by dy on 5/15/17, 7:23 PM with 230 comments
by pixelmonkey on 5/15/17, 9:30 PM
The strange part is, the overwork also seems to be pervasive among the attending physicians who have been out of residency for decades. Not just the residents.
As a tech founder analyzing the system from the outside, I think this writer has nailed the core issue: "... a doctor is just one of the many commodities in this complex industry. It’s no longer about the patient. It’s about the business of hospitals."
If doctors were viewed in their industry the way software engineers are viewed in ours -- as specialized skilled labor with extreme leverage and limited time -- then we would have well-supported, well-rested, and well-compensated doctors.
But as it stands, we have overworked and overtired doctors buried under a mountain of clerical work, who need to slot their patient in to 15-minute "encounters" in clinic to keep the profit machine running. Meanwhile, administrators, health insurance executives, and medical equipment CEOs work 9-to-5 and earn millions. It really boggles the mind and infuriates me, as a technologist.
p.s. Don't listen to any of the comment threads here that say long hours are required to reduce patient handoffs. Yes, it's true, patient handoffs cause some danger. But tired doctors make mistakes. Period. And, as this post indicates, a perpetually tired doctor burns out and either quits the profession or (worse) commits suicide, which is the worst possible outcome for the system.
by pc2g4d on 5/15/17, 10:47 PM
Yeah?
I just recently had a friend completely burn out of medicine, sell his house, and start traveling the world. He was brilliant, a good doctor, a good person. It's a shame he's been driven out, and so many others.
I also recently had the experience of seeing a young doctor bright-eyed and busy-tailed treat me once, and then six months later see him again. The toll that those six months took on him was visible. He was just about haggard with the work. It's easy to imagine he won't last long.
I feel there's an interesting parallel with teaching. Teaching and medicine both have licensure requirements, both have a strong appeal to people who care and want to make a difference in the lives of children/patients. And in both cases the profession is gradually being taken over by administrators and subject to increasingly onerous regulations.
I also recently had a friend burn out of teaching. She's set to work in a completely unrelated industry now. She put up with crap for a long time due to her care for the children, but at last she couldn't take it.
My libertarian side says these are two improperly functioning markets, with massive human casualties. It's a shame.
by protonfish on 5/15/17, 8:49 PM
by robbiep on 5/15/17, 11:05 PM
Last week was the Royal Australasian College of Surgeons Annual scientific Congress in adelaide so physician wellbeing is well and truly on the radar, in particular following 3 suicides in the last 6-9 months of junior trainees, one of whom was a friend of mine from medical school.
There is now an enquiry into Doctor suicides and wellbeing being performed at the state level in NSW and we (doctors) expect this scope to be broadened to nationwide
by drewg123 on 5/15/17, 9:53 PM
[1] http://www.usatoday.com/news/health/2005-03-02-doctor-shorta...
by kendallpark on 5/16/17, 12:23 AM
Missouri just passed the first bill of its kind to try and combat mental health issues in med school.
http://krcgtv.com/news/local/medical-student-suicide-prompts...
> The bill, also known as the Show-Me Compassionate Medical Education Act would establish a committee to study mental illness, suicide and depression in the state's six medical schools. The bill would also prohibit any medical school from restricting a study on the mental health of its students.
The absolute disturbing part is right here:
> While lawmakers debated the legislation, Frederick said the deans from each of the state's medical schools sent him a joint letter expressing opposition to his proposed law.
In other recent news, Saint Louis University fired their med school dean that was the absolute champion of promoting the mental health of SLU's students.
http://news.stlpublicradio.org/post/slus-medical-school-remo...
Furthermore, as part of the licensing process, you are asked whether you were diagnosed with a mental illness in the past. There will likely be an investigation if you say yes and it could impact your career.
This stigmatizes mental illness within the profession and keeps people from seeking help when they need it.
by Gatsky on 5/15/17, 10:46 PM
Simplistic supply and demand analysis of this issue is annoying and ignores basic economic theory.
You don't want to increase doctor supply, you want to increase the capacity of the healthcare system to deliver good care (obviously?). Doctor supply is one part of that, but if you pump medical students in at one end and do nothing else, you will fail - this is what the Australian gov has done, and you can see the result here, where trainee conditions are poor (so much competition that you don't complain about conditions, power is concentrated in hospitals and senior drs in charge of training programs and hiring who align the system in their favour), and incumbent physicians like the one that committed suicide work like demons and burn out.
The financial corollary is fiscal stimulus without any production capacity - GDP doesn't go up, inflation does.
As always, it doesn't have to be this way, but nobody is in charge who cares enough to fix it, and all the stakeholders look after their own interests.
by aabajian on 5/15/17, 9:01 PM
by joshuaheard on 5/16/17, 1:03 AM
by Melchizedek on 5/16/17, 2:16 PM
Karl Marx
by logfromblammo on 5/15/17, 8:54 PM
I can't even recall how many young software companies I have sent my resume to that turned out to be in the business of building software for insurers and hospital systems that end up telling physicians how to do their jobs. Of course, the metrics all back this up as a solid plan that increases productivity and reduces expensive errors and negative outcomes due to inattention, but I know it just has to suck for the docs to have to experience exactly the same thing that has already happened to most other jobs.
by Mz on 5/15/17, 10:53 PM
I am sort of a medical system drop out. I took my toys and went the fuck home. (No, I was not a doctor. I was a patient who could not get my needs adequately met and walked away from conventional medical treatment for my condition.) So, a lot of people assume I am very anti medicine. They think I am some crazy who just hates modern medicine.
This is absolutely not true. But I do hate certain aspects of the system. I think Direct Primary Care would be a step in the right direction.
If you are interested in reading a bit about that, I have written a few pieces about Direct Primary Care.
http://micheleincalifornia.blogspot.com/search?q=direct+prim...
by douche on 5/15/17, 8:51 PM
If all this administrative work needs to be done, do surgeons necessarily need to do it? Can we hire more clerical specialists to offload that work onto, or more PAs or RNs to handle less specialized work?
A few measly hundred million in the federal budget could probably be dredged up to subsidize medical school tuition and take some of the sting out of the long, expensive marathon of medical schooling, maybe?
by themantalope on 5/16/17, 12:52 AM
I think the part that struck me the most was his comments about time. I have diverse academic interests. I studied math and bio in undergrad. I love machine learning and software development (esp python). I lived in China to study the language for a year. All that gets sucked out of medical school though. We are expected to learn a ton of material in the first two years. Then in the second two years, we are basically working a full time job in the hospital/clinics while also studying. We are constantly evaluated. We are also expected to do research and publish papers. I've forgotten what a guilt-free day off feels like.
by johan_larson on 5/15/17, 9:02 PM
by electriclove on 5/15/17, 10:22 PM
by erikb on 5/16/17, 7:20 AM
I don't think that we're heading into a zombie apocalypse level destruction. Highly skilled people will always have one of the best lives. But it gets harder for everybody, and no matter how much we complain there isn't anybody who can give us a better life at the moment. Everybody is losing something.
by markroseman on 5/15/17, 8:42 PM
by markroseman on 5/15/17, 11:04 PM
In Canada, we have a fair number of people in certain specialties that cannot find work - think a radiation oncologist who needs some pretty specialized and expensive equipment that only exists in a few places to be useful. But also even more basic... gastroenterologists who can't get enough OR time to do scopes on their patients.
by harmonicon on 5/19/17, 7:51 PM
The managing class (Company CEO, Hospital/University administrators) is ever in the pursuit of more profit, euphemized as "efficiency" or "optimization", at the expense on everything else. How can we squeeze the employees a little harder so we don't have to hire as many? How can we increase "productivity" so more patients can be seen(and pay up)? How can we eliminate waste (lower cost of care as much as possible so we can make more) to the patient? How can we make more money by tweaking our charging model (Insurance rewarding loyal customer by charging them more, Hospital Chargemaster etc)? Oops, I see people are complaining a lot. Let me pay some lip service about appreciating our employees and valuing our customer/patients. Heck I am feeling extra generous right now , let's put up some cheap program they can participate in. There, they should feel happy now.
This is all too familiar in the corporate world. Any employees with a half a brain will get the message loud and clear: employers do NOT care. Or maybe they do, just nowhere near money. See, their incentive is aligned quite nicely: cost cutting/profit increasing actions are how they justify their pay and the profit it generates is how they pay themselves. Everything else can be sacrificed.
Caring for a patient is a very intellectual, specialized and dare I say it creative task. Doctors are paid well above many other professions though one can argue it is not for the years they have to invest into training and the work hours. The point is, at the end of day they are glorified laborers, being told by their boss what to do, just like the rest of us. Prestige has shielded the medical profession for decades but now the grip of corporate America has finally caught up. And lo and behold, what scant voice and influence do we have!
We absolutely do need managers/administrators. We need them to make sure companies/hospitals are running smoothly, is well funded and serve the customer well. But the lack of voice and the power imbalance in employment is suffocating. We are partners not servants or slaves. And the all consuming focus on money has got to stop. Human welfare deserve to be at the top. not profit.
by tejaswiy on 5/15/17, 9:20 PM
Innovation in Health IT happens usually because CMS (Agency that administers Medicare, Medicaid etc) looks at the landscape and comes up with a carrot / stick rewards system to force Hospitals and practices to update their software. They generally do things like:
* Hey you need to store records electronically. If you do this by X, you will get Y$. If not, you will be penalized Z$ every year after X.
* Hey the system you built - It needs to actually be able to talk to other systems. If you do this by X.. you get the point.
* The data you're collecting in your system is stupid. We need X, Y and Z reports to ensure you're actually using the system as we meant for you to use the system. Do this by X.
Several other misc things I noticed:
The industry by itself is extremely complex with business requirements that vary between hospitals, practices, labs and so on. This makes connecting systems together a nightmare. Even when you manage to integrate systems, each hospital and practice has a set of business practices (forms they collect, the way they organize information etc) that make rolling software out very hard. Configurability is king. Making everything configurable and having configuration engineers set things up makes automated testing very hard at a UI level. This leads to some sharp corners and contributes to bugs and general UX clunkiness.
UX design isn't generally valued and suits / "business requirements" / timelines are prioritised over usable, stable, secure software. This is a typical UI: http://uxpajournal.org/wp-content/uploads/2014/07/smelcer3.g...
Standards are out of date and the only thing pushing innovation here is CMS doing its best. The problem with this is that they're a govt agency, so they're generally slow and they're an insurance company, so their primary motivation is to cut cost of care.
Doctors are generally smart, and you can sometimes get good feedback from them, but they're already overworked and can't really vocalize what they find frustrating about software.
I hate to generalize, but in my experience atleast, all other people (middle management, front-desk staff) are useless. By that I mean they just don't understand how software works.
There are some smart CIOs, but they care about their position and the hospital bottom-line, so trying to sell them something that doesn't exactly line up with the CMS carrot / stick model is basically impossible.
by qrbLPHiKpiux on 5/16/17, 11:30 AM
by yakult on 5/16/17, 12:42 AM
by known on 5/16/17, 3:34 AM
by Ericson2314 on 5/16/17, 11:19 AM
*Probably would need to be government as would need exceptions from tons of laws.
by k__ on 5/15/17, 9:57 PM
by hourislate on 5/15/17, 9:46 PM
by timwaagh on 5/16/17, 8:08 AM
indispensible. irreplacable. the rest of the industry should therefore be focussed on getting as much value out of these doctors. which means they should be focussing on taking any paperwork out of docs hands.
by novalis78 on 5/16/17, 12:14 AM
by woodandsteel on 5/16/17, 12:43 AM
by bluetwo on 5/15/17, 9:02 PM
by Floegipoky on 5/16/17, 5:47 PM
I always see people ragging on EMRs. They're inefficient, have poor UX, require way too much documentation, etc. These are all fair criticisms, but I don't think people spend enough time asking why. Why are all the major EMR systems shitty in exactly the same way?
I think there's 2 main parts to the answer. The first is the sales process. The people selling EMRs to hospitals aren't selling their product to clinicians, they're selling their brand to the hospital administration. It's like the saying "nobody ever got fired for choosing Oracle", but far worse. The end result is years-long implementation processes, broken promises, and terrible tools that are optimized to allow the hospital to fire a few members of the low-level administrative staff (billing, coding, etc) instead of providing better care to the community they serve.
The second part of this problem is overregulation. The justification is that EMRs should be able to meet a certain level of functionality. Based on personal experience working with these regulations, I'm convinced that the real reason these certifications exist is to prevent new players from entering the market. They are very much in the spirit of "well all these legacy systems do [something], so _obviously_ everybody else should too" without ever leaving room to come up with a better solution. They shackle you to terrible design choices and assume that all hospitals, from a 10-bed critical access hospital to a 500-bed academic medical center, should all be run the same way. And worst of all, they make it impossible to design a system based on what the HOSPITAL needs, because half of the system is devoted to what the GOVERNMENT needs. Kind of like how people complain about interoperability between electronic medical systems. So the government introduces legislation to mandate interoperability, by requiring implementation of poorly-defined "standards" (designed by committees comprised mostly of, you guessed it, representatives from legacy vendors). From personal experience, I can say that every. single. one. of the interfaces required for federal certification is completely unable to be reused by actual hospitals. But that's the entire purpose, that's exactly why lobbyists paid so much money to get the regulations passed in the first place! If potential new competition has to sink thousands of man-hours every year into building useless functionality, that's thousands of man-hours that didn't go into making their product competitive and disrupting the marketshare of legacy systems. Meanwhile, legacy systems are maintaining their market share, not by improving their product and helping healthcare providers do a better job. Instead they're actively creating situations where smaller hospitals are forced to choose between buying onto the licenses of larger hospitals or shutting their doors.
Obviously this is all just my personal opinion.
by kapauldo on 5/16/17, 11:28 AM
by andy on 5/16/17, 1:35 AM
