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Thursday, January 29, 2015

The Root of Physician Burnout

Regardless of all the politically correct statements about primary care, and the need for more physicians to be an entry point into the healthcare system, the simple truth is that the 'burnout rate' for family physicians, or general practitoners is very high.


ATTRIBUTION: 

Richard Gunderman, MD, PhD, is a contributing writer for The Atlantic. He is a professor of radiology, pediatrics, medical education, philosophy, liberal arts, and philanthropy, and vice-chair of the Radiology Department, at Indiana University. Gunderman's most recent bookis X-Ray Vision.



"Last week Dr. Elaine Shattner described a new report in the Archives of Internal Medicine that indicates that rates of burnout among U.S. physicians significantly exceed those of the general population. This is a very serious issue with effects that will ripple throughout society, and it warrants widespread, earnest attention. The solution, though, does not lie in incentivizing physicians with money or restructuring systems to minimize stress on physicians -- it lies in finding earnest professional fulfillment.



According to psychologists, signs of burnout include decreased enthusiasm for work, growing cynicism, and a low sense of personal accomplishment. As the name implies, individuals suffering from burnout feel as though a fire that once burned inside them has dwindled, and perhaps even been entirely extinguished. In many cases, they report a sense of having "run out of fuel," and like my colleague, feel as though they "have nothing left."

Of nearly 7,300 physicians who participated in the Archives of Internal Medicine's national survey, 46% reported at least one symptom of burnout, and the overall rate of burnout among physicians was 38%, as opposed to 28% among other US workers. The highest rates of burnout were reported among primary care physicians, including family physicians, general internists and emergency medicine physicians.

Why should rates of burnout be higher among physicians? For one thing, physicians tend to work longer hours than other workers, on average about 10 more hours per week. Moreover, striking an appropriate work-life balance appears to be a bigger challenge for physicians, in part because they often tend to keep work and personal life more separated than other workers. The authors of the study speculate that such a high rate of burnout could only result from system-wide issues in medicine, as opposed to the personal susceptibilities of a few physicians.

Despite all the talk about the affordable care act and how it will make health better for patients, it offers physicians nothing, whether they are generalists or specialists, rather it increases the burden of caring for patients by physicians, who are now at the mercy of insurers, government and regulators. The burden is not just an increase in the quantity of patients, but also the increase in non-clinical bureaucracy, and a perceived decrease in quality of care as digital influences and algorithms replace physician wisdom.

There is no solution for this problem, and none in the forseeable future. Physicians have been forced to make decisions that outright conflict with their sworn hippocratic oath. At one time physicians were captain of the ship, now they have a ship at which they have nothing to say in the wheelhouse.  

The issue of physician burnout is important. As the US population grows and ages, the number of physicians needed to care for them increases. When burnout leads physicians to reduce or cease their practice altogether, patient access to medical care is diminished. Moreover, burnt-out physicians are likely to be less productive, make more mistakes, and generally deliver a lower quality of care than their fully engaged colleagues. Finally, physicians are human beings too, and their suffering should summon no less compassion and concern than anyone else's.

Physicians react to burnout in a number of ways. Some, like my colleague, withdraw from their practices, reducing their workloads or leaving the practice of medicine entirely. Others become less engaged with their patients and the profession and suffer a decline in the quality of their work. Still others turn to unhealthy and even self-destructive habits, such as alcoholism, excessive or inappropriate use of prescription drugs, and even illicit substances. Some consider suicide. Others may turn to colleagues, friends, or family for help, or seek professional counseling.

Unfortunately, individuals and organizations often respond to burnout by recommending coping strategies focusing on the reduction of stress. The rationale for this approach is straightforward: individuals suffering from burnout seem to be overly stressed. They feel overworked, excessively scrutinized, or overburdened with unnecessary or unfulfilling tasks. To combat burnout, some suppose, we need only reduce such stressors, by cutting back on working hours, relaxing intrusive oversight, and finding ways to lift the burden of "busywork" from the shoulders of physicians.

While useful in some respects, the stress-reduction approach addresses only the less important of the two sides of the problem. Reducing stressors in the work environment may offer real benefit, but often it does get at the problem's real roots. It is like providing symptomatic relief to a patient without ever addressing the underlying disorder or encouraging the development of life habits that foster a positive state of well-being. Instead of merely reducing the bad in medical practice, we need to enhance the good.

The key to combatting physician burnout is not to reduce stress, but to promote professional fulfillment. And promoting professional fulfillment is not merely a matter of reducing costs and error rates or increasing clinical efficiency. Nor is it a matter of protecting and promoting the incomes of physicians. As Herzberg reminds us, efforts to alter physician behavior through income-based incentives and disincentives are inherently demoralizing. The reason is simple: they imply that physicians care more about money than their patients. This constitutes a self-fulfilling prophecy of cynicism.

At their core, good physicians are not mere moneymakers. Good physicians are professionals. And though today we often forget it, being a professional means more than merely getting paid for what we do. Being a professional means above all professing something, declaring openly in work and life that we stand for something beyond our own narrow self-interest. The more we treat physicians as though they were self-interested money grubbers, the more we de-professionalize them. And a de-professionalized physician is inevitably a demoralized and burnt-out one.

Medicine is not a job. It is not even a career. At its heart, medicine is a calling. When it comes to physician burnout, an ounce of prevention is worth a pound of cure. We must begin early in medical education to help medical students and residents explore and connect with a sense of calling to the profession. Even late in their careers, physicians need to recall that they are summoned to something older, larger, and nobler than themselves. They must never forget that a career in medicine represents one of life's greatest opportunities to become fully human through service to others."

It reminds me of when I was a young physician and I was told, "don't be afraid to borrow money, you will have a high income and pay it back." This  obscures and identifies the fallacious belief on non-physicians that money will make up for all the negatives of providing health care."

The current generation of students are borrowing more and more, equivalent to a home mortgage.  

"If we are genuinely concerned about physician burnout, we need to focus less on reducing stress and more on promoting what is best in physicians: compassion, courage, and above all, wisdom. Only by keeping what matters most at the forefront can we reap a full harvest of professional fulfillment. Burnout is not a disease. It is a symptom. To combat it, we must focus primarily on what underlies it. And here the key is not eradicating the disease but promoting professional wholeness, which flows from a full understanding of the real sources of fulfillment."










This article contains vignettes about medical students and practicing physicians who sucumb to the unimaginable burdens of solving patient's problems when there is no one else to turn to.  Insurance companies who thwart physician judgment for the sake of saving their insurance company profits are a key factor for physician disillusionment.

A message from Greg

Subject: Piece of My Mind
Read this if you have time. It resonated with me especially well this morning. I like these two paragraphs:
“I love practicing medicine. Unequivocally. Yet it sometimes seems as much a burden as a privilege. We begin our careers in the anatomy room, a ghoulish lab in which many ‘civilians’would faint. We cut our teeth in bloody operating rooms and intensive care units from which few people leave intact. We spend our lives bearing witness to the sufferings and diseases of troubled souls. We are well paid, intellectually stimulated, and, if we are lucky, trusted and maybe even loved by our patients. Yet on certain days, when our patients do not do well, the trade-off seems untenable.
How are we to protect ourselves from the emotional hazards of the practice of medicine? How are we to stand with our patients through the very worst while avoiding depression, significant stress reactions, and even substance abuse or addiction?”
Love, Greg

The thrill of saving lives and/or improving the quality of a patient's life is sometimes inadquate in the face of a system designed to thwart  physician judgment.


Would they be alive?



Health Train Express Hot Topics for 2014

There were many developments in health reform and health information technology during 2014.  Not the least of which was the first year of implementation of the Affordable Care Act.

Health Train Express 2015.  The blog began in 2003, while I was still in clinical medicine seeing patients who had vision challenges.  As a surgeon opthalmologist for over 25 years at that time I felt the need to participate and contribute some of my ideas to physicians and also begin a second career as a physician and patient advocate. Authoring  a blog with meaningful content (no  pun intended) involves research, thought and actual writing time.  My posts are written by myself over 99.9% of the time.  Other bloggers  have many guest authors.

Clinical Medicine is a jealous mistress....it constantly demands one's attention, not just availability for patients, but also the blizzard of continuing medical education, regulatory and administrative functions. Physicians are now faced with analytics, something that electronic health records has enabled, for better or worse in terms of patient care.

I have always been suspicious about statistics. Statistics can be very misleading.  Averages mean very little unless one understands standard deviations, and other statistical metrics I once knew about, but have deleted from active recall.  For individuals the chances of occurences are new each time the dice are rolled.  In other words, all other things being equal having a cancer or diabetes do not alter the chances of  getting another disease.

An example is if you have diabetes the chances of getting hypertension are increased somewhat but says little about your individual chance of having both diseases.

I decided to look at the analytics for Health Train Express and my other blog Digital  Health Train.

The readers are mostly from the United States, Australia, Indionesia, India, The Russian Federation, and Europe. Most of the inbound links are from Google's search engine. Health Train Express enjoys as much international attention as from the United States, (a true measure of  how much the internet has encouraged openness and transparency and global access to knowledge.  The effects of 'democratization' of knowledge are easily observed.

So how has Health Train Express impacted readers?




Readership (as measured by Google's analytics) fluctuates wildly, ranging from 75 to over 800 per day. This of course is a paltry regular following, however it is limited by search engine ranking. There are many who  use our RSS feed.  Feedjit, which appears in the right hand side bar gives us a real-time indicator of our readership.









   

Monday, January 26, 2015

The Morning After the Day Before

This is a re-print of a post I made several  years ago...somewhere between 2010 and 2014, the time between the enactment of the Affordable Care Act and it's implementation.

We all know the failed roll out of insurance exchanges, confusion about providers, misinformation and other challenges. In January 2015 enforcement of penalties will begin. While there are exemptions, which are loosely described there is no mention of other financial hardships (specific) such as disability or unusually high expenses precluding the payment of premiums. Penalizing those who still cannot afford Obamacare, despite it's misnomer as the "Affordable Care Act" is tyrannical, especially since those at risk are those who are in the least able to contest penalties. For them a trail of tax delinquency, levies, and possible liens and/or garnishments are real possibilities.

The reality is that the expense of 'enfnorcement' upon society will be considerable, as another 'white crime' appears in the lexicon of government legales.


dated:  January 26, 2015


It is a sad fact that those who propose a government run health care system, are misinformed about containment of health care costs.  They argue that ‘non-entrepenurial’ systems elimlinate abuse and misuse of health care resources. However,the end game of reducing costs to the  patient, and payor is offset by the increase in bureaucracy. Institutions, and provider groups will hire watchdogs as overseers to monitor the ‘quality’ of healthcare. The expense of this will be considerable to providers organization. The cost however will be absorbed and shifted to the ‘producers’ of the organization.  I was mistaken about this in my own ‘opinions’ about containing costs until I worked at a military hospital as a civilian contractor.  These organizations compete internally for allocation of ‘fixed dollars’ by ‘proving’ they produce. Departmental budgets are determined by ‘utilization, which is monitored by evaluating RVUs generated by providers. If RVUs diminish so too does there budget.  (or overall institution).  Coding experts regularly ‘train’ providers to ‘upcode’ their services. The military in particular has their own system of using CPT codes. I would be honest in stating that this is not due to greed, but the fear that by not reporting every RVU nickel that department would be penalized. The emphasis is to ‘spend every dollar’ each fiscal year for fear of losing it in the next billing cycle.   I was amazed one day to see an emergency patient who came in with a ‘simple migraine headache’  The ER provider note’s treatment plan included a  “screening MRI”.  Perhaps this is the new paradigm for younger   providers who do rely much more heavily upon technology. Providers in this environment also seem to order more lab tests because they don’t think it ‘costs’ the system’ when a patient (or they ) never see a ‘bill’ to whomever supplies the services.  Particularly in the military these services are provided by ‘outside contractors’ who must be reimbursed as well. 


Many of the military functions are now provided by  outside civilian contractors, such as security or supply chain functions.  This also occurs for medicine and health. For the short term of needed services hiring a contractor also involves a human resources company who does the actual hiring. The intermediary company is often paid on the basis of the reimbursement for the contractor. These firms often charge an equal amount as to what the contractor is reimbursed.  Hidden in this cost if housing and transportation.

Those who observe “our system’ from 40,000 feet really have inadequate knowledge of how the systems work internally.  Those who regulate have little involvement in how and how much it costs to regulate. That is contracted out to third parties, whose costs are ‘hidden’  Congressman Pete Stark frequently tell us the overhead for medicare is 2-3%. That is just not true.  Medicare costs us much more due to cost shifting to private payors and hospitals because their rates are miserably low, and other payors pick up the difference.  Medicare and Medicaid do share in only a portion of the costs of the uninsured. This is passed on to County and State governments.  Statistic lie.






A loud rumbling is being heard at the Internal Revenue Service.  During 2013 complaints were filed by many organizations filing to become  non profit status. Delays have increased, telephone inquiries are answered less than 80% of the time by live personell, tax return and income verifications are not done in real time, as well as bizarre events such as over 2,000 refund checks being sent to the same physical address.  It seem automation and computerization can only go so far. Increasing public, national debit have resulted in sequestration, a budgetary fix that among other things has reduced the IRS budget by 10%, and IRS training by 87%.  Taxpayers can no longer obtain accurate or reliable information from the IRS.


Couple this with the  Affordable Care Act and the additional mandate for the IRS to administer compliance with the indivual insurance mandate and for enforcement…..this is an event and disaster waiting to happen. The internal revenue service references a "Taxpayer Scenario" of form 5157 for qualifying tax preparers to use as a guideline.

Individual shared responsibility paymentThe penalty related to the individual mandate of the Affordable Care Act. This penalty will be applied to a taxpayer's return if anyone in their tax household does not have qualified health insurance or claim an appropriate exemption.



If you are upset about the government running General Motors, just wait….Is health care deemed “Too big to fail?” or Too big to suceed”?



Friday, January 23, 2015

Disease Risk -- Measles

There has been a concern about the recent increase in incidence of Rubeola (Measles)

Measles (also known as Rubeola or morbilli) is a viral infection of the respiratory system.  It is classically characterized by initial fever followed by a rash that covers most of the body.  Measles is highly infectious and is spread through aerosolized droplets from infected persons.  It is contagious from 2-4 days prior to and 2-5 days after the onset of the rash.  Prior to vaccination, 90% of the population in the US contracted measles by the time they turned 15.  Although it is generally a mild illness, it can be accompanied by very serious complications (pneumonia, encephalitis, SSPE) or death in a small number of cases. [1]    Measles can be very serious in immunocompromised persons.

There is considerable evidence that the risk from severe measles disease is highly variable depending on factors influenced by economic and living conditions.  Morbidity and mortality due to measles is far higher in the developing world.  In a study from the UK, Maclure found that the risk of hospitalization from measles in children living in deprived households was over 10 times higher than in areas where households were not deprived.[7]  For measles, overcrowding and unemployment were more correlated with measles hospitalization than vaccination rates.  In the developing world, the majority of complications occur in the younger children.  Gordon et al describe that in Guatemala, nutritional supplements reduced the annual mortality rate by 65% while medical care reduced it by almost 70% [8].




Measles typically begins with
  • high fever,
  • cough,
  • runny nose (coryza), and
  • red, watery eyes (conjunctivitis).

Measles Rash



Image of measles infection
Skin of a patient after 3 days of measles infection.

Two or three days after symptoms begin, tiny white spots (Koplik spots) may appear inside the mouth.
Three to five days after symptoms begin, a rashbreaks out. It usually begins as flat red spots that appear on the face at the hairline and spread downward to the neck, trunk, arms, legs, and feet. Small raised bumps may also appear on top of the flat red spots. The spots may become joined together as they spread from the head to the rest of the body. When the rash appears, a person’s fever may spike to more than 104° Fahrenheit.
After a few days, the fever subsides and the rash fades.

Measles photo collection:


Don't wait.....Vaccinate !




Thursday, January 8, 2015

100 Ways To Change Your Life In 10 Minutes Or Less

The most effective way to meet any goal, experts say, is through a series of tiny changes. Here are 100 that work.


1. Wipe down your office doorknob.
Using disinfectant wipes on commonly touched objects like doorknobs can reduce the spread of cold- and flu-causing viruses by up to 90%, according to researchers from the University of Arizona.




2. Meditate in the morning.
"I start my day with a simple meditation practice; it sets the tone for my day and clears my head to prepare for what's ahead," says Tiffany Cruikshank, an internationally renowned yoga instructor and the founder of Yoga Medicine. 
3. Eat sardines twice a week.
They're packed with protein and omega-3s, and most worthy of a place on your plate. Try these 3 easy recipes with sardines—your heart will thank you.
4. Make your own salad dressing.
Skip the not-so-healthy bottled stuff; all you need are a handful of ingredients to bring out the best in your greens. Try these easy 5-ingredient salad dressings.
5. Cook with blood-pressure-lowering herbs.
Add these super-healthy spices to your recipes, and check out these 25 healing herbs you can use every day.

6. Get Sugar Smart.
Americans eat an insane amount of sugar—and much of that sugar is hidden in foods without you realizing it. Take back control with The Sugar Smart Diet, written by Prevention's own Anne Alexander (published by Rodale, which also published Prevention).
MORE:.........
Answer an email in person.
Not only is it friendlier, but it also forces you to walk around, which you should do at least once every hour if you have desk job, says Martha Gulati, MD, director for preventive cardiology at Ohio State University Wexner Medical Center. Studies link sitting to weight gain and poor heart health.
Make a food plan for the week.
Chalkboards are trendy, but they're also good for guiding your mind and your mouth toward a healthy meal at the end of the day. (Fill your menu with these freezer-friendly recipes you can make ahead of time.)
Volunteer your time.You get what you give: Research shows volunteering regularly can lower your risk for death by up to 24%. All that usefulness and altruism might cause your brain to produce more oxytocin and progesterone—good-vibe chemicals that curb stress and reduce harmful inflammation. (Here's how to find the good deed that matches your personality.)

There are many more excellent ideas, such as 
Wear sunscreen every single day.
With a reduced risk of skin cancer, and fewer wrinkles and sunspots, there are a million reasons to protect your skin, says Alison Sweeney, author of Scared Scriptless and host of The Biggest Loser. "Each morning, I make a point of taking care of my skin by applying moisturizing sunscreen. It gives me a few minutes of quiet and I'm protecting myself for that day and the years ahead."
Spike your breakfast with cinnamon.
The spice has been shown to reduce insulin resistance and may help lower cholesterol and triglycerides, blood fats that could contribute to diabetes risk. Find it in these 12 energy-boosting breakfasts.

Take your walk to greener pastures.
The University of Essex in the UK found 30 minutes of walking in a green scene reduced depression in 71% of participants.

and....


 Wearable Devices add a new flare to your fitness program




 Simple nasal irrigation is painless, eliminates many allergens such as pollern, mold, and reduces  frequency of colds.
Yogurt and honey.....what more to say.











6 inflammation-causing foods no one talks about..
There's a five-alarm fire sounding these days about inflammation, and with good reason. Heart disease, cancer, Alzheimer's, and acne are just some of the possible consequences of too much inflammation in the body.According to Nicholas Perricone, M.D., the pioneering nutritionist and dermatologist (who wrote the book on anti-inflammation eating), our bodies actually depend on temporary inflammation to help fight off sudden injuries or infection. But when that inflammation becomes chronic, "the immune system mistakenly attacks normal cells, and the process that ordinarily heals becomes destructive.Like so many health issues, the main culprit is too much sugar, and surprise, some Yogurts may not be healthy.
Not all frozen yogurts are created equal, says Andrew Weil, M.D., director of the Arizona Center for Integrative Medicine at the College of Medicine, and an anti-inflammatory evangelist. "Some frozen yogurts contain the milk proteincasein, which may increase inflammation," he explains. "Others contain specific probiotics that may actually reduce it." (And some frozen "yogurts" contain no dairy at all and use coconut milk.)

Froyo has two potential inflammatory culprits: sugar and dairy. Milk can boost insulin levels and male hormones, and it's a common allergen, which means it can trigger inflammatory reactions (anything from diarrhea to hives). 

Try some of these and make notes about your progress.


Sunday, January 4, 2015

What's happening in Vegas: the CES 2015 keynotes you won't want to miss

What's happening in Vegas: the CES 2015 keynotes you won't want to miss


What dedicated health technologist can miss CES ?


The biggest day of CES is the day before CES. Come to think of it, the day before that (today, Sunday) is pretty big too. But Monday is press conference day

The day some of the industry’s biggest and most important companies get on stage and launch somewhere between five and five thousand new products. (Some of them will be washing machines.) If you’re excited about the future of technology and the gadget industry, there’s no bigger day than CES Day Zero.
That day is tomorrow. Monday, January 5th, 2015. We’ll be live all over Las Vegas, following every event, every announcement, every time Michael Bay melts down during a Samsung event because he forgot his lines and should probably stick to directing. For the biggest events, we’ll be on the scene liveblogging, bringing you everything in real time as it happens.

To learn more:  Digital Health Space

Monday, December 29, 2014

Hey Doc, Please go Away

Aaron Carroll,  over at The Incidental Economist,summarizes a study suggesting that patients do better when cardiologists are away at academic meetings.

High risk patients admitted with heart failure during meetings had a 30-day mortality rate of 17.5%, compared to 24.8% when more cardiologists were there. Cardiac arrest 30-day mortality was 59% during meetings and 69.4% at other times. 
Why is this?
There are a number of ways to interpret this. Maybe the best cardiologists were the ones who stayed home. Maybe with fewer cardiologists available, fewer invasive procedures get done, and that leads to better outcomes. Maybe they tell more low-risk patients to wait when fewer cardiologists are available, which gets the higher risk patients more attention and better outcomes. Maybe it’s something else.
I favor the second explanation and am reminded of the excellent judgment of my PCP back in 2007 when I was asked by the touring company to take a stress test before a two-week long kayaking trip to Patagonia.
She says, “No. I refuse to order a stress test for you.”
“Huh?” I reply intelligently.
“Here’s the deal,” she says. “If I order the stress test, our especially attentive (knowing who you are) cardiologist will note some odd peculiarity about your heartbeat.


 He will then feel the need, because you are president of the hospital, to do a diagnostic catheterization. Then, there will be some kind of complication during the catheterization, and you will end up being harmed by the experience.”

Minor ST segment changes, may be non-specific.
” I will not authorize a stress test.”