Walking up to the waiting room door, I knew what lay behind it. The gnawing torment started the day before, sometimes two. Three parts nausea, two parts dread, and a dash of anxiety—the recipe was always the same. Just add an organic grass-fed physician, and the health care system has a nice little snack to chew up and unceremoniously spit out.
This is my story: a successful emergency physician by external parameters, but strained by internal ones. What came out of residency—a supremely confident physician ready to take on the world—would never recognize himself 11 years later. My experiences in our health care system transformed me, and my story is not unique. A sickness seeps into clinicians, and it is as easy to catch as influenza and as hard to treat.
“Health care system” is a phrase I find difficult to write because it is an inaccurate representation of what it intends to describe. If we take the words “health care” to mean the mishmash of hospitals, physicians, insurance companies, and vendors that profit from our physical and mental maladies, then perhaps we would be more accurate calling it “sickness billing.”
It is truly sickness that we try to solve in our current model, not health, and it is billing with which we spend the better portion of our time, not care. The word “system,” which means an organized set of things working together for a common goal, would be better replaced with “ataxia” given the uncoordinated manner in which this mishmash operates, but “ataxia” is too exotic, so I'll use the term “industrial complex” with the coded chart as our industry's widgets.
The sickness-billing industrial complex (SBIC) is an uncoordinated amalgam of special interests profiting from a series of unintended consequences of poorly designed policies. How did we get here? What happened in the past 20-30 years? Here is my version of the story:
Government policies, such as subsidizing corn and promoting sugar and carbohydrate-rich foods as low-fat alternatives, and societal changes in expectations of portion size and taste, resulted in a massive increase in calorie-dense, nutrient poor, and highly processed “foods” in our diet (corn syrup, refined wheat). These dietary changes led to dramatic increases in obesity, diabetes, heart disease, cancer, and autoimmune disorder rates (Curr Allergy Asthma Rep 2014;14:404; http://bit.ly/2yw0yZd), swelling costs borne by Medicare and insurance companies within a strained system unprepared to handle the increasing need for preventive care. CMS responded by creating obstacles to physician reimbursement, believing this strategy could help reduce its expenditures. This is why some physicians ask patients seeking care for an ankle sprain about constipation, vaginal bleeding, and tinnitus.
Barriers to Payment
These obstacles started as documentation-focused rules, requiring physicians to record a certain number of data points for each medical visit; otherwise, reimbursement would be reduced. (Medicare Learning Network, Evaluation and Management Services, 2016; https://go.cms.gov/2K0wut3.) This is why we ask patients who sought care for an ankle sprain about constipation, vaginal bleeding, and tinnitus.
Physicians, often slow but never dumb, adapted to the new rules, learned how to document their charts to recover lost revenue, and spent extra time asking and documenting endless nonsense. Medicare responded to the physician adaptation with yet more barriers—the Core Measures. (CMS.gov, July 28, 2017; https://go.cms.gov/2t5Z0zM.) Of course, Medicare couldn't admit these were barriers to paying physicians and hospitals, so it called them a switch to value-based care. The problem was that most of the parameters on which it based value were questionable or had little basis in the scientific literature, so most physicians saw the parameters for what they were: ways for CMS to pay us less.
One ED where I worked decided that all patients with the remotest possibility of pneumonia in triage were to be given a dose of antibiotics by mouth immediately because Medicare had decided that antibiotics within six hours of arrival was a measure of quality. Some patients received antibiotics they did not need; others needed IV antibiotics but received oral instead. We were practicing bad medicine to meet our “quality” goal.
Medicare created more games, represented by a never-ending litany of acronyms that read like a Sesame Street song, PQRS, MIPS, and MACRA. These new programs were so complex that many physicians faced three stark choices: spend hundreds of hours of their own time to learn and adapt to the new rules, sell their practice to a hospital or group with the resources to hire a consultant to figure out how to play the game, or accept significantly lower payment.
Sadly, many physicians opted to sell their practices and give up their autonomy to a corporate entity. This is a major loss to our communities because independent practices are the last refuge against the corporate practice of medicine. Just as sad are those physicians who try to stay afloat in the sea of acronyms, barely staying above water, seeing patients more hastily with less face-to-face time, more stress, more rushing, more mistakes, and more frustration, all of which may lead to decreasing empathy, a dangerous state for a physician.
None of these new Medicare programs will solve the problems in our sickness-billing industrial complex because we are not dealing with the core fundamental issues. We treat sickness instead of fostering health, we focus on billing instead of care, and we are completely uncoordinated. We have an unhealthy population gorging themselves on sugar-rich foods, developing preventable diseases like type II diabetes with expensive complications (kidney failure, heart attack, stroke, blindness, etc.), and holding false expectations that physicians and medicines can work miracles to reverse years of horrendous nutrition. Meanwhile, physicians are coerced into spending a majority of their time figuring out how to play documentation games instead of engaging patients in real health-oriented change.
The transformation of our system from volume to value is a much needed one, but it is missing one key element of success (which generates my cynicism), and this element is well explained by the Stanford behavior scientist, B.J. Fogg: For a new behavior to succeed, you must make the desired behavior easier.
Raise your hand if you think MIPS and MACRA are easy to understand, let alone implement. Which of you believe the EMRs have done everything possible to help us succeed with all these new measures? In fact, most of us earn $20 per hour less than we should to subsidize the cost of a scribe, a resource now required to finish your shift with your sanity intact.
Into this sickness-billing industrial complex in 2006 came a fresh, young, eager, new emergency physician. I truly loved learning about and practicing emergency medicine when I began my career. It was exhilarating—the tight-knit teams dealing with the chaos of endless streams of patients, time pressure, challenging problem-solving, and quick decision-making. Great teamwork, amazing saves, and warm appreciation from patients were the norm.
Then, in my second year, came my first lawsuit as an attending. It was a case I remember with photographic precision because it was one of my most intense. He wasn't even my patient. He had been seen by several other physicians and admitted for a complaint with an atypical presentation. The patient crashed during my shift, and my team and I did our best to save him. I remember having a heartfelt, warm, and sad moment with his family at his bedside before we sent him via helicopter for an emergency surgery that we could not perform at our hospital. That night, I was saddened by this gentleman's death but proud of my team's effort.
I recounted the scene in court, including how the blood bank coordinator, an older woman we rarely saw, ran her fastest into the ED with several units of O-negative blood, knowing that every second counted. Every single person was doing everything possible to save this man's life.
I felt like a leader of heroes. Yet, we were sued and treated like criminals. To be sued when you've done something egregiously wrong is understandable, but it is demoralizing and discombobulating to an unimaginable degree to be sued when you're proud of your effort, skill, and decision-making and when you cannot see what you could have done better. To be sued when you remember standing by the patient's bedside, your eyes welling up with tears because you are a human being who feels the suffering of those around you—nauseating.
I did my best, what I thought was right. Every medical decision and intervention I made was correct, but somebody thinks I did everything wrong, so much so that they want to ruin my life and end my career. Somebody thinks I am evil. Such was the narrative in my mind for the two years this case was active. Sleepless nights. Stressful shifts. Two years of self-doubt chipping away at my confidence and pride.
Self-doubt taking hold in an emergency physician is poison. The hallmark of a great emergency physician is the confidence to make quick decisions with limited time, information, and resources. No amount of training or knowledge can supplant low confidence, and patients can sense it immediately.
I remember as a young attending that I could sense decreasing confidence in some of the older attendings. They shied away from some of the more complicated cases, and we younger attendings happily took these on. I remember thinking quietly to myself back then, “I hope I never lose my confidence,” and now I was starting to feel it.
My colleagues and bosses thought my performance was great. I was seeing patients quickly, providing great medical care, and achieving high patient satisfaction results. I posted among the best numbers in my practice for quite a few years, but I felt increasingly unsure of myself. One of my older colleagues joked to me privately that emergency medicine is the only profession in which you can feel more unsure the longer you practice it. Not only does emergency medicine rank among the highest lawsuit rates of all specialties, but we also deal with the unintended complications from every other specialty. This means that the more an emergency physician practices, the more acutely he experiences the tragic ways the sickness-billing industrial complex can fail. We learn quickly, from seeing tens of thousands of cases of our own and our colleagues', that no matter how good of a physician you are, you are going to miss certain things, you are going to make mistakes, and certain things are going to happen to your patients that nobody could predict or prevent.
We also learn, unfortunately, that society is not OK with that. Society wants somebody to blame. Family members want somebody to blame. Hospitals want somebody to blame. Society expects perfection. Physicians aren't human; they don't make mistakes. I told my colleagues that being a physician is like being a wildebeest crossing the Mara River: The crocodile is going to eat one of us. And then he'll get another and another, whenever he chooses, each and every time a devastating shock to the wildebeest and those around him.
I saw some of my colleagues get taken down by crocodile lawsuits in the ensuing few years while I continued to deal with my own. Meanwhile, Medicare ramped up its value-based programs, increasing the documentation burden on physicians and hospitals. The first and second generations of electronic medical records were deployed in hospitals. EMRs were intended to streamline medical documentation, but they dramatically reduced physician productivity. The chief reason was that EMR companies got away with designing software with horrendous user interfaces and workflows.
How? Unlike most consumer software, the purchase decision-makers in the SBIC world are not the end-users. EMRs sold the C-suite on integration, and nobody paid attention to usability. The Mayo Clinic just announced in May that they were paying $1.5 billion to switch to the Epic EMR system. (Healthcare IT News, May 1, 2018; http://bit.ly/2M4kyUj.)
Pause for a moment: How could software cost $1.5 billion? When your user interface is so unintuitive that you have to hire and deploy an army of consultants and trainers to hold each user's hand for two weeks, it can lead to truly “epic” implementation costs. As if this were not bad enough, the internet buzzed with stories of Epic bullying anybody who criticized its software, and this happened to me as well. (KevinMD.com, Sept. 29, 2015; http://bit.ly/2K1DHc9.)
Can you imagine the backlash if Microsoft or Google instituted gag orders to prevent criticism of its software? Yet this is the world of the sickness-billing industrial complex. The negative effects of poorly designed EMRs on physician morale and productivity are well documented. (Harvard Business Review, March 30, 2018; http://bit.ly/2yjIW2g.)
Don't Make Mistakes
With reimbursement declining because of Medicare's new rules and physicians becoming less productive because of EMRs, physician practices were forced to make their physicians work faster and leaner than ever before. Hospitals increasingly expected higher and higher patient satisfaction results from physicians (some of whose unintended consequences we are seeing in today's opioid epidemic). Practices expected the physicians to work leaner and faster. Patients and families expected perfection in care—no complications or unexpected events allowed. Insurance companies expected perfectly documented charts or else no payment. EMR vendors expected you to use their dreadful software and keep your mouth shut.
Work faster, make everybody happier, document more, and, oh, yeah, don't ever make a mistake.
The feeling for me before an ED shift flipped from being one of excitement, eagerness, and energetic anticipation to one of nausea and dread. One of my residency colleagues developed a trepidation of ED shifts even before graduating from residency, and promptly quit emergency medicine the day he graduated. Only later did I truly appreciate what he must have felt.
All physicians and nurses, especially those in our nation's EDs, make personal sacrifices to enter and practice a profession that provides the opportunity and the honor to heal, comfort, and advise their fellow human beings at all hours of the day or night, working weekends, overnights, and holidays while most people are sleeping or spending quality time with friends and family. When the constituent forces in the SBIC repeatedly insult, trample, and interfere with the humanity and virtue of medical physicians, they do great damage to the physician's ability to empathize.
Damage to a physician's ability to empathize is the sickness within our providers to which I referred in the beginning of this essay. Every condition needs a name, so I shall coin the term “empathitis.” Empathy, in my personal perspective of its application to the medical profession, is the ability to preserve your sense that you are treating another human being, not just “Room 12” or “the hypertensive stroke patient” but rather a human being with a name, a story, family, friends, hopes, and fears, a human being who deserves your full attention, your touch, and your diligent and meticulous thoughtfulness.
Empathitis: an acute or chronic reduction in a person's ability to empathize, often affecting his work and life performance. (Purely fabricated word and definition).
When the forces surrounding me made it difficult for me to be the type of physician I wanted to be and had trained to be, when those forces repeatedly directed my attention to documentation, billing, EMRs, and moving patients as fast as possible, and when those forces continually chipped away at my mountain of empathy, reducing it to scarcely a handful, I knew the time had come to say goodbye to the ED. My last ED shift was last summer.
Luckily, my departure from the physical world of hospital EDs did not signal the end of my medical career. I was fortunate during my career to work for a medical practice that gave me the opportunity to develop skills and experience in health care technology, data analytics, business development, and telemedicine, and now I have the great pleasure of practicing telemedicine with CirrusMD, an innovative group of amazing human beings transforming how health care is delivered.
Now when I see patients from my computer screen, I can chat with them as long as I want. They share stories with me, and sometimes we laugh. I advise them the same as I would advise my own family. We don't rush anything. More often than not, they just need reassurance and a little bit of guidance. I am no longer placing central lines and doing intubations, but I feel more like a true physician than ever before. I spend time talking to patients about health, not just sickness.
In addition to dealing with whatever the patient's acute medical condition might be, we talk about food choices, exercise regimens, sleeping habits, behavior modifications, and stress reduction techniques and how these things may be connected to the patient's acute condition. Sometimes we discuss fears and anxieties; I've even coached patients through full-blown panic attacks online. Now I can truly focus on health and care, not just sickness and billing. Now I operate in a system that I actually like to use and that supports me and my mission.
I feel blessed, but I know that many of my former colleagues and friends in the world of emergency medicine continue to endure and suffer. Less than half of my residency class is still practicing traditional emergency medicine. In an era of physician shortages and long wait times in EDs, I felt this story was important to share, so we can finally talk about what lies behind the waiting room door.
Our special reports usually focus on clinical advances or trends in emergency medicine, but we thought this essay was worth deviating from that practice. Nowhere has an author so brilliantly been able to capture the root causes of burnout in emergency physicians. This moving account eloquently summarizes the pressures of modern emergency physician life.—Lisa Hoffman, Editor
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