Failure to Thrive: Is the Diagnosis Really Burnout?

December 03, 2020

December 2, 2020

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00:00I think the hours upon us and
00:03we'll go ahead and get started.
00:05Good evening, my name is Mark Mercurial.
00:07I'm the director of the Program
00:09for Biomedical Ethics at
00:10the Yale School of Medicine.
00:12And delighted you could join us tonight
00:14for our evening ethics seminar series.
00:16Tonight is a special night for reasons I'll
00:18get in a second on the previous slide.
00:20I'm you saw a list of upcoming
00:22seminars in the next couple of months,
00:24and it's a it's a wonderful lineup
00:27and will hope you will join us
00:29for some of those as well.
00:30But tonight's a special night with
00:32Doctor Danielle Ofri and I'll tell
00:34you why I think I told this story.
00:36In the in the mailing I sent
00:38that with the invitation is it
00:40was actually in June of 2019.
00:41I believe that I read an op Ed in the
00:43New York Times that was so good and it
00:45had to do with physician exploitation.
00:48And I read this and I thought this
00:50is really so insightful and so good.
00:51I don't know who this person is,
00:53but I've got to see if we can get
00:55it to come up to Yellen speak.
00:57Well, did a little homework and it
00:59turns out I was probably, you know,
01:01probably a lot of people who already
01:03know who she is,
01:04and I learned very quickly.
01:05Doctor Danielle Ofri is a clinical
01:07professor of medicine at NYU.
01:08She's also an attending physician at
01:10Bellevue Hospital and she's the editor in
01:13chief of the Bellevue Literary Review.
01:16She's written over 200 articles
01:18arranged from everything from
01:20the New York Times to The Lancet.
01:22She's written seven books,
01:24including one, most recently,
01:26that's in press on medical errors.
01:28She has run numerous awards as a writer.
01:31She has a bachelors degree from McGill.
01:33She got a PhD in pharmacology,
01:35then why you an MD at NYU and then
01:38went on to do a medicine residency?
01:40Then why you?
01:41She actually did grand rounds for
01:43us this afternoon in Pediatrics
01:45and it was marvelous and I expect
01:47it's going to be another excellent
01:49session tonight to for those of you
01:51who are unfamiliar with our format,
01:53Doctorow Free will talk for
01:55about 45 minutes or so,
01:57and after that I will moderate.
01:59I'll moderate a session
02:00of question and answer,
02:02so I'll ask you at that point
02:03to send your questions through
02:05the Q&A portion on the zoom,
02:07and I'll read the questions to Doctorow
02:09free and then you'll get a chance
02:11to respond and let me just know it.
02:13Let you know ahead of time.
02:14I may not get to all of them,
02:17and Moreover.
02:17It may well be that we get to 6:30
02:20and I haven't gotten to them and
02:23we do have a hard stop at 6:30,
02:25so please don't be offended if you
02:27were hoping I'd get to your question.
02:29I didn't because it will be.
02:31We will be stopping at 6:30,
02:33but right now I'm delighted
02:35to introduce to you Doctor
02:36Danielle Ofri from New York University.
02:38Dr ofri. Hi, thank you.
02:40It's so nice to be here.
02:42Thank you all for having me.
02:43You know so in medicine.
02:45I guess we all face this in
02:48our various specialties.
02:49We were so many measurements of quality.
02:51Come up, you know 30 day re
02:54admission rate I always getting
02:56dinged on my A1C control.
02:58We get reports in our catheter
03:00infections DQ ulcers.
03:01But I always thought there should be
03:04another quality measure out there
03:06and it should be the number of times
03:09that a board certified physician or
03:11a license RN is a sobbing in their exam room.
03:15And this Dandan Mian on April 1st,
03:192019 year and a half ago.
03:22Hospital switch to epic.
03:23Now I don't know,
03:25in retrospect of choosing April Fools Day,
03:27as the major changeover was like some
03:30cosmic oversight or some techies idea of wit.
03:33But as you might imagine,
03:34it was a momentous, you know,
03:36we had these countdown clocks.
03:38It was like the second coming of the Messiah.
03:41And you know we switched flip
03:43the Switch an on the 1st week.
03:45We had, you know half the number of patients.
03:48Second to exterminate boom,
03:49you guys are ready to rock and
03:51you know those first couple of
03:53months were quite a nightmares.
03:55Every batch of new patients came all
03:57with you know 16 chronic conditions.
03:5918 medications.
03:59They speak Bengali at best or
04:01Sylheti the dialect of Bengali.
04:03From there's no interpreter and you
04:05had to get that done in 20 minutes.
04:07And I just found myself day after day.
04:10Feel like I cannot do this.
04:11I can't give the right medical care either.
04:14I you know,
04:15I skipped the diabetes or I
04:16skip the depression,
04:18or maybe I'll skip the heart failure.
04:20Which am I going to skip in
04:22order to get most of this done?
04:24And I was just crying in my exam
04:26room several times and I began
04:28talking to my colleagues and they
04:30were also kind of quietly breaking
04:32down in their rooms and an.
04:34You know it for me,
04:36it ended up giving rise to a set
04:38of four articles about this,
04:40of which that Times article was one.
04:42And it's not all about Epic.
04:44And you know,
04:45even though I have my beef with epic,
04:47you know these things are great.
04:49They do amazing things and each
04:51one of the systems have some sort
04:53of breathtaking assets and some
04:54have their snarling annoyances.
04:56But what I was going through this transition,
04:58I thought that I was burned out.
05:00You know, I've been at it for 20 years.
05:03Maybe it's time to move out to pasture,
05:05you know?
05:06There's a certain like you know,
05:07shelf life of doctors,
05:08and maybe I was hitting my expiration date.
05:11But At least I know baby,
05:14I'm not burned out because I.
05:16The truth is I love my job.
05:18I love it every single day and
05:21I'm never unhappy to go to work.
05:23And although I was miserable at that time,
05:26I recognized, you know, grudgingly,
05:27that I didn't hate my job.
05:29I hated how I had to do,
05:32and those are two different things.
05:34And it dawned on me that I'm not burned out.
05:37I'm angry, I pissed,
05:38and there is a difference.
05:40And I was angry because I couldn't.
05:42Do a good job.
05:44An you know by now where we you know 2020.
05:47I feel as though.
05:49Corporate medicine has milk just
05:51about all the efficiency it can
05:53get out of the system, right?
05:56Mergers, streamlining?
05:57They've pushed those productivity
05:59numbers about as far as they can go.
06:02But there's one resource
06:04that seems endless and free.
06:07And it's the professional ethic
06:08of the medical staff members.
06:10And you can keep adding work
06:11and it always gets done right.
06:13You can toss epicon everywhere in
06:15the middle of their breathing,
06:16waking life and give them twice
06:18as much work the same number of
06:20patients and of course is going
06:21to get in because you know I'm
06:23not going to skip the diabetes
06:25or the congestive heart failure.
06:26I'm just going to stay late enough
06:28until I've figured out each
06:30one of my patients conditions,
06:31gotten them all tucked into place
06:33and then move on to the next.
06:35And that's the way it is for
06:36everyone in medicine.
06:37And so you can keep adding work.
06:39And it's this like miraculously
06:41elastic system.
06:41Now,
06:41if you think about an assembly
06:43line right in a factory,
06:45if you simply dropped 30% more
06:46work right into the assembly
06:48line without any changes,
06:49it's going to grind to halt.
06:51Its going to be complete chaos.
06:53Imagine giving a lawyer 30% more work,
06:55or a plumber.
06:56You know it is not going to happen.
06:58Well, they'll charge you know Bill
07:00you by the minute for the extra time,
07:02but it's not going to magically get
07:04done out of the kindness of their heart.
07:07But in medicine it happens all the time,
07:09every single day, right?
07:10Doctors and nurses we don't leave.
07:12I mean,
07:13if every doctor nurse clocked
07:14out when our paid time ended,
07:16the whole thing would fall apart,
07:18right?
07:18It's the one thing that holds the whole
07:20medical enterprise together is that
07:22doctors and nurses and medical staff.
07:24We largely do the right thing
07:25and not that we're perfect.
07:27But by and large,
07:28most people do the right thing and
07:31don't leave until the work is done.
07:33And I think this is all of us
07:35took some sort of both when
07:37starting practice and if I can
07:39speak from the point of position,
07:41you know we the Hippocratic Oath
07:43is very meaningful an there's a
07:44covenant between a doctor and patient,
07:46and between a nurse and a patient.
07:48Anan the coven.
07:49Is this the patient,
07:50gives you their trust, right?
07:52They have to trust you because
07:54they really don't have any
07:55other choice but to trust you.
07:57And then our ends that we put the
07:59patient first ahead of our interest.
08:01And I think we largely do this.
08:04But I also think that when we go
08:06into practice, there's a covenant
08:08between us in our profession,
08:10the medical profession in the
08:11nursing profession, right?
08:12We sacrifice years,
08:13sometimes decades of our lives.
08:15To this career, we pledge ourselves to a
08:17career path that doesn't offer shortcuts,
08:19right? But it's worth the sweat equity.
08:22It's fantastic job.
08:23I mean I, I look at my.
08:25Friends and colleagues and business.
08:27You know, sitting in these endless meetings
08:29about widgets and scalability and thinking.
08:31Oh, shoot me first, man,
08:32I could not survive like in a
08:34corporate board room, you know,
08:36talking about how to make $0.10
08:37more on some product and I think
08:39that's why we're all here, right?
08:41We wouldn't be here otherwise.
08:43We have the cement Prilosec we
08:44get to help patients feel better.
08:46And so I think in exchange and
08:48so we put in the work and we
08:50stayed overnight in hospitals.
08:52We slept in our clothes.
08:53We got vomit on our shoes.
08:55We did all of that.
08:56Anne Anne Anne.
08:57It's worth the sweat equity and I think
08:59in giving that time in the commitment
09:01and an often a lot of debt to get there.
09:04I think we were promised in exchange in the
09:06covenant that we would get a professional.
09:08That's not only fulfilling
09:09but also principled.
09:10Like we're in a profession
09:11that does the right thing,
09:12which is a relief.
09:13I think if you work in other professions,
09:16you know maybe you're working for a bank and
09:18you're maybe you're doing it in the bank,
09:20but you feel like,
09:21Oh my God,
09:22I'm doing all this work just so
09:24someone else can make more money,
09:25like the principles don't
09:26necessary resonate with you, but.
09:28I think we're fortunate that we work
09:30for profession whose principles
09:31you know we largely agree with.
09:33So we joined a profession that
09:35would a job that would be fulfilling
09:38but also principled and have a
09:40moral code that we believe in.
09:42And and we place our trust
09:45in our professions. But now.
09:48That trust feels revoked.
09:51Somewhere along the line,
09:53the medical profession was seated
09:55to the healthcare industry.
09:58It's been this other thing of
10:00this sort of anastamosis this
10:02unholy anastamosis of merger,
10:04avid hospitals and these Orwellian emr's,
10:06which are clearly developed
10:08for billing and patient care,
10:10just comes on 2nd,
10:11but they create this system in which
10:14medical care has been commoditised
10:16down to checkbox aghbal items that
10:19fit neatly onto a spreadsheet.
10:21Or until quarterly stock report or
10:23onto an obscene paycheck for health
10:25care executive who has never once
10:27populated the pulse of the patient
10:29or hasn't done so in 30 years.
10:31And no,
10:32I do not pine for the days of the
10:35Giants or the days of the paper charts.
10:37Frankly,
10:38no amount of polishing of rose
10:40tinted glasses would make me yearn
10:41for the good old days, right?
10:43Paternalism towards patients.
10:44The Old Boys Club of Medical Leadership,
10:46you know, good riddance to those days.
10:49But the despair that I sense among our
10:52colleagues today is more than just burnout.
10:55It's a betrayal of trust,
10:58the trust that we gave to our own
11:01profession were not burned out.
11:04We are heartbroken.
11:05And many of us no longer
11:08recognize the professional.
11:10We entered hospitals.
11:11They now look like an investment
11:13firms or Silicon Valley.
11:14You know, campuses are academic Deans there.
11:17Now CEOs like when did that
11:19happen at our patients,
11:21our customers or clients week wishes are
11:23providers like we're vending machines,
11:26you know, insert coin,
11:28provide health.
11:29It just feels so strange.
11:31You know the upper echelon
11:34executives or their salaries.
11:37They require scientific notation
11:38right to express those,
11:39but somehow there's never room in the
11:41budget to hire enough nurses or to get,
11:44you know, enough staff in the
11:45clinic were always short on money,
11:47but those salaries,
11:48you know those seven or 8 digits.
11:50They seem to always be happening.
11:53Healthcare has become this commodity
11:55whose profit margins are dissected more
11:57tenaciously than tumor margins in a path lab,
11:59and this is not what we signed up for.
12:02It's not where we place our trust.
12:05In response, we're told to focus
12:07on Wellness or resilience.
12:09You know,
12:09it just makes me want to object guys.
12:12You know,
12:13on a good day in clinic when I
12:15can almost managed to keep my
12:17head a hair's breath above water.
12:20These terms strike me as ironic.
12:23On a bad day,
12:24when the impossible math of the
12:26system undercuts my ability to
12:28care for my patience and I see
12:30their health suffering as a result,
12:33these feel downright cynical.
12:34Resilience come on,
12:35the doctors and nurses I work with,
12:37and I see they are the most
12:40resilient people in existence.
12:42That they managed to soldier on
12:44in this soul crushing system.
12:46Mostly managing to take good care of
12:49their patients and not walk out en masse.
12:51That's resilience.
12:52Wellness that were just makes
12:54my stomach curdle.
12:56Wellness.
12:56That's like the kindly offer of
12:58an ice pack from a mafioso effort.
13:01He's like kneecapped with a metal
13:03baseball bat and I don't doubt that this
13:05emphasis on resilience and Wellness
13:07comes from benevolent intentions right there.
13:10Not trying to kind of send to us, but.
13:13It puts the onus on the medical
13:15staff to make themselves feel better.
13:18Take up yoga, right,
13:19meditate during your lunch break,
13:21right?
13:21Well, I don't know who's got lunch break,
13:24but I certainly don't engage in mindfulness.
13:26There's a word that makes me crazy.
13:28Are they kidding, right?
13:30Have they ever done a days worth
13:32of clinic or manage award full
13:33of patients like mindfulness?
13:35I'm trying to be mindful,
13:37you know,
13:37at four 5:00 o'clock that my blood
13:40pressures and hit 210 / 110 every time
13:42my patients Med list of 20 minutes.
13:45Evaporates into the ether,
13:46right it's expired or gone.
13:47You know,
13:48this cardiac meds their integration.
13:50They're all expired,
13:51it just kills me.
13:52And now the EMR is not the entire culprit,
13:55even though it feels really good to blame it.
13:58But it is certainly a heavy hitter, right?
14:00Each time there's a new rollout. Alright?
14:03What they like determine upgrade
14:04like something is going to be better.
14:07It just feels like there's more work to do,
14:10right? Every upgrade is more work,
14:11and it reminds me of remembering
14:13microlab those auger plates in
14:15the bacteria doubling time.
14:16Every time it comes out, it's doubled.
14:19You know there's twice as
14:21many required fields now.
14:22Studies show that primary care
14:24doctors now spend an average of 6
14:26hours a day just doing data entry,
14:28which is twice as much as they
14:30do with direct patient care,
14:32and that's doubled since just
14:34a few years ago.
14:35And every time I start a visit,
14:37I feel like I've entered the jungle, right?
14:40Need to kind of machete your way through
14:43the EMR just to get to the spot.
14:45We can actually start the actual
14:47medical care.
14:48It's exhausting and this technology.
14:50It's supposed to serve us,
14:51but it feels like the reverse that we.
14:54Our job is to serve it to make sure
14:56you get all these things checked off
14:58and make sure you do this and do that.
15:01It's it's exhausting.
15:02In particular,
15:02we are just pummeled by the
15:04tyranny of the in basket.
15:05Now we've been with Epic
15:07now for a year and a half,
15:08and our patients are just
15:10getting the hang of that.
15:11They can email the doctors well every day,
15:13you know,
15:14walk into a gazillion emails from my patients
15:16'cause it's they know they can email me.
15:18And then I'm going to respond.
15:20Because of course I'm going to respond.
15:22I have too.
15:22And so every day it seems like that
15:25invested gets bigger and bigger.
15:27And the number of things we have
15:29to check off on and check in
15:32an approve just gets larger and
15:34larger an when Epic first came and
15:36we had like the in basket.
15:38But what a quaint word in basket.
15:41Like conjured visions of checkered
15:43napkins and a picnic in age.
15:45Bri and some fine wine but.
15:48It is more like the labors of Sisyphus,
15:50right?
15:51No matter how assiduously you work,
15:53you can never get it done right,
15:55you even if you achieve that
15:57magical clearing of the queue.
15:5910 seconds later you know they
16:01start rolling right in like that,
16:03so it never happens.
16:04It's just you can never be done.
16:07And in fact there are some studies that
16:09correlate the level of burnout with
16:11precisely with the size of the investments,
16:14particularly in primary care.
16:15You know a lot of the specialists,
16:17they have a little default.
16:19Oh, defer to primary care doctor,
16:21Defer to primary care and
16:23they can unload it all on us,
16:25and it feels as though medicine
16:27has devolved into busywork,
16:28and that it's slowly.
16:30Ceasing to function.
16:32Recently I had a patient.
16:35You know my typical patient,
16:36she's got,
16:37you know,
16:3789 chronic condition chronic conditions to
16:39take care of.
16:40Each visit is a handful of acute complaints.
16:42You know, back pain or dis Pepsi a.
16:44She's on a dozen plus medications.
16:46Just got a couple of forms to fill out
16:48and needs prior authorization for this.
16:50And so the first issue is that her
16:52blood pressure is not controlled.
16:54I need to adjust her meds so I
16:56turned to the MRI start working
16:58on the hypertension problem.
16:59But during the pause,
17:01while I'm like getting in my way
17:03around the hypertension ones.
17:04Little bit of silence.
17:06She intuits the natural turn of conversation
17:07so she starts in with her Gerd.
17:09Symptoms that aren't getting better.
17:11Now I don't want to miss what she's saying,
17:13but I don't want to make a mistake
17:15on the blood pressure meds.
17:16So I say hold on one second
17:17just hang out with that.
17:19Let me just do the blood pressure,
17:20and so there's a dip of silence.
17:22Now, while I pack away.
17:23But after a polite moment of silence,
17:25it seems like it's her turn to talk again.
17:27So she brings up the rheumatologist
17:29recommendation that she
17:30should get children surgery.
17:31But she's really nervous about that.
17:33Now works or did not.
17:34To multitask right?
17:35We know that that's a setup for error,
17:38but I also know that I can't
17:40decide on what's the best third
17:42line blood pressure medicine.
17:44While simultaneously discussing the
17:45pros and cons of shoulder surgery,
17:47so I say you know he's hang on one
17:50second while I just finish this
17:51an I feel so rude 'cause I keep
17:54putting her off and stopping her.
17:56But each thing she brings up it
17:58requires my full attention and I
18:00want to focus on what she's saying.
18:03It's respectful,
18:03it's good medical care helps
18:05me avoid diagnostic error.
18:06It helps me not over order tests,
18:08but if I talk to her about her
18:11questions about Gerd while ordering the
18:13meds or the labs for blood pressure.
18:15It's a perfect storm for medical error
18:17and so this puts me in an impossible bind.
18:20Now I could of course I could fake it,
18:24right?
18:24I can listen with half an ear kind
18:26of nodding and randomly white
18:28right away through the note that's
18:31recommending shoulder surgery
18:32passed the 50 screens of copy paste,
18:35MRI reports,
18:36and then every lab tests ordered
18:38since the Eisenhower administration.
18:40Your rheumatologist I am looking at
18:42you out there just to find the three
18:44lines that had the meat of the note.
18:46And simultaneously,
18:47and trying to check up to date.
18:49Because honestly,
18:50I don't remember what's the best third
18:52line blood pressure medication in
18:53someone with impaired renal function,
18:55fatty liver gout,
18:56crappy insurance,
18:57an inversion to polypharmacy.
18:58So I keep nodding and Ming while
19:01simultaneously chasing down the
19:03657 fields that have to satisfy in
19:06the EMR in all its oracular glory.
19:08Now,
19:08so many of us we muddle through
19:10a clinical encounters like this
19:12where half listening, half typing,
19:14half muttering,
19:15half thinking about what the patient
19:17said. Three issues that go half debating
19:19which test to order half scouring the six
19:21open windows on the screen kind of member.
19:24How do you order B12 injections?
19:26I can never remember.
19:27Half chiding ourselves about
19:29oversight from our last patient half,
19:31ignoring all the red flag alerts that keep
19:33popping up every time we click anything.
19:36Half thinking about the next three
19:38patients who are waiting for us and then
19:40half pondering whether any of the EMR
19:42buns could do something useful or practical,
19:44like conjure up a coffee and a sandwich.
19:48The only thing that's not diminished
19:50by half is the feeling that we're
19:53cutting corners in every front and
19:56scraping by with mediocre medical care.
19:59And doing a mediocre job
20:01is just the worst feeling.
20:04And what's become really clear now is
20:06that there are three of us in the room,
20:08even when it's a virtual.
20:09There's the doctor or the nurse,
20:11and the patient and the EMR.
20:13And the EMR which started out as a tool
20:15as a database for storing information
20:18more officially in the paper chart,
20:20which it does,
20:21but it's now inserted itself as a full
20:24member of the medical team and what used
20:27to be a tango between the doctor or
20:29the nurse and the patient is now a troika.
20:33And as with any menajahtwa,
20:36there are always consequences and one
20:39potential consequence is patient safety.
20:43And you know,
20:44having worked on this book
20:45on a medical error,
20:46it's really become clear to me that
20:48our technology in the EMR really play
20:51a role both in improving medical error,
20:53but also making things worse.
20:54So, for example,
20:55I think that Mars do many wonderful things
20:57to improve patient safety, like for example.
21:00I can actually read the
21:02ophthalmologist handwriting now,
21:03which I never could before.
21:05Of course, I don't know what it says,
21:07but I can actually read it,
21:09right?
21:10And you know it can help us identify
21:12infection outbreaks and can help us you know,
21:15pick up early sepsis.
21:17Lots of things that you can do well.
21:19But I also believe that it
21:22jeopardizes patient safety by
21:23pushing patients to the margin.
21:25By requiring the conditions to focus
21:27more attention on documentation than on
21:30patient care, and you know right now,
21:32hospitals have to report a number
21:34of patient safety measures.
21:36For example,
21:37the number of hospital acquired
21:39infections and they actually get
21:41fined when the rate is too high.
21:43So I think.
21:44The hospital should be required
21:46to also measure the EMR burden and
21:49be fined when it detracts from
21:51from actual medical care, right?
21:53It's the same thing.
21:54It's harming patients in harming
21:56their medical care.
21:57And given how much that Mars
22:00affect patients medical care.
22:01They should be treated like any
22:04other medical intervention may be
22:06subjected to thorough scrutiny.
22:08I mean, do we even know?
22:11FM R provides health gains for
22:13patients with the evidence is mixed.
22:15I mean, if you think about it,
22:17if any other medical intervention,
22:19a new medication and device,
22:20you gotta test it out in a randomized trial,
22:23but EMR? So here's a device we throw
22:26into everyone know testing at all.
22:28And so I tried to look to research,
22:31whether in fact there's any documented.
22:33Benefits and health outcomes
22:34for patients and and really,
22:36the data are very mixed.
22:38Some show yes, I'm so no.
22:40But my favorite study of all time,
22:42that of all the outcomes measured.
22:45Increased EMR use was most strongly
22:48associated with guess what?
22:50Increased ability to generate reports.
22:51That was the only measure.
22:53Nothing clinical, but the ability to
22:55generate reports that came out higher.
22:57And of course those reports.
22:59They're going to be in your in
23:01basket for you to sign off on right?
23:02So we need to see evidence that
23:05the benefits outweigh the harms.
23:06You know, lots of things seem
23:08logical and beneficial at the time,
23:10but when we subjected them to
23:12rigorous science, they fell short.
23:14Remember, actually, in replacement therapy,
23:16Vioxx Swan catheter Swan Ganz catheters
23:18cardiac Cath for stable coronary disease.
23:20All those things?
23:21They're great at the time.
23:22Yet when we studied them, in fact,
23:25they detracted from patient outcomes,
23:26and we have retired them.
23:28So why does the EMR get a free pass
23:30from rigorous evaluation before
23:32we apply to every single patient?
23:35But mostly mostly the EMR
23:37is just dispiriting.
23:38You know,
23:39we spend our days hunched over a terminal,
23:42squinting at a screen,
23:43abjectly clicking away until our
23:45collective carpal tunnels disintegrate
23:46into a collagenous pudding.
23:48And you know, when we have in person visits,
23:51I think with video visits to
23:54some degree or a little bit,
23:56you know, protected from that.
23:58But with in person visits,
24:00you know it's so awful when you're staring
24:02at the screen and your patient is like.
24:05You know,
24:06staring off at the supply cabinet,
24:08the trash can,
24:09the exam table,
24:10and I imagine a higher being would
24:12peek into exam room and be unable to
24:14distinguish the doctor or the nurse
24:16from the blood pressure cuff, right?
24:18It's all the same,
24:19just inanimate object annopol.
24:21OK, get ascribed, get, describe,
24:22but I feel like scribes just
24:24treat this symptom right to me.
24:26Giving ascribe because you don't
24:28have time to write stuff down is,
24:30like you know,
24:31you've given your patient too
24:32much beta blocker.
24:33So now we put them into heart block.
24:36Let's give a pacemaker,
24:37no.
24:37Let's just cut back the beta
24:39blocker to begin with,
24:41and I feel as though in the end
24:43the EMR turns out to be a vehicle
24:46for the wholesale transfer of work
24:48and of liability on technicians.
24:50So take for example, medication alerts,
24:52right?
24:52Of course,
24:53you want to know when their drug
24:55interactions, but the way it happens,
24:58it is just a transfer of liability.
25:00The other day,
25:01I forgot his prescribing in
25:03a 62 year old woman.
25:04I got a high alert for
25:07caution with lactation.
25:08Thinking this patient is over 60,
25:09the chances for lack tating are
25:11pretty darn low, but there was that
25:13alert and I had to respond to it.
25:15And of course there are so many
25:17that you end up ignoring them.
25:19An I actually once try to read
25:20every alert now is defeated in my
25:23first comment inpatient, right?
25:24You know once you get 50 of them,
25:26I just click the mall.
25:28But it makes me angry because buried
25:30in there is something important.
25:31I want to know,
25:32you know if my Norvasc and
25:34my sinus Tanner interacting.
25:35I want to know that.
25:36But of course I'm not seeing it
25:38can always stupid, you know,
25:40pregnancy and lactation things from all
25:42my patients over 60 'cause I haven't
25:44checked off that their menopausal.
25:45And I feel like that's not so
25:47much a patient safety feature,
25:49but a transfer of liability.
25:50Bad outcomes happens.
25:51Well, the doctor checked the box,
25:53so it's not our fault.
25:56And of course, the Mars,
25:57conveniently available from home,
25:59so we keep working at night because our
26:02professional ethic doesn't allow us
26:03to drop the ball mean for most of us.
26:06If you work in healthcare,
26:08it's unthinkable to walk away
26:09without completing your work,
26:11because dropping the ball that
26:12could endanger patient,
26:13so we never leave until the work is all done.
26:17And so the work and keep going.
26:19And of course we keep doing it.
26:22But I don't want to forget our
26:25favor compliance modules right?
26:27The Fraud awareness module,
26:29the hippo ones, the annual mandates,
26:31the jimmies time studies.
26:33And they're all important stuff.
26:35I'm not knocking my think they're great,
26:37but you're supposed to complete
26:39them between patients.
26:40OK sure, when that time is but made him,
26:43you're supposed to be doing your
26:45mindfulness meditation between
26:46patients under HIPAA compliance module.
26:48So in the end we put in hours
26:51and hours of extra work,
26:53all of which is unpaid on a daily basis.
26:56And you know,
26:57it can feel unseemly to complain about money.
26:59I mean doctors for sure are well paid,
27:02and we acknowledge that it's not.
27:04It's not about the money,
27:06but you're being asked to work many more
27:09hours in your paid for an in other fields.
27:12This is called wage theft,
27:14right?
27:14And people bring court cases when
27:16employers expect their employees to work.
27:18Extra time and not compensate them
27:20and it really matters for a lot of
27:23clinicians for whom those extra
27:25hours you know take away from
27:27their family time and they're not
27:29being appropriately compensated.
27:30And again,
27:31if we all left when our hours were up,
27:34the system would collapse and I
27:37believe that the system knows this now.
27:40I stopped short truly of accusing this
27:42system of drawing up a premeditated
27:44business plan to manipulate medical
27:46professionalism into free labor.
27:47Now there are people who disagree with
27:49me and think that it is premeditated,
27:52but I will give the benefit of the doubt.
27:55I think it's more result
27:56of administrative creep,
27:57right? There's one extra task
27:59after another is put over.
28:01One more thing, make sure you do the asthma
28:03action plan and do the depression screening.
28:06And don't forget to ask about HIV screening.
28:09All these things come up and they're
28:11all important. But you know,
28:13we just the clinicians who see it.
28:15We can't, and we won't say no Ann.
28:17And they know that.
28:19So no matter how much work is piled up,
28:22you know all the patients on the wards.
28:24They get their medications.
28:25The nurse is somehow get all
28:27those medications at all.
28:29The surgeries happen.
28:30The office does it somehow get done?
28:32It all manages to get done some
28:34magical way at all happens.
28:36And so from an administrative perspective.
28:38All seems to be purring along just fine,
28:41but of course it's not fine.
28:43Not not at all.
28:44We know that doctors and nurses take
28:46their own lives by suicide at a higher
28:48rate than almost any other profession.
28:51And we know that higher burnout rates
28:53are associated more medical errors
28:55and compromised patient safety.
28:56There's no surprise there, right?
28:58It's it's terrible for the patients.
29:00I'm never talking interviewing
29:02a patient who said, you know, I,
29:04I don't want my doctor to never
29:06take vacation.
29:07I don't want them over work because
29:10I want them to be there for me.
29:12So it's really not good for patients.
29:14And there's also an enormous economic
29:16cost associated with burnout, right?
29:18People quit, they cut back hours.
29:20Hiring new people, training new people?
29:22That's paying temps.
29:23That's very expensive.
29:24In fact,
29:25someone calculated that.
29:26The level of burnout and staff
29:28turnover comes to about $7000
29:30per employee physician per year.
29:32That is a ton of money that's paying
29:35for the cost of this burnout money
29:37that could be used to hire more nurses
29:40to improve the chemotherapy suite to
29:43do all the things we want to hire.
29:46Another vaccine vaccine nurse.
29:48And so the status quote.
29:50It's not sustainable,
29:51not for the medical professionals
29:53and also not for our patients.
29:55It's really not sustainable for them either.
29:58And all of our hospital mission statements,
30:01they're replete with terms like excellence
30:03and high quality and commitment synergy.
30:05All these great words.
30:07And they may sound like
30:09Madison Ave buzzwords,
30:10but I think they represent the
30:12core values of the people who
30:15labor in these institutions.
30:16Health care is by no means perfect,
30:19and I'll be the first to admit that.
30:21But what good does exist?
30:23Is there because of the individuals who
30:25strive to do the right thing everyday?
30:27Who entered their professions because
30:29they want to help patients are not
30:31there to make a Buck through there
30:33because they really want to be answer
30:35this very ethic that I think is being
30:38used everyday to keep the enterprise afloat.
30:41And listen,
30:41no one minds working hard.
30:42No one minds going the extra mile and I
30:45think we even appreciate being in a field.
30:48We're going,
30:48the extra mile is standard
30:50operating procedure and
30:51I think we all felt that in the spring
30:53watching our colleagues everyone go
30:54the extra mile an how great to be
30:56in a place where no one pulls up.
30:58You know my hours are done.
31:00I'm not going to help out here.
31:01I think we felt inspired by seeing
31:03everyone step up to the plate
31:05without one word of complaint.
31:07I think in this era of unabashed
31:09transactional ISM of the nonchalant
31:11narcissism that we see in the
31:13business world and in politics,
31:15the casual corruption I think we
31:17are so fortunate to be in a field
31:20where people are largely driven
31:21by an ideal that means something.
31:24We are so lucky.
31:27But when it's clear that the professional
31:29good conscience is not just the glue,
31:31that whole thing that holds things together,
31:33but the very bricks and
31:34mortar of the enterprise.
31:36Something is wrong, right?
31:37An IF and you know we don't
31:39pull back and say, well,
31:41I'm going to quit at 5:00 o'clock because.
31:44The whole thing comes crashing down.
31:46It comes crashing down not just on
31:48this system but on our own patients.
31:50Well,
31:51something we cannot bear to see happen,
31:53so we stick it out because they
31:55don't want patients to get harm.
31:57Even we don't care so much whether
31:59the institution gets harmed an I think
32:02that counting on nurses and doctors
32:04to suck it up because, you know,
32:06you know we won't walk away from
32:08patients that is bad business strategy.
32:10But also.
32:11And maybe most importantly,
32:12it's bad medicine.
32:13And if you think about our
32:15patients with chronic illness,
32:17which is really what most
32:19of medicine is today?
32:20These patients can be adequate cared for
32:23in 15 minute visits or nursing staff.
32:26You know, down to 80% capacity and there
32:29are really some impressive studies done.
32:31If you look at inpatient medical
32:34services and understaffed nursing.
32:35For every additional patient
32:37that's added to nurses roster,
32:39the odds of the patient dying within 30 days
32:43increases by 7% for every one patient added,
32:46the odds of dying goes up
32:48by 7% within 30 days.
32:50And of course,
32:51nurse burnout goes even higher.
32:53Another study that really blew me away
32:56is that overall mortality and hospital
32:58goes up by 2% for every individual
33:01shift that's short staffed by nurses.
33:03Think how many shifts you work on where
33:07the nursing staff is short staffed.
33:092% mortality goes up by 2%.
33:11That's a really powerful outcome,
33:13and I think we already know this.
33:15We know that you can't take adequate care.
33:17Sick patients.
33:18We don't have enough nurses,
33:19but there are data to show that.
33:23So what's the RX?
33:24Well,
33:24the first step is your teachers
33:26and professors always told you
33:28to make the correct diagnosis.
33:30And most of us are not burned out
33:32in the true sense of the word.
33:34We love what we do.
33:35We love taking care of patients and
33:38we just want to be able to do that.
33:41We don't need more resilience or Wellness,
33:43although I'm not going to say no.
33:45If you put a massage therapist in our clinic.
33:48And we are happy to go the
33:50extra mile for patients.
33:52And really, I think we want to do that.
33:55But we don't want our commitment
33:57to be exploited right?
33:59That extra mile.
34:00That's for patient care
34:01for things that matter.
34:03It's not for some new round of EMR
34:05Adcs or some other initiative.
34:08Or doing that extra mile is
34:10reserved for patients so.
34:12Let's recognize that the EMR
34:13is in medical device and ought
34:15to be regulated as such, right?
34:17The vendors ought to be held responsible
34:20when their product harms patients.
34:22They need to show that evidence
34:23to show evidence that the
34:25benefits outweigh the harms,
34:26and I think we can show many harms we
34:28need to see that on average patients are
34:31benefiting from this and not being hard,
34:33and we don't know that.
34:35Right when it comes to patient safety,
34:38hospitals are required to measure
34:39hospital acquired infections,
34:41and they're fine when the rate is too high.
34:44As we mentioned,
34:45they should also measure the
34:47EMR burden and be fined when
34:49you distraction medical care.
34:51You know, in government,
34:52when there's a new policy, it requires
34:55an environmental impact assessment.
34:57EIA, well, you know.
34:58For every new EMR upgrade
35:00or some new hospital policy,
35:02I think we need a CIA.
35:05A clinician impact assessment
35:06before it's rolled out.
35:08While we're at it,
35:10how about a patient impact assessment, right?
35:12How many patients are going to be affected
35:15by some new initiative and new EMR rollout?
35:17And then we need to rethink
35:20the structure of healthcare.
35:21Over the years,
35:22there's been kind of a stratification
35:25of the system.
35:26Would like to call it a kind
35:28of corporate chromatography,
35:29and there's this sort of sedimentary
35:31layer of clinicians topped by every
35:34more abstruse layers of bureaucracy.
35:36And the speaker Ocracy has ever more
35:39tenuous connections to actual patient care.
35:41Between 1975 and 2010,
35:43the number of healthcare administrators
35:46increased by more than 3000%, right?
35:49That's about 10 admins for everyone doctor,
35:53right?
35:53Think about that.
35:55If you compare clinical staff is
35:58about 6 clinical stack per MD,
36:00but ten administrators for every MD.
36:03What are they all doing?
36:05I know.
36:06I mean, it seems ridiculous to say,
36:08but Healthcare is about taking care
36:10of patients, not about paperwork.
36:12It's not about the medical arms race
36:14and not about the corporate mergers.
36:16In my humble opinion,
36:17if we converted even half of
36:19those admin salary lines,
36:21two additional nurses and doctors.
36:23You won't have enough clinical staff
36:25members to actually handle the work.
36:27And so my feeling is that.
36:29Every single person was a role in healthcare.
36:32Should be required,
36:34I mean required to work directly
36:36with patients as part of the job.
36:39Even just a little bit.
36:41Those folks in the sea suites,
36:42they can do one or two mornings,
36:44a clinic,
36:44a month or two weeks in wartime each month,
36:47right?
36:47That's not so hard to do.
36:49And if you're an admin who doesn't
36:51have an MD or an RN degree,
36:53you can staff the front desk and
36:55or staffing call Centers for
36:56a day or two a month, right?
36:58That would surely be an
36:59eye opening experience.
37:00And Lord knows,
37:01we could use the extra hands on
37:03deck answering the phones because
37:04I think the people making decisions
37:06they need to do some patient care.
37:09They need to experience how
37:10the system often thwarts your
37:12efforts to do the right thing.
37:15And I'll add as a footnote,
37:16it wouldn't be a bad idea to have some
37:19term limits on medical leadership roles,
37:21right?
37:22And promote some of the folks in
37:24the trenches to be making decisions.
37:27You know,
37:27we hear a lot of talk about
37:29patient satisfaction rates.
37:31It's big money right now because
37:33the reimbursement depends on those
37:34patient satisfaction scores.
37:36But usually it comes down to,
37:37you know,
37:38Graham crackers in the waiting room where
37:40some fancy coffee machine and listen.
37:41I'm not going to try an ice coffee machine,
37:44but.
37:44Why don't we actually ask patients
37:46whether they want valet parking or
37:49longer visits with their doctors?
37:51I'm sure they will pick longer visits, right?
37:54Ask them.
37:54Do you want a medical campus?
37:57It looks like a Silicon
37:58Valley investment firm,
37:59or you know,
38:00a tech center.
38:01Or that when you push the call button
38:03and nurses able to come right away and
38:06you know what patients will choose.
38:08Hospital profits reached 88
38:10billion dollars last year.
38:12Right, that's the profits alone.
38:14And recall that more than half of
38:17all US hospitals are what they are.
38:20Non profits but close to 100
38:22billion dollars in profits.
38:24And that represented a 27%
38:26increase in four years.
38:27So for nonprofits,
38:29they're doing pretty darn well.
38:31If the health care industry is
38:33as patient centered as a claims,
38:35those profits ought to be prioritized.
38:37Tord giving doctor sufficient
38:39time with their patients and
38:40fully staffing the nursing ranks.
38:42Because when it comes,
38:43the fundamentals of good medical care,
38:45sufficient time with clinicians,
38:47is the most important thing.
38:48Everything else,
38:49most everything else is secondary,
38:51and patients will go to the most
38:53decrepit hospital with peeling
38:54paint if they know they get good
38:57care from their doctors and
38:58nurses they know we're good.
39:00Care is an. They're not fooled by.
39:02Fancy surroundings more time
39:04with their doctors and nurses
39:06would be what most patients want.
39:09Right now, amazingly,
39:10applications to medical school in
39:12nursing school are at all time highs.
39:14I mean, it's still the most.
39:16These are still the most rewarding
39:18professions, hands down.
39:19Perfect, it's not.
39:21We know that we've got our bad apples,
39:24as in every field.
39:25But overall,
39:26for most clinicians the compass
39:28is pointed in the right direction
39:30in the direction of our patients.
39:32And so I think it's time for
39:35healthcare to reprioritize patient care.
39:36It has the money to do it,
39:38and it has the staff.
39:41And it surely has enough disease
39:43with no shortage on
39:44that. And it also has the secret ingredient,
39:47and that is that helping someone feel better,
39:51even just a little bit.
39:54Is the most amazing thing.
39:56Moving the needle even just a few degrees,
39:59it doesn't get better than that,
40:01and that is why we're here.
40:03And I think we can pull all
40:05of our health care staff,
40:07even those people doing admin roles
40:09into more patient contact rolls
40:11to get the sense of that feeling.
40:14Because that is why we're all here,
40:16and I think all we ask is
40:17to just let us do our jobs.
40:19Thank you so much.
40:27I can't start my video, there we
40:30go now we can start the video.
40:34Terrific, that was wonderful, Danielle.
40:36Thank you so very much.
40:38We have some time for conversation.
40:40I mean so much of this Rang true for me.
40:44So much of it I knew an much of it.
40:47I hadn't really thought of before.
40:49An an thought of in a new way or just
40:52new ideas and ways of looking at it,
40:54but I think the exploitation of
40:56physicians is terribly important.
40:57Which is why, frankly,
40:58your article Rang true for me and so
41:01much of this in terms of how, how we,
41:03how we have profession has changed over the
41:05course of my career is really important,
41:07and I think that you're a little bit of
41:10a voice crying out in the wilderness.
41:12Even their excision isn't exactly
41:14the wilderness, but.
41:14But you make a terribly important point.
41:16I want to invite or several termly
41:18important points I I have seen,
41:20and I we've all seen situations
41:22where you say, well,
41:23why would they pay if they
41:24know you'll do it for nothing,
41:26and so you'll see people who
41:28are of course will do it.
41:30We're not going to let the patient suffer,
41:32and so we do it.
41:33And so from a purely business standpoint,
41:35sometimes it seems like it makes sense.
41:37It makes sense to to have the
41:39physicians just do this as extra
41:41time and extra work in the long run.
41:43It doesn't help any aspect of the mission.
41:45And I think that that finding ways
41:48to articulate that the way you have
41:50could go along way to help us fix some
41:52of what's wrong with the profession.
41:54And with that said,
41:56there's some folks who have
41:57things they want to add and ask,
41:59so I'm going to read some questions.
42:01I invite all of you.
42:02If you have a question or a comment,
42:05please put it in the Q&A portion and I'm
42:07going to start right now with the 1st,
42:10as medicine has become more
42:11and more commoditized,
42:12physicians have become disenfranchised.
42:13Administrators and insurers seem to
42:14hold higher authority than ever.
42:16How do we gain back or autonomy
42:17so that we can practice medicine
42:19in the way that was promised?
42:22Well, it's interesting because you
42:24know we hold more power than we think.
42:26An you know we can't go on strike right?
42:28We can't walk out because a
42:29strike would hurt our patients.
42:31We don't want to do that.
42:33Here's my proposal.
42:34What if we had a national no coding day?
42:37We all take care of patients,
42:39we just don't code the visits.
42:42And that would have an effect.
42:44We would see that an.
42:46I think that we have some power an
42:48we may have to speak collectively.
42:50Now of course the unionizing is
42:52not not a very popular thing
42:54in the medical profession.
42:56But certainly most places institutions
42:57Quake when they hear unions.
42:59But the idea that we can speak together,
43:02we do have a large voice,
43:04and I think there's really two ways
43:07to phrase are complaints in a way
43:10that I think higher ups will hear.
43:12An one is patient safety,
43:14so when there's an issue.
43:16So for example,
43:17the medications expiring so it is
43:19been killing me. We have all this.
43:22Drive to making medication list
43:23accurate 'cause that is key for patient
43:26safety and so we've been investing blood,
43:28sweat and tears and making her medications
43:30accurate and then suddenly they expire.
43:32So now I'm on the phone with patient
43:34and they're trying to spell out.
43:36You know,
43:37they'll valsartan for me because I can't,
43:39it's gone.
43:39It's gone from the list and So what I
43:42found after complaining and complaining I
43:44filed a formal patient safety complaint.
43:46I said this is a.
43:48Hazardous to patient health because once
43:50you file a patient safety complaint,
43:52it must be followed up on and
43:53you know what I started getting.
43:55You know the hospital CEO you know.
43:57Call him what's going on and they
43:59looked into and it turns out that
44:01epic defaults to making medications
44:02expire after a year no matter what.
44:04Even if you market a long
44:06term chronic medication.
44:07And I said,
44:08well, you know,
44:09if it's if we take the time to
44:11market long term accommodation,
44:13it should never expire right there?
44:15Insulin never expires folks.
44:17And so I start filing patient
44:19safety complaints when I find
44:20things like that or and it can be
44:23anything that's just one example.
44:24But if you find something in the
44:27system and you can articulate how it
44:29harms patients safety file a report
44:31because they have to look at that.
44:33The second thing is patient satisfaction,
44:35right?
44:36Because patient satisfaction
44:37is very important.
44:38So when patients have a
44:39difficult time like you know.
44:41Getting through to us or making
44:43an appointment because you
44:45know whatever too booked up,
44:46I encourage them to file a complaint
44:48because I want you know the patient
44:51satisfaction side to be there.
44:53And again,
44:53patient satisfaction so often
44:55is window dressing stuff,
44:56but we know and I think if we
44:58ask our patients they really
45:00want more time with us,
45:02their doctors and nurses in
45:04their medical team and less
45:05with the window dressing stuff.
45:07So I tried to frame things about patient
45:10safety and patient satisfaction.
45:12And then you try to speak up,
45:14you know community. For example,
45:15we had a time where they want the faculty
45:18to fingerprint to do our time in there.
45:20Having the whole staff due to
45:22some kind of Kronos crazyness.
45:24And the hospital is doing it.
45:26But we found so degrading we just refused.
45:28Right now. You can fire all 35 primary
45:31care doctors if you want in our group,
45:33but that who's going to see those
45:35hundreds of patients, right?
45:37You know you can't just fire.
45:39I mean you can,
45:40but you're going to huge mess so you can
45:43group together and we refuse to do it.
45:45And you know they back down so
45:47you can do it if you kind of
45:50work together and use your voice.
45:53Thank you and I
45:54get comments just along the lines of Brava.
45:57Completely agree and thank you so
45:59much that from one of our associates,
46:01directors, Doctor Hull, Fantastic.
46:02If Doctor Ofri becomes the boss of medicine,
46:05I'll come back to work, says one of our
46:08highly regarded retired physicians.
46:10OK, so be careful what you wish for John,
46:13'cause maybe maybe we'll get it.
46:15Come back and then you
46:17gotta come back to work.
46:18Federal legislation,
46:19ACA assume the Cures Act played a causal
46:23role in the EMR getting that followed.
46:25Healthcare organizations are often
46:27responding to federal regulation and billing
46:30requirements from payers such as Medicare,
46:32Medicaid, or commercial insurance.
46:33If we can change these incentives,
46:36the substantial the substandard
46:38products from Epic and Cerner etc
46:40will rapidly lose their attractions.
46:42What do you think about that?
46:45Yeah, you
46:45know, I. One thing that the Covid
46:48crisis has shown us. Is that?
46:51We suddenly have a voice,
46:53you know, I think that we just
46:55did our job in the spring.
46:57I don't think we did anything
46:58particularly heroic,
46:59but suddenly the public realized wow are
47:01nurses and doctors and health care staff.
47:03They really care about us, you know.
47:05And that whole 7:00 PM cheer.
47:07I mean, that was so I always like moved.
47:10It hears every time that happened and I
47:12think that we have gained some credibility.
47:14And so I think now is the time
47:16for us to speak up.
47:18I think society looks at us right now,
47:20maybe a little over inflated at the moment,
47:23but.
47:23Be that as it may,
47:25we have a position right now with
47:27some amount of moral standing and now
47:30could be the time to speak up and say,
47:33you know, these are the things these are.
47:35These things actually harm patients, right?
47:37These well intentioned regulations
47:39actually backfire that's,
47:40I think,
47:40where our professional organizations
47:42have to step up to the plate because
47:45we need them to have the access
47:47on the Hill and in government.
47:49One of someone from our General Medical
47:51group at Bellevue was just picked
47:53for Bidens Cova team Celine Gounder,
47:55so we're very excited to have a Bellevue Doc,
47:57you know,
47:58in the room where it happens,
48:00and I think that you know,
48:02practicing clinicians ought to
48:03be there an we should we need to
48:06use your voice to point that?
48:07I don't think the public understands that
48:09sometimes these things will backfire,
48:11and that's really our job to articulate that,
48:13and I think we need to learn a
48:16little bit more about how we.
48:18How we communicate?
48:19So for example,
48:20when the ACA Act back in 2016 or
48:2217 was threatened with repeal and
48:23doctors and nurses began to speak up
48:26about how it harmed their patients.
48:28That was very powerful in a lot of people.
48:31It was the first time they ever
48:33called a Congress person.
48:34And when you say hi,
48:36I'm doctor so and so I'm more so
48:38and so you know, people do listen.
48:40You have some credibility,
48:41so don't be afraid to use that
48:43position you have because you
48:45know the effects on the patients
48:47and you can speak with authority.
48:49That people in politics can't,
48:50and I think even more so now.
48:53You know,
48:53post covid or as we waned down
48:56from covid that we have even more
48:58authority and we should use that
49:01to benefit our patients.
49:03Thank
49:03you. A different question
49:05from a different angle high,
49:07I agree wholeheartedly.
49:09I've enjoyed your work,
49:10especially how doctors feel.
49:12I'd love to hear more about
49:14your writing discipline,
49:16and the question is,
49:18what is your creative discipline?
49:20Perhaps creative
49:22process well? Chaos would probably
49:25be the best word for that,
49:28so I try to, you know right now.
49:31So the Bellevue Literary Review,
49:33which I'll just you know.
49:36Just show our new our new
49:37two new newest issues.
49:39So after 20 years of being under NYU
49:41we had to leave during the pandemic.
49:43So we incorporated a new as an independent.
49:45So over the last six months or five months.
49:48Now I've been trying to make an
49:50independent nonprofit which is
49:52taken almost all of my time.
49:53Unfortunately my writing time,
49:54but I do want to get back to it so the
49:58times when I'm not in the hospital.
50:00Is is my own time for writing and I try
50:03to if I can two or three times a week,
50:06snag an hour or so over writing,
50:08I consider that a success.
50:10And for me, in order to write I
50:12have to have a narrative drive.
50:14I can't write about a topic,
50:15I need to have a story.
50:17Patient story.
50:18Aurora Clinical story,
50:18something to start out.
50:19So for example,
50:20when I started when we do harm,
50:22you know, I wanted to write about
50:24medical error whether or not medical
50:26error was the 3rd leading cause of death.
50:28But I couldn't sit down and write
50:30the book until I had a story.
50:32And so I began casting about in
50:34posting till I found.
50:36Destroy the scene like this is
50:37going to be the narrative backbone.
50:39The same for what doctors feel
50:41an for what patients say.
50:43What doctors here?
50:44Each of those?
50:45There's a story that you know.
50:47It's kind of the Ark of the piece, and
50:49then I can put the information on with it,
50:51but I can't just write about a topic,
50:53it doesn't.
50:54It doesn't work for me.
50:55So my process.
50:56For what it's worth,
50:57is to have some kind of story either in the
50:59abstract or or the particular that starts,
51:01and then I kind of filled in after that.
51:03And then,
51:04you know,
51:04catchers catch can man
51:06when I get time to write.
51:08It it's
51:09working well.
51:11I have a different question for you.
51:16Sometime back when I was young and crazy,
51:19now I'm old and crazy when I was
51:21young and crazy I I got a letter
51:24from an administrator or boss who,
51:26by the way was very smart and
51:28very good and very helpful.
51:30But I got this letter with all
51:32the Department have gotten saying.
51:34Can you please tell us what you're
51:36doing to improve customer satisfaction?
51:38So I actually wrote back to this guy and
51:40I can't remember if that use this phrase,
51:43but I'm pretty sure I did I
51:46actually wrote back saying.
51:47I don't drag my fat ass out of bed for
51:50a customer with no money at 2:00 AM.
51:53Alright, so for patients with no money,
51:55I do it all the time.
51:57I don't have any customers.
51:58I have patience and thankfully for me
52:00this guy understood rows coming from
52:02and just ask me. Hey can I use this?
52:05I said yeah you can use.
52:07My question is,
52:07you alluded to this in your
52:09talk a little bit.
52:10The notion of customers,
52:11and if this is kind of change tonight
52:14and I sorta get it because frankly,
52:16I think out in the world often
52:17customers in the business world in the
52:19in the commercial world were in fact
52:21treated better than patients in the
52:23medical setting on some level in some ways,
52:26but I have felt an and I get the sense that
52:28you agree that something's really been loss,
52:31that in fact the patient should be something
52:33of a higher status than a customer.
52:35And for example,
52:36we help them even mean I.
52:37I've told the story of the medical students.
52:39I said my father was in the
52:41watch business and you know,
52:42I said I remember the time that he
52:43got a call in the middle of the
52:45night and then from the guard at the
52:47factory where he works with that made,
52:49the watch is in these to make washes
52:50in Connecticut in regarding the
52:52factory said there's a guy here
52:53who has no watch and he asked you
52:55to come here right now and make
52:56him a watch and give him a watch.
52:58And by the way he hates you.
52:59He hates your family an I said my
53:01father got out of bed and went down
53:03there and gave the kind of watch
53:05and I said of course that story is
53:06a lie that never happened 'cause
53:08it's not a business like.
53:09Any other business and when
53:10people say that about medicine,
53:12I think it really misses the
53:14angle so their patients,
53:15they're not customers,
53:16and to me it feels
53:17like something different like it's
53:19very different because I think that
53:20patients are uniquely vulnerable,
53:22right when you're going
53:23to buy a microwave or.
53:25Or piece of furniture.
53:26You can choose where you want to go.
53:27You know you can read reviews,
53:29you can take it or leave it,
53:30but when you're sick, you don't always
53:32have the option to take it or leave it.
53:34You may not have the option of where to
53:36go if your insurance company puts you in.
53:38You know one system only or you
53:40don't have insurance.
53:41And also when you're sick,
53:42you're not in the same frame
53:44of mind to be cool evaluating.
53:46You know this product versus that part.
53:47It's not the same thing when
53:49I'm trying to buy a couch,
53:51I can gussy up my energy and make a
53:53decision or I can bag and walk away.
53:55I don't need the couch that much,
53:57but you know.
53:58You know when your child is sick?
54:01Cutely in the middle of the night,
54:02you're not in this frame of
54:04mind to be reading the reviews
54:05and make rational decisions.
54:07You're terrified, or you yourself are sick,
54:09or your feverish or nauseated.
54:10And so we're not trying to
54:12sell something to our patient,
54:13trying to take care of them.
54:15And there's a big difference,
54:16and I think.
54:17The part of customer service that
54:18I think we should adopt is that it
54:21should be easy for patients to get in
54:23touch with us to get what they need to be.
54:25We should have to fight,
54:26so you should know the price
54:28of what you're buying, right?
54:29I mean,
54:29it's crazy that you have no idea and
54:31the patients in how much will the
54:33CAT scan cost and I have no idea.
54:35They think I like Doc.
54:36How can you not know?
54:37I don't know what it costs and I
54:39can't even find out if I wanted
54:41to see how much you got right.
54:42So that part, yes,
54:43I think we should have that
54:44for that customer service.
54:46That patient should know
54:46what it's going to cost,
54:48what their options are.
54:49And ease of manipulating around,
54:50but then the other part is no,
54:52it's not the same.
54:53We're not trying to sell a business,
54:55we're trying to get the best care for
54:58our patients and recognize that they
54:59may not be in the position to be an
55:02equal partner in that at that moment.
55:04And ideally, yes, it's a full partnership,
55:06but with one member of the
55:08partnership is sick or vulnerable.
55:10You know,
55:10we can't expect them to like hold up
55:12their end of the bargain we have to,
55:14you know, be interested to do.
55:16You know more for them than an
55:19equal partnership would be,
55:20so I think there's a big difference
55:22and we have to recognize that,
55:25and so then the burden is
55:26on us that are critical.
55:28Customers come to us with the
55:30vulnerability and that we have
55:32to treasure and protect that
55:34and be extra careful,
55:35not, you know, take care.
55:37I just participated in a
55:38podcast called Doctor Death.
55:40If you've heard of it,
55:41but it's two seasons and they did
55:43one on this horrific neurosurgeon
55:45in Dallas who was just.
55:47Doing terrible things,
55:48but this season now is on.
55:50He mocked person who basically was
55:52milking the system for money giving
55:54patients chemo who didn't need it.
55:56It was the most horrible thing to watch
55:59a certified board certified MD taking
56:01advantage of his patients as customers.
56:03In essence an milking it for money.
56:05He finally got arrested.
56:07But it was just.
56:09It was so shocking to see like that is
56:11that that's the customer service model,
56:13taken to the extreme,
56:14because what our business is doing to us,
56:16they want to milk every dollar from
56:18US to that's their Golden make money.
56:20But that's not our goal,
56:22so we have some things in
56:23common with customer service.
56:24But some things that are
56:26fundamentally different,
56:26and I think we have to be very aware of that.
56:30Thank
56:31you. A question for you please in other
56:34fields, outside medicine and healthcare
56:36labor exploitation have been fought by
56:38unionizing and collective bargaining.
56:39Would it help or hurt to think about labor?
56:43An unionizing in medicine and healthcare?
56:46You know, I think it's time to consider.
56:48I mean certainly you know's residence,
56:50the residence union.
56:50I mean a lot of things didn't happen until
56:53there was a union there to help them.
56:56Obviously there are times when I think
56:58things get maybe ossified and get taken
57:00to the extreme that I can't work one
57:02minute past five 'cause of my union rules,
57:04but I think that maybe we ought to organize,
57:06and I think that there could be
57:08a role for Union for unions,
57:10and I know that's you know,
57:12a radioactive word when it comes
57:13to corporate medicine.
57:14But if we don't have a way
57:16to collectively speak,
57:17and unions are one possible way,
57:19there are others too,
57:20but I think the idea that we
57:22Together have a lot of power,
57:24whether it be in how we earn
57:27money for institutions,
57:28how we represent our professional
57:30organizations, what we know,
57:32what we do right now.
57:34This whole kovid pandemic depends on us.
57:36There's no one else but us who's
57:38going to take care of this and so,
57:41and society recognizes that and
57:42we're in this unique position,
57:44so we have a collective voice.
57:46And so I think we have to find
57:48a way to use it.
57:50And unions are definitely
57:51one possible way to do it.
57:53An we should also typically
57:55reticent about speaking up,
57:56but I think that it's incumbent because in
57:58the end this is harming our patience, right?
58:01If we're being exploited,
58:02it sucks for us,
58:03but it double sucks for our patients.
58:05And that's why I think we have a voice
58:08that is not self interested owed,
58:10not paying us enough,
58:11or you're stealing our wages.
58:12But this is harming our patients.
58:14This is substandard medical care and I
58:16know it every time my cutting corners
58:18to catch up because I'm falling behind.
58:20It's like it's corrosive to the spirit,
58:22right?
58:23If we didn't care,
58:24if you're just in it for the money,
58:26then it wouldn't matter if I OK fine
58:28cut corners, but because we do care.
58:31That's why it's corrosive,
58:32but we didn't care.
58:34It wouldn't be an issue,
58:35but we're all,
58:36you know,
58:37the sense of this moral injuries
58:38because we do care about doing the
58:40right thing and doing a good job.
58:43And that's where we recognize that
58:44that is not just a sin against us.
58:47Descendants are patients because we're
58:48not doing as good a job as we could do.
58:51And as we want to do.
58:54Thank you.
58:56Why do you suggest putting staff in
58:58patient facing work if their expertise
59:00is not as such and it doesn't seem like
59:02it would directly impact the senior
59:04level decision makers perspective?
59:05Or are you suggesting that's
59:07the question here?
59:08Are you suggesting it might very
59:09much impact their perspectives? I
59:11think it would, so if they're not
59:13expertise in hematology, fine,
59:14but anyone can work at the front desk.
59:16Imagine imagine your CEO system.
59:18Does the call center?
59:19Does the front desk and get a
59:22sense of what it's like to make a
59:24clinic run or to make a word run?
59:27I think they have no idea.
59:29They have no idea how often
59:31award a patient is calling.
59:33Funders and there's no nurse
59:34available because they're all short.
59:35Staff had been floated to 17 W
59:37how often the phone is ringing,
59:39and that you cannot think for a second.
59:41You have not even a minute to clear
59:43your mind to think about a patient.
59:45All of those things I think
59:47they can experience if they do
59:49have clinical expertise.
59:49Yes, you know,
59:50get out of your office and you know,
59:53being clinic or if you don't
59:54sit next to me for a day,
59:56just sit with me in my office for a
59:58day and you can experience what it's
01:00:01like to take care of a panel of.
01:00:03Very sick patients, you know,
01:00:04walk with award winners for one shift, right?
01:00:07Just stay by their side and see what
01:00:09it's like to give medical care.
01:00:11We are trying to get medication for being,
01:00:13you know the phones are ringing.
01:00:15The pages are going off.
01:00:17People are stopping in the Hall
01:00:19asking for directions and for
01:00:20ginger ale see what it's like.
01:00:22And so I think will be very salutary
01:00:24for the folks making decisions to
01:00:26see what it's like to actually give
01:00:29medical care in today's world.
01:00:31Thank
01:00:31you. Next, thank you so
01:00:33much for the great talk.
01:00:35I definitely appreciate you validating
01:00:36how it sometimes feels like.
01:00:38Our professionalism and philanthropy is
01:00:40exploited as how it felt earlier this year
01:00:42during covid times when I was a resident.
01:00:45I love your idea about how leadership
01:00:47needs to change in the system.
01:00:49Shift back to the doctors and patients.
01:00:51It makes me think we will need
01:00:53support at the advocacy level.
01:00:55Are there any medical organizations or
01:00:57representatives who have supported your
01:00:59thoughts that we can follow in support?
01:01:02Well, it depends on your group.
01:01:04I've seen some on my end in
01:01:06internal medicine. I see that.
01:01:08Society for General Internal Medicine
01:01:09seems to be stepping up the game a bit
01:01:11in the American College of Physicians.
01:01:13A bit. AMA is a little,
01:01:16you know, catching up.
01:01:17Shall we say I think that they are
01:01:19historically their goals align a little
01:01:22more with the economic, you know,
01:01:24consistency for physicians and maybe not
01:01:26so much in for the experiential part.
01:01:29But maybe they're getting there.
01:01:30But I think that we have to let them
01:01:33know and we're paying tons of due
01:01:36to these folks every year. You know,
01:01:38this is where I need you to be lobbying.
01:01:42And so I think we have to
01:01:44let them know how I feel.
01:01:46I haven't yet seen anyone
01:01:47that's blown me away,
01:01:49but I think there are promising signs like I
01:01:51see that the American College of Physicians,
01:01:54for example,
01:01:54taking on things like gun safety,
01:01:56an issue that comes up a
01:01:58lot for us as clinicians,
01:02:00that it wasn't traditionally
01:02:01taken up by doctors.
01:02:03And starting to get into this,
01:02:04you know there was another Institute
01:02:06of Medicine report on the EMR burden,
01:02:08so I think we're we're starting to get there.
01:02:11But you know,
01:02:11it's always sort of like a few
01:02:13steps behind those of us in there.
01:02:15Right now.
01:02:16We see it right here,
01:02:17and I suspect that you know,
01:02:19those in the position to have a say.
01:02:22The most the work full-time
01:02:23clinicians right there,
01:02:24you know they are now doing desk jobs,
01:02:27and so that's different.
01:02:28So we need to bring bring them in.
01:02:31Honestly,
01:02:31when I see the desk sent with
01:02:33the phones going off,
01:02:34they can use three or four more people
01:02:35to answer the phones and I don't know
01:02:37why the CIO can answer the phones.
01:02:39You know,
01:02:39for a day that I think we very
01:02:41helpful and very educational.
01:02:43Thank you so on right?
01:02:45Simon oncology, NP.
01:02:46At the VA and formerly worked for
01:02:4810 years as an inpatient nursing,
01:02:50a bone marrow transplant unit that
01:02:52converted to epic while I was there.
01:02:54So this all rings very true.
01:02:56I have notice that my ability to focus
01:02:58and think is so inversely related
01:03:00to the volume of interruptions,
01:03:02the alerts and the many ways that staff and
01:03:05patients can now reach me in real time.
01:03:07Calls, texts, email, Skype.
01:03:08This is only gotten more challenging
01:03:11this year with working remotely.
01:03:12No question, that's just a comment
01:03:14from one of our colleagues.
01:03:16You know it's so true,
01:03:17and part of it. You know.
01:03:19When I was working on this medical
01:03:21error book, you know some kinds
01:03:23of errors like procedural error.
01:03:24Those are pretty easy to
01:03:26tackle with checklists,
01:03:27but diagnostic error is very hard to tackle.
01:03:29You can't really checklist how you think
01:03:31and so we haven't made a lot of progress
01:03:33as a profession on diagnostic error.
01:03:35And I had a patient one day
01:03:37who walks in regular visit.
01:03:39He hands me a prescription paper from
01:03:41another Doctor Who's like ordered
01:03:43some executive profile with and have
01:03:44found a high or low cortisol level.
01:03:46And rights rule out adrenal insufficiency
01:03:50rule out rheumatoid arthritis, unlike.
01:03:52RA, an AI at the same time in one
01:03:55visit and this guy already has
01:03:57like 10 other chronic issues like
01:03:59I don't even remember how to do.
01:04:02You know, dexamethasone suppression test?
01:04:04And I realize that I can't possibly
01:04:06think like those two things I need
01:04:08to think I need to clear the deck.
01:04:09I need to read up on them again
01:04:11and remember how they present,
01:04:13how to test for them.
01:04:14And there's no way in a visit I
01:04:16could think because of all the
01:04:18things that were coming up.
01:04:19And So what I do I kind of squeaked by.
01:04:22I kind of faked it an it was crappy
01:04:24medical care and I felt so bad about
01:04:26that that I stayed up all night
01:04:28like rereading and rethinking the
01:04:29case and figure out right now I
01:04:31have a plan of what I want to do,
01:04:33but it took me in.
01:04:35Our to do that because there's no,
01:04:37there's no room to think and I
01:04:39think that that's fine for you.
01:04:41Know a standard in a low back pain
01:04:43case when patients get complicated
01:04:45as many more do.
01:04:47Our patients are older and sicker and
01:04:49much in our discharge much sooner.
01:04:51They are more complex and that
01:04:53inability of time to think,
01:04:55I think,
01:04:55is very dangerous.
01:04:56I think it's raises the level of diagnostic
01:04:59error and risks medication mix ups at risk.
01:05:01Certainly over ordering tests mean.
01:05:03Why bother thinking?
01:05:04I just, you know,
01:05:05refer to endocrine or ordering MRI.
01:05:07Faster than thinking it out,
01:05:09but of course it costs more and
01:05:10of course raises the stakes for
01:05:12more possibilities for error.
01:05:13So yes, you are totally right.
01:05:15Impossible to think.
01:05:18I have just a comment here
01:05:19from the physician wants to
01:05:20come back from retirement.
01:05:21When you take over,
01:05:22you notice that he didn't run that
01:05:24by his wife before he wrote it,
01:05:25so I'm just having second thoughts.
01:05:27Maybe I'm not sure. Um?
01:05:29Here's from one of our one of our trainees.
01:05:32Thank you so much for your insightful
01:05:34talk in the arena of medical education
01:05:36and maintenance of certification.
01:05:38There seems to be an ever increasing push
01:05:40for more benchmarks and requirements.
01:05:42Likewise, trainees frequently faced the
01:05:44brunt of moral distress given their
01:05:46position in the hierarchy of care.
01:05:48How do you suggest we as a field
01:05:51balanced training well rounded,
01:05:52incompetent conditions?
01:05:53With preventing burnout when
01:05:55careers are just beginning.
01:05:57It's a great point and certainly we
01:05:59had this in spades during covid,
01:06:02and you know the residents in our
01:06:04institution asked for Hazard Pay,
01:06:06which did not go down well with the powers
01:06:08that be an email got leaked an internal
01:06:11email about the sort of ungrateful
01:06:13residence and which is just shocking.
01:06:15I really saw our house staff and all
01:06:18house and all the institutions really
01:06:20stepped forward without any hesitation.
01:06:23You know, again,
01:06:24if all the house Def stop working all
01:06:26these vaunted academic medical centers.
01:06:28They'd collapse, right?
01:06:29It's not going to work without
01:06:31the House staff.
01:06:32And so I think you know you have
01:06:34a voice in that part of it is,
01:06:37you know, looking for a real ally.
01:06:39So finding in your program Directores
01:06:41who are the people who understand this.
01:06:43And can you know,
01:06:44make that case vocally and again
01:06:46to point out that you guys not
01:06:48just burnout but moral injury?
01:06:50And how dangerous is moral
01:06:52injury to patient care?
01:06:53And it's also dangerous to the clinicians,
01:06:55but I don't know if that's as powerful
01:06:57statement to the powers that be
01:06:59between put in terms of patient safety.
01:07:01This is really endangering our patience.
01:07:04Right, you know it's not that
01:07:05we care about the money,
01:07:06but it's endangering our patients.
01:07:08If you know the situation to keep sort of.
01:07:10You know how hounding the idea
01:07:12that it is harmful to our patients,
01:07:15I think, is the best way.
01:07:17And then when you start looking for a
01:07:19fellowships or or your next faculty position,
01:07:21your first job, you know,
01:07:23get a sense of what is the
01:07:25feeling amongst the group?
01:07:26What are the attitudes?
01:07:27How open is the leadership to
01:07:29change and get yourself in a place
01:07:30where you feel like those things?
01:07:32Get her.
01:07:33Dan,
01:07:33you know if you talk in the group
01:07:35on you can figure out which places
01:07:37are more amenable to that and
01:07:39which are more sclerotic.
01:07:42Thank you. You know,
01:07:44with regard to benchmark,
01:07:46so I run a division as well as the
01:07:48ethics program and one of the things
01:07:51that I've struggled with is that we are
01:07:53in terms of benchmarks we are chasing
01:07:56forever a certain RV you to CFTE ratio,
01:07:58and I know you're familiar with this
01:08:00and some folks in our audience will
01:08:03be familiar with more than others.
01:08:05Relative value units for clinical
01:08:06full time equivalent,
01:08:07so we're trying to get to the 50th or
01:08:1075th or whatever percentile as we pursue,
01:08:12but our view to see FT ratio, it strikes me.
01:08:15Is essentially well.
01:08:16The RV uses.
01:08:17We use bundled charges when I work in the
01:08:20intensive care unit and the CFT is there,
01:08:22there are a certain number of
01:08:24hours are supposed to work.
01:08:26So basically the higher the RV you for
01:08:28CFT ratio it means the more patients you
01:08:30saw per hour and and so that basically
01:08:33translates as we chase these benchmarks.
01:08:35The mission is to spend less time
01:08:37with patients less time per patient,
01:08:39not with patients overall but less time
01:08:40per patient and peer institutions.
01:08:42This becomes our benchmark to
01:08:44spend as little time as possible.
01:08:46So we can track the reviews not
01:08:47vested when I would not suggest here.
01:08:50In fairness,
01:08:50too much of the leadership here,
01:08:52I would not suggest that that's
01:08:54all they were interested.
01:08:55It's really not,
01:08:56but I think that we have to
01:08:57really be cautious about this.
01:08:59When we set these benchmarks that
01:09:01basically can be reached by cutting
01:09:03corners in our patient care.
01:09:04Actively delivering something more
01:09:06mediocre that this has affects not
01:09:08just on the quality of patient care
01:09:09but also on the satisfaction of the
01:09:11people who are providing it now.
01:09:13Absolutely.
01:09:13And then I find these things so absurd.
01:09:16Also, we I get a. Benchmark on the
01:09:18percentage of patients with an A1C
01:09:20less than 7 less than 8 and you know
01:09:22it dawns on me that so I have a
01:09:24patient who is a onesies 13 nonstop.
01:09:26'cause she won't take her insulin.
01:09:28Now if I'm nasty to her and she
01:09:30leaves my practice, my numbers go up.
01:09:32But if I really want to engage her in Karen,
01:09:34she stays my numbers look worse.
01:09:36So which is the better doctor?
01:09:38I don't know, but it's certainly
01:09:39suggest incentive to keep the patients
01:09:41who can't control their diabetes.
01:09:42So I get why they're trying
01:09:44to encourage us to do better.
01:09:45But it actually can be, you know.
01:09:47Perverse incentive,
01:09:48we need to recognize that so
01:09:50point out that yes,
01:09:51you know what you're doing is saying
01:09:54spend less time with patients.
01:09:55And is that really what you want?
01:09:58Is that really what you're looking?
01:10:00Are there other metrics we can
01:10:02use to show our efficiency?
01:10:04No, there was a a colleague that
01:10:05I knew another institution who
01:10:07checked her ratings on line and
01:10:09she found that she was ranked low
01:10:11for efficiency and not very high.
01:10:12And she was disappointed 'cause
01:10:14she's a considers herself a good
01:10:15doctor and works hard.
01:10:16So she dug into the stats and it
01:10:18turns out she was ranked as low
01:10:20efficiency because she spent too much
01:10:22time with their patients and that's
01:10:24what was giving her a low grade as a
01:10:26doctor of course is a patient thing.
01:10:28That's the doctor I want.
01:10:30They wanna spend too much time with
01:10:32their patients but it came out as.
01:10:34You know, not a good doctor,
01:10:35so they won't choose her.
01:10:36They will choose someone else
01:10:37so they all you know.
01:10:38We have to think about what
01:10:40these metrics really means.
01:10:41Some of them are so absurd.
01:10:42And what do we do with the reports?
01:10:45Nothing.
01:10:45We just make more reports and then
01:10:47we make more reports and then a
01:10:48few more reports an then what like?
01:10:50It's just these reports take on a
01:10:52life of their own and when we have
01:10:54to hire 10 people to do the reports.
01:10:56Forget that I already know five
01:10:58nurses in three physical therapists
01:10:59in two more attendings.
01:11:01Instead of hiring people to do reports.
01:11:03Maybe she
01:11:04was a good physician,
01:11:05but not a good employee.
01:11:07Perhaps that's how it might be framed.
01:11:10So here's an interesting question for you.
01:11:12How do you find your cello practice now?
01:11:14I don't know if you talked about tonight.
01:11:16We talked about that this afternoon.
01:11:17I don't know if we talked about it tonight.
01:11:20You were cello playing.
01:11:21How do you find your cello?
01:11:22Practice figures into your ability
01:11:23to navigate the stresses of clinical
01:11:25care and using epic?
01:11:26It's interesting because you know,
01:11:28I feel like there,
01:11:29specially when I had my kids were younger.
01:11:31There's about one hour in the day.
01:11:33You know you finish the child
01:11:35care stuff before you collapse
01:11:36into bed about one usable hour,
01:11:38an without usable hours.
01:11:40I could, you know, you could exercise,
01:11:42I could catch up on the news.
01:11:44I could read a novel,
01:11:45I could read the New England
01:11:47Journal and catch up on that.
01:11:49I can catch up on those great Netflix series,
01:11:52but for me,
01:11:52I just feeling so one hour to play cello,
01:11:55and I think it's because.
01:11:57Is temperamentally the opposite of
01:11:59life in the hospital right life in the
01:12:02hospitals like this chaos phones and
01:12:04beepers interruptions and everything.
01:12:06And with music like you.
01:12:09You focus on a page and then align and
01:12:11then a measure and then in a single note.
01:12:14And of course with string and you
01:12:16have to get that note to be right,
01:12:19which is very hard to do.
01:12:21But there's even a step beyond that.
01:12:24'cause it doesn't just have to be right,
01:12:27it also has to be beautiful.
01:12:30And beauty does not get a lot of
01:12:32shift in medicine, but in fact.
01:12:34There's a lot of beauty in medicine,
01:12:36even though a lot of medicine is
01:12:39sadness and people suffering,
01:12:40there's a sort of sensual,
01:12:42wriggling aspect of being alive.
01:12:44And there's a beauty in that.
01:12:46And the beauty that we get to be.
01:12:50We're so fortunate to be in that
01:12:52moment with our patients in
01:12:54their most vulnerable moments to
01:12:56help them ease that moment.
01:12:58Sometimes we cure them.
01:12:59Sometimes we ease their passage,
01:13:01we decrease the pain we make them feel heard,
01:13:04and even that little bit.
01:13:06There's something beautiful in that.
01:13:09And I'm not quite sure if
01:13:11I've answered your question,
01:13:12but the idea so for me the music
01:13:14is just like turning inward and
01:13:17completely pushing all that garbage
01:13:19out and justice focus right now.
01:13:21So one of the things you do on the
01:13:23cello as you tackle the box suites
01:13:26and it's this lifetime journey.
01:13:28So I'm on Suite 4 and I've
01:13:30been at this for now.
01:13:32My daughter just turned 15.
01:13:34I started when she was born.
01:13:36And I just got to turn the page from
01:13:38the album on to the current, which is.
01:13:41It takes about a year to turn the
01:13:43page and each one of these things.
01:13:45And of course it has to be memorized.
01:13:47My teacher is very strict.
01:13:48Bach must be memorized,
01:13:50which is a whole other skill,
01:13:51because once you get off the page
01:13:53and just sort of hear the music,
01:13:55it's just wild.
01:13:56But you know,
01:13:57with with a single line of music,
01:13:59he's putting the melody of the
01:14:01harmony of the counterpoint.
01:14:02An you can focus entirely to think
01:14:04about making something beautiful.
01:14:06How impractical is that an it's
01:14:07so liberating to do something
01:14:09entirely impractical because
01:14:10everything went in during data?
01:14:12Practical gotta be efficient and
01:14:14get it done and close the visit.
01:14:17And so being impractical is just
01:14:19like this breath of fresh air.
01:14:21The other thing I'm working
01:14:23on is the Cesar Franck.
01:14:24It's the Concerto for violin,
01:14:26but it's often played by the
01:14:28cello and it's just gorgeous.
01:14:30It's very French and.
01:14:31I have the piano accompaniment on on
01:14:34my computer and I play with that and
01:14:35to get to this world of some random
01:14:38pianist I don't even know who this guy is.
01:14:40I'm playing with him.
01:14:42Again, completely impractical.
01:14:43It doesn't, you know,
01:14:44get a promotion and it doesn't earn a grant.
01:14:47Doesn't cure,
01:14:48patient doesn't make any money,
01:14:49and the impracticality of it is
01:14:51like this huge counterweight to the
01:14:53ridiculous practicality of the EMR.
01:14:55Everything do all day.
01:14:56So there's a long answer to your question.
01:14:59And when we're done,
01:15:01I'm going to practice.
01:15:03It
01:15:03was a long answer,
01:15:05but one worth here, that's for sure.
01:15:07Thank you for the lecture.
01:15:09I have to say that as an outside
01:15:10of the overload paperwork in
01:15:12parentheses and quotes paperwork,
01:15:14here is enormous here mean presumably
01:15:16meaning New Haven is enormous and
01:15:17to try to find them necessary and
01:15:19accurate information in the epic
01:15:21is so time consuming or over.
01:15:23I feel that I work for the building
01:15:25sector instead of the opposite.
01:15:27My feeling is that the expectation
01:15:28from the heads of departments in
01:15:30the hospital to continue to work at
01:15:33home and to embrace this type of
01:15:35work with the quote excuse that when
01:15:37they were young they worked harder.
01:15:38Now I I I'm sure I should clarify
01:15:40or it is different,
01:15:41but I think the expectation
01:15:43about working at home.
01:15:44They're not talking about
01:15:45during the pandemic.
01:15:46I suspect this refers to the expectation
01:15:47prior to the pandemic when we were
01:15:49doing all our clinical work in person.
01:15:51But then there's still the
01:15:52expectation was often that you're
01:15:54not going to finish your notes,
01:15:55so you do them at home after hours.
01:15:58You know it it.
01:15:59It makes me want to gag the idea
01:16:02that I worked hard back then.
01:16:04You know those days,
01:16:05the Giants they never existed, right?
01:16:07Every era has its Giants.
01:16:09Ann has its shortcomings and every
01:16:10year is different and you cannot
01:16:12compare different errors, right?
01:16:14These folks who trained a
01:16:15generation ago they worked hard.
01:16:17I'm not saying they didn't,
01:16:18but what they did for
01:16:19medicine was very different.
01:16:21Write the word emissions 24 hours a day.
01:16:23Patient or patients were insecure.
01:16:25Taking care of many patients.
01:16:26There are many fewer treatments.
01:16:28It's not a fair comparison and
01:16:29so because I did it you did.
01:16:31It is such a feeble excuse,
01:16:33it really really makes me want to
01:16:35object and that we have to resist those
01:16:38reflexes that things were better back then.
01:16:40Yeah, maybe it's better back then
01:16:41because you had a wife at home doing
01:16:43everything for you to worry about it, right?
01:16:45You know it was better back then because
01:16:47you know you made enough money to
01:16:49have to worry about all these things.
01:16:50It's just not.
01:16:51It's not comfortable.
01:16:52They had their challenges,
01:16:53they work really hard.
01:16:54We have different challenges, Anar trainees.
01:16:55They have different challenges.
01:16:56We have to be.
01:16:58Honest enough to recognize the differences,
01:17:01respect them.
01:17:02But no,
01:17:02we don't have to re writing notes at home.
01:17:05I think that it's fair enough
01:17:07that we do our work.
01:17:08You know,
01:17:09during the day you know,
01:17:10once in awhile, fine,
01:17:11but not as standard operating procedure.
01:17:13That's wage theft or time.
01:17:145th let's I think most of us think
01:17:16more in terms of time and money
01:17:18because it steals your time from
01:17:20your family an you only have kids.
01:17:22It's only one round with those
01:17:24children when they are out the door,
01:17:25it's gone an if your job takes 2
01:17:27hours every night and you Miss
01:17:29bath time and you missed the
01:17:31recital and you missed the play
01:17:32in helping with the homework.
01:17:34You will not get those days back and
01:17:36you know for the hospital it's bupkis
01:17:38like it just disappears into the ether.
01:17:40But for you,
01:17:40you've lost those irreplaceable
01:17:42time and it is really time theft.
01:17:44I think I'll change my lecture.
01:17:46It's time theft.
01:17:47One point brought up
01:17:49was disenfranchisement of physicians as
01:17:51contributing to moral distress and burnout.
01:17:53Anna, recognizing our own
01:17:54voice as a current resident.
01:17:56I sensed that this disenfranchisement
01:17:58is Insidious, starts early,
01:17:59and is related to the hierarchical
01:18:01nature of medical training.
01:18:03Do you have any pointers for those of
01:18:05us in medical training in advocating
01:18:07for ourselves and for our patients?
01:18:10And how to help empower each
01:18:12other during medical training?
01:18:15Well, well thing is that you know
01:18:16that we are each others keepers
01:18:18and really to be very attuned to
01:18:20how your colleagues are doing.
01:18:22Because there's always someone
01:18:23who might be struggling.
01:18:24And I think one thing is we often
01:18:26all suffer in silence, you know.
01:18:28And my opening anecdote in this
01:18:30talk of crying in my office,
01:18:32I felt so alone I am so incompetent.
01:18:35I am a technical, you know, loser.
01:18:37I cannot manage epic.
01:18:38I'm really I'm ready.
01:18:39I'm ready to be done I thought, OK.
01:18:42That's just me and it took me weeks
01:18:44to like check in and someone everyone
01:18:46else was sobbing and office Reno
01:18:48offices too because they also felt
01:18:50incompetent and so just checking in with
01:18:52each other is very important in an.
01:18:54Ideally our leadership is proactively
01:18:56doing that, but often they're not.
01:18:57All you're all fine, you know,
01:18:59just tough it out a little bit,
01:19:01but I think that really being
01:19:03there and stepping, saying, hey,
01:19:04you like you're struggling.
01:19:06Let me step in and take over for a few
01:19:08minutes while you go out and you know.
01:19:09Take a breather is very important
01:19:11and then and then again 2 voice
01:19:13your you know your issues, you know,
01:19:16inarticulate way.
01:19:16That doesn't sound, you know,
01:19:18like we're just whining,
01:19:19but here's a clear thing that's
01:19:21going on an icy it not just to me,
01:19:24but I see it in the students below me,
01:19:26right?
01:19:27Those students I'm an intern for
01:19:29those students are in my purview
01:19:30and I don't want them to be coming
01:19:32through medical school and already
01:19:34being jaded like and these students.
01:19:36When you talk to the higher ups,
01:19:38those tools are going to be your doctors.
01:19:41Right,
01:19:41you have a selfish interest in
01:19:43these students not being burned
01:19:45out on day one because they'll be
01:19:47taking care of you in 15 years.
01:19:49We want this next generation of doctors
01:19:51not to be burned out at the starting gate,
01:19:53so speaking up,
01:19:54speak up for those behind
01:19:56you and those around you.
01:19:58But it's I recognize that it's
01:20:00not so easy but to keep trying.
01:20:02It's
01:20:02good advice. You know we had some
01:20:05I heard someone speak years ago.
01:20:07It was a beautiful analogy about a culture
01:20:10that that believed in reincarnation,
01:20:12and so part of the ethos of the culture
01:20:15was you should always raise your daughter
01:20:17as if she may someday be your mother.
01:20:21And the analogy being that that we
01:20:23should raise our medical students
01:20:25as if someday they will be our
01:20:27physicians and they will be.
01:20:29And there will be an so taking care
01:20:31of them now seems wise both as a
01:20:34as a generous gesture on our part,
01:20:36has also a self interested gesture
01:20:38on our part. We're going
01:20:40to have an add to that to keep our
01:20:42vision beyond our little field.
01:20:44Like when you're the resident on the Ward.
01:20:47Pay attention to how the
01:20:48nurses are feeling and doing,
01:20:50and the physical therapist nutritions
01:20:52of social workers are all you know.
01:20:54We tend to only notice our own immediate
01:20:56little work family, but you know,
01:20:58we're all this interconnected web and
01:21:00I think so often we forget about that
01:21:02and see who struggling stepped in to
01:21:05take that extra moment to let them
01:21:07know when they've done a great job.
01:21:09So when you see that there you know
01:21:11it's too much for them to bear.
01:21:13You know you can go get the head
01:21:15nurse if you see a young Noah junior
01:21:17nurses struggling and let them
01:21:19know that someone is having a hard
01:21:20time you and vice versa.
01:21:21You know, for the nurses who
01:21:23see you in turn struggling.
01:21:25Let the program director
01:21:26now let the attending know,
01:21:27because sometimes you may be only
01:21:29person who observes that you know
01:21:31why is substance abuse so high in our
01:21:33professions higher than any other
01:21:35ones because people don't have a place
01:21:37you know to be honest with their pain,
01:21:40then we turn inward.
01:21:41So we really need to keep an eye
01:21:43on everyone in the sort of greater
01:21:45healthcare family again for ourselves,
01:21:47but also for our patients,
01:21:49right?
01:21:49If if our nurse or internal struggling
01:21:51are patients going to suffer so
01:21:53we have even a higher calling.
01:21:55To be on the lookout for that.
01:21:58Thank you, I have a comment and a question.
01:22:01The comments Ed Pellegrino used
01:22:02to talk about illness as a state
01:22:05of existential vulnerability,
01:22:06your term that fundamentally
01:22:08alters our obligations.
01:22:09Tord them, that vulnerability and the
01:22:11inherent knowledge slash power differential,
01:22:13and what we do is what makes patients
01:22:15distinct from consumers and makes medical
01:22:18ethics distinct from other fields.
01:22:20I agree wholeheartedly.
01:22:21The vulnerability being ill is
01:22:23fundamental in being neglected by
01:22:26the dominant consumer model of care.
01:22:28That's a comment from a colleague,
01:22:31and I think acknowledging Doctor
01:22:33Pellegrino's feelings on this and yours.
01:22:37At Milan, Anatoly Broyard wrote about
01:22:39his experience with prostate cancer,
01:22:40and he said, you know, for my doctor,
01:22:43I'm just another patient on his rounds.
01:22:46But for me, it's the crisis of my life.
01:22:49And I think we have to remember that
01:22:51even though you've seen 25 pneumonia,
01:22:54as you know that one day or 25
01:22:56cases of covid for each patient,
01:22:58it's the existential crisis.
01:22:59And and when I find myself getting jaded,
01:23:02sometimes I try.
01:23:02I think you know what?
01:23:04If that patient were my father or my child,
01:23:07right? For them,
01:23:08they've been waiting weeks to see
01:23:10you in the clinic or there waiting
01:23:12hours for you to get there in around.
01:23:14Try to remember that there could
01:23:16be one of your family members.
01:23:18What would you want, your doctor or nurse?
01:23:20To say or do it is it's the peak
01:23:23drama for this person's life and to
01:23:25try and keep that in mind that we
01:23:28never get so jaded that we forget
01:23:30that every patient is suffering
01:23:32sometimes to the Max in their life.
01:23:34And we might be the only person who
01:23:37takes the extra second to listen.
01:23:39You know to get their reading
01:23:41glasses that were lost when they
01:23:42were moved from the ER to the floor,
01:23:44and little things like that
01:23:46make a huge difference.
01:23:47So keep your ears peeled for that.
01:23:50Thank
01:23:50you a final question.
01:23:52Thank you so much for your talk,
01:23:54it's so appreciated.
01:23:55You are including nurses.
01:23:57You know all of your
01:23:58examples coming from a nurse.
01:24:00I really enjoyed the systemic changes
01:24:02you suggested and hope that they
01:24:04will be implemented in some way soon.
01:24:06Do you have any recommendations
01:24:07for individual changes?
01:24:08Nurses and providers can
01:24:10make themselves to help us
01:24:11thrive with patient care.
01:24:13Well, I think you know it's very hard because
01:24:16you're in a system that's so much bigger,
01:24:19but you clarifying for yourself
01:24:20reminding yourself This is why I'm here.
01:24:23And you know, when you feel like
01:24:25I've just become sort of a job or
01:24:28a drudgery you can stop and say you
01:24:30know you know what did I do yesterday?
01:24:32It made someone's life better,
01:24:34you know did I did I move the telephone
01:24:37closer to the bedside or the box of
01:24:39tissues so they could actually reach it?
01:24:41Tiny thing, but huge for that patient.
01:24:44Right, right? Just the lay six times
01:24:46they could get out of the house,
01:24:48you know, not have to find a
01:24:50bathroom in the public sphere.
01:24:52Those little things did I remember
01:24:54to ask how their mother in law with
01:24:56cancer back in Ecuador is doing so I
01:24:59wrote it down in my note last time.
01:25:01Remind yourself of all the good
01:25:03you do and remember,
01:25:04even if you don't never get an award for it,
01:25:07you're never going to raise
01:25:09or knowledge Minton,
01:25:10that one patient knows it and
01:25:11you know take some pride in that.
01:25:14And then don't be afraid to speak up
01:25:16for your patience and N for yourself.
01:25:18You know, as much as the system allows you.
01:25:21And often there are ways to provide
01:25:23some feedback anonymously.
01:25:24I think any good place should allow that.
01:25:26If you're uncomfortable or seek
01:25:28an ally who might you know higher
01:25:30place might be able to do it.
01:25:32So sometimes, like I find is,
01:25:34you know, when junior faculty feel
01:25:36awkward taking up a thing.
01:25:38That is a more senior faculty.
01:25:39I'll speak up and say 'cause
01:25:41I have less on the line.
01:25:43I'm not as afraid.
01:25:44I've also stopped caring what anyone thinks,
01:25:46which isn't incredibly
01:25:47liberating place to be,
01:25:48and I highly recommend it,
01:25:50but you can find an ally a little
01:25:52more advanced.
01:25:53Who can maybe take up the cost for
01:25:55you if they have less on the line.
01:25:57So look for those allies and ask them
01:25:59to make the case for you and just
01:26:02congratulations on doing what you're doing.
01:26:04Happy to talk more if you want to reach me.
01:26:07My websites just danielleofri.com and
01:26:08there's a contact and that just goes
01:26:10to me somehow it answer questions.
01:26:12We send data monthly email
01:26:13with articles and things.
01:26:14If you're interested,
01:26:15you're welcome to sign up and
01:26:17just thank you so much for this
01:26:19opportunity is really a lot of fun.
01:26:21Have a great night guys.
01:26:24So you know one of my best friends from
01:26:26high school when he's asking me about
01:26:28what I do and why I do it and we we.
01:26:31This is the guy used to help
01:26:32through chemistry class.
01:26:33Good guy, but it was very motivated
01:26:35to make some money so we got out.
01:26:37He went kind of a different path
01:26:38in the business world and made a
01:26:40whole lot more money than I did.
01:26:42And one time when we were still relatively
01:26:44young as I explained what I was doing
01:26:46and he explained what he was doing,
01:26:47he was gonna shake his head and I and I
01:26:50say I said I don't tell you what he said.
01:26:52I said every day I get to work
01:26:54with somebody that I admire.
01:26:56He said to me, no, I don't.
01:26:57I rarely get to work with anybody in my
01:27:00rice about every day I get to work with
01:27:02somebody that I that I really admire.
01:27:04And today, Doctor Ofri was no exception.
01:27:06What a privilege it's been to
01:27:07host you for this session tonight.
01:27:09You have my respect and admiration
01:27:11for the way you think.
01:27:12The way you teach, the way you right.
01:27:15It's been a wonderful evening.
01:27:16I thank you so much on behalf of the many
01:27:19people who were here tonight in the program,
01:27:22and we do with.
01:27:23Thanks guys,
01:27:24I really appreciate it.
01:27:25Have a great night everyone.