No Longer Caught Between Two Paradigms

(A before and after story)

Six and a half years ago I felt stuck between the healthcare goals of speed on one hand and quality on the other. For every year that passed since then, things have become worse.

In 2017, I predicted that things would change very soon, but they haven’t yet. So I changed - jobs!

Let me start by repeating what I wrote back then. After that, I will describe my new job, my new lifestyle and my renewed enthusiasm for being a doctor.

In the very near future, clinics like ours will be paid according to how well our patients do medically, or at least according to how consistently we provide certain medical tests and interventions.

This includes frequency of diabetic blood tests, foot exams, eye exams, prescriptions for heart and kidney protective medications, achievement of pre-set targets for blood pressure, body mass index and immunization rates, and other measurable “quality indicators”.

But paychecks for medical providers as well as short term financial viability of clinics like my Federally Qualified Health Center depends, besides Federal grants for being open in the first place, almost entirely on the fixed revenue we receive from every face to face encounter we have with patients.

If I spend an extra ten minutes with a diabetic to help him quit smoking and avoid a heart attack ten years from now, I don’t bring in any more money than if I send him out the door with a pat on the back and “see you next time”. But if I cut his visit short and see his grandson for a sore throat, I generate as much income for us as I would have done for a lengthy visit with his newly diagnosed diabetic wife. Any face to face encounter generates the same revenue, no matter how short.

My productivity target clashes with my quality targets. I am constantly balancing between them. And so are physicians everywhere, even if non-FQHCs get paid per Relative Value Unit (RVU), which rewards them to a degree when patient visits are longer and more complex.

In the old paradigm, a physician is only working when he or she is face to face with a patient. The new paradigm claims the importance of reading and being aware of incoming reports from hospitals and specialists, conferences with nurses and care managers, review of population health data and planning future interventions.

But right now, those are money losing activities. How many organizations have the courage, and the deep pockets, to do right now what will hopefully be paid for some time in the coming years?

So, in reality, doctors skim over their incoming reports or sign them off unread. Nurses and care managers read them and enter diagnostic details and new medications prescribed by hospitalists and consultants in each patient’s EMR, but the busy providers don’t have enough time to talk in depth with the care managers whose chart entries take as long to read as the outside reports would have taken in the first place.

We struggle to find the time to talk to our patients, and rely on others to communicate with them. When we work that way, information can get lost or distorted, so we risk making tangential or inappropriate clinical decisions. A patient calls back reporting to the medical assistant or receptionist that they are not better from their antibiotic and the physician prescribes another one, when the real message may have been that they are only 75% better and most likely will be fine in another day or two. So resources are wasted, unnecessary treatments are prescribed, and opportunity for patient education is lost. All because we are too busy to gather the clinical information that we have the training and experience to collect.

It is obvious that this incongruence between paradigms is a setup for physician burnout, but on a bigger scale it also makes me wonder about organizations. Can they experience burnout too?

I read somewhere about the causes of burnout:

“Maslach, Schaufeli and Leiter identified six risk factors for burnout: mismatch in workload, mismatch in control, lack of appropriate awards, loss of a sense of positive connection with others in the workplace, perceived lack of fairness, and conflict between values.”

All of today’s healthcare seems to fit this description. We must go forward, or even back, but we can’t stay too long where we are right now.