems merging at the local, regional and national level.
The rise of consumerism is affecting healthcare particularly the retail/primary care area where consumers are spending with their own money in a world of high-deductible healthcare.
The growth of digital health offers the opportunity to disrupt traditional care interactions in both the management of chronic conditions and in routine primary care. And there is a whole new set of patient decision-makers such as millennials who bringing with them different sensibilities in terms of access to services.Continue reading…
I think I speak for most physicians when I say that we did not choose to go into medicine to shape health care policy. Medicine is a calling, and I treated it as such. I immersed myself with taking care of patients, and keeping up with the ever changing knowledge landscape that is medicine. I left the policy making to the folks I voted for the last 8 years. These were the adults, the intellectuals – they would take care of the task of taking out the bad elements of our healthcare system and leaving the good. I truly believed. I eagerly began the ehr/meaningful use saga believing this would result in better care for patients.
It took me two years to realize the meaninglessness of meaningful use. I still can’t believe how long it took me to realize that creating a workflow in my office to print out and deliver clinical summaries to patients didn’t do anything other than fill the trashbin. I still held out hope. I thought – this was a first draft, improvements would come. What came instead were positively giddy announcements of the success of the meaningful use roll out. The administration was actually doubling down. There was no acknowledgment for the mess that had been created – onward and forward on the same road we must continue to march. Except the road would no longer be paved and we would be walking uphill.
The survey results are appalling. After all, when you receive text message reminders about your upcoming credit card bill or ask your airline a question about your flight reservation via email, why can’t you communicate with your doctor in the same convenient way? Why are we still using the technology of the 20th century to communicate with our doctors in the 21stcentury?
The answer has three sides to it: Economics, technology management and regulations.
While serving as a panelist at a recent health care conference in New York, an audience member asked me how we’re advising clients to help them navigate the transition from volume to value-based systems.
So I talked about Goldilocks, using the time-honored children’s story as a metaphor for steering clear of extremes, maintaining a steady pace, and not going too fast or too slow. Heads nodded in agreement, a sign I was striking a responsive chord.
I’m not comparing the complexity of current health reform to a fairy tale. But, choosing the path that’s “just right,” to quote Goldilocks herself, is central to an organization’s ability to adapt to a value-based care system that relies on new and creative collaborations and data analytics to reduce cost and improve patient outcomes.
How would you judge the value of your health care? A longstanding definition of treatment holds that value is the health outcomes achieved for the dollars spent. Yet behind that seemingly simple formula lies much complexity.
Think about it: Calculating outcomes and costs for treating a short-term acute condition, such as a child’s strep throat, may be easy. But it’s far harder to pinpoint value in a long-term serious illness such as advanced cancer, in which both both the outcomes and costs of treating a given individual—let alone a population with a particular cancer—may be unknown for years. And then there’s the complicating issue of our individual preferences, since one person’s definition of a good outcome—say, another few years of life—may differ from another’s, who may be seeking a total cure.Continue reading…
There are always two parties, the party of the Past, and the party of the Future. The Establishment and the Movement.
— Ralph Waldo Emerson (1903-1882), Notes on Life and Letters of New England
On July 20-26, 2015, a new physician organization, the United Physicians and Surgeons (UPSA), held a conference, dubbed the Summit at the Summit, in Keystone, Colorado.
The conference featured over 40 speakers. Speakers represented many physicians and physician organizations, both bearing workable innovative ideas. The conference was designed to restore physician autonomy, protect the patient-physician relationship, and reset relationships between overreaching government and corporate entities.
Conference attendees were enthusiastic about this physician Movement to restore the voice of medicine.
But inevitable questions arose: Where do physicians go from here? How do we sustain the movement? Where will funding come from? What form will the Movement take? How will physicians inform hundreds of thousands of fellow physicians and millions of their patients about grievances of physicians, their ideas for the future, and what can be done to improve quality and convenience and confidentially of care?
I got an e-mail from out of the blue the other day.
The e-mail informed me that a colleague, a man I respected greatly, had tendered his resignation at the hospital. That coming Friday would be his last day. There would be an informal gathering for staff at the hospital cafeteria and that would be that.
I was shocked. The physician in question was an institution at our hospital. As far as I knew he was happy, his patients loved him, he was respected by his peers. I could think of no earthly reason for him to go. This did not did not sound like the old friend I knew.
I did what any friend would do: I picked up the phone and called him.
“I just got the e-mail. What’s going on?” I asked “Is something up at home? Is everything ok with Sarah and the kids?”
“Nothing’s wrong. I’ve just been doing a lot of thinking. I’ve decided I want to spend time with the kids and explore some outside projects.
Outside projects? What sort of outside projects?
My friend was the not kind of guy who you thought of as spontaneously quitting his job. I pressed him. He finally broke down and confessed. He was miserable at work.
“It’s the bean counters. They’re everywhere. Every day I get an e-mail that says I’m underperforming on this metric or that metric. It’s making me crazy. My self-esteem can’t take it. Last week, I got an e-mail that told me I need to do a better job of answering patient e-mails. I didn’t even know they were allowed to e-mail us. How long has this been going on? I tell you, I love my patients, but I just can’t take it anymore.”
There is optimism that Congress will soon pass the 21st Century Cures bill. The draft bill proposed by the House Energy and Commerce Committee aims to foster medical innovation by streamlining the FDA regulatory process and increasing NIH research funding by $10 billion. The draft bill has overwhelming bipartisan support and will benefit patients, medical researchers and pharmaceutical companies. However, it also includes a passage, which aims to amend the Sunshine Act and exempt pharmaceutical companies from reporting the payments they make to physicians for continued medical education (CME) programs. The supporters of this change argue that physicians learn about the latest developments in medical science through CME programs and that requiring the disclosure of these payments would discourage pharmaceutical companies from financially supporting educational programs. Ultimately they believe it could inhibit the diffusion of medical innovation among doctors.
I took a look at the data released by CMS on the financial transactions between the pharmaceutical companies and individual physicians. In the last five months of 2013, more than $120 million were paid to physicians who participated (as faculty or speakers) in CME programs. The payments constitute 26 percent of the total financial transactions between pharma and individual physicians. The proposed change essentially allows pharmaceutical companies to hide more than a quarter of their payments to physicians. Exempting the pharmaceutical companies from reporting the largest part of their financial relationship with doctors will not help to foster medical education, rather it will add to current suspicions about the unjustified impact of such payments on the drugs that physicians prescribe to their patients.
If CME programs legitimately increase the awareness of physicians about the latest medical innovations and provide them with unbiased information about new drugs, then both pharmaceutical companies and those physicians who serve as speakers and faculties of such programs should be extremely proud of their role as champions of innovation and envoys of the latest knowledge in the medical community. If that is the case, one would wonder why they wouldn’t embrace and support the efforts that shed light on their noble role.
Patients heavily rely on the recommendations of their doctors to make any kind of decision regarding their health and thus have the right to be informed about the possibility that their doctors have a conflict of interest. Congress should refrain from amending the Sunshine Act and avoid jeopardizing the patients’ right to have access to information.
Niam Yaraghi is a fellow at the Brookings Institute Center For Technology Innovation. His posts appear regularly on THCB and on the Brookings Institute Tech Talk blog, where this post first appeared. This post also appeared as an opinion column on the US News and World Report site.