When my junior year in medical school started in September of 1971, my classmates and I entered daily notes in patients’ hospital charts, loose leaf notebooks that documented their medical progress – or not – over the course of their hospitalizations. The notes were official, legal – and largely useless. About half of what was entered by faculty and consultants on any single day was so illegible that the medical alphabet more resembled cuneiform than English. The possibility of a note being misread was not lost on one of our senior professors, who mumbled: “If you can read my note, you know the patient was sick,” as he slowly wrote a note on a patient who qualified as “sick”.
Above the Fold
Physician Burnout Presents Differently in Male and Female Doctors
Burnout is a chronic epidemic in physicians and a major threat to patient satisfaction and quality care. Recent research is showing that women and men experience burnout differently.
Numerous studies have shown that an average of 1 in 3 practicing physicians are suffering from symptomatic burnout on any given office day … worldwide, regardless of specialty. There is good evidence to believe the physician burnout rate is higher in the USA than in other world markets simply because of the uncertain political and payment environment and the massive merger and acquisition activities across the country. As evidence, the 2015 Medscape Physician’s Lifestyle Survey showed a 46% burnout rate, 16% higher than the same survey in 2013.
The three classic signs and symptoms of burnout are measured by a standardized evaluation; the Maslach Burnout Inventory (MBI) developed by Christina Maslach and her team at the University of San Francisco in the 1970’s.
Here is Maslach’s description of the experience of burnout: “… an erosion of the soul caused by a deterioration of one’s values, dignity, spirit and will.” The three symptoms of the MBI are.
Did Dr. Virginia Apgar worry about work-life balance?
Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine: Then and Now“, in the journal Anesthesia and Analgesia.
I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:
“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.
2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.
Fear-based Medicine: Using Scare Tactics in the Clinical Encounter
How often do doctors say something like this to patients? “It’s really important for you to do this; if you don’t you might … have a stroke, go blind, lose a leg, die or (insert a scary outcome here).” There are no solid data to answer this question, though patients report that conversations containing such direct threats are common in clinical encounters. The more important question is, do scare tactics work?
Fear-based messages in clinical encounters
Health communication experts call these types of messages fear-based appeals. Fear appeals create an emotional reaction to some “threat” of disease, disability or death, which in turn, is thought to motivate behavior change. Doctors may use fear-based messages when counseling patients about chronic disease self-management or prevention, especially when faced with a patient we believe to be unmotivated or non-adherent. In such situations, using fear as a tool is appealing because it is easy, doesn’t take much time and we know intuitively that fear can be a powerful motivator. Yet despite decades of research on the subject, there is no consensus on whether or how fear can be used effectively to motivate long-term behavior change.
Research supporting the effectiveness of fear appeals is generally from public health campaigns, where frightening facts or images can quickly capture the audience’s attention. This makes sense when a message sender is competing for audience attention among many billboards, advertisements and other messages. But it rarely makes sense when a doctor is alone in an exam room with a patient. For many patients, the 15 minutes they have with their doctor will be the 15 most important minutes of their day.
A Classic Non-Reaction Reaction From Screening Proponents
Is it just me or has there been a deafening silence from the wellness proponents of forced HRA/biometric screening since Dr. Atul Gawande’s article Overkill appeared?
Two salient quotes from the article capture the issue. The first about over screening and testing in general, not specific to wellness but applicable:
“Often, these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish. If you look closely and often enough, almost everyone will have a little nodule that can’t be completely explained, a lab result that is a bit off, a heart tracing that doesn’t look quite right.”
Now, read the article and Dr. Gawande’s story of how he treated a patient who’d been diagnosed with thyroid cancer. Please-read it, this is what overscreening leads to and can do to your employees. It is not an academic issue, real people are impacted. His quote here is especially impactful
“All the same, she thanked me profusely for relieving her anxiety. I couldn’t help reflect on how that anxiety had been created. The medical system had done what it so often does: perform tests, unnecessarily, to reveal problems that aren’t quite problems to then be fixed, unnecessarily, at great expense and no little risk…An entire health care system has been devoted to this game.”
Non-Profit IDNs: Where’s Da Beef?
I have followed this narrative for quite some time albeit inside the industry contained debate of whether so-called ‘non-profit’ [501(c)3] hospitals or their parent systems (really more aptly characterized as “tax exempt”) actually earn this financial advantage via material ‘returns’ to the communities they serve.
As can be expected you have the party line of the American Hospital Association (AHA) a trade group of predominantly non-profit members vs. that of it’s for-profit brethren The Federation of American Hospitals (FAH). You can guess which side of the argument each of them favor.
Now thanks to a recently published landmark study ‘Integrated Delivery Networks: In Search of Benefits and Market Effects’ by Healthcare Futurist Jeff Goldsmith, PhD et al, of the 501(c)3 cast of characters in the related but more often than not distinctly different ‘IDN culture’ we extend that line of inquiry into what has been a somewhat conversational ‘safe harbor of sorts’ – not any longer?
The Executive Summary notes both the rationale and basis to study the market ‘incident to’ a more focused pricing (via asset concentrations) power line of inquiry:
In January 2014, the National Academy of Social Insurance commissioned a study of the performance of Integrated Delivery Networks (IDNs), incident to its Study Panel on Pricing Power in Health Care Markets. The premise of this analysis was that any examination of the role that hospitals play in health care cost growth is complicated by the fact that in most large markets, the significant hospitals are part of larger, multi-divisional health enterprises. In these markets, hospitals may be part of horizontally integrated hospital systems operating multiple hospitals; vertically integrated health services networks that include physicians, post-acute services and/or health plans; or fully integrated provider systems inside a health plan (e.g. with no other source of income than premiums) like Kaiser Permanente. The latter two models are collectively labeled IDNs.
Creative Minds: Building a Better Electronic Health Record
Is 5 too few and 40 too many? That’s one of many questions that researcher David Chan is asking about the clinical reminders embedded into those electronic health record (EHR) systems increasingly used at your doctor’s office or local hospital. Electronic reminders, which are similar to the popups that appear when installing software on your computer, flag items for healthcare professionals to consider when they are seeing patients. Depending on the type of reminder used in the EHR—and there are many types—these timely messages may range from a simple prompt to write a prescription to complex recommendations for follow-up testing and specialist referrals.
Chan became interested in this topic when he was a resident at Brigham and Women’s Hospital in Boston, where he experienced the challenges of seeing many patients and keeping up with a deluge of health information in a primary-care setting. He had to write prescriptions, schedule lab tests, manage chronic conditions, and follow up on suggested lifestyle changes, such as weight loss and smoking cessation. In many instances, he says electronic reminders eased his burden and facilitated his efforts to provide high quality care to patients.
Still, Chan was troubled by the lack of quantitative evidence Continue reading…
The Smoking Gun: How U.S. Health Care Came to Cost Insanely More
Cost is the big factor. Cost is why we can’t have nice things. The overwhelmingly vast pile of money we siphon into health care in the United States every year is the underlying driver of almost every other problem with health care in the United States from lack of access to waste to fragmentation to poor quality. We can’t afford to fix the problems, cover everyone, do real outreach, build IT systems that are interoperable and transparent and doc-friendly — or so it seems, because at least on weak examination every fix seems to add even more cost. And in the old ways of doing things in health care, the way we have been used to doing business, the conclusion of the weak examination has been correct: Despite the tsunami of money, there is never enough to do it right.
Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.
Life Is Complicated
“I want to tell you my story now,” a patient recently told me, a woman who suffers from many physical and emotional ailments. She had the diagnosis of PTSD on her problem list, along with hospitalizations for “stress,” but I never asked beyond that.
“OK,” I answered, not knowing what to expect. “Tell me your story.”
She paused for about 30 seconds, but I knew not to interrupt the silence. “I killed my husband,” she finally said.
OK. Unexpected.
She went on to explain a horrible set of circumstances involving alcoholism and physical violence, that resulted in her shooting her husband in self-defense. She spent the two following years on trial for murder, eventually being cleared on all accounts. Despite this, the rifts in her family continue, and she (obviously) still relives this terrible moment.
Deep breath. How can I ever hold any emotional instability against this woman? Who wouldn’t struggle? It brings me back to my oft-repeated mantra: everyone has a backstory.
Not all backstories are so dramatic. One woman, who is very lovely and vibrant from first meeting, revealed that it had been ten years since she was intimate with her husband. She does her best to hide the pain, but the toll of feeling unloved and rejected over ten years has taken a heavy toll. In some ways, her skill at hiding the pain inside causes even more pain, as she faces the daily need to screw up happy emotions she doesn’t have. In her own way, this pernicious pain of rejection has made her walk through life feeling distant from everyone. She smiles to everyone, but the pain doesn’t leave.
How can I know what this is like?
A Shout Out For Our Sponsors: Health Catalyst
THCB would literally not exist without the support of our generous sponsors. This blog and the work we do is made possible by the forward-thinking people at companies like HealthCatalyst who have come on board as flagship sponsors. Love THCB? Want to send a message of support? Head over and take a look at what they’re up to for a few minutes. Today’s online boot camp (Health Catalyst Academy) is a great intro. Quality improvement is a tough, bloody fight. Many enter the contest. Not everybody survives. If you’re a hospital administrator, this online boot camp event (Weds 27th 1 PM / archive available) will give you the tools you need to lead successful quality improvement initiatives at your organization and may even make you rethink how you lead data-driven change. If you’re a clinician or healthcare provider involved on the front lines of the quality improvement fight, you’ll come away with an advanced understanding of how data can transform your organization, as well as the role you can play along the way. You can find out more here. Great stuff. — Matthew Holt
