Social Media Discovers Managed Care and Rages - Or Not?

I watched TMZ last night and they were fascinated about the homicide of Brian Thompson the CEO of United Healthcare in New York City the night before.  The hosts could not approach that topic directly so they brought on Taylor Lorenz who they described as a social media expert.  She made some posts about healthcare companies.  She claims that the “entire internet left and right” was united in celebrating the death of this CEO because “Somebody stood up to this barbaric, evil, cruel violent system.”  Her rational is that if you see a loved one die because an insurance company denied care it is natural to want to see that person dead and this is not advocating homicide. It is a justice fantasy.  She went on to say that United Healthcare has murdered tens of thousands of Americans by denying healthcare.  She sees this as a revolution and it is a problem that should be addressed without violence.  She suggests letter writing and possibly politicians and journalists getting a clue and seeking to correct this imbalance. 

I have been aware of United Healthcare for at least 30 years.  They are renowned in Minnesota for their initial emphasis on not funding psychiatric care and moving on from there.  Physicians like me have been railing against United Healthcare and other managed care companies for decades.  And nobody - and I mean nobody cares. No politicians, nobody in the media, and nobody in physician professional organizations.  There has been an occasional activist state Attorney General suing these companies into a temporary correction that they can easily wait out.   The American Medical Association just recently came out against prior authorization one of the main forms of managed care denial – just a few years ago.  It has been in place along with utilization review – the other main form of denial for at least 40 years.

These business practices have transformed the practice of medicine into a high productivity and low-quality enterprise where medical judgment is replaced by the judgment of middle managers with no medical training and company profit in mind. Physicians have been displaced in their roles in managing the treatment environment and now it is staffed by business people concerned only about the bottom line. If a company decides it is not going to cover a medication or a procedure or a hospitalization – the general message to the patient is “you are out of luck.”  I worked at the same hospital for 22 years and during that time we went from providing care to anyone who walked in the door to care based on businesses telling us what to do.  At one point to make things less contentious (and after we were bought out by a managed care company) – the external review was replaced by the same kind of decisions made by internal staff.  Some physicians became "managed care friendly" in order to move up the corporate ladder.

How did these organizations get so much power over healthcare?  A lot of it depended on lying to gullible politicians.  The original sales job was that physicians were just too expensive.  They order too many tests.  They were going to close down or buy out the expensive specialists and greatly expand primary care.  That primary care expansion would lead to more prevention and reduce the overall costs of medicine. But once these organizations were granted all the power they wanted, they began acquiring specialists and providing their own specialty care.  They also greatly expanded middle management to micromanage staff and basically tell them to work harder.  The result is a system that is much more expensive rather than more cost effective.  Shareholder profits and CEO salaries require a lot of denied care to fund.  This article about the company is an indication of the amount of money that we are discussing. We are talking about executives that are making tens of millions of dollars in an organization that rations health care.

Of course, people are angry about the situation of rationed health care. But it is more about how things are organized and all the associated politics. I think we can all agree that there do not seem to be many bright politicians out there and that low bar took an even more precipitous drop in the last election. Even managed care companies know more than to ration vaccines or give everyone hydroxychloroquine for COVID.

 Politicians have invented this system at every step of the way and made it impossible for the average citizen to get any satisfaction when their health care is denied. Federal and state governments both side with healthcare companies to support the denial of care and (incredibly) indemnify them from liability when their denials result in bad outcomes.  Death is just one of many bad outcomes. 

The press does not get it. I am tired of writing about it for physicians.  The only bright idea that group seems to have come up with is not contracting with these companies and either charging cash or asking the patient to seek their own insurance reimbursement after paying their bill. This obviously has limited application and doesn't work if the patient needs more resources like operating rooms or rehab facilities.  So - Ms. Lorenz’s solution of writing letters certainly will not work.

Some news services seemed to connect a policy reversal by Anthem Blue Cross/Blue Shield (ABCBS) to the homicide. Some of the original stories claimed that anesthesia time per procedure would be limited and the patient might need to pay the balance. Subsequent stories state that the insurance company planned to pay the time allotment indicated in the estimated relative value units (RVUs) for the surgery.  They claim their reversal was based on misinformation. RVUs are another form of rationing – paying only a set amount irrespective of the complexity of the case.  It is another way that psychiatric services were also rationed by reduced reimbursement.  In some cases, it leads clinics to stop seeing all the patients from a particular insurer based on low reimbursement to the physicians and providers.  Lorenz posted a caption of the ABBCBS story with the additional line:  ‘And people wonder why we want these execs dead.'     

This is the state of medicine in the US today. We have just had an election that puts the most rational parts of the fragmented healthcare system (the ACA or Obamacare, Medicare, and Medicaid) at risk.  The party in power espouses gun extremism and uses political tactics that direct violence and aggression toward specific individuals or groups. The party in power favors the top wage earners rather than production or knowledge workers. That includes large healthcare conglomerates that all function by rationing care and access to medications and procedures. And in that context, we have a social media expert claiming that we now have bipartisan rage against these health care companies who have murdered tens of thousands of people by denying their care.  I certainly know many people who have been harmed by the denial of care.  In some cases, I spent hours advocating for them and trying to get the care they needed but I was simply ignored.   

At this point, the crime is being analyzed like it is just another true crime TV show. Endless analysis about the perpetrator’s behavior and possible motivations.  It is all highly speculative but made as controversial as possible.  All the analyses I have seen so far seem way off the mark – but I am not going to add mine at this point.  I am more than a little suspect about all the social media rage. Is it real or just generated by a few provocative trolls?  Will it lead to a typical Congressional show hearing where members manufacture outrage and nothing changes. One thing is for sure – the current state of events is not a good sign.  It is a sign of just how corrupt, ignorant, and not self-correcting the American political system is - and just how much those politicians collude with businesses.

In the end, Americans end up paying top dollar for a healthcare system that may refuse to treat them, an airline system that may refuse to fly them, a financial system with excessive charges and minimal interest payments on savings, and a system for workers that disproportionately pays the people who do not do any of the brain or physical work.  Is it any wonder that 4 people in the US possess more wealth than 50% and that 50% are essentially left hoping for changes that never come.

 

George Dawson, MD, DFAPA

References:

Jeremy Olsen.  Shooting of UnitedHealthcare CEO revives criticism of company’s medical claim denials.  Some mourn the shooting of chief executive but still have scorn for the insurance company he ran.  StarTribune.  December 5, 2024.  https://www.startribune.com/why-unitedhealthcare-is-a-four-letter-word-to-critics/601191492

 

Addendum:

As any reader of this blog can attest – I do not consider homicide as a solution to any problem.  The two main features of homicide that I consistently observe on this blog is homicide as a primitive value and a primitive solution.  It has no place in civil society.  In the anthropological literature homicide as a solution dates to prehistoric times when minor conflicts escalated from individuals to entire villages.  Modern man has not uniformly progressed very far as evidenced by every active war in the world right now and ever.  The shooting of Brian Thompson is no exception. Given everything, I have listed in the above post – it changes nothing.  It was a cowardly, immoral act, and unlawful act. I hope that the perpetrator is caught and punished.  I hope that the privacy of Brian Thompson’s family is respected.  

The problem with inpatient units…

 

Why are many psychiatric units in the United States such miserable places?  That question came up today on Twitter and there was a consensus by the responders.  It is a chronic question that comes up episodically and there are never any good formulations or solutions. I started working on an inpatient unit in 1988 after three years as the medical director of a community mental health center. At the mental health center, I travelled twice a week to an inpatient unit in a small town where I provided the only psychiatric coverage. Without those visits the inpatient unit would have closed. The new position was at an acute care hospital that accepted all of the emergency psychiatric admissions on the east side of St. Paul, Minnesota.  I was on the unit that accepted the most aggressive patients triaged through the emergency department. Over the next 22 years, a number of factors came into play that made that job impossible to do and resulted in my resignation and moving on to an outpatient job. What follows are my observations about what went wrong.     

1:  Management is strictly on a financial basis with minimal to no psychiatric input and no consideration of quality care.  That means administration typically has no expertise in managing the environmental aspects of care apart from blaming inpatient psychiatrists for any complications that occur. The most glaring deficiency is management of violence and aggression.

When I first started out – there was a psychiatrist who headed the department and set all of the administrative policies. There was a business manager who reported to the head of the department. With the advent of managed care, financial managers replaced psychiatrists as department heads and set administrative policy.  The only variation on that theme is a psychiatrist who carries out administrative decisions from the managed care company administration. The expectation is that the psychiatrists working on inpatient units have minimal to no input on administrative decisions that affect them. There is no discussion of the multiple failed administrative policies from business administrators.

2: Financial management dictates that the admission indication and reason for ongoing care is dangerousness loosely defined as a danger to self or others.  Reviewers aligned with the financial interests of the insurance company make this determination using proprietary guidelines by looking at documentation.  At their discretion they can stop payment for any patient who they determine is not dangerous or suicidal enough to be treated on an inpatient unit. That patient is often immediately discharged.

The clearest sign of failed policy from financial administrators is the current standard for inpatient care. That indication is dangerousness. That means a reviewer can say at any time that a patient will no longer be funded because they are no longer dangerous. This criterion is problematic at many levels. First, it is an inappropriate admission standard that makes it more difficult to assess people in the emergency department. Most people in need of psychiatric admission are in distress but not dangerous. It is not appropriate to turn them away if nothing has been done to alleviate their distress.  Second, dangerousness is stigmatizing and perpetuates the myth that people with psychiatric problems are dangerous. Third, there is no objective way to draw a clear line on a day-to-day basis in order to make a rational discharge decision.

3:  As a direct result of #1; aggressive patients are often triaged to the 5-10% of community hospitals in each state that might be able to contain aggression.

This only applies to states with multiple psychiatric hospitals and in some states that is not true.  Even in states with multiple community hospitals, only a minority of those will have psychiatric units. A select few will admit and treat highly aggressive patients. The reason again is financial. It requires specialized and more intense staffing that costs money.

4:  Length of stay (LOS) is short (3-5 days) to optimize profits.

One of the most perverse incentives are DRG payments. The theory is that the average cost and LOS for a specific diagnosis can be estimated by a group of experts. To financial managers that means, the patient must leave by that duration or less and less is much better. During my tenure in acute care reviewers would call me demanding to know “where is the dangerousness?” that necessitated ongoing inpatient care. Carefully explaining that the patient was not stable enough to function outside of a hospital did not count.  As time went by and managed care companies acquired hospitals this review process was internalized. Inpatient psychiatrists now faced case managers in their team meeting who were basically acting like external reviewers. That impacted not only patient care but the morale and enthusiasm of the inpatient team.

5:  The units are managed to keep all of the beds full irrespective of patient need and there are no private rooms.  This often leads to very incompatible roommate and one of them wanting to leave as a result.  The ability to admit patients is often out of the control of the psychiatric staff and is run by administrators.

Since all inpatient psychiatric beds are rationed in the US and kept at an artificially low aggregate number, these beds are at a premium. In any large hospital the emergency department, the consultation liaison teams, and psychiatric outpatient clinicians are all competing for bed space.  From the minute inpatient psychiatrists arrive in the morning they are pressured to discharge people.  The triage system for admissions is often out of control of the psychiatrists. That results in room mate mismatches and patients not being admitted to their desired specialty units. In both of those situations the inpatient staff and psychiatrists have to address the resulting complaints from patients and families including frequent demands for discharge because of these problems.

6:  Patients are discharged before they are stable to optimize profits.

Severe psychiatric problems rarely respond adequately to treatment in 3-5 days. No medication or psychosocial therapy works that fast. In order to meet the artificial time constraints people are treated aggressively with medications – increasing the risk of side effects.  The ability of the patient to care for themselves in a stable environment is less of a priority.

7:  Many inpatient environments are markedly deficient relative to medical/surgical units (less modern, poor air quality, more crowding, different food service)

This may be changing to some extent with the continued closure of inpatient units. Many of them are dated facilities.  In hospitals where medical surgical patients have private rooms that may not exist on psychiatric units.  In hospitals where there is an ala carte food service for medical surgical patients those choices may not exist on inpatient psychiatric units.  There are many rationalizations for these discrepancies, but when you see the glaring deficiencies in person there is clearly a lack of equal treatment.

In addition to the lack of privacy, practically all acute care units in the US are locked. That certainly reduces the elopement risk and may be necessary from a legal standpoint for involuntary patients, but it is possible to have more liberal policies and allow people off the ward for exercise and passes with their family or friends.  Some research suggests that people may do better on an unlocked unit. The overriding financial oversight comes in to play - with many companies saying that if a person doesn't need to be on a locked ward they don't need to be in a hospital.  Another variation on the dangerousness theme. 

8:  Follow up care is typically lacking in availability and intensity.

For a lot of people, quality inpatient assessment and treatment is their one good shot at stabilization and adequate care. There are many people who have severe mood disorders, bipolar disorder, episodes of psychosis, and postpartum mental illness who have never been stabilized on an outpatient basis. Many have been ill for decades.  Adequate inpatient care can make a significant difference but it will not happen in the span of 3-5 days.  Once adequate care has been established, follow up care is a problem. It is more of a problem if the patient is forced to leave before they are stabilized.

9:  Some units have a disproportionate number of involuntary patients undergoing civil commitment. If committed they may face a very long LOS waiting for transfer to a state hospital in a unit that was not designed for long term care.

The most obvious deficiencies of an inpatient unit come into the light when a patient ends up stranded there for a month or two. They start to experience the cramped quarters and lack of leisure time activity as imprisonment. There has been no work done on how to redesign units for people who have to remain there for extended periods.

10:  Even though substance use disorders are a common comorbidity – they are often seen by the insurance company as a reason for immediate discharge from a psychiatric unit, even when relapse is imminent, it is a life-threatening problem, and no residential beds for the substance use disorder are available.

Insurance company reviewers often insist that patients with severe depression and alcoholism or some other substance abuse problem be discharged the next day. That can even occur if the patient was exhibiting suicidal behavior while intoxicated.  Appropriate detoxification and adequate treatment were not a priority – only the reviewer’s idea that the directly observed suicidal behavior was due to acute intoxication. Most inpatient units do not have immediate access to substance use treatment facilities and it is imperative that these patients are detoxed and stabilized prior to discharge. Business and financial pressure backs up all the way through the psychiatric unit to the emergency department where the message becomes – “people with substance use disorders should not be admitted to psychiatric units.”  This can result in high-risk home detox scenarios and continued relapse with less chance of recovery.  Some counites have "non-medical detox" that patients are transferred to.  They are sent back to the hospital in the event that they have continued significant detox symptoms and may be admitted to a medical service or intensive car unit at that time. 

11:  There is often minimal to no contact with the outpatient staff who were treating the patient prior to admission.

Many outpatient psychiatrists are very cynical about inpatient care. First, they have no control over admissions. They may know inpatient colleagues but realize that it is futile to call them in order to admit one of their patients. They have to tell the patient to go to the emergency department and get assessed for admission. Second assuming that goes well – inpatient staff often do not have the time or energy to consult with outpatient docs about the plan. Finally, they receive many of their patients back who have not improved, are still in crisis, but are now taking higher doses of medication. They typically do not get discharge summaries or other paperwork form the hospital including the discharge medications. 

12:  There is often minimal communication with the family and federal privacy regulations are often given as a reason.

Acute inpatient care is often associated with a family crisis and family members want communication with inpatient staff and the inpatient psychiatrist. Work intensity on the inpatient unit along with staff burnout often results in either a lack of communication or a perceived lack of caring by the family. That can add more conflict to the treatment environment.

13:  The psychiatrists working in these settings have an intense work load and get minimal administrative support. In many cases there is a policing attitude on the part of administrators rather than an affiliative effort.  The psychiatrists are policed on the basis of productivity, LOS, and complications – none of which are under their control.  Staff splitting often occurs because of siloed administration that is commonly used by administration to elicit criticism of specific staff psychiatrists.

Instead of being treated like valuable experts with acknowledged expertise, inpatient psychiatrists are treated like production workers. Administrative staff make decisions that lead to the environment seriously deteriorating and often manage that by becoming more authoritarian and rigid.

14:  Medical coverage is not standardized and emergency department triage is often not enough.

Medical coverage varies greatly depending on the hospital and staff availability. Psychiatrists may not ever touch a patient in some settings or in the case of my inpatient unit – they may be responsible for the complete medical and psychiatric care of the patient.  In some settings there are free standing psychiatric hospitals where ill patients have to be sent by ambulance to an emergency department. In other hospitals there is complete access to all medical and surgical specialties.  In recent years another managed care innovation – the hospitalist has come to inpatient psychiatrist units. That basically means the same psychiatrist works 7 days shift on and 7 days off. Medical coverage is still contingent on local conventions. I have not seen it formally studied, but interviewing Internal Medicine hospitalists left me with the impression that cognitive performance dropped off significantly after 5 days.

Whoever is working the acute care units as a psychiatrist the risk for unrecognized physical illness and destabilized medical problems is always very high. In a chaotic, stressful, unpredictable environment a psychiatrist needs to be at the top of his or her game.

15:  There is intense regulatory interference at all levels.

It is often not obvious that all of the factors I am mentioning here are the direct result of government intervention. The federal government invented the rationed managed care system and early in this century turned the reins over to the insurance industry. It is the single largest conflict of interest interfering with quality care in psychiatry today.  Managed care alone is responsible for many inpatient psychiatric units closing. State sponsored units are rationed on the same principles by human services departments. Both have resulted in a large influx of psychiatric patients into jails where most people do not receive adequate care. Further initiatives like regulating the number of ligature points on an inpatient unit have resulted in further unit closures.

16:  Staff turnover:

It takes a mature and often experienced person to work on an inpatient psychiatry unit – irrespective of their profession. The best inpatient units are held together by a team of psychiatrists, nursing staff, social workers, and occupational therapists. I am convinced that I have worked with some of the best folks from all of those professions. But being the best and being mature enough to be empathic with a unit full of people in extreme distress is not enough. The staff have to be supported and given what they need to be successful. Without that support crises start to happen among the staff. How does that look?  It looks like a social worker who has spent all day on the phone calling 25 nursing homes in order to get a patient placed and being told that they are not doing enough and need to work on placing other patients.  It looks like nursing staff having complex patients taking care of too many patients with high acuity and complicated medical problems with not enough staffing. It looks like nursing assistants being falsely accused of wrongdoing and not being supported.  It looks like various staff members experiencing homicidal threats and nobody knowing what to do about it. Those are just a few examples of what leads to staff turnover.

The staff I worked with knew that we were short of resources. They did everything they could to make the environment more supportive for patients and families. At the Christmas Holiday the occupational therapists would organize a celebration and every patient there got a present and was able to participate. Nursing staff organized a used clothes closet so that patients could be resupplied with clothing if necessary. In some cases we raised cash and transportation on the spot for patients who were leaving abruptly, had no way to get back home, and had no money to buy food.  The inpatient staff is a significant human resource but they can’t compensate for decades of rationing and the irrational polices that play out on their units every day.

17.  Competing forces that increase length of stay that are never addressed by managed care companies:

There are many. The most obvious are probate court polices that affect patients being treated on an involuntary status. Any probate court procedure adds about 2 weeks to the length of stay in the place where I worked.  During that time the patient had no obligation to follow treatment recommendations. That could allow any insurance to refuse payment based on the fact no treatment (apart from containment and psychosocial therapies) was being given.  That creates a number of pressures from administrators and an associated bed shortage. If civil commitment does occur that patient may be waiting for weeks to months for transfer to a state hospital. A more proactive approach in this situation would be to do the hearings on an outpatient basis in the context of community treatment.  I never saw that happen.

Many patients need a therapeutic environment to be discharged to.  They are either homeless or not able to function well enough for independent living. The responsibility of insurance and managed care companies ends at the hospital door. If the inpatient staff cannot find a suitable county or charity funded setting many of these patient are discharged to the street.

Even standard discharge planning to an outpatient clinic can be a problem. Many organizations use a guideline that the patient must be seen in clinic 1-2 weeks post discharge. It is difficult if not impossible to get those appointments even if the inpatient unit and outpatient clinic are in the same organization.  In some cases the appointments are months out with no flexibility in the system to accommodate discharged patients.

All of the factors prolonging inpatient stays by delaying treatment or discharge magnify the pressure on inpatient staff.  Ineffective administrators who cannot negotiate contracts or other arrangements with these outside sources of inpatient utilization transfer that burden directly to the inpatient staff.  The only way to compensate is greater patient turnover and more admissions.  That typically is not possible and the inpatient staff are the obvious scapegoats.

18. Lower reimbursement for equivalent service.

In large metropolitan hospitals psychiatry is an invaluable service in terms of patient flow and discharge planning. Patients with overdoses on medical units and various injuries associated with their psychiatric diagnosis on surgical units – need to be rapidly assessed and transferred or discharged from those primary admitting services.  The emergency department needs to admit psychiatric emergencies to inpatient units. These processes are critical to the function of large hospitals.  Despite that fact, psychiatry is reimbursed at much lower levels for the equivalent amount of care provided by other services. This is an artifact of the long standing carve-out mentality of managed care companies.  In the 1980s they made a decision that psychiatric services were not like the rest of medicine and could be paid for by a separate and lower level of reimbursement. Some of my friends in other specialties, know this and they know that in a hospital setting the high margin services (generally proceduralists) transfer at least part of their profit to cover psychiatric services.  This could all be avoided with equitable reimbursement. Without it funding depends on this transfer of funds and generating as much turnover as possible on the inpatient units.

19:  Psychiatric units in hospitals are the only specialty services that are supposed to be all things to all people.

Most specialists have the luxury of admitting people with a fairly well-defined set of problems. Even if the people are diverse – their problems are not and that specialty service is set up to focus on that set of problems. In the case of inpatient psychiatric units – those rules no longer apply. If the patient has a significant medical or surgical problem and a significant psychiatric problem and the staff psychiatrist has no input into the admission decision – that patient may be admitted to psychiatry. As a result, there are a large group of patients on any unit with significant medical problems that are often acute and need close monitoring. Those problems can interfere with both the patient’s ability to participate in any available programming and also make is difficult to assess any treatment progress focused on their primary psychiatric disorder. The array of these problems can range from acute delirium to a terminal illness requiring intensive nursing care. Since psychiatric units are rarely designed, equipped or staffed to provide this level of care these situations place additional stress on the inpatient environment.  Managed care companies may deny reimbursement for this care on the basis that “the patient should be on a medical unit”.  But of course the medical unit sent the patient in the first place.

20:  Decades of admission avoidance has led to a non-functional admission procedure that is focused on hospital administration needs over outpatient staff and patient needs.

Many outpatient psychiatrists have complained to me over the years that it is impossible to get their patients admitted on a timely basis. On the inpatient side it makes complete sense since the inpatient units are managed to maintain full capacity, there is a chronic bed shortage, and the admissions are not in control of the inpatient psychiatrists. That means the only practical way to get a patient admitted is to send them to the emergency department.  That is true even if the outpatient psychiatrist has consulted with inpatient staff who agree with the admission.  The backlog in the EDs is legendary and there are rules in lace to send the patient to a remote hospital even if that hospital is hundreds of miles away.  There are very few people who want to be voluntarily admitted to a psychiatric unit and even fewer who want to be sent to a remote hospital. 

This conflict plays out in other ways.  In the case of patients with severe depression requiring electroconvulsive therapy (ECT) - they typically cannot be directly admitted and may have to go through the emergency department.  Patients with complicated detoxification related problems - like benzodiazepine detoxification prior to surgery with an associated severe psychiatric problem may not be admitted at all.  There are frequent conflicts about admission and discharge times, because the inpatient staff may end up working long hours (12-13/day) indefinitely due to the timing of the admissions and discharges. In some cases, a hospital may close down their bed capacity and divert all of their admissions to a nearby hospital to avoid this problem.  

21:  Admission Avoidance: This has always been a goal of managed care organizations on both the psychiatric services and medical side of the operation.  There has been a long series of interventions to try to compensate for what amounts to a lack of service and spin it in the most positive light.  About 25 years ago in the New England Journal of Medicine there was an article describing what were essentially crisis units that were supposed to divert potentially short stay psychiatric admissions and house them in a less intensive settings with psychiatric services.  Many counties have this kind of service that is paid for by the county so the cost has been shifted away from managed care companies or federal payers.  I recently attended a conference on a “new” model where a large open hospitable room and psychiatric services are provided. Each patient gets their own lounge chair (the photos I saw showed gerichairs).  There were no beds on the unit. Patients were expected to sleep in those chairs if they had to stay overnight.  Nobody on a 72 hour hold or requiring any significant degree of medical care would be admitted to this unit.  The expectation is that most people would be discharged in about 6-8 hours.  The only real difference from the ED is that patients had more immediate access to psychiatry staff and were not just sitting there waiting to be seen at the next transfer. I suppose some might see this as an innovation. I don’t think you can focus on what is needed on an inpatient unit and what those patients need if you are constantly focused on an artificial admission avoidance concept and putting resources into that.  If anything, it suggests that there are not enough staff and resources on inpatient units.

22.  There is a lack of collaboration with outpatient staff:  Good inpatient care proceeds from the assumption that the main focus of treatment is with the primary psychiatrist or treatment team. For me that attitude goes back to an attending physician I worked with as an intern on an Internal Medicine rotation. He let us know about the term “local MD” and why that was a pejorative. He pointed out that it was arrogance and assumed that the inpatient team who had brief contact with the patient knew more about the care of that person than the outpatient physician.  I did not have enough experience at the time to know one way or the other, but over the years have developed a nuanced view of the problem. But I have no doubt that the inpatient process needs to support outpatient care and that unilateral plans from the inpatient side are by definition suboptimal.

By more nuanced there are a number of reasons for a lack of communication. The only acceptable reasons are that the patient does not have outpatient care, the patient refuses to consent to the communication, or the outpatient physician or their proxy cannot be contacted with a good faith effort. Being on both ends of that call - a good faith effort to me means leaving a cell phone number with the message to “call me at any time.”  I have found that effort is required in an era of overproduction and no set times in the outpatient clinic for necessary phone calls.

In addition to the outpatient psychiatrist, consultants also need to be contacted. I have found that direct communication with the patients cardiologist, endocrinologist, nephrologist, primary care physician, and neurologist is necessary. In fact, there are cases where I do not make any changes to the patient’s medications until I have talked with one of these specialists.

In terms of specific outpatient care, a lot of history needs to be reviewed in the case of complex care.  The outpatient clinic can more efficiently send the records after a brief call. What the outpatient psychiatrist wants to see happen and the endpoint of inpatient care are very important areas that need to be covered. On occasion, the patient expresses dissatisfaction with outpatient care and that conversation can occur in a way that does not split care providers.  For example, one common scenario is the patient with a first manic episode after being treated for years for depression in the outpatient clinic.  A neutral discussion of the difficulty of making a bipolar disorder without a clear manic episode may facilitate transition back to the outpatient psychiatrist.  These problems highlight inpatient psychiatrists needing to maintain a realistic outlook on what has been done and what can possibly be done in the future. 

23:  All of the above factors translate to a chaotic and poorly run inpatient units.  There is no overall clinical guidance because it is typically taken away from psychiatrists and placed with administrators who clearly know nothing about inpatient psychiatry.  

Many inpatient units are nerve wracking places. The first order of business for me after a team meeting was to address as many crises on the unit as possible.  That could include agitated and aggressive patients, patients actively harming themselves, patients refusing medical care for a life-threatening illness, patients refusing surgical care for an obvious problem, and instability due to detoxification from alcohol or benzodiazepines. By addressing these crises, I always hoped to bring a measure of comfort and reassurance to the patient and everyone else who was distressed. I hoped to bring the noise level down. I hoped to have all of the biohazardous material cleaned up.  It is without a doubt a very tough job – made tougher by the fact that you only have the illusion of control. The people really responsible for this bedlam are out of touch. I actually had an administrator tell me to imagine that there was a firewall between me and the administrators who made all of the decisions affecting me, my staff, and the patients. That firewall was there to block my input and the input of my colleagues.

I had planned to do inpatient psychiatry until I retired, but I could not take it anymore. The interpersonal dimension was the most draining. Rather than dwell on that I often think about a deluxe psychiatric hospital that I visited instead. Several years out of residency, I was invited down to this campus by the former chief resident from the program I graduated from. It was a modern campus connected by broad boardwalks running to the compass points. My friend’s office was modern, open and airy. He told me about all of the services and activities available to his patients including excellent cuisine in the cafeteria. At the time the length of stay at his hospital was 2-3 months.  He had no concerns that his patients were unstable at the time of discharge and described none of the stressors that were impacting me on a daily basis. He had set office hours and left at a predictable time every day.  In the subsequent blur of my inpatient tenure, I never found out what happened to this hospital. My suspicion is that managed care eventually shut them down.

I don’t believe for a second that psychiatric inpatient units need to be miserable places that patients and their families want to avoid. I don’t believe for a second that they can’t be therapeutic and stimulating for the dedicated staff that work there.    

But that transformation clearly can’t happen if it is run by business administrators empowered by government edicts.

 

George Dawson, MD, DFAPA

Supplementary 1:

Almost exactly 10 years ago, I had an interview about my thoughts on managed care and psychiatry published in the MetroDocs periodical.  You can read it here but it will probably require adjusting the screen view.

Supplementary 2:

 I have also been interviewed on this theme by Awais Aftab, MD for his series Conversations in Critical Psychiatry.  You can read that interview at the following link.

The Bureaucratic Takeover of American Psychiatry

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."

The Bureaucratic Takeover of American Psychiatry

 

This interview was posted on the Psychiatric Times web site today.  It contains bit and pieces from blog posts here over the past 8 years. It is a rare opportunity for people to see what is wrong with American psychiatry and that is - it is not run by American psychiatrists. It is run by managed care companies, pharmaceutical benefit managers, and government bureaucrats who all have the common goals of restricting access to psychiatric services.  And by psychiatric services, I am including substance use disorders and their treatment as well as the considerable amount of treatment of organic brain disorders that is provided by psychiatrists. 

I expect that some people will say: "What is special about psychiatry? Aren't these same rationing techniques applied to all of medicine?"  To a certain extent that is true.  Primary care physicians, medical specialists, and surgical specialists have to contend with similar rationing techniques.  It is however a question of scale.  I have talked with physicians who were around when the psychiatric rationing started and psychiatric services were chosen as the target of the express purpose of elevating the stock price of a company.  I was there when the Hay Report was released in the 1990s showing disproportionate rationing of psychiatric services relative to any other specialty.  I saw the original figures released in 2002 showing that Cardiology services were reimbursed at a 20% premium, while psychiatric inpatient services were discounted by 60%.  That led to some immediate closures of psychiatric hospitals and a continued trend of lower and lower bed availability.   There are endless examples of this disproportionate rationing on this blog and as I point out in the interview it is one of many reasons I write this blog.

One of the key questions that any observer of psychiatry should ask themselves is: "Why is George Dawson the only guy writing about this issue?"  Apart from the fact that this rationing has impacted my care of patients nearly every day of my professional life there are some obvious considerations.

1.  The people who self identify as the critics of psychiatry - clearly know very little about the practice environment or its constraints. I have seen two articles now that use the same example that psychiatrists believe that every mental disorder should be treated with a medication and that this is biological psychiatry.  The model of care they are referring to is not how psychiatrists are trained (see the above figure).  It represents a blended government and managed care model of how patients are scheduled, seen, and billed.  That bureaucratic model at one point employed an M code meaning a 5-10 minute visit with a psychiatrist.

2.  The critics similarly ignore highly innovative and individualized therapies that were invented by psychiatrists such as the Assertive Community Treatment  model that I mentioned in this interview as well as the myriad ways that psychiatrists have figured out how to talk in therapeutic ways with patients in rationed time slots and how those relationships result in recovery.

3.  The critics systematically ignore the lack of infrastructure to support psychiatric treatment.  There are very few inpatient units in each state that allow for the treatment of people with severe mental illnesses. By contrast, there appears to be no shortage of state-of-the-art facilities to treat heart disease, cancer, and gastrointestinal problems.  There is no shortage of state-of-the-art surgical facilities to treat any condition where surgery may be indicated.  In the mean time, mental illness and substance use disorders are the number 1 debilitating disease condition in the United States.  Rather than invest in the necessary infrastructure to provide an equivalent level of care, people with severe mental illnesses are incarcerated instead.  Rather than reversing that trend, several Sheriffs in the country propose designated parts of county jails as psychiatric hospitals and treating people in jail who should not have been incarcerated in the first place. 

I could keep going with additional points like I have in the past, but at this point would encourage any interested reader to take a look at the interview at this link.  Then take a look at the summary at the top of this post and consider my point. Psychiatrists are well trained to do a lot for people with mental illnesses and substance use disorders. We want our patients and their families to have access to the same amount of resources that other medical or surgical specialists have. Don't accept any criticism of psychiatry that does not address these basic points.  

George Dawson, MD, DFAPA 

Reference:

Awais Aftab, MD.  The Bureaucratic Takeover of American Psychiatry: George Dawson, MD, DFAPA
Psychiatric Times.  November 13, 2020    Link

Supplementary 1:

Dr. Allen's comment made me realize a critical deficiency in my graphic and also the interview and that is impact on the academic environment. One of the most exciting aspects of medical school and residency was learning to understand the medical literature and apply it to patient care. I met hundreds of physicians and colleagues with their own unique approaches. In training environments in the 1980s and early 1990s the expectation was that you were researching and reading about your patient's problems and diagnoses and were prepared to intelligently discuss it.  As an attending you had to keep on top of the literature to be a competent teacher and also as a marker of professional competence. Teaching rounds, grand rounds and other teaching based meetings were the most exciting aspects of going to work each day.  I modified my managed care timeline to illustrate the impact on the academic side of the work environment.  

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.

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.