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Beyond Burnout: Docs Decry Moral Injury From Financial Pressures of Health Care

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 This story was originally published on the Kaiser Health News website. Illustration by Maria Fabrizio for Kaiser Health News.

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’t need any tests to diagnose the viral infection that causes a rash and searing pain.

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

The excessive testing, Corl said, stemmed from a model of emergency care that forces doctors to practice “fast and loose medicine.” Patients get a battery of tests before a doctor even has time to hear their story or give them a proper exam.

“We’re just shotgunning,” Corl said.

The shingles case is one of hundreds of examples that have led to his exasperation and burnout with emergency medicine. What’s driving the burnout, he argued, is something deeper — a sense of “moral injury.”

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 “moral injury” to describe their inner struggles at work.

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 the emotional, physical and spiritual harm people feel after “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.”

Drs. Wendy Dean and Simon Talbot, a psychiatrist and a surgeon, were the first to apply the term to health care. Both wrestled with symptoms of burnout themselves. They concluded that “moral injury” 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.

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, comments, calls and invitations to speak on the topic.

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. And the physician suicide rate is more than double that of the general population.

Dean said she and Talbot have given two dozen talks on moral injury. “The response from each place has been consistent and surprising: ‘This is the language we’ve been looking for for the last 20 years.'”

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.

Those barriers can be particularly intense in emergency medicine.

Corl said he has been especially frustrated by a model of emergency medicine called “provider-in-triage.” 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’ ailments and get a head start on solving them. The patient is usually wearing street clothes and sitting in a chair.

These brief encounters may be good for business: They reduce the “door to doc” time — how long it takes to see a doctor — that hospitals sometimes boast about on billboards and websites. They enable hospitals to charge a facility fee much earlier, the minute a patient sees a doctor. And they reduce the number of people who leave the ER without “being seen,” which is another quality measure.

But “the real priority is speed and money and not our patients’ care,” Corl said. “That makes it tough for doctors who know they could be doing better for their patients.”

Dean said people often frame burnout as a personal failing. Doctors get the message: “If you did more yoga, if you ate more salmon salad, if you went for a longer run, it would help.” But, she argued, burnout is a symptom of deeper systemic problems beyond clinicians’ control.

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 — a recipe for hospital-acquired delirium.

“Hallway medicine is such a [big] part of emergency medicine these days,” said Jarman, 35, an assistant professor of emergency medicine at UC-Davis. Patients are “literally stuck in the hallway. Everyone’s walking by. I know it must be embarrassing and dehumanizing.”

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.

Being responsible for discharging patients who are stuck in the hallway is “so frustrating,” Jarman said. “That’s not what I’m good at. That’s not what I’m trained to do.”

Jarman said many emergency physicians she knows work part time to curtail burnout.

“I love emergency medicine, but a lot of what we do these days is not emergency medicine,” she said. “I definitely don’t think I’ll make it 30 years.”

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’ve 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.

Sawyer, 38, said he has suffered moral injury from treating patients like this one: A Latina had a large kidney stone and a “huge amount of pain” but could not get surgery because the stone was not infected and therefore her case wasn’t deemed an “emergency” by her insurance plan.

“The health system is not set up to help patients. It’s set up to make money,” he said.

The best way to approach this problem, he said, is to help future generations of doctors understand “how decisions made at the systems level impact how we care about patients” — so they can “stand up for what’s right.”

Whether these experiences amount to moral injury is open for discussion.

Cynda Rushton, a nurse and professor of clinical ethics at Johns Hopkins University, who has studied the related notion of “moral distress” for 25 years, said there isn’t a base of research, as there is for moral distress, to measure moral injury among clinicians.

But “what both of these terms signify,” Rushton said, “is a sense of suffering that clinicians are experiencing in their roles now, in ways that they haven’t in the past.”

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.

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

Their work is attracting praise from a range of clinicians:

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 “a dramatic shift” in the culture there, where “revenue became all-important.” The company cut in half the time for each patient’s 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. “I felt I short-shrifted them.”

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 “I couldn’t offer the care I wanted to because of time restrictions.” 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, “often my job was impossible to do.”

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’s ailment — and spending nights and weekends slogging through paperwork required by insurers.

“There was a grieving process, leaving primary care,” he said. “It’s not that I don’t like the job. I don’t like what the job has become today.”

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’t use that method.

He said many people frame burnout as a character weakness, sending doctors messages like, “Gee, Keith, you’ve just got to try harder and soldier on.” But Corl said the term “moral injury” correctly identifies that the problem lies with the system.

“The system is flawed,” he said. “It’s grinding us. It’s grinding good docs and providers out of existence.”

An Insurance Company Auditor Tried to Destroy My Career

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It’s no secret that in today’s health care market, insurance companies are calling the shots. As a pediatrician in private practice for almost two decades, I’ve seen insurance companies transform into perhaps the single most powerful player in today’s health care landscape – final arbiters whose decisions about which procedures or medications to authorize effectively end up determining the course of patient care.

Niran_Al-AgbaDecisions made by insurers, such as MassHealth, have arguably killed patients. But it was only when I got caught in the crosshairs of an insurance company auditor with a bone to pick that I fully appreciated their power to also destroy physicians’ careers.

My nightmare began around two years ago, when my late father, also a physician with whom I was in practice, and I opened our Silverdale clinic on a Saturday. It was the start of flu season, and we’d just received 100 doses of that year’s flu shot. Anxiety about the flu was running high following the death of a local girl from a particularly virulent strain of the virus a year before, and parents were eager to get their kids immunized as soon as possible.

Under Washington law, adults don’t even need to see their doctors to get flu shots. They can get them at Walgreens, directly from pharmacists. But because children under 9 are more susceptible to rare but life-threatening allergic reactions, they must be immunized by a physician. This meant that, for convenience sake, parents often scheduled their kids’ annual checkup on flu shot day, thus allowing them to condense much of their routine care into a single visit.

That particular Saturday went off without a hitch, with my father and I seeing and immunizing around 60 patients between the two of us over a 12-hour day.

Three months later, a representative from the insurance company requested to see some of the patient charts from that flu clinic as part of an audit. Aimed at rooting out insurance fraud by cross-checking doctors’ records, these audits have become a routine fixture in medical practices today. To incentivize their auditors to ferret out the greatest possible number of irregularities, and thus boost the corporate bottom line, auditors work on commission, being paid a percentage of the funds they recover.

The auditor in charge of my case failed to turn up any irregularities in our documentation. But, still, she issued a stern admonition to my father and me, ordering us not to open our clinic on Saturdays to administer flu shots.

This struck me as an outrageous restriction, considering our clinic is a private entity where we set our own hours and schedule accordingly, and so I called the auditor. But instead of backing down, she ratcheted up her rhetoric, saying she was also forbidding me from examining my patients before immunizing them; clearly a bid to save her employer even more money. I was shocked. Her directive amounted to practicing medicine without a medical license — which is, of course, illegal in the state of Washington and many other states across the nation.

I shot back that immunizing infants and small children is a serious undertaking, requiring proper caution and care, informed her there was no way I would be complying with her mandate. Following this brief exchange, she took it upon herself to report me to the Medical Quality Assurance Board, the government-backed body charged with shielding the public from unqualified or unfit doctors. The accusation levied against me? Not following an insurance company mandate, which, in her opinion, amounted to unprofessional conduct.

It didn’t matter that the charges against me were ludicrous. The potential consequences were only too real, and potentially catastrophic. Had the State Medical Board decided against me, I could have lost my license. I hired a lawyer, sinking more than $8,000 into legal fees. I was cleared by a unanimous committee vote. But other physicians facing similar situations may not be as lucky.

The 18 months of excruciating stress that followed my altercation with the auditor made it patently clear that insurance companies wield far too much power. Bureaucrats are making life-and-death medical decisions without a single minute of medical training, and their auditors are terrorizing physicians by coercing state medical boards to act as their henchman. Unfettered by any consequences for enforcing policies that fly in the face of rules protecting patient safety, insurance companies will continue to harm doctors and patients alike if no one can stop them.

Niran S. Al-Agba is a pediatrician in Sliverdale, Wash., who blogs at MommyDoc

Fix the Broken Windows of the Medical Profession

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  By Suneel Dhand, MD

This story was originally published on www.kevinmd.com and is reprinted with permission.

I am honored to be a member of the medical profession. Being a physician is a great job and a highly rewarding thing to do. One of the aspects that I like most, unlike so many other desk or number jobs, is that you can never go home in this line of work thinking that you haven’t done something good with your day (if you do, there’s something seriously wrong).

The everyday interactions with patients and families ― getting to know them and using one's skills to serve them — are not only deeply rewarding but also very humbling. It’s those positive interactions that sustain me, even on the worst days. I have zero regrets about becoming a physician, something that I’ve also written about previously.

Having said all of this, it’s no secret there’s an epidemic of physician burnout and job dissatisfaction out there. This is for a multitude of reasons, but everything ultimately boils down to a monumental loss of autonomy and independence among doctors, as there’s been a dramatic shift of power and clout away from individual physicians and toward administrators and the business side of health care. Somewhere along the journey, we have lost our direction completely. Unfortunately, in many ways, we have nobody but ourselves to blame collectively because for any large group of respected people to surrender so much autonomy so quickly, a lack of strong leadership must always be a factor.

I am a huge fan of the "broken windows" theory of getting a grip on a problem. In the 1980s and early 1990s, New York was a city in terminal decline. Growing up in England, I knew many people who came back from trips to America telling us about how terrible and dirty the city was. Times Square was basically a no-go area full of aggressive panhandlers. It was a dangerous and scary place. Enter Mayor Giuliani in 1994, and the city underwent a rapid transformation. I understand that some aspects of what Mayor Giuliani did were viewed by (some) as controversial, but not wanting to get into politics, the results were unquestionable. The broken windows theory of turning around New York City went something like this: Heavily target the minor offenses first. Zero tolerance for broken windows, graffiti, and other things such as “squeegee men” who would aggressively approach you when your car was at a red light. So the philosophy goes: Clamp down on the small infringements, and the bigger things will take care of themselves.

The results of this clampdown for New York City were indisputable. By the time I first visited America in 1998 ― New York City being my first stop on a countrywide tour with my family ― Manhattan had become one of the safest and most pleasant places in the country. There was a visible police presence on every street corner, and the city was immaculately clean. Whatever people say — drastic circumstances call for drastic actions. Even today, Manhattan is still one of the safest cities in America, and tourists from all over the world give glowing accounts of their stay in the Big Apple (in fact, low-level crime is actually much lower than in many European cities, including my home city of London). Thank you, Mayor Giuliani.

We all probably have our own personal experiences of how true the broken windows theory is and its everyday applicability. Teaching children good behavior is one such example, when not allowing major bad habits to flourish starts with forbidding the small things first. But let’s get back to health care. For positive change to occur, consider these seven broken windows for physicians:

1. Completely reject the word “provider.” I have written previously about the implications of the now universal use of the word “provider” and have also penned an open letter with the chief executive officer of the American Board of Physician Specialties, William Carbone, to all medical societies and organizations. The word really has taken over, especially evident during the last decade. I am equally shocked by how new residents are being churned out of some of the most prestigious academic centers in the country (my experiences are with the ones in Boston) and are adopting the word so casually, happily describing themselves as “providers” on correspondence, including their social media accounts. The business and marketing world really has done a number on us and has run rings around the medical profession. Unfortunately, physicians are also very naïve as a group in understanding the immense power of words and how not calling ourselves “doctors” or “physicians” anymore is extremely bad for our profession. I personally am okay with many other terms if a more encompassing one is required for certain correspondence, including “clinician” or “practitioner” — but "provider" is deliberately dehumanizing and, also in my view, an insult. If you refuse to use the word and call people out on it, they will stop calling you one. It should be removed from all administrative correspondence including information technology (IT) systems.

2. Insist on a good physician lounge in your hospital. It’s so much more than a physician lounge. It is a marker of professional respect and autonomy. This (very small) job perk has rapidly fallen away. I recently wrote an article on this, which went viral online, being shared more than 20,000 times. That’s because it struck a chord with thousands of physicians who have seen it happen. Lobby for its return in the hospital where you work, and encourage physicians to use it again in their downtime — even for brief meetings.

3. Stand your ground with administrators. As much as hundreds of thousands of employed physicians across the country have a fraught and tense relationship with their administrators. Let’s be realistic: Administrators are very much needed in any organizational structure, and health care desperately needs good ones. However, if you sense that any directive is coming through that will interfere with, or be detrimental to, frontline care, it’s crucial that you sensibly and, of course, diplomatically stand your ground. If you don’t stick up for good health care and your patients, nobody else will.

4. Fix electronic health records. Almost every current study of physician job satisfaction and career burnout lists the burden of cumbersome and clunky electronic medical records at or near the top of the list of everyday frustrations. It’s an issue that is almost invisible to bureaucrats and administrators, but no doctor went to medical school to spend the vast majority of his or her day filling out click boxes and typing out bloated notes for billing purposes. Most electronic medical record systems (I’ve worked with nearly all of them, and in my opinion they all suck) can be optimized in small ways to improve workflow and reduce the “click burden.” What it does require is relentless feedback to your hospital IT department to do so (remember, the main vendor has no motivation whatsoever to improve things because it has a monopoly once the system is installed). Electronic medical records are one of the only examples of technology where the end-user is not the “customer” (imagine how bad the iPhone would be if it worked like that). The companies sell to administrators, so it’s up to physicians to be as vocal as they can.

5. Keep other physician perks. Being a physician is one of the most intense and grueling jobs one can have. Practicing medicine is not for the faint-hearted. Yes, everyone in health care works hard — but no profession should be actively losing things. Are other useful perks like car parking, a nice office, or cleaning services being taken away from you? Well, they shouldn’t. What about the other useful workflow issues, such as the transcription service axed to save costs (now stuck with tremendous inefficiency, with what used to be a thorough, logical note dictated in five minutes now becoming a series of tick boxes, typed sentences, and incoherent computer-generated mishmash)? It may take multiple emails, phone calls, or face-to-face meetings, but you should insist on keeping job perks that a professional of your level of education and intelligence deserves. If the executives in your hospitals have reserved parking spots and secretaries to make their lives easier, there is no way that the physicians should not!

6. Collegiality. No profession is anything without collegiality. It’s one of the reasons why the physician lounge issue is so important. Doctors need to see themselves again as a unified profession — not one that is fragmented where everyone is in their own little corner specialty. Get to know as many specialists as you can, organize social events where all physicians can mingle, and talk to each other about how you can get things done. Along the same lines, the link between primary care and hospital-based specialists has been breached by the fact that primary doctors no longer come to the hospital (even as a hospital medicine doctor myself, I see immense drawbacks to this). We need to restore communication among all physicians, especially primary care physicians.

7. Professional respect. I am all for respecting everyone I work with, and health care is a team-based effort. But when it comes to a clinical situation, the physician is the leader of the team. Period. However, there are lots of ways in which I’ve noticed physicians nowadays being treated much more as “coworkers” rather than as the team leaders they are (and to be fair, physicians also need to step up to the mark). One such example I’ve noticed is that many colleagues in the hospital now immediately address doctors by their first name instead of “doctor.” Now, I’m not someone who minds being called by my first name, and thankfully most people ask first — but I just find it inappropriate when someone in the hospital, who may actually be much younger than me (frequently also including administrators), walks up and calls me off the bat by my first name. Interestingly, I have heard feedback that this actually tends to happen much more to female than male doctors. Every physician has earned the title and deserves to be addressed as such initially in the professional setting. Again, this is not to sound haughty — but most doctors will find anything else a bit uncomfortable and not protocol. The same applies to certain other professionals — university professor, airline pilot, or even military personnel — titles are the norm of introduction until told otherwise.

These are just seven of many relatively low-hanging fruit scenarios in which physicians can, on a daily basis, work toward making sure they retain their professional status. Most of them are free or with minimal associated cost. Remember, we are an ancient and noble profession, and being a doctor is very special. It’s a privilege to use our education and skills to help people get better each and every day. If you want to advocate for the medical profession, deal with low-level stuff, and the rest will start to take care of itself. Of course, there are undoubtedly much bigger things than the seemingly small things noted above: reimbursements, overwhelming bureaucracy, and information technology, to name just a few. They will all have their time and place to be dealt with. But, doctor, start fixing those broken windows first.

Suneel Dhand is an internal medicine physician and author. He is the founder of DocSpeak Communications and cofounder of DocsDox. He blogs at his self-titled site, Suneel Dhand.

Photo Credit: Wikipedia