Happy Labor Day 2023!

 

Over the years of writing this blog I have put out a Labor Day message to describe any progress in the physician workspace in the past year.  The practice environment for physicians has deteriorated significantly over the past 3 decades and those changes are generally locked in by the healthcare business managers backed by both Congress and state governments. I have used the following graphic several times on this blog to illustrate what happened over specific time frames and it is probably time to add some additional details.

The impact of managed care on medical practice has been clear for the past 30 years.  In many cases that model is being adopted by physicians in private practice settings. For example, it is common now to see a specialist initially but in follow up see one of the physician extenders working with them. That can make health care a lot less personal and it leads me to think about the reason why physicians are trained to provide continuity of care in the first place.

But even more than that issue is the explosion of online services provided for flat rates that focus on seemingly basic problems in exchange for payment. On my streaming services that typically involves a company that offers prescriptions for depression, anxiety, hair loss, and erectile dysfunction.  A second company offers beta blockers for performance anxiety.  Given the side effect potential for these medications – I am curious about how comprehensive the initial evaluations are and the follow up visits.

I was recently hospitalized and had a first hand look at what the modern hospital workplace looks like.  When I was in training there were discrete teams by specialty and they consisted of physicians at all levels of training.  A typical team might have 1-2 med students, 1-2 interns, a resident, a senior resident or fellow, and the attending. The work load would depend on whether your service admitted people to the hospital (typically internal medicine, surgery, neurology, renal medicine, cardiology, psychiatry) or consulted to those teams (infectious disease, endocrinology, pulmonology, rheumatology, cardiology, psychiatry).  The admitting services were the most intense because of irregular admissions and complicated unstable patients. Teams generally had places to meet, where patients were presented to the attending and there were formal didactics. Bedside teaching occurred on rounds.

During my hospitalization, I was not seen by a single physician in my room. When I went out into the hallway, both sides of the hall were lined by people facing computer screens. There was one consulting team standing outside a patient door – visible only because it was obvious the fellow and attending were discussing cases. The level of crowding was striking and it left me with the impression that all these people could not possibly be physicians.  Managed care shaped the form of these teams and who was in that hallway. First, they eliminated the usual admitting services and replaced them all with hospitalists. Then they replaced at least some physicians on those teams with non-physicians. Those moves benefit business decisions but I have not seen a single adequate study on the impact it has on medical care.

Training physicians in hospitals has typically involved hands on learning, consultation from senior and expert physicians, and active learning environment, and in many cases the opportunity for research.  All these areas need to be preserved in the practice environment in order to stimulate practicing physicians to maintain high standards. An environment that leads to burnout, sleep deprivation, and moral injury is not adequate to the task. The question always has been whether physicians have any kind of leverage that could lead to appropriate modifications. That question has never been put to the test and in fact, healthcare organizations in the United States generally flaunt their power over physicians rather than attempting to negotiate with them.

Will a union make a difference? My experience with unions started out in my family of origin.  My father was a member of the Brotherhood of Locomotive Firemen and Engineers (BLFE). He worked as a locomotive fireman and then an engineer.  He had to be a union member in order to work.  He generally was not very happy about it. The railroad industry was run on a seniority system and as railroad utilization decreased – younger workers like my father had a difficult time finding job assignments. Even though they were technically employed by a railroad and reimbursement for the work was good, it seemed like only the most senior engineers benefitted to the point that they could make a good living.  As a result, the contracts negotiated by the unions did not mean that much to my father. He also tended to see the union as corrupt because, the union officials clearly made far more than he was making trying to work in their system.  Railroads unions were also compartmentalized - so a strike against one railroad did not mean a strike against all.  As a result, workers from the railroad that was the object of the strike could work for competing railroads during the strike. If similar rules apply to physicians a uniform practice environment is no guarantee, but the onerous aspects might be eliminated.   

Unions for physicians and residents are becoming increasingly popular but they have more restrictions that in a blue-collar environment. The National Labor relations Board (NLRB) enforces the National Labor Relations Act (NLRA) and decides what public sector employees can form unions (1). Independent contractors, supervisors, and managers are excluded because the focus of the act was on laborers. The general categories are loosely defined so it takes an NLRB investigation to determine who can be in the union. Tenure and tenure track employees were eliminated by a Supreme Court ruling. Only salaried employees who do not do a significant amount of supervision are allowed to be union members. If a union is allowed, the goals in terms of collective bargaining, representation, and impact on hospital policies need to be determined.  Although the momentum for unions is building, there is a considerable amount of inertia from the managed care era. During that time, we had many physicians who were eager to escape a deteriorating practice environment to become administrators and basically enforce business policies. It remains to be seen if unions can have a favorable impact on local health care policy and practices – but just establishing more is a step in the right direction.    

More resistance to Maintenance of Certification by various boards and the American Board of Medical Specialties is also growing. I went to the alternate system National Board of Physicians and Surgeons (NBPAS) certification in 2018 and have not looked back. At the same time, I realize that I was outside of any system demanding that I recertify through an ABMS board and as a result – in a unique situation relative to younger colleagues. A petition was started in July to end ABMS MOC and so far there are 20,000 + signatures. There was an initiative in the APA to stop MOC about 10 years ago, but the administrative process prevented it from being put on a ballot. The basic problems with MOC is that there is no evidence it is necessary for quality care, in fact most health care organizations have abandoned true quality programs. Second, it is not reflective of clinical practice. Most physicians – even generalists end up in a niche and focus their educational efforts and mastery in that area. It makes no sense to keep taking examinations outside of that area. Third, it is a substantial time and financial commitment and it clearly generates a lot of revenue for ABMS specialty boards. Fourth, there is some suggestion that MOC should be tied to state licensing (Maintenance of Licensure or MOL). This would allow states and health care organizations even more power in controlling physicians – even during their private times when they would need to spend time studying for barely relevant examinations. Elimination of MOC is another positive step in the direction of restoring a more reasonable practice environment.

Beyond a better practice environment and what it takes to make that politically – the profession of medicine is at stake.  I have written about a lot of the technicalities – but this is deeply personal. Going to medical school and studying medicine was the best thing I could have done with my life. By identifying with the practicing physicians in my various training programs I learned how to live and breathe medicine and psychiatry 24 hours a day. Always thinking about it, never far from a journal article that I wanted to read, and always focused on how that translated to clinical practice – usually a very hard problem I was seeing in practice. From the very first patient contact, the importance of communicating with people in an empathic, unhurried and comprehensive way was obvious.  We cannot afford to lose that transformative effect that medicine has on people.  We cannot dumb things down for the business world and make human biology less complex. I know there are many docs out there that think like me.  Whether we can unionize or cancel MOC – we can never lose sight of the fact that we need to preserve a transformative profession for the sake of future generations of physicians and their patients.

 

 

George Dawson, MD, DFAPA

 

References:

1:  Bowling D 3rd, Richman BD, Schulman KA. The Rise and Potential of Physician Unions. JAMA. 2022 Aug 16;328(7):617-618. doi: 10.1001/jama.2022.12835. PMID: 35900755. 

Fantasy Foundation For The Preservation of Psychiatry

Psychiatry is on the ropes.  The content of this blog illustrates the prevalent biases against the field that all eventually trickle down to less resources to work with and managed care companies rationing those meager resources in order to make money.  One of my favorite fantasies lately is to think about what I would do to save psychiatry if I ran a foundation with significant resources.  I have thought about it long enough and hard enough to come up with a number of guideposts:

1.  Save the teachers - probably the most beleaguered people in the field these days are the teachers of psychiatrists.  There are a lot of bloggers out there complaining about the "ivory tower" academics who just don't know how life is on the front lines.  The usual gripe is that they make too much money or are in some kind of shady consulting deal.  How dare they dictate to the rest of us how to practice?  That has not been my experience, and I have probably taught as much to medical students and residents as the next guy.  I see people trying to make a living and teach at the same time.  I see people needing to meet absurd "productivity" expectations and teach at the same time.  Teaching in generally is not counted as "productivity" in a managed care environment.  I see people who give up their ability to type up more patient notes at noon so that they can give a lecture to mostly disinterested medical students or fatigued residents.  They end up typing those notes at night on what is supposed to be their own time.

When I ask myself what would help them the most it comes like a flash - free high quality graphics for PowerPoints.  I have a parallel blog with some ideas, but there is nothing like great graphics that are free to use and save your faculty hours of sleep trying to come up with their own and not violate somebody's copyright.  You would think that professional organizations, like the American Psychiatric Association (APA) would support this idea.  Like everybody else, they produce downloadable PowerPoint slides for their major journals.  If you read the small print, you are supposed to go to the CopyRight Clearance Center and pay a fee.  I paid a fee of $45 for a lecture to a class of 12 and $85 to lecture a class of 42.  That was to project the slide and include it in my PowerPoint for the day.  I currently give about 32 lectures a year.  Considering the reimbursement I get for the lecture, it is not a commercial presentation, and I have been paying lots of money to the APA for about 30 years - you would think I could get a break.  As the head a a great foundation, I would purchase the rights to several good resources like Blumenthal's Neuroanatomy Through Clinical Cases or Atlas' MRI of the Brain and Spine and make them freely available to any instructors of psychiatrists.

2.  Free neuroscience conferences - there need to be much better basic science courses to bring clinical psychiatrists up to speed on the latest neuroscience and how it applies to the field.  Typical conferences are centered around some clinical activity that most of us are doing anyway.  Do we really need to hear more about something that we are doing everyday?  Something that we know everything about including the usual limitations?  Why not expand back into a consciousness based discipline looking at innovative ways to conceptualize problems and solutions.  Neuroscience is critical to that and there are several very articulate voices in the area.  I would plan a conference every years that was free to psychiatrists for 2 - 4 days of neuroscience.  There is a lot of neuroscience out there and I would ask some of the top journals like Nature, Science, Neuron, Biological Psychiatry, and Molecular Psychiatry to submit a program of Neuroscience for psychiatrists.  I would award the grant competitively to the best submitted program.

3.  Free computerized psychotherapy and an affiliated institute of psychotherapy using computers - I previously posted about John Griest's work in computerized psychotherapy and its effectiveness.  The whole point of the post was to emphasize a significant source of non-medication based treatment that is essentially not limited by manpower requirements.  There are several groups who have implemented this already, but to my knowledge none of them are major U.S. health care organizations or managed acre companies.  The commonest managed care approach is to give everyone a non specific depression rating scale, call that a quality marker, and then put as many people on antidepressants as soon as possible.  There is enough IT available that a foundation could take the lead in this area, develop the programs, and accept referrals from psychiatrists across the country for specific types of computerized psychotherapy.   

4.  Free clinical workgroups -  I have posted on the University of Wisconsin Memory Clinics collaborative clinical network across the state that focuses on maintaining a high level of expertise in all of the cooperating clinics for the diagnosis and treatment of Alzheimer's Disease and other dementias.  There is no reason that model cannot be extended to Depression, Bipolar Disorder, Post Traumatic Stress Disorder, or Attention Deficit Hyperactivity Disorder.  When people talk about collaborative care, they are usually talking about a managed care model that marginalizes psychiatrists.  A recent post suggested that some of the promoters of the managed care model have challenged naysayers to come up with an alternative.  I am a naysayer to anything that resembles managed care and the UW model is definitely a competing model that emphasizes psychiatrists at the top of their game in diagnosing and treating mental disorders.  That would be my priority over a managed care model that is so watered down, you don't even need a psychiatrist on the premises.

5.  An independent certification process - The American Board of Medical Specialties (ABMS) has a chokehold on all board certification processes with the exception of the American Board of Addiction Medicine (ABAM).  ABAM has their own certification and recertification process.  The current controversy involves the recertification process and whether it should be a standard blind exam with no learning aspects and a review of patients in a physicians practice or not.  I have posted some details about this to show how highly politicized it has become.  There is really no good evidence that recertification beyond the usual CME requirements is needed.  Although the American Board of Psychiatry and Neurology (ABPN) and the APA has gone along with ABMS ideas, most members find the process onerous and not conducive to learning, especially when they are in a labor intensive work environment that allows little time for study.  Any professional organization should be innovative enough to come up with an ideal process that would keep members up to speed professionally while not intruding on their limited time.  My foundation would develop a recertification system based on the APA's Focus journal an develop a process that would allow members to study on their own time and recertify by taking the Focus examinations.  It should eventually be possible to incorporate modules from the ongoing neuroscience seminars and what is learned in the computerized psychotherapy lab as study modules.

Using these innovations and hopefully more, my foundation would seek to improve the technical expertise of all psychiatrists, highlighting what is possible for the future and bring every clinician out of the current misery of political overegulation and managed care overproduction.  The whole idea that we currently have a professional organization and a specialty board that are not protective of psychiatrists is one thing.  The idea that they are actually doing things that are counterproductive to the ongoing professional education of psychiatrists and increasing burnout by creating a more stressfull practice environment is another.

My fantasy foundation would hope to reverse those trends.

George Dawson, MD, DFAPA

Evidence based Maintenance of Certification – A Reply to ABMS

The politics of regulating physicians is no different than politics in general and that typically has nothing to do with scientific evidence.  From the outset it was apparent that some people had the idea that general standardized exams with high pass rates and patient report exercises would somehow keep all of the specialists in a particular field up to speed.  That assumes they were not up to speed in the first place.

As a member of a professional organization embroiled in this controversy it has give me a front row seat to the problems with physician regulation and how things are never quite what they seem to be.  From the outset there was scant evidence that recertification exams were necessary and with the exams no evidence that I am aware of that they have accomplished anything.  The American Board of Medical Specialties (ABMS) actually has a page on their web site devoted to what evidence exists and I encourage anyone to go there and find any scientific evidence that supports current MOC much less the approaching freight train of Maintenance of Licensure or linking MOC to annual relicensing by state medical boards.  Feel free to add that evidence to the comments section for this post.

Prior to this idea there were several specialty organizations that had their own programs consisting of educational materials that were self study courses that could be completed on specific topics relevant to the specialist every year.  A formal proctored examination and all of the examination fees that involves was not necessary.  The course topics were developed by consensus of the specialists in the field.  A couple of years ago I watched a CME course presentation by a member of the ABMS who pointed out that three specialty boards (of a total of 24) wanted to continue to use this method for relicensing and recertification.  They were denied that ability to do that because the ABMS has a rule that all of the Boards have to use the same procedure that the majority vote on.  The problem was that very few of the physicians regulated by these Boards were aware of the options or even the fact that there would be a move by the ABMS for a complicated recertification scheme and that they would also eventually push for it to become part of relicensing in many states.

If the ABMS is really interested in evidence based practice, the options to me are very clear.  They currently have no proof that their recertification process is much more than a public relations initiative.  Here is my proposal.  Do an experiment where one half of the specialists to be examined that year complete a self study course in the relevant topics for that year.  That can be designated the experimental group.  The other half of the specialists receive no intervention other than self study on their own for whatever they think might be relevant.  Test them all on the topics selected for the self study group and then compare their test scores.   See who does better on the test.  Secondary endpoints could be developed to review the practices of each group and determine whether there are any substantial differences on secondary measures that are thought to be relevant in the tested areas.

Until this straightforward experiment is done, the current plan and policies of the ABMS are all speculative and appear to be based upon what has been called conventional wisdom.  Conventional wisdom appears to be right because all of the contrary evidence is ignored.  There is no scientific basis for conventional wisdom and it falls apart under scrutiny.  Physicians in America are currently the most overregulated workers in the world.  The rationale for these regulations is frequently based on needing to weed out the few who are incompetent, unethical, or physically or mentally unable to practice medicine.  Many regulatory authorities grapple with that task and maintaining the public safety.  In many cases it is a delicate balance.  But we are far past the point that every physician in the country should be overregulated and overtaxed based on conventional wisdom because regulatory bodies are uncomfortable about their ability to identify or discipline the few.   If the ABMS or any other medical authority wants evidence based safeguards for the public based on examination performance – it is time to run the experiment and stop running a public relations campaign to support the speculative ideas of a few.

George Dawson, MD, DFAPA