Can We Make Medicine Better in 2018 or will the Politicians get in the Way?

26167657_1405077166288605_6566726140975836839_nMilton Packer described three ways that we could move forward in the New Year to improve healthcare.

It is traditional at this time of the year to look back at our experiences and look forward to our opportunities. Most people do this on a personal level, and communities (including those in the medical community) do so as well. Yet, it is really hard to engage in this exercise in an unbiased manner. If we are feeling well, we may highlight the positives of 2017. If we have been disappointed, we may focus only on events that we regret.

There are likely to be generational issues. Those early in their careers often find themselves tackling issues that none of us could have imagined decades ago. Those who have already made their major contributions may be grateful that these new challenges will largely be addressed without them.

I grew up in an era of unbridled enthusiasm and optimism, much of it undeserved. My children are growing up in an era where options are more limited, and traditional institutions are no longer trusted. One might think that they would be horribly pessimistic about life. Yet, the emerging leaders of the future seem to be more optimistic than I would have ever imagined. The older generation may have experienced fewer impediments, but we largely ignored the problems that we had or that we created. In contrast, the younger generation sees the problems for what they are and are no longer content with sweeping them under the rug. Many are determined to repair things and make them work.

There are three roles that we can play in 2018 and beyond.

Some of us will look at the world as a crumbling place and will strive primarily to achieve a path of survival. They will focus on themselves: How can we endure and prosper in a world with distorted values? How can we capitalize on the weaknesses of the current system so that we will benefit? These are the takers.

Others look at the challenges in the world and work to devise ways to make things better — for everyone: How can we recreate (or create) mechanisms of trust? How can we make the world fairer and more sustainable? They will accomplish that goal by taking thousands and thousands of small positive steps. These are the doers.

Still, others will simply throw in the towel: emotional surrender. They think of the world as being hopeless and beyond repair, so they will neither strive to exploit it nor make it better. They will simply complain, acting as if that were somehow useful. These are the cynics.

There is comfort in being cynical, but it is short-lived.

To maintain a feeling of self-worth and comfort, the cynic needs to find (or invent) new targets. Otherwise, the machinery of cynicism runs out of fuel. But finding targets is not equivalent to finding solutions. When they confuse the two, cynics deceive themselves into thinking they are making a positive difference in the world.

Cynics often espouse the belief that everything needs to be destroyed — reduced to ashes — before things can get better. That attitude allows them to avoid the responsibility and risk of proposing solutions.

Yet, proposing (and perhaps trying) thousands of small solutions is the way that we will meet our current challenges.

I eagerly look forward to hearing your thoughts and reactions. The readers of this blog have made it a popular platform for the past year. And I hope that you will help me — and MedPage Today — make it a mechanism of change in 2018. We can all be doers.

Now How Do We Fix Medicine’s Broken Windows?

Starting with the small things applies to healthcare, too, says Suneel Dhand, MD. Dr. Suneel Dhand stated that 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 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 becoming a physician, something, which I’ve 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 toward administrators and the business side of healthcare.

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 and respected group of 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 starting to get a grip on a problem. In the 1980s and early 1990s, New York City was a place 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 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 is 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 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 behavior is one such example: not allowing major bad habits to flourish starts with forbidding the small things first.

But let’s get back to healthcare. For positive change to occur, here are seven broken windows for physicians:

Completely reject the word “provider.” I have written previously about the implications of the now universal use of the word “provider,” and also penned an open letter with the president of the American College 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 have 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 the 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 systems.

  • 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 over 20,000 times. That’s because it struck a chord with thousands of physicians who have seen it happen. Lobby for its return to the hospital where you work and encourage physicians to use it again in their downtime — even for brief meetings.
  • 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 administrations. Administrators are very much needed in any organizational structure, and healthcare 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 you sensibly and diplomatically stand your ground. If you don’t stick up for good healthcare and your patients, nobody else will.
  • 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 their day clicking 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 they have a monopoly once 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 administrations, so it’s up to physicians to be as vocal as they can.
  • 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 healthcare 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, like 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!
  • 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 different specialties 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 care 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 between all physicians, especially the primary care offices.
  • Professional respect. I am all for respecting everyone I work with, and healthcare 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 “co-workers” 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 that minds being called by my first name, and thankfully most people ask first — but I just find something 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 for certain other professions — be it a university professor, airline pilot, or even the military — titles are the norm of introduction until told otherwise.

These are just seven of many relatively low-hanging fruit scenarios that physicians can, on a daily basis, work towards 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 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 five 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. Suggestion doctor, start fixing those broken windows first.

And Politics still gets in the way as we consider that the CHIP Funding Could Run Out On Jan. 19 For Some States.

Some states are facing a mid-January loss of funding for their Children’s Health Insurance Program despite spending approved by Congress in late December that was expected to keep the program running for three months, federal health officials said Friday.

The $2.85 billion was supposed to fund states’ CHIP programs through March 31. But some states will start running out of money after Jan. 19, according to the Centers for Medicare & Medicaid Services. CMS did not say which states are likely to be affected first.

The latest estimates for when federal funding runs out could cause states to soon freeze enrollment and alert parents that the program could soon shut down.

The CHIP program provides health coverage to 9 million children from lower-income households that make too much money to qualify for Medicaid. Its federal authorization ended Oct. 1, and states were then forced to use unspent funds to carry them over, while the House and Senate try to agree on a way to continue funding.

Phil Galewitz reported that Congress extended funding on Dec. 21 — and said the temporary patch would give states enough money to continue the program while Congress works on a long-term funding solution. But a CMS official says it can only guarantee that appropriation will be enough to fund all states through Jan. 19.

CMS says the agency is in discussions with states to help deal with the funding shortfall.

“The funding … should carry all the states through January 19, based upon best estimates of state expenditures to date,” says CMS spokesman Johnathan Monroe. “However, due to a number of variables relating to state expenditure rates and reporting, we are unable to say with certainty whether there is enough funding for every state to continue its CHIP program through March 31, 2018.”

“States need to know whether they will need to find additional funding for children covered under the Medicaid CHIP program at a much lower federal matching rate; send letters to families and reprogram their eligibility systems,” says Lisa Dubay, a senior fellow at the Urban Institute. “Of course, the implications for families with CHIP-eligible children cannot be understated: Parents are worried that their children will lose coverage. And they should be.”

Although the program enjoys bipartisan support on Capitol Hill, the Republican-controlled House and Senate have for months been unable to agree on how to continue funding CHIP, which began in 1997.

The House plan includes a controversial funding provision — opposed by Democrats — that takes millions of dollars from the Affordable Care Act’s Prevention and Public Health Fund and increases Medicare premiums for some higher-earning beneficiaries.

The Senate Finance Committee reached an agreement to extend the program for five years but did not unite around a plan on funding.

Before the CHIP funding extension on Dec. 21, Alabama said it would freeze enrollment Jan. 1 and shut down the program Jan. 31. Colorado, Connecticut, and Virginia sent letters to CHIP families warning that the program could soon end.

After the funding extension, Alabama put a hold on shutting down CHIP. “Some states will begin exhausting all available funding earlier than others,” a CMS official says. “But the exact timing of when states will exhaust their funding is a moving target.”

Bruce Lesley, president of First Focus, a child advocacy group, says Congress should have known its short-term funding plan was not enough. “The math never worked on the patch, as it only bought a few weeks,” he says. “Congress must get this finalized before Jan. 19.”

Are we ever going to make improving the health care system about delivering good health care to the voters and not about politics?

I guess it is time to exam the possible solutions to a sustainable health care system here in the U.S.A. Single payer system????

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