Medical Journals Continue To Support The Business Intrusion Into The Profession

Ran across an article that was posted to Twitter today entitled “The medical profession is breaking its psychological contract with medical students and trainees.”  It was not posted on Medline yet so I am concluding that this is a blog post on the British Medical Journal website. As far as I can tell none of the authors are physicians. The qualifications listed suggest they are all business school professors. Rather than accept my brief summation of the article, I encourage anyone reading this post to read the article in full at this link.

The authors develop their argument from a business concept called the psychological contract. They link to it in their post.  It is from a 1995 book written by Denise Rousseau called Psychological Contracts in Organizations - Understanding Written and Unwritten Agreements.  Searching the author shows that she is a University Professor at Carnegie Mellon University in Organizational Behavior and Public Policy.  The closest definition I could find in this section of pages occurred on pages 9 and 10:

“When two people work interdependently, such as a worker and a supervisor, agree on terms of a contract, performance should be satisfactory from both parties’ perspectives. As individuals work through their understandings of each other’s commitments over time, a degree of mutual predictability becomes possible: ‘I know what I want from you and you know what you want from me’. Commitments understood on both sides may be understood based on communications, customs, and past practices.”  

By the second paragraph the authors have concluded that a violation of the subjective psychological contract has led to the well-known morbidity and mortality within the medical profession although they are focused primarily on trainees for the purpose of their argument. They provide links to burnout, stress, and depression. They suggest that this provides direct evidence that violation of the psychological contract has occurred.  They go on to point out how training environments or “cultures” have a neagtive effect as a number of vaguely defined and poorly quantitated negative outcomes. They never really comment on how widespread the abusive culture is or the total number of people affected. One of their stunning conclusory statements is:

“A cursory examination of the first interactions that physician trainees have with medical schools and residency or specialty training programmes suggests that from day one, the relationships begin somewhat adversarially, suspiciously, and with potentially lower levels of trust between the parties.” 

When I looked at that sentence - as I hope any physician reading this will do - I asked myself if these were the kinds of relationships I had with attending physicians on day one of my residency training. I also asked myself if I had these kinds of relationships with my medical school professors and the residents and medical students that I was teaching. The answer was a resounding “No!”. Medical training is of necessity intense and prolonged but it is not focused on “book smarts” and "high-stakes”.  The authors lack an understanding of why medical training requires this approach and that has to do with pattern matching. Medicine is not learned by “book smarts”. Medicine is learned by seeing as many possible patterns of illness as you can during residency training. In the case of surgical training, that involves as many supervised surgical procedures as possible. Only when this pattern matching has occurred will a physician be safe to see patients and practice medicine independently. If there is any expectation at all on the part of trainees it should be that their training program provides them with these experiences and adequate time with attending physicians so that they might also benefit from the experience of those physicians. 

Every good training program provides that experience as well as the necessary relationships with attending physicians. All through medical school and residency training, a training physician has direct contact with senior residents, attending physicians, and various consultants. They all have varied skills and motivations for teaching, but it is hard to imagine that the training in the United States one cannot find several outstanding teachers and role models in any residency program. I have role models and residents that I trained who I am in contact with to this day. We are still all focused on patient care and united by the goal of quality care and being able to take care of patients with complex problems.

I also have first-hand experience with what directly interferes with the teaching experience. Without a doubt it is the intrusion of business practices into academic settings. Pharmaceutical sales and detailing has been the usual focus but that is completely benign compared with managed care. I have highlighted a few major problems with managed-care and academic medicine in the table below and will elaborate on some of those points.

Business Practices Adversely Affecting Medical Education

1. Lack of quality - before the intrusion of business practices there were medical standards of quality. Those of been replaced by business standards of “value” that have essentially no meaning in the practice of medicine.  The role of physician as a "steward of resources" is a business idea and not a medical one.

2. Unrealistic productivity standards - any academic practice that requires RVU production and awards no credit for teaching productivity necessarily detracts from medical education.

3. Unscientific metrics - medical students and residents can observe attending physicians being ordered around by nonphysicians based on business metrics such as length of stay that have nothing to do with patient care.

4. An unscientific environment - is there adequate time in a managed-care teaching setting to discuss something other than rationing techniques? Is there time on rounding to discuss the latest scientific research? In most cases it is seriously eroded.

5. Documentation burden - it is currently immense relative to before businesses took over the field and that necessarily leads to less direct contact with teachers and mentors and less academic discussion.  This is an artifact of a very low quality information technology environment both in terms of records and security that is the direct result of business based standards in medicine.

6. Less disagreement and controversy - one of the key concepts that every medical trainee must learn is that medical science is an active dialogue and critical papers and concepts change over time. The business influence on teaching environments suggest otherwise and make it seem as though completely unscientific ideas like utilization review and prior authorization represent some sort of immutable standard - the criteria for which never seem to be completely available.  Science is secondary to the proprietary business environment.  Physicians on the faculty who disagree with that are frequently scapegoated and fall into disfavor. Managed-care companies cull the ranks of trainees looking for “managed-care friendly physicians” to maintain the business-based practice.

7. Revolving door policies - there is probably nothing more demoralizing for an intern than to have to readmit a patient who has been discharged because they were in the hospital too long and who returns because they were not stable at the time of discharge. Those discharges are generally based on business metrics.  These policies also eliminate the possibility of residents seeing their patients recover and verifying that their diagnosis and treatment plan was correct.

8.  Unnecessary bureaucratic burden - I was fortunate enough to be an intern at the time managed care was just starting to take off. At that time I had a critically ill patient in an intensive care unit and I was contacted and told that they needed to be transferred to another hospital because of their insurance contract.  Today practically all physicians routinely encounter the managed-care intrusion into their patient care on a daily basis. With physicians in training it is no different. They are still subjected to the review processes and spending far too much time getting medications approved that are clearly indicated. All of this detracts from teaching and learning time.

I have directly observed all the above items taking its toll on teaching and learning medicine but I have a couple of anecdotes that bring together many of these areas. The first was my experience on a neurosurgery rotation as a medical student. I did two neurosurgery rotations with the same residents and attendings and at one point hoped to be a neurosurgeon. There is no more rigorous course of training. All of the senior residents were essentially on-call 24/7 all year long. In those days we were rounding on about 35 patients 10 of which were in the neurosurgery intensive care unit. We would typically be done with rounds in two hours and the documentation would be done at about the same time. Our documentation would include the postoperative day number, patient’s subjective status, what the surgical wound looked like, and review of their vital signs, labs, and physical exam. A typical note was no longer than five lines and we could complete it as we were moving from patient to patient. Over the years the federal government developed documentation guidelines that were turned over to the managed-care industry so that every medical encounter these days takes an excessive amount of documentation. If we were doing the same rounding procedure today it would take us additional 2 to 3 hours just to complete the documentation. That 2-3 hours would detract from time in the operating room where residents were learning how to perform neurosurgery and medical students were learning by observing those procedures. That 2-3 hours would detract from time where the senior neurosurgeons would teach imaging rounds and review all of the brain and spine imaging from all of our patients that week.  In short, business practices would have essentially cancelled out most of the teaching on neurosurgery.

My other anecdote has to do with materials available for teaching. At my last teaching position I enjoyed presenting an annual review for psychiatric residents taking the annual “in training” exam. This examination includes questions about neurology, neuropsychiatry, and brain imaging. As an attending physician focused on neuropsychiatry I always had plenty of brain images that were relevant to the practice of psychiatry. With the electronic health record implementation it was relatively easy to download and de-identify those images for teaching purposes. When I sought permission to do that from the medical director at our clinic she stated: “Why would we let you use our images?”  I was stunned because prior to the takeover by businesses, reviewing films even if they were not de-identified was standard teaching practice.

The final anecdote is probably the best. Back in the early days of the business takeover of medicine, the FBI was actually engaged in investigating medical billing and making sure physicians completed the correct documentation template. If they didn’t they could be charged with a crime up to and including a RICO violation. Of course these templates were completely subjective but that is not the way the FBI was treating them. There were several well-known prosecutions of large medical clinics based on the fact that attending physicians were not documenting enough when they supervised residents.  There were no guidelines at the time about what might be involved and so my business people were telling me that I had to document the standard note whether I was working with a resident or not. You can imagine the demoralizing effect that has on a resident when they notice their attending is putting in a separate note every day and their note seems to be irrelevant. When I noticed that happening I suspended all of my teaching of residents because I did not want to insult them just because business and government bureaucrats were telling me what to do. Eventually that guideline was relaxed so that I could go back to documenting that I had discussed the case with the resident but not until considerable damage had been done.

Based on these experiences and more, the opinion piece in BMJ strikes me as another effort to exert top-down control by business interests on the field of medicine.  It is an extension of three decades of failed business initiatives that nonetheless still dominate the practice of medicine in the United States.  Businesses and governments alike are still using the failed strategies. As I pointed out, the same failed strategies have already taken a toll on medical education. And yet these authors suggest that another vague business concept should be applied to medical education.

When I think about my mentors, my colleagues, the residents I have mentored, and what we have all accomplished - we need to keep business concepts out of medical education. We also need to look at the overall strategy and why business authors keep appearing in the pages of our journals. It all seems to be based on the premise that is business managers are experts at everything. 

That is clearly not true in medicine.  They have introduced chaos and stress into the clinical field.  They have already seriously stressed medical education and this opinion piece provides another non-solution that can only be suggested in the context of having wrested control of the clinical practice of medicine away from physicians. 

George Dawson, MD, DFAPA



Supplementary:

I have seen recent psychiatric treatment that may illustrate what happens when business managed settings limit patient contact.  In my current employment, I see a lot of people who are treated with antipsychotic medication, antidepressants, and mood stabilizers for a presumed psychiatric diagnosis.  The medications are started and titrated rapidly.  By the time they see me they are experiencing clear side effects, taking too much medicine, and the diagnosis is not clear.  Hospitalizations today are so short and so focused on doing something in a short period of time that physicians in training have limited exposure to the concept of substance induced psychiatric disorders and how they can be best treated.  That also includes the appropriate detoxification of these patients - many of whom are sent out to social detoxification units unless they worsen and are sent back.  All of this decision making should be part of the knowledge base of psychiatrists and primary care physicians.