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Recovering Professionalism
The American College of Physicians has recently published a position paper on reducing administrative hassles in medical practice.[1] They note defining burdens (hassles) is the first challenge, but propose a Venn diagram approach to thinking about the issue. There are two “good” administrative tasks: those that improve the quality of care and those that promote timely and appropriate care. These overlap, but these activities are, by definition, worth doing. There are two negative tasks: those that question physician judgment and those that have a negative financial effect. Of course, these should not be done, but what to do when these negative tasks overlap with the two positive tasks? How should we decide what to do? They propose seven recommendations, the chief of which is to eliminate those tasks that fall into the negative group as defined above as well as regular review of all processes to make sure “data creep” is not setting in. They also urge standardization of the requirements for documentation so that the same data does not have to be reformatted constantly to suit the needs of individual organizations. They also call for further research into best practices and efforts to disseminate those identified so they can become adopted widely. The accompanying editorial’s title sums it up—Designing and Regulating Wisely: Removing Barriers to Joy in Practice.[2] Dr. Sinsky notes for every hour of patient contact by the primary care physician, two hours is spent on documentation and administrative burdens. “The high volumes of clerical work, along with poorly designed technology, and the resultant time pressures are among the major drivers of alarming levels of physician burnout.” She adds one more proposal to the ACP paper by asking what is the value of a signature? She notes the average primary care physician has 75 messages in the inbox every day requiring authentication by the doctor. To which I would add the mountains of paper work for durable medical equipment, home health services, and so forth. Dr. DeWitt offered personal testimony from her time practicing in Australia and Canada compared to the United States.[3] She noted that as an internist, she was a consultant, seeing complex patients for the general practitioners who provide the bulk of routine care. As such she practiced “at the top of her license,” saw more patients and ended the day more satisfied with the work she had done. She noted the transcriptionists in Australia complained that her American-style notes were too long. Finally, Fleming and McDonald discuss the “professionalism charter” as a guideline for the practice of medicine, the organization of medical care, and the conducting of the business of medicine.[4] This document builds on the Physician Charter on Medical Professionalism which was issued some 15 years ago. They divide the commitments into four domains. First is patient partnerships, which include engagement, shared decision-making, collaboration and community coordination, and measurement of things that matter to patients. Second is organizational culture. This includes the well-being of individuals, teamwork, a healthy workplace, inclusion and diversity, and accountability. Third is community partnerships to address the social determinants of health, advocating for access and high-quality health care, and other community benefits. Fourth is organizations and business practices. This includes protecting patient privacy, ethical operations, transparent management of conflict of interests, aligning incentives with core values, high-value care, innovation, accounting and financial reporting standards, and ensuring fair and equitable access to health care. The authors admit these are aspirational goals, and those of us in practice now can see we have a long way to go to produce some semblance of these standards. I think we have made progress in my years in practice with patient engagement and shared decision-making. Unfortunately, I think we have lost ground on collaboration—we don’t have time for those informal conversations that represented a true collaboration to improve outcomes. The issues with our organizations have been a subject of many of the articles I have written, so I will not repeat the arguments here. I continue to believe that efforts to constrain expenditures—these days trumpeted as the value proposition—are having numerous unintended consequences, many of which are becoming apparent to even the true believers. The simple notion that doing the right care, the right way, at the right time will be cheaper than doing it wrong has gotten terribly distorted in our current turmoil. Our communities still see their hospitals as a source of economic well-being, if not necessarily medical well-being, but I don’t see as many partnerships as there should be to improve both our organizations and our communities. Lastly, I continue to believe most of our medical organizations are doing a poor job maintaining the balance between the clinical and the business sides of the house with the result we make bad decisions for patients even when we aren’t thinking about patient care at all. On the other hand, seeing these high-level attempts to address the issues is encouraging. Perhaps 10 years too late, but better late than never. Perhaps if the practicing physicians and the academic organizations can sit down with the payers, particularly CMS, some progress can be made. Maybe these papers will lead to local efforts to implement some or all these ideas rather than passively responding to unfunded mandates. Or maybe the whole thing just collapses and we use these principles to rebuild the structures. How optimistic are you today? 11 July 2017. [1] Erickson SM, Rockwern B, Koltov M, McLean RM. Putting Patients First by Reducing Administrative Tasks in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med 2017;166:659-551. doi:10.7326/M16-2697. [2] Sinsky CA. Designing and Regulating Wisely: Removing Barriers to Joy in Practice. Ann Intern Med 2017;166:677-678. doi: 10.7326/M17-0524. [3] DeWitt DE. A Tale of Two Countries: How I Saw More Patients With More Joy in Internal Medicine Practice. Ann Intern Med 2017;166:669-670. doi:10.7326/M17-0244. [4] Fleming DA, McDonald WJ. Professionalism Charter Provides Guidance to Health Care Organizations in These Troubled Times. Ann Intern Med 2017;166:665-666. doi: 10.7326/M17-0388. |
Further Reading
Organizing for Success - Another Viewpoint Organizing for Success - Key Requirement Physician Engagement Is physician engagement a strategy to promote physician leadership, or a code word meaning how do we get the doctors to do what we want? Putting Patients At The Center Of Healthcare Putting patients at the center is crucial for healthcare organizations, but how can it be done? The Case for Physician Leadership Why the successful healthcare organization of the future must find a way to create physician leadership if it is to achieve the IHI Triple Aim. |