{"id":31847,"date":"2020-02-05T11:28:06","date_gmt":"2020-02-05T19:28:06","guid":{"rendered":"https:\/\/pocketwisdominsights.com\/pwicolab\/?p=31847"},"modified":"2020-03-30T16:34:10","modified_gmt":"2020-03-30T23:34:10","slug":"no-place-for-good-doctors","status":"publish","type":"post","link":"https:\/\/pocketwisdominsights.com\/pwicolab\/healthcare\/medical-device-co-lab\/medical-device-co-lab-blogs\/third-party\/no-place-for-good-doctors\/","title":{"rendered":"No Place for Good Doctors"},"content":{"rendered":"

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Opening Insights: Moral Injury<\/h2>\n

The health system is not set up to help patients. It\u2019s set up to make money.
<\/em>DR. NICK SAYER<\/strong><\/p>\n

Those who practice medicine today are facing a systemic challenge of corporate values that directly conflict with the Hippocratic Oath they swore to fulfill at the onset of their entrance into the field of healing people.<\/p>\n

The term Moral Injury<\/em> was first used to describe a phenomenon common to the PTSD experienced by war veterans. A Psychology Today article<\/a> defines moral injury<\/em> as, \"a cluster of symptoms \u2014 similar to those associated with posttraumatic stress<\/a> disorder (PTSD<\/a>) \u2014 that result from personal experiences, which violate a person\u2019s deepest and most closely held values and principles.\"<\/p>\n

Informational Insights: Treading on the Hippocratic Oath<\/h2>\n

The following article was published by Kaiser Health News (KHN), \"a nonprofit news service committed to in-depth coverage of health care policy and politics.\" It was written by Melissa Bailey, \"Boston-based correspondent on the KHN enterprise team, focusing on aging and dying.\"<\/p>\n

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Dr. Keith Corl was working in a Las Vegas emergency room when a patient arrived with chest pain. The patient, wearing his street clothes, had a two-minute exam in the triage area with a doctor, who ordered an X-ray and several other tests. But later, in the treatment area, when Corl met the man and lifted his shirt, it was clear the patient had shingles. Corl didn\u2019t need any tests to diagnose the viral infection that causes a rash and searing pain.<\/p>\n

All those tests? They turned out to be unnecessary and left the patient with over $1,000 in extra charges.<\/p>\n

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice \u201cfast and loose medicine.\u201d Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.<\/p>\n

\u201cWe\u2019re just shotgunning,\u201d Corl said.<\/p>\n

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What\u2019s driving the burnout, he argued, is something deeper \u2014 a sense of \u201cmoral injury.\u201d<\/p>\n

Corl, a 42-year-old assistant professor of medicine at Brown University, is among a growing number of physicians, nurses, social workers and other clinicians who are using the phrase \u201cmoral injury\u201d to describe their inner struggles at work.<\/p>\n

The term comes from war: It was first used to explain why military veterans were not responding to standard treatment for post-traumatic stress disorder. Moral injury, as defined by researchers from veterans hospitals, refers to<\/a> the emotional, physical and spiritual harm people feel after \u201cperpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.\u201d<\/p>\n

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term<\/a> to health care. Both wrestled with symptoms of burnout themselves. They concluded that \u201cmoral injury\u201d better described the root cause of their anguish: They knew how best to care for their patients but were blocked from doing so by systemic barriers related to the business side of health care.<\/p>\n

That idea resonates with clinicians across the country: Since they penned an op-ed in Stat in 2018, Dean and Talbot have been flooded with emails<\/a>, comments, calls and invitations to speak on the topic.<\/p>\n

Burnout has long been identified as a major problem facing medicine: 4 in 10 physicians report feelings of burnout, according to a 2019 Medscape report<\/a>. And the physician suicide rate is more than double that<\/a> of the general population.<\/p>\n

Dean said she and Talbot have given two dozen talks on moral injury. \u201cThe response from each place has been consistent and surprising: \u2018This is the language we\u2019ve been looking for for the last 20 years.'\u201d<\/p>\n

Dean said that response has come from clinicians across disciplines, who wrestle with what they consider barriers to quality care: insurance preauthorization, trouble making patient referrals, endless clicking on electronic health records.<\/p>\n

Those barriers can be particularly intense in emergency medicine.<\/p>\n

Corl said he has been especially frustrated by a model<\/a> of emergency medicine called \u201cprovider-in-triage.\u201d It aims to improve efficiency but, he said, prioritizes speed at the cost of quality care. In this system, a patient who shows up to an ER is seen by a doctor in a triage area for a rapid exam lasting less than two minutes. In theory, a doctor in triage can more quickly identify patients\u2019 ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.<\/p>\n

These brief encounters may be good for business: They reduce the \u201cdoor to doc\u201d time \u2014 how long it takes to see a doctor \u2014 that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee<\/a> much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without \u201cbeing seen,\u201d which is another quality measure.<\/p>\n

But \u201cthe real priority is speed and money and not our patients\u2019 care,\u201d Corl said. \u201cThat makes it tough for doctors who know they could be doing better for their patients.\u201d<\/p>\n

Dean said people often frame burnout as a personal failing. Doctors get the message: \u201cIf you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.\u201d But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians\u2019 control.<\/p>\n

Emergency physician Dr. Angela Jarman sees similar challenges in California, including ER overcrowding and bureaucratic hurdles to discharging patients. As a result, she said, she must treat patients in the hallways, with noise, bright lights and a lack of privacy \u2014 a recipe for hospital-acquired delirium<\/a>.<\/p>\n

\u201cHallway medicine is such a [big] part of emergency medicine these days,\u201d said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are \u201cliterally stuck in the hallway. Everyone\u2019s walking by. I know it must be embarrassing and dehumanizing.\u201d<\/p>\n

For example, when an older patient breaks an arm and cannot be released to their own care at home, they may stay in the ER for days as they await evaluation from a physical therapist and approval to transfer to rehab or a nursing home, she said. Meanwhile, the patient gets bumped into a bed in the hallway to make room for new patients who keep streaming in the door.<\/p>\n

Being responsible for discharging patients who are stuck in the hallway is \u201cso frustrating,\u201d Jarman said. \u201cThat\u2019s not what I\u2019m good at. That\u2019s not what I\u2019m trained to do.\u201d<\/p>\n

Jarman said many emergency physicians she knows work part time to curtail burnout.<\/p>\n

\u201cI love emergency medicine, but a lot of what we do these days is not emergency medicine,\u201d she said. \u201cI definitely don\u2019t think I\u2019ll make it 30 years.\u201d<\/p>\n

Also at UC-Davis, Dr. Nick Sawyer, an assistant professor of emergency medicine, has been working with medical students to analyze systemic problems. Among those they\u2019ve identified: patients stuck in the ER for up to 1,000 hours while awaiting transfer to a psychiatric facility; patients who are not initially suicidal, but become suicidal while awaiting mental health care; patients who rely on the ER for primary care.<\/p>\n

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a \u201chuge amount of pain\u201d but could not get surgery because the stone was not infected and therefore her case wasn\u2019t deemed an \u201cemergency\u201d by her insurance plan.<\/p>\n

\u201cThe health system is not set up to help patients. It\u2019s set up to make money,\u201d he said.<\/p>\n

The best way to approach this problem, he said, is to help future generations of doctors understand \u201chow decisions made at the systems level impact how we care about patients\u201d \u2014 so they can \u201cstand up for what\u2019s right.\u201d<\/p>\n

Whether these experiences amount to moral injury is open for discussion.<\/p>\n

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of \u201cmoral distress\u201d for 25 years, said there isn\u2019t a base of research, as there is for moral distress, to measure moral injury among clinicians.<\/p>\n

But \u201cwhat both of these terms signify,\u201d Rushton said, \u201cis a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven\u2019t in the past.\u201d<\/p>\n

Dean grew interested in moral injury from personal experience: After a decade of treating patients as a psychiatrist, she stopped because of financial pressures. She said she wanted to treat her patients in longer visits, offering both psychotherapy and medication management, but that became more difficult. Insurers would rather pay her for only a 15-minute session to manage medications and let a lower-paid therapist handle the therapy.<\/p>\n

Dean and Talbot created a nonprofit advocacy group called Moral Injury of Healthcare<\/a>, which promotes public awareness and aims to bring clinicians together to discuss the topic.<\/p>\n

Their work is attracting praise from a range of clinicians:<\/p>\n

In Cumberland County, Pennsylvania, Mary Franco, who is now 65, retired early from her job as a nurse practitioner after a large corporation bought out the private practice she worked in. She said she saw \u201ca dramatic shift\u201d in the culture there, where \u201crevenue became all-important.\u201d The company cut in half the time for each patient\u2019s annual exam, she said, down to 20 minutes. She spent much of that time clicking through electronic health records, she said, instead of looking the patient in the face. \u201cI felt I short-shrifted them.\u201d<\/p>\n

In southern Maine, social worker Jamie Leavitt said moral injury led her to take a mental health break from work last year. She said she loves social work, but \u201cI couldn\u2019t offer the care I wanted to because of time restrictions.\u201d One of her tasks was to connect patients with mental health services, but because of insurance restrictions and a lack of quality care providers, she said, \u201coften my job was impossible to do.\u201d<\/p>\n

In Chambersburg, Pennsylvania, Dr. Tate Kauffman left primary care for urgent care because he found himself spending half of each visit doing administrative tasks unrelated to a patient\u2019s ailment \u2014 and spending nights and weekends slogging through paperwork required by insurers.<\/p>\n

\u201cThere was a grieving process, leaving primary care,\u201d he said. \u201cIt\u2019s not that I don\u2019t like the job. I don\u2019t like what the job has become today.\u201d<\/p>\n

Corl said he was so fed up with the provider-in-triage model of emergency medicine that he moved his ER clinical work to smaller, community hospitals that don\u2019t use that method.<\/p>\n

He said many people frame burnout as a character weakness, sending doctors messages like, \u201cGee, Keith, you\u2019ve just got to try harder and soldier on.\u201d But Corl said the term \u201cmoral injury\u201d correctly identifies that the problem lies with the system.<\/p>\n

\u201cThe system is flawed,\u201d he said. \u201cIt\u2019s grinding us. It\u2019s grinding good docs and providers out of existence.\u201d<\/p>\n

https:\/\/khn.org\/news\/beyond-burnout-docs-decry-moral-injury-from-financial-pressures-of-health-care\/<\/cite><\/p><\/blockquote>\n

This article originally appeared on February 4, 2020 in KAISER HEALTH NEWS:<\/em> Beyond Burnout: Docs Decry \u2018Moral Injury\u2019 From Financial Pressures Of Health Care<\/a><\/p>\n

Kaiser Health News<\/a> (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation<\/a> which is not affiliated with Kaiser Permanente.<\/p>\n

Possibilities for Consideration: Making a U-Turn<\/h2>\n

Sure, medical care is expensive, but to focus principally on managing costs to the exclusion of the intent <\/em>of the Hippocratic Oath is to tread upon the values intrinsically required for healthcare to be effectively practiced. <\/p>\n

Imagine what it would be like to have a steady stream of ill people, who you swore to heal \"to the best of [your] ability and judgment,\" and you possessed the means to heal them, but in order to fulfill administrative and fiduciary requirements, those ill people remained untreated, insufficiently treated or incorrectly treated. <\/p>\n

What would that do to you, as their caregiver?<\/p>\n

Changing the Way Things Get Done<\/h3>\n

To overcome the challenge of misguided corporate and administrative values treading upon and replacing the socially responsible values necessarily upheld by caregivers requires a change in the way organizations are directed by their leadership. In order to be accepting of a different way of doing things, a readiness for change<\/em> in individuals and their organization culture must be seeded and cultivated. <\/p>\n

Historically, lasting change has been all but impossible to achieve for most people, organizations and cultures.<\/p>\n

What if a lasting socially responsible change (<\/strong>to change the way we <\/strong><\/em>think, reason and act<\/em>) could be successfully implemented at a community scale \u2013 one community at a time?<\/strong><\/p>\n

Awareness Communication Technology, LLC (AwareComm\u00ae<\/sup>) is a multi-gold certified Microsoft Research and Development partner with the mission of harnessing the collective power of Microsoft Technologies with AwareComm\u2019s Technology, Methodology and Sentience Data Science <\/em>to solve systemic organization <\/em><\/strong>challenges, which in turn solves systemic community <\/em><\/strong>challenges. This process raises Adaptive Intelligence <\/em>(AdI<\/strong>™<\/strong><\/sup>)<\/strong> and drives social-cultural change. <\/p>\n

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By raising AdI™<\/sup> in individuals, teams and organizations the power for collective change is created and the power of deceive, divide and conquer is eliminated. This is the strength of collaboration and unity that the AwareComm\u00ae<\/sup> platform was built to propagate.<\/p>\n

AwareComm's Team 20\/20<\/strong> was formed to implement a new method of partnering businesses, nonprofits and their hosting communities. For example, it's a way to unite the healthcare industry around a common set of principles and values, as it once was in times past.<\/p>\n

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If the idea of accountability and values as well as honest, open and clear intentions as a foundation to cultivate communities of caregivers is important to you then examine the questions below. If answers come to you as a result, then consider completing the SocraticQ exercise toward the bottom of this page.<\/p>\n

Add Your Insight<\/h2>\n

Take a moment and examine\u2026<\/p>\n