Happy Labor Day 2024

 

More labor like I am used to seeing it in the upper Midwest. 

In keeping with the tradition of previous labor days - this is my annual greeting. I started writing these Labor Day greetings as an update on the work environment for physicians.  My rationale is that over my nearly 40 years in medicine that environment has continuously deteriorated.  Like any field there have been obvious improvements and innovation in clinical care along the way.  Even though that has happened the work environment has worsened every year leading to widespread physician dissatisfaction, burnout, and moral injury along the way. 

I was fortunate enough to hang on until about three years ago when I retired.  Compared to working my entire career as an employee - retirement is quite literally a walk in the park. I  stay active in the field by reading, writing this blog, and working on various publications. I get plenty of rest and exercise. I have time for activities that were on hold for decades during my working years. I have not seen or treated any patients in about 3 years. A friend of mine who went back to work told me that he had to work on an inpatient unit for 2 months because the organization he worked for had that requirement for anyone who had not seen enough patients in the past two years.  If you were an acute care psychiatrist like myself that requirement makes little sense. Reading all of the notes and plans from the first week of outpatient practice should suffice.  After all we have a Presidential candidate who brags about passing a rudimentary cognitive screening exam - and he has a briefcase with all of the nuclear missile launch codes. 

I do miss the detailed conversations with people and discussions about how to approach their problems.  In some of the discussion formats there is still controversy about psychotherapy in psychiatry.  The only way I can see this as a real controversy is if we are arguing that all psychiatrists should be psychoanalysts.  I don't think that anyone believes that any more. But it has always been clear to me that psychiatric practice needs to be informed by psychotherapy and that includes psychoanalytical/psychodynamic psychotherapy both on the expressive and supportive sides. Psychiatrists need to be able to talk with people in a therapeutic way across a number of diagnoses and settings.  Psychiatrists need to be able to maintain relationships with people who have a very difficult time maintaining relationships with anyone. Psychiatrists need to maintain relationships with people who are actively avoided by their own families and acquaintances.  The only way that will happen is if a psychiatrist is trained in these techniques.  Without them - a person is just talking with another doctor about medical treatments. 

As I have stated many times on this blog in the past - that type of quality psychiatric treatment takes time.  Taking time away from psychiatrists and their patients is one of the functions of modern healthcare administration.  It leads to the previously mentioned problems in the work environment.  I did an update just before typing this post by searching developments in the physician work environment in the past year.  The same concerns about dissatisfaction, burnout, and moral injury were still there.   There was something slightly more specific on the AMA web site pointing out how Medicare reimbursement is not indexed to inflation and does not cover the expenses.  That leads to higher volume work (something that managed care rationing was supposed to prevent) and in many cases lower quality.  It can also lead to a lack of available care as physicians drop out of Medicare or just have too much low reimbursement work to see new patients.  But that message from the AMA is far from optimal.  It seems to imply that if patients were aware of these problems they would lobby politicians to improve working conditions for doctors.  Patients already know the problems - at least some of them.  I had several patients comment on the low reimbursement I was getting from Medicare for seeing them.  It might be useful if physician organizations like the AMA provided information on how to set up a practice that would maintain financial viability.    

I did try to volunteer as a research analyst.  I was involved in a great research project at the time I left my last employment.  I offered to analyze data for a local large healthcare organization (one of the three largest in Minnesota).  I emphasize again that I offered to work for free on this data analysis and any subsequent publications.  The research project I suggested had never been done in a large healthcare organization - but had been done in registry studies in Sweden and Denmark.  There are no national registries in the United States and all of the data is proprietary.  That company was not interested in me working for free even though I did plenty of free work for them when I was an employee working on research committees.  The only difference was that I still had to generate revenue by seeing enough patients while doing the additional work for free.  That offer still stands for any serious research being done in psychiatry.

That is my brief Labor Day message this year.  It is repetitive because physicians have very little leverage against businesses and governments and that had led to the current work environment problems.  I continue to go to conferences and see a lot of people who I know are still actively working.  From their descriptions they are working too much.  Like me they enjoy talking and working with people.  That is probably how a person ends up in psychiatry.  I wish them well in the coming year and hope for developments that will make their work easier.  And as always - I hope all of my colleagues make it to retirement.

George Dawson, MD, DFAPA

Supplementary 1: I decided to include this graphic from about 4 years ago that I made to indicate how much physician/psychiatrist time is diverted away from clinical care basically to satisfy some administrative requirement.  It should be obvious that has increased greatly over time and although other health care providers are also affected the burden is somewhat disproportionate on the physicians.  As I pointed out - during this time frame I replaced 4 full time employees when I was expected to also do their work.  It is also apparent that a lot of this worked is free for other organizations (managed care organizations, pharmacy benefit managers, etc).  

 

Graphics Credit:  click directly on the photo and it will take you to detailed information on the origins, credits, and CC license on Wikimedia Commons. 

Happy Labor Day 2021

 

This is my annual Labor Day greeting to my physician colleagues. I had to go back and look at last year’s greeting to see if I had factored in the pandemic or not.  It appears at the time that I was fairly enthusiastic about telepsychiatry and its applications during the pandemic. Ironically, I will be giving a presentation on telepsychiatry later this year and in reviewing a fairly massive amount of information my initial enthusiasm has been tempered. Although it appears to have had a semi-permanent effect on the regulatory environment there are still unanswered questions about its optimal applications. How it will be used by the business community is also unknown at this point.

One of the articles I reviewed in New York Magazine - outlined a pattern of questionable business practices at least as it was applied to therapists. Direct interviews with therapists suggested that they were being exploited by being paid much less than their going rate with the expectation that they would be more available after hours and by texting. Preliminary surveys indicate that there are psychiatric clinics popping up looking for psychiatrists to staff telepsychiatry visits. There are many unknowns about their practice. In another article, some employers were asking therapists to see people outside of the state they were licensed and hope that the regulatory environment would catch up with the employment practice. Those are not good signs for the labor environment.

I noticed in my 2020 post that I had an initial drawing of how the practice environment had changed and now that drawing has been expanded and includes many more details. It captures most of what I have endured as employed psychiatrist. I include a graphic below and hope that as physicians we can reverse the trend at some point.

The pandemic has clearly been demoralizing for physicians in general but much more for frontline acute care physicians responsible for COVID-19 patients and their frontline colleagues in nursing and hospital support. There has been a shortage of personal protective equipment (PPE), beds, adequate ventilation, and supportive services. There have been deaths and resignations compounding the personnel problem. As the staffing ratios worsen - the emotional stress is at an all-time high. Local disasters compound the COVID crises in many areas.  All the descriptions I see indicated that the healthcare system will end up permanently altered by this pandemic and probably not in a positive way. There seems to be no effort to incorporate a public health approach into the current subsidized business rationing approach that dominates American healthcare. That is not only detrimental to physicians and their coworkers but also the public health infrastructure in general.

A new dimension to the demoralization has been the misinformation industry associated with the pandemic. Physicians trying to provide information in good faith have been attacked and even threatened by some of the zealots associated with or affected by that misinformation. That includes some of the top experts in the world who have been active in research and teaching immunology, epidemiology, virology, and vaccine production. Physicians are given the message that is up to them to communicate to the zealots and convince them that the pandemic is real, it is a really a virus, and that immunizations are the best approach. There appears to be no convincing a large group of people that wearing masks may reduce viral transmission even though that practice was widespread in the 1918 epidemic in the US and is currently widespread in many parts of the world. Physicians are getting the message that they have to magically find a way to communicate with this group of people who have rejected all of the usual channels.

It seems obvious to me that physicians are the only group that are excluded from empathic communication. The expectation is that physicians will be all-knowing, all understanding, and that somehow will correct most of the anti-vaccine, anti-science, anti-expert, and anti-COVID sentiment out there. I think that is a fairly naïve approach and what physicians need is concrete help from politicians, community leaders, and regulators.  Social media is gradually coming around but has responded at a glacial rate. 

I also notice in my greeting from last year that I commented on an APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the US.  I saw no further action and that and was not able to find it in a search. That potential bright spot maybe on hold due to the pandemic, a lot also depends on the conclusions if they are available.

Progress against the burnout industry has been maintained but it is clearly a war of attrition. Physicians in general reject the idea that burnout is due to some inherent personal deficiency and are more likely to see it as the real product of an unrealistic work environment. In many cases that unrealistic work environment has increased many-fold due to the pandemic and all of the associated problems. I hear from physicians every day who are able to exercise minimal self-care due to overwork and limited time away from work. Weight gain is common due to unhealthy diet and no time for exercise. A solution for some has been to leave those work setting behind even if it means early retirement or taking an undetermined period of time off. Many physicians who could easily have worked into their early to mid-70s are retiring at age 65.

Employers seem to be doubling down in this adverse environment. I quit my last job in January 2021. Since then, I have been actively looking for new positions. There has been a recurrent pattern of highly leveraged job descriptions, that I would accept only if I really needed employment. By highly leveraged I mean that the job description contains anywhere from 20 to 30 bullet points, the majority of which have nothing to do with being a clinical psychiatrist. To cite one example, many of the applications describe a “leadership role” where the really is none. No organization that I am aware of wants a frontline clinical psychiatrist to attempt to correct their obvious administrative problems. I received a cold call one day from a recruiter who asked me if I was interested in a “very good” inpatient position. I asked him what the productivity expectations were and he said I have the options of seeing 18 or 22 patients per day. He quoted a disproportionately greater premium for seeing 22 patients a day. He seemed convinced that I would accept the position until I asked him “When am I supposed to live or sleep?” I had the thankless job of covering inpatient unit of 20 patients for an entire year with the help of an excellent physician assistant and that almost killed me.

The unrealistic expectations being placed on physicians are still out there and they are as bad as they ever have been. It is why I used a heavy lifting graphic for this post again. Despite the pandemic the business leverage against physicians is not letting up and that is not a good sign. To make matters worse, there always seems to be room for it in the medical literature. The latest example I can think of is a recent essay in the New England Journal of Medicine claiming that digital healthcare fee-for-service payments are unsustainable and there must be a capitated system. That seems to be part of the master plan to continue a rationed-for-profit system that guarantees over-employment of bureaucrats and business managers as well as corporate profits at the cost of treating physicians like highly paid laborers as depicted in the above diagram.

I don’t think physicians will have any reason to celebrate Labor Day, until that rationed- for-profit system is dismantled.  Until then do what you need to do to take care of yourself and survive. Help from professional organizations would be useful, but there are too many conflicts of interest for that to be realized.  I am still hopeful that we can get back to the stimulating clinical environment of the 1980s, but I will be the first to admit - there is no obvious path back in the face of a trillion dollar healthcare rationing business - largely invented by Congress.

 George Dawson, MD, DFAPA

 

Graphic Credit:

Robert Yarnall Richie, No restrictions, via Wikimedia Commons. "Workers Adjusting Tracks, Texas Gulf Sulfur Company."

Happy Labor Day 2020

Over the years that I have been writing this blog - I have written a Labor Day greeting to my physician colleagues generally documenting the lack of progress on the work environment. This posts range from discussions about the importance of knowledge workers and their characteristics to how physicians are treated. The most important one of those characteristics is that they cannot be treated like production workers. That is of course the way most physicians are treated these days and it is not a new development. Another important dimension has been the intrusion of business interests on the physician-patient relationship. Those business interests rationed the level of care in order to make corporate profits and prevented physicians from providing the best possible care. All of these intrusions happen across the board but my particular specialty is affected more than others. I learned just this year that when managed-care companies decided to target psychiatry 30 years ago, their goal was double their stock price. No access or quality goal - just more money in the pockets of shareholders and company officials. The end result has been a seriously eroded practice environment, decreased access, County jails being used as psychiatric hospitals, lack of availability of substance use treatment and detoxification, and very brief hospital stays where hardly any treatment is provided or the patient ends up being committed and staying far too long on a short stay unit that almost resembles a jail. None of this is good news for laboring physicians and none of it is changing. 

There was one recent bright spot. The headline in Psychiatric News on August 21 announced that the APA Presidential Task Force on Assessment of Psychiatric Bed Needs in the United States had been created by Jeffrey Geller, MD, MPH the president of the APA. Dr. Geller correctly identified a current “public mental health crisis” but he failed to describe its chronicity. There are apparently 30 members on this task force and they will be delivering a white paper in December that “includes a workable model for determining hospital bed needs within a community that can be refined and updated over time”. There are six subgroups including a modeling subgroup. There is a panel describing “how we got here” and stating “inpatient care falls prey to economic forces, ideology”. Nowhere in the article did I see the words “managed-care”. Instead - I see a number of managed-care friendly quotes especially from the panel. The APA has a long history of task forces and boards with so many conflicts of interest that either nothing gets done or something gets done that is in direct opposition to the needs of clinical psychiatrists who go to work every day and typically have to tolerate a very difficult work environment. 

I have written about how other groups have assessed the bed problem. An obvious but innovative way is to look at the beds necessary to prevent committed patients from staying long periods of time in acute care hospitals, the beds necessary to prevent emergency department bottlenecks, and beds necessary to prevent patients with obvious severe mental illness from being incarcerated for minor offenses. Another obvious deficiency in practically all cities is treatment for substance use problems. We need acute detox and people are often sent to a nonmedical detox unit until they develop medical complications. Adequate environments to accomplish all these tasks are needed and support the physicians doing it are critical. I will be interested in the eventual white paper but considering the APA track record against 30 years of managed-care, utilization review, and prior authorization I am not optimistic at all. 

I can’t let this catastrophic year slide without commenting on telepsychiatry. As readers can tell from my previous posts I am fairly enthusiastic about it even though I do prefer talking to people in person. I also take my own vital signs and do brief examinations as necessary and that just can’t happen over a computer network. I suppose there are people who have much better integration with the EHR, clinical systems, and electronic prescribing than my current system and I think that is where hope lies. I have three state-of-the-art computers that are much faster than medical software I am using. There are still plenty of glitches and communication problems that need to be solved but I am hopeful that they eventually will be. There is an associated regulatory burden and that is a wildcard when the pandemic recedes. Specifically will there be a rollback and telemedicine and less development. I am hopeful that better systems and more integrated systems will evolve to the point that there are no delays and the physician work environment is much more seamless. Like most things that physicians deal with we still have to dedicate our time to support software that is supposed to be supporting us. 

The tide has turned on the burnout industry. I am seeing more and more colleagues not accepting blame for their burnout. Burnout is not a yoga or meditation deficiency. It is a direct product of an inadequate and at times hostile work environment. The pandemic highlighted many deficiencies and many questionable administrative decisions. Maintenance of Certification (MOC) and Maintenance of Licensure (MOL) - still loom largely in the background. Dr. Geller has apparently stated one of his goals is to get rid of MOC but I will believe it when I see it. I recently read a document that the APA gets to million-dollar year payment from the American Board of Psychiatry and Neurology (ABPN) - the MOC body. That is a significant conflict of interest from the membership perspective. The ABPN is currently collecting $500/yr from all of its certification holders in additional to fees necessary to access required reading. If 30,000 psychiatrists are paying these fees every year, that exercise generates $150M for the ABPN very ten years. There is no evidence anywhere that investing this significant time and effort produces a superior psychiatrist. The ABPN response is” “The public demands it!” In fact, the public still doesn’t know the difference between a psychiatrist, psychologist, or nurse practitioner. Burnout will end when physicians can stop doing the work of billing and coding specialists, typists and other clerical workers, IT workers, and surrogate employees of pharmaceutical benefit managers and managed care companies. No physician can be expected to do all of that additional work and work a full time stressful job. That is the real unstated problem of burnout. 

 Is there a high ground left for psychiatrists? I have often closed a post with the statement that: “Psychiatry needs to be focused on innovation and the future. The best position to be in is looking at everyone else in the rearview mirror?” Is there still a way to do that? I think that there is. A survey of many of my posts on this blog focus on what is really irrelevant criticism from the past. I have lived through the era of the biological psychiatrists versus the psychotherapists. I have lived through the era of brainless versus mindless psychiatry. I have survived the Decade of the Brain. It seems that both our detractors and internal critics tend to focus on false dichotomies or irrelevant history from the past. The way forward is to stay focused on modern theories and forget about the rest. 

 What will that take? I would suggest – a firm shift to an all-encompassing view of the field that makes us more resistance to petty criticism but at the same time more focused. When I say focused -  on clinical care, research, and theory. We have at least two models of that as elaborated by S. Nassir Ghaemi (1) and others. The most modern all-encompassing theory comes from Kandel as interpreted by Ghaemi (1). In his book, Ghaemi makes a compelling argument for pluralism as the defining approach in psychiatry over eclecticism and the biopsychosocial model of Engel. Pluralism essentially means that multiple methods are necessary to treat mental illness and that there are no single methods that will work. He cites several traditional theories in psychiatry about how to diagnose and treat mental illness as well as the theorist who suggest more than one approach is necessary. He provides a checklist (p. 308) to determine if you might be a pluralist. It contains questions like: “Can you accept the absence of a single overarching theory in psychiatry, yet also reject relativism and eclecticism?” Thinking about that question I don’t know why psychiatry would be different from the rest of medicine. Is there a single overarching theory in medicine? Why would we expect to see it in the most complex organ in the body? He is clear that he sees psychiatry stuck at the point of dogmatism and eclecticism.

He describes integrationism as an approach that removes the barrier between the mind and the brain as opposed to pluralists believing that there may be some differences between the mind and the brain. Integrationists believe that the brain is required for mental phenomenon but not sufficient. The brain can affect mental phenomena and mental phenomena can affect the brain. It is reminiscent of emergent properties that consciousness theorists tend to talk about. Stochastic factors or genetic factors in the brain that randomize expected behavioral outcomes may also prove to be important at some point. Ghaemi outlines a 5 principle integrationist model of psychiatry that looks at all mental processes/mental disorders being derived from the brain, the effect of genetic and environmental factors on the brain and these processes, and the effect of both biological and psychological treatment affecting the brain through mechanisms of brain change. 

 Although this all sounds fairly basic at this time – it is not. The discovery of brain plasticity or experience dependent changes in the brain was a major revolution in seeing the brain as a dynamic organ that could be altered easily by practicing the violin or lifting weights or talking to a therapist. There are ways to measure these changes. Everyone trained as a physician and a psychiatrist – sees the effects of structural changes in the brain from observing the effects of trauma, various brain diseases, and global brain dysfunction. An integrationist approach is practically intuitive but the model is not widely taught as the basis for clinical work. With that model there would be more uniformity in clinical approaches to the patient and standardization of clinical care. Patients could expect more than just a discussion of medication for example. They could expect psychotherapeutic discussions along with the medication and possibly more time and more visits with their psychiatrist. Instead of the rare research paper discussing this type of session – exchanges about it and innovation would be commonplace. It would also help to establish the necessary environment (physical, administrative support) for this kind of work to be done. 

Labor Day is a reminder for me that where we labor and what we can do for our patients is meaningful. A better work model might help that irrespective of political success in changing the system or not. The work model itself can also be invigorating if it includes elements of clinical work and basic science and helps us to make continuous sense of what we are seeing and expected to treat. 

George Dawson, MD, DFAPA

References: 

1.  S. Nassir Ghaemi. Concepts of Psychiatry – A Pluralistic Approach to the Mind and Mental Illness. The Johns Hopkins University Press. Baltimore; 2003. 

Graphic Reference: 

Carpenter, F. G. (ca. 1920) Paris, France. France Paris, ca. 1920. [Photograph] Retrieved from the Library of Congress, https://www.loc.gov/item/2001705736/. No known copyright restrictions.

Happy Labor Day 2019

I decided to keep posting a Labor Day greeting to my fellow physicians. I’ve been doing this since 2013 and previously linked to all of those pages. Now there is a search feature in the upper right corner of this blog and you can just search on Labor Day if you are interested. My post this year is truncated based on the fact that very little has changed since my fairly comprehensive post 2018. If you will look up that post I comment on physician productivity, the EHR, pharmaceutical benefit managers, managed care and health insurance companies, maintenance of certification, and burnout in some detail. The advances in these areas have been too trivial to comment on in terms of either progress or the chronic lack of progress. I am sure that some organizations would like to debate that. The APA for example would point out that a health insurance company was successfully sued for failing to reimburse care for mental illness. The judge in that case actually made some fairly critical remarks directed at the managed care company, but on a day-to-day basis the average psychiatrist and the patients they are treating notice nothing but continued oppression.

Psychiatrists and their patients traditionally have fewer resources than other physicians and standard medical and surgical care. The overwhelming signs of this include jails being used as psychiatric holding tanks (I refuse to consider them hospitals) and the ongoing bed shortage. That bed shortage leads to overcrowding in emergency departments and a tendency for patients with mental illness to be the only ones discharged untreated from emergency departments. That often happens after they’ve been held there without treatment for days at a time.

There is something basically wrong with a government and political system that refuses to provide humane and equitable care for people with mental illnesses on the one hand and blames them for societal problems on the other. Just earlier today in the context of yet another mass shooting I heard the President describe the perpetrator as being “very mentally ill”. This occurred after a recent visit to the White House by a National Rifle Association representative. During that visit the president was talked out of advocating for universal background checks and the party line became “blame the mentally ill for mass shootings”.  It appears that the executive branch has a red line that they won’t cross when it comes to rational gun policy and a second red line that they won’t cross when it comes to providing equitable treatment for people with mental illness and addictions.

I think that is a relevant Labor Day observation for physicians because these irrational policies affect all of us. As psychiatrists we see very mentally ill people go in and out of hospitals and administrators pressure us to get them out before they are stable.  They are typically discharged to minimal outpatient services. We experience the tension of trying to get people off of inpatient medical and surgical units or out of the emergency department to appropriate psychiatric settings when there are none. Our physician colleagues feel that pressure. We all recognize that we were not taught to treat people this way in medical school. The only reason we do is that physicians no longer control the practice of medicine. Business administrators and people with no medical qualifications do control the practice of medicine. I repost the graphic here that was sent to me by David Himmelstein, MD who also gave me permission to use it on this blog.  Just getting rid of all of that bad management would result in saving a trillion dollars and bringing US health care costs in line with the country with the second highest per capita costs - Switzerland. 

It is clear to me that the problem with the physician work environment - the place we all labor intensely for too many hours - is a problem with administrators. Never before in the history of medicine have we had so many administrators telling us what to do. The graphic clearly illustrates that.  As working physicians we all know what that means.  We know it means when an administrator suddenly has a “great” idea that is not based on science or medicine and we all have to live with it for months or years. We all know what it means when a group of administrators suggests that we are not getting patients out of the hospital fast enough even when they are still ill.  We know what it means when we have a lengthy meeting with administrators for our “input” only to learn that they didn’t really want our input they just wanted to tell us how things were going to be for the rest of our career. And if you are as old as me, you might recall a time when medical departments were run by physicians and they had business managers who took care of business. In those days there were clear boundaries between medicine and business - not like it is today.  We are well past that point now.  The practice environment is a boundaryless morass of business people telling physicians, pharmacists, and patients what to do.  The rationale for this morass (cost containment) is no longer visible - probably becuase this model has failed miserably. Instead there are massive costs and a massive transfer of those direct costs to patients and indirect costs to physicians.

It has also resulted in the lowest possible quality of care.  The quality of medical care and how that is measured became a secondary consideration when businesses took over medicine.  A clear example is the treatment of depression on an outpatient basis. One of the standards promoted by the managed care industry is measurement based care using a scale like the PHQ-9 for ongoing assessment.  Unfortunately this process lends itself to using the measurement as a diagnosis and rapid route to treatment with antidepressants. Several approaches to depression including subsyndromal depression in primary care settings are ignored and PHQ-9 scores are followed as a measure of quality improvement.  This is the type of gross oversimplification that occurs when clinical medicine (1) is ignored in the context of businesses claiming that their measurement process is superior.

These inefficiencies in the day-to-day work of physicians are presented as improvements that we should all be happy to go along with.  In many cases administrative catch phrases like: "Change is good" accompany the poorly thought out and unscientifically implemented policies. The practice environment for physicians will only improve if the  bean counters no longer run medicine.

Until then Labor Day will be just that.

George Dawson, MD, DFAPA




Reference:

1: Arroll B, Chin WY, Moir F, Dowrick C. An evidence-based first consultation for depression: nine key messages. Br J Gen Pract. 2018 Apr;68(669):200-201. doi: 10.3399/bjgp18X695681. PubMed PMID: 29592945

Happy Labor Day VI

I missed my Labor Day message last year for some reason.  I must have been too burned out.  Burnout has been a big theme in the physician  community in the last several years.  It is almost like it is a new discovery or another new epidemic.  Now we have detailed comparisons of degree of burnout by medical specialty and even some country to country comparisons.  The curious phenomenon about burnout is how physicians are blamed for it.  The typical intervention is to have a "course" on how to "handle" burnout.  You know mindfulness, meditation, yoga, and time management.  There is never any focus on the fact that physicians just work too hard because they have to work free for so many people.  Managed care companies, pharmaceutical benefit managers, government bureaucrats at various levels, and their own employers have come to expect that American physicians have nothing better to do than devote their time and energy to the betterment of those collective businesses.  By that metric physicians are the most exploited employees in the USA.  There is no other group expected to work for so many businesses for free.

Don't get me wrong.  I am not saying that physicians are not paid well.  I am saying that according to the studies I read they are being paid for anywhere between 50-75% of the time they work.  Even the time that they are being paid for is deeply discounted.  What other group of professionals in the USA is expected to work on an arbitrary productivity scale that varies greatly from payer to payer and has a superimposed global budget and federal incentives and penalties superimposed on top of that?  Only physicians work in that environment.  Only physicians are expected to teach future medical professionals for free.  Another one of those cases where the the term "professionalism" can be marched out and used against you.  An example:  "You can just pick up this course for the medical students or residents.  It should not take much time and I know you like to teach.  They want you to teach."  The next several weekends (whether you are on call seeing patients or not) will be devoted to to coming up with PowerPoints.  Lectures and seminars in medicine these days don't happen without the ritualistic exchange of PowerPoints.  In the process PowerPoints get blamed.  I actually like PowerPoints if they are done correctly.  I think they are unfairly blamed when the burden to suddenly produce them is displaced onto the medium rather than the process.

But the focus of my missive today is not burnout or the root cause of excessive uncompensated work.  It is one of the sources of uncompensated work and that the the electronic health record (EHR).  The attitude toward the EHR has shifted in a direction that I have promoted for over a decade.  When the group I was working for was presented with the EHR and trained on it, I knew it was a problem from the start.  We were moving from a hospital wide system that was basically for entry of medication orders by health unit coordinators, vital signs, labs, and nursing notes.  All of the progress notes were dictated or hand entered. At the end of the day I printed out the MAR (record of medications given) for each of my patients and double checked all of the medications they were getting.  The MAR was a single page table showing all of the medications in the left margin and day columns to the right with times of administration.  It was all dot matrix printing - so not as stylish as modern printouts.

Back at the time when politicians were overhyping the EHR and how it would save the health care system hundreds of billions of dollars - I did a little experiment with one of my new hospital admissions.  I decided to read all of the outpatient medical notes to see how many significant medical diagnoses were being carried over in the EHR.  At the time we were online with the new system for about 8 years.  It took me 4 hours to find and read all of the notes from Internal Medicine, Endocrinology, and Cardiology.  There were 236 notes in all. But in the end I noticed that 10 significant diagnoses had been dropped somewhere along the line.  Nobody ever seems to want to acknowledge the complexity in medicine.  As people get older they accumulate an incredible number of medical problems and in some cases the only indication is a very long list of medications that they are taking.  They have been seeing an equally long list of physicians truncating that list of diagnoses because of time constraints.  In the EHR you eventually end up looking at a very short list and need to reproduce a comprehensive evaluation from scratch.  So much for the time savings of the EHR.  Even the politicians are quiet on that one for now.

A new EHR experiment happened to me just recently.  I still treat medically complex patients and often receive them from acute care hospitals where they may have been in intensive care units.  Since many of them were taking various psychiatric medications, I felt obligated to see what the intensivists, cardiologists, pulmonologists, and gastroenterologists all had to say about these medications and whether they complicated critical care or ongoing care of the chronic medical problems.  I want to see the results of ECGs, labs and imaging studies.  I want to know if the patient received any of their usual medications when they were in the ICU or general hospital.  Before there was an EHR all of this information was contained in about 10 very readable pages consisting of the admission note, discharge summary, MAR, and a couple of sheets including the actual ECG tracing and lab reports.

For the event in question I read through the EHR printout.  It was 48 pages long.  It contained limited data.  Blood pressure trends and readings were not printed even though that was one of the critical parameters being followed.  The physician notes were jumbled paragraphs considerably less that traditional reports.  The bulk of those notes consisted of checklists and imported data in different fonts and margins.  The appearance was chaotic.  Who uses 14 point Courier font in documents these days?  I haven't seen that since the days of the telegraph.  In that entire 48 page document there were about 6 lines in a cardiologist's note that made sense so I locked onto those for my report.

I was less optimistic about Phase Two.  I have been working in my current position for about 7 years and during that time I have requested MARs on hospitalized patients about 50 times.  I have received exactly zero.  In this case for some reason it went through.  I received a 60 page fax that was the MAR.  The patient was critically ill and delirious at one point, so there were five different infusions used in intensive care spread out across many of the pages.  The composition of the solutions were listed and the specific rates of infusion.  If I wanted to know the exact amounts that the patient received - it was up to me to figure it out.  Two critical factors from the MAR that were not evident from the EHR printout.  First, the patient was much more critically ill than described in the EHR printout.  Second, none of the maintenance psychiatric medications were given.  Total time to figure all of this out - 60 minutes.  In addition to the read of the EHR printout and interview - total time for the evaluation and report was 2.5 hours.

It is impossible for physicians to do a good job of patient care without all of the material I reviewed in this case.  On the other hand, there are few places in the USA where the physician has 2.5 hours for each new evaluation.  That is how you end up with truncated problem lists, partial medical care, and physicians staying in clinic 3 hours after everyone else has left.  Without the data there is not enough information for the physician to have a decent informed consent based discussion with the patient on the new set of risks associated with a critical illness.

The real culprit here is the fact that physicians have lost control of their profession.  We have had an overhyped, inefficient, ridiculously high-priced piece of software foisted upon us by politicians and the businesses that they support.  It is really no better than personal database software that I was using in the 1990s and that software produced a more readable and coherent report.  The only reason the software works at all is because there are a million physicians out there with work arounds and doing the uncompensated hard work necessary to keep it afloat.

There is no better topic to comment on this Labor Day.  This is my wish to all of my colleagues trying to avoid repetitive stress injuries from the mouse clicks and typing necessary to support EHRs everywhere (I had to switch to my left hand about ten years ago).

Happy Labor Day!


George Dawson, MD, DFAPA          


Attribution:

Picture is Titian's work Sisyphus in the Public Domain from Wikimedia Commons at https://commons.wikimedia.org/wiki/File%3APunishment_sisyph.jpg


         

Happy Labor Day IV

This is my fourtth Labor Day writing this blog and it is my custom to summarize the work environment for physicians like I did in Happy Labor Day I, II, and III.  Things have not improved very much and there was a timely piece by an anonymous physician filed on another blog entitled Confessions of a Burnt Out Physician.  That post is full of anecdotes about physicians being managed like production workers and to the point of not even having an adequate work space to conduct work that requires focus and confidentiality.  Another key element of managing physicians is to make sure that their days and nights are filled with the modern equivalent of paperwork - e-mails and charting that is read by nobody except the occasional coding and billing staff.  If that is not demoralizing enough, there are always the suggestions that physicians are not doing enough, even though they are easily in the hospital for 4 or 5 hours after all of the business people are long gone.  This can all be handled masterfully.  As an example, the RVU productivity system was in many cases introduced to physicians as a system of "fairness".  That is - the idea that everyone has to pull their own weight.  That works very well in any environment of competitive physicians.  It was dovetailed in nicely with multimillion dollar lawsuits by the Department of Justice that were based on charting.  Now physicians could be fined or imprisoned if their documentation was not up to snuff.  And of course the Department of Justice wanted every physician in this country to know that any discussion of fees was a potential antitrust offense.  When all of that business rhetoric had settled out, the only things that really changed was how easily physicians could be manipulated and overworked while their professionalism was completely ignored.  Apparently none of us knew how to work or act before managed care came along.

There have been some additional business innovations in the last year to make physician's lives even more difficult.  I read another blog recently where the topic of physician managers affiliated with Big Pharma were desired to bring money into departments and how that and key opinion leaders (KOLs) from that field was a key corrupting influence in medicine and psychiatry.  That influence is trivial compared with the business influences on medicine and their adverse effects.  Excellent clinicians, teachers and researchers now need to get an MBA before they are considered as a department head.  A managerial class that is progressively less competent to manage may be an acceptable business standard but it seems like an extravagance in medicine and one that has cost us hundreds billions of dollars and untold unnecessary work for physicians.

Furthermore, we know what works in terms of physician management.  I worked in tens of departments where the department head was a physician who was in that position because of skills pertaining to clinical care, teaching and research.  That doesn't mean that they were necessarily easy to get along with, but in teaching institutions their skill set was on display every day.  That model transitioned to one where a physician and an administrator of some type both co-lead the department.  The physician leader was still affiliated with physicians in the field at that point and could feel their pain.  The next step was removing any physician with those alliances from an administrative position.  In many cases, this meant people who had no hesitation to manipulate physicians either by a "It's my way of the highway" attitude,  making the environment so hostile that they forced selected dissenting physicians to quit, or after pretending that the physicians had some input (usually through endless mind-numbing meetings about the business) simply telling them that no matter what their opinion was - this was what would be happening.  Throughout the process there was an endless stream of "Change is good", "Cost effectiveness", and "Managed care friendly" propaganda.  But it didn't stop there.  Managed care run institutions have an entire cadre of case managers whose primary job is to "manage" physicians and make sure they are discharging people according to the companies proprietary standards.  If there are any disagreements that low level administrator can easily go up the change of command to get decisions in their favor or identify physicians who are not in lock step with the company.  Everywhere within these organizations there are rules about identifying "disruptive physicians" and penalizing them.  I am not talking about doctors throwing scalpels across the operating room.  The threshold can be so low these days that a "disruptive physician" is anyone who gets into it with an administrator for any reason, including legitimate disagreements.

The effect on the psychological environment of physicians has been corrosive.  Within a generation we have gone from a training environment where medical students and residents could identify with senior physicians who embodied professionalism and an intellectual approach to medicine to managed care employees who use a business approach.  Instead of rounding on patients and learning the importance of medicine as a life-long intellectual pursuit, trainees are focused on the business manager's pursuit of getting patients out of the hospital so that corporate America can keep making money by easily beating the fixed reimbursement scheme set up by the government.   The business rationalization has always been "of course we need to make money to keep the doors open", but that never addresses the trade-offs.  In this case the trade-off is no relationship or plan to assist the patient.  In the case of patients with psychiatric disorders, there are inadequate inpatient and outpatient services, both due to business rationing to maintain profits in a rationed and cost-shifted world.  In many cases health care systems have carried these plans to their absurd conclusion - just close any inpatient beds, close the outpatient clinics, and hope that some taxpayer funded clinic or jail can pick up the slack.  The typical health care manager has an endless stream of bad ideas.

Are there any bright lights on the horizon?  I think that there are.  I would count the movements against the medical specialty boards and the proposed maintenance of certification (MOC) programs.  It is very positive that physicians are standing up and saying that they are unnecessary, not evidence based, and a tremendous waste of time, money, and resources.  More importantly all of that stress falls squarely on overworked physicians.  There is now at least one parallel certification organization that depends primarily on initial board certification and then continuing medical education courses - the historical standard.  It will take a significant commitment, especially from younger physicians to keep this movement alive because it is just a matter of time before credentialing committees for clinics and hospitals will be putting the squeeze on their physicians to use the labor intensive MOC programs.  There is also the question of medical boards.  Will they require MOC for maintenance of licensure (MOL)?  Only time will tell, but like all things American - the bet is on the oligarchs and that currently is everyone making a lot of money out of managing physicians.  At some level that includes professional organizations populated by members who are very friendly to the business world.  If anyone doubts the benefits to professional organizations, just visit the American Psychiatric Associations Learning Center and the MOC offerings.  If the monopoly can be broken, it suggests that physicians may have the ability to counter the business and government strategies that keep what is basically an anti-physician system afloat.  Business strategies have nothing to do with the practice of medicine.

Another bright light that I neglected to comment on initially is the young psychiatrists going into private practice.  At first I was reluctant to endorse this idea, primarily because it contrasts so starkly with my experience in community psychiatry, acute care psychiatry, and general hospital psychiatry.  I was concerned that there would not be enough psychiatric expertise to care for very ill people.  But in conversations with many young colleagues they are some of the brightest, happiest, and enthusiastic physicians that I have seen.  The reason I am given by these docs is that they decide who they are going to see and what their schedule is and not some administrator.  They decide what their clinic policies are and not some administrator.  Some of them have worked in managed care settings and had the courage to walk away after the standard "performance evaluation", especially when it had become an exercise in a loyalty oath to the company and trying to dredge up anonymous critical remarks from coworkers.  My opinion on this private practice trend is that it is a good one.  Any person consulting these folks is going to get recommendations based on quality psychiatric care and not proprietary managed care guidelines.  They will also be talking with a psychiatrist who has not seen ten other people before them and one who has the energy to focus on their problems and possible solutions.  Some of these private physicians also spend days in community mental health centers and on community support teams - treating patients with severe problems.      

So my fourth Labor Day message is slightly brighter than the last three, but not much.   I have to say that there are a few of us around yet who know exactly what happened and what is possible -  and I feel your pain.  If you feel up to it post your anonymous story here.


George Dawson, MD, DFAPA

Happy Labor Day III

This is the third Labor Day of this blog.  I usually take the opportunity to mark the lack of progress in the physician work environment and this year is not much different.  All of the usual corporate and government buzzwords being promoted to suggest why physicians need to be managed by somebody who knows nothing about medicine.  All of the hype about computerization and how the grossly overpriced electronic health record will save us all, even as the printout from that record looks less and less coherent.  I just read a copy of The Institute from the IEEE on Big Data.  From that report:

"It's is estimated that the health care industry could save billions by using big-data health analytics to mine the treasure trove of information in electronic health records, insurance claims, prescription orders, clinical studies, government reports, and laboratory results.

Analytics could be used to systematically review clinical data so that treatment decisions could be based on the best available data instead of on physicians' judgment alone...."

The state of current electronic health records as the worst value in the information technology sector is is probably not too surprising given the above observations or the following:

"Instead of seeing only 20 patients a day, doctors are able to see 75 to 100 people and get ahead of the wave..."

I don't know what kind of doctor sees 75-100 patients a day or what the quality of these visits is, but I have never met a physician who wanted to see that many people in a day and wonder if it would not trip a billing fraud flag somewhere in the CMS data base.  I have talked with many physicians who were overwhelmed by coming into the office and having 200 tests to review and sign an additional 30-50 orders in addition to seeing 20 patients that day.  We are decades away from any machine intelligence being incorporated into the medical record.  The current EHR has destroyed the narrative, especially in psychiatry and converted the basis of care to a checklist.  Instead of higher order machine assisted decision making the electronic health record has not resulted in the expected savings or utilization of technology.  Paying tens of millions of dollars in licensing fees per year and larger IT departments with thousands of PCs running 24/7 to access the sever farm has not produced a nickel of savings and has added large recurring costs.

So I have not noticed any striking improvements in the practice environment.  At the same time, it is at such a low level that it is difficult for me to say that it has deteriorated any further.  The American Psychiatric Association (APA) the largest professional organization for psychiatrists still supports collaborative care - a managed care model of psychiatric care that in some cases eliminates any direct access to psychiatrists.  The American Medical Association also seems managed care friendly largely due to their support of the PPACA.  Both organizations support the onerous recertification process mandated by the American Board of Medical Specialties.

The only bright spot I can think of this year was being seated at the same table with 3 younger colleagues at at a Minnesota Psychiatric Society CME event.  They had all been practicing for 10 years or less.  They were all in private practice to one degree or another.  They were all women and although I haven't seen it studied I think that women may have a greater skill level (at least relative to men of my generation) in setting up and managing a private practice.  I was quite interested in their experiences and they listed all of the positives.  The overwhelming positive that I took away from that meeting was that their practice environment was very positive because they ran it and had eliminated all of the toxic administrators along the way who were supposed to manage them.  They did not have to tolerate the notion that just because they were an employee that they suddenly needed supervision from somebody who was not qualified to supervise them.  Near the end of our conversation they tried to talk me into going into private practice myself.  I have always been an employee, but my current vocational trajectory has been predicated on fleeing toxic administrators.  I gave the usual excuses about being one bad cold away from retirement and an old dog not being able to learn new tricks.

If I was starting out today - I would only be working for myself and I would try to design the practice to reflect my interests in neuropsychiatry and severe mental illnesses.   Any resident reading this should consider this career path.  The decision may be as easy as contemplating seeing 75-100 patients a day and meeting with an administrator who suggests that you could see more.

Happy Labor Day to any physician reading this whether you are in private practice or on the assembly line in a clinic or hospital somewhere.  And good luck to physicians everywhere in avoiding unnecessary administration.


George Dawson, MD, DFAPA

Kathy Pretz.  Better Health Care Through Data.  The Institute September 2014.  p 6 - 7.

Happy Labor Day II - To All of the Docs on the Assembly Line

Last year I posted a Labor Day greeting to all of the docs laboring in American medicine.  I used the assembly line metaphor for obvious reasons - physicians were no longer being treated like knowledge workers but were being treated like assembly line workers.  Circumscribed patient visits were the widgets.  In the case of proceduralists the procedure was the widget.  One of my friends referred to himself as a "scope monkey" based on the expectation for the number of procedures he was supposed to produce every year.  Have there been any substantial changes in the last year?

The bad news is that there have not been. Managed care continues to consolidate its monopoly.  The final product under the Affordable Care Act (PPACA) will result in unprecedented leverage on the part of that industry over physicians and patients.  I often compare the healthcare industry to the financial services industry when it comes to an example of government determined monopolies.  The 401K is a great example of how this works.  The 401K was sold to the American public as a great way to save for retirement.  When the choices in 401K were limited it was sold as a way to simplify the 401K for most people.  The truth about 401Ks is that they have not been a very successful investment vehicle.  They put trillions of dollars of retiree savings at risk and the fees they charge are even more outrageous than medical fees.  I just looked at a bond fund prospectus this morning that shows on an investment of $10,000 I could expect to pay $1,000 in fees every 10 years.  Considering that there are about $9 trillion dollars in 401Ks and IRAs that generates about a trillion dollars in fees (about $90 billion a year) for the financial services industry.  Those fees are generated independent of the general goal of retirement funds - actually having money for retirement.  My prospectus has the usual disclaimer: "The value of your investment in the fund can go up or down.  You can lose money by investing money in the fund."  As many baby boomers found out that can be 30-40% of your principal.

How does managed care compare?  The most interesting game has been the idea that all fees will increase substantially with the implementation of the PPACA.  This bill allows for unprecedented merger and efficiencies.  It allows for only 80% of the health care premium to be devoted to the actual provision of health care services.  It is logical to assume that a greater percentage of the health care dollar devoted to health care would also decrease premiums.  There will be significant hidden savings associated with a model of care that is integrated and minimizes the amount of physician billing.  Insurance company rhetoric suggests that provided additional services to the uninsured with no limitations on pre-existing conditions will more than cancel out the monopoly advantages.  If that was true why lobby for large monopolies?

One of the indicators to me of just how much leverage the managed care industry has is the expected out of pocket costs for a retired couple on Medicare.   That number is currently $220,000 not including nursing home costs.  That is roughly more than four times the average retirement savings for most Americans.

The financial services industry and the medical industry are basically government mandated hidden taxes on the American people.  In exchange for that huge subsidy we get an industry that charges us significant fees to place our retirement funds at risk all of the time and another industry that rations health care and charges whatever they want in order to make money.  In the case of the medical industry the overriding philosophy is not consistent with an enlightened approach to employees that probably know a lot more about the provision of quality medical services than the administrators.

That conflict of interest is central to the deterioration of the practice environment and a diminished focus on quality care and a continued focus of the study and academic aspects of medicine.   Having medical care dictated by administrators using business guidelines or managed care reviewers using the same approach is demoralizing.  Unless this conflict of interest is adequately addressed - the focus of health care will be turning out widgets.  Only the widget producers will be valued.  Administrators making arbitrary decisions run the whole show.

All of this remains decidedly grim in terms of the practice environment where most physicians work.  It is only fair to consider some solutions.  I will try to avoid the political decisions I have advanced in APA and other medical forums over the past 20 years.  Physicians are uniquely oblivious to the fact that the science of medicine is routinely trumped by business and politics.  Are there any possible solutions?  For many years private practice was always considered an option.  With the PPACA that route will be more difficult because the solo practitioners and groups will probably be off the network and professionally isolated, but some will be able to practice in this environment.  There is still niche work where physicians can be paid professional salaries and still have adequate time to complete all of the administrative tasks and focus on quality work, but they are rare.

A single exciting model that I think can disrupt the usual managed care and government restrictions that I expect to flow from the PPACA comes from the University of Wisconsin and their Memory Clinics approach.  This is a statewide network of clinics focused on providing state-of-the-art and quality care across a number of settings.  Guidelines, continuing education, and consultation is provided from a University based department and there is a minimum requirement for for ongoing education every year.  I don't see why this model cannot be widely applied across psychiatry and all other medical specialties.  It brings the academic focus back into medicine instead of the current focus by governments and business.  The practice environment of medicine needs this academic focus and it would greatly enhance the practice environment and get us out of widget production.

That is my hope between this Labor Day and the next.

George Dawson, MD, DFAPA