healthy4u: learned helplessness

On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission.<br /><br />This speaks for itself.  I believe there are a great number of medical professionals who would speak out this way, if they did not fear retaliation (as does my colleague, hence anonymity) or if they were not suffering from the syndrome of clinician <b>learned helplessness</b> (<a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html</a>):<br /><br /><blockquote class="tr_bq">Scot,<br /><br />Yesterday I spent some time in a family docs office in [redacted] who has been experiencing an EHR failure in his office. Naturally its messed up his work flow not to mention occupying hours on end of his ostensibly personal time. His reaction was mostly one of frustration.<br /><br />In another situation, the ABMS is acquiring near dictatorial powers over physicians' livelihoods by essentially mandating an expensive, time consuming jumping through of hoops in the form of MOC requirements which may well evolve into MOL. Its a shakedown. Except for a few thousand members of AAPS that is seeking legal redress in Federal court, organized medicine is silent. Physicians who are undoubtedly frustrated just play the game in a grim resignation.<br /><br />Where is the moral outrage? Where is the righteous anger? Another physician, a close friend of mine, feels exactly the same way. This healthcare system is poisoning our souls and is engaged in a full frontal assault against our ability to ply our trade (which we have invested so dearly in) as critical, free thinking human beings. <br /><br />Extortion at its best. <b>More ominously, we are being extinguished, not transformed,  as a profession. Remolded into subservient "providers". With little blow back. Can you even imagine any other profession allowing this to happen? Try bending a lawyer over a barrel.</b> We are exploited blue collar workers without union representation. We are essentially working in a  meatpacking plant that Sinclair Lewis wrote of.<br /><br />I am so tired and ashamed of being associated with a gutless group of people who call themselves physicians. I just had to get it off my chest. </blockquote><br />If people remain indifferent to having their physicians bureaucratically overburdened and demoralized, the outcome will not be pretty in times of medical extremis.<br /><br />-- SS

On the destruction of medicine as a profession: "Try bending a lawyer over a barrel"

From a physician colleague, a dedicated professional, reposted with redaction of locale with permission. This speaks for itself. I believe ...

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Guest Post: Incompetent Management Breeds Demoralized Physicians

<span style="color: blue;"><i>Health Care Renewal presents a guest post by <a href="http://imh.utmb.edu/about-us/faculty/howard-brody">Dr Howard Brody,</a> John P McGovern Centennial Chair of Family Medicine, Director of the  Institute for Medical Humanities at University of Texas - Medical Branch  at Galveston, and blogger at <a href="http://brodyhooked.blogspot.com/">Hooked: Ethics, Medicine and Pharma</a>. </i></span><br /><br /><span style="font-family: inherit;"><span style="font-size: small;">Danielle Ofri, a prominent internist/author at Bellevue in New   York, started a recent <a href="http://danielleofri.com/an-epidemic-of-disillusioned-doctors/">op-ed</a> piece, “Last week I was ready to quit medicine."</span></span><br /><br /> <br /><div class="MsoNormal"><span style="font-family: inherit;">She described an encounter most physicians can relate to—a 15-minute appointment slot, a new patient who spoke only Bengali, a long and complicated problem list, a bag containing 18 different medicines, two forms that had to be filled out by the doctor on this day’s visit, and a computer that froze while she was trying to keep up with the electronic charting. She described how, 45 minutes into the supposedly 15-minute visit, she had a phone in one ear with the Bengali translator and tech support on hold in the other ear.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">Ofri’s plaint caught my attention because I had recently put up a <a href="http://hcrenewal.blogspot.com/2013/05/guest-post-physician-rebels-against.html">guest post on Health Care Renewal</a> about another highly skilled, caring physician who was seriously considering quitting practice. <span style="font-size: small;">This led me to write a <a href="http://www.utmb.edu/newsroom/article8763.aspx">column</a> for some of our local newspapers about demoralized doctors</span></span></div><div class="MsoNormal"><span style="font-family: inherit;"></span></div><span style="font-family: inherit;"><br /></span><div class="MsoNormal"> </div><div class="MsoNormal"><span style="font-family: inherit;">In the space allowed in an op-ed column, you can’t go into great depth in analyzing a complicated situation. So here’s what I would have wanted to say.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">We can list all the management failures that this encounter represents. I won’t even start with the electronic record as that’s such a frequent theme in this blog. Who scheduled such a patient for a 15-minute visit? Where is the pharmacist who could have done a better job of going through all the lady’s medicines? Where is the staffer who could have filled out the forms for Dr. Ofri to sign? This is just to scratch the surface.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">There are two things worrisome about this long list of management failures. If the goal of the health care system is actually to take good care of patients, then it seems obvious that Dr. Ofri, who wanted to try to provide high-quality care, had roadblock after roadblock thrown in her way.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">Cynics will protest that this system obviously has no interest in quality patient care and seeks only to maximize revenue. If that’s so, is it really true that a board-certified MD is the most efficient labor source for keyboarding data into a computer, filling out paper forms, and doing all the other busy-work tasks that Dr. Ofri had to juggle? Can anyone really believe that this management structure supports <i style="mso-bidi-font-style: normal;">either</i> quality care <i style="mso-bidi-font-style: normal;">or</i>efficient resource use?</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><span style="font-family: inherit;"><span style="font-size: small;"> If the management of U.S. hospitals was severely understaffed or underpaid, then we could perhaps forgive such lapses. But we know that while the growth of physicians in the U.S. has been slow, the number of administrators has grown by leaps and bounds [The number of health care managers increased by 726% from 1983-2000 while physician numbers increased by 39%, look <a href="http://hcrenewal.blogspot.com/2005/04/growing-proliferation-of-managers.html">here</a> - Ed]  . And we know that at least at the high end, these managers are paid <a href="http://hcrenewal.blogspot.com/search/label/executive%20compensation">munificent sums</a>, and are lauded for their supposed genius (look <a href="http://hcrenewal.blogspot.com/2013/06/no-blues-but-lots-of-green-for-st-louis.html">here</a> for example). </span></span><br /><span style="font-family: inherit;"><span style="font-size: small;"><br /></span></span><br /> <br /><div class="MsoNormal"><span style="font-family: inherit;">So we appear to have a system that is slowly (in some cases rapidly) driving the best doctors out of practice, and yet somehow imagines that everything is going all right and there’s no problem—or if there’s a problem, it’s those whining doctors.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">All us medical educators know that when we ask the first-year class how may of them have been told by practicing physicians that they’re making a big mistake coming to medical school, the majority will raise their hands. Yet the managers of America’s health systems apparently believe that they can go on demoralizing good practitioners and nothing bad will happen.</span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div class="MsoNormal"><span style="font-family: inherit;">This may sound as if I am saying that health care managers are all evil people, but that’s an unfair characterization. These folks are simply trying to do what our society tells them. As I <a href="http://hcrenewal.blogspot.com/2012/03/golden-calf-explains-how-economism-lead.html">explained</a> some time ago,<span style="font-size: small;"> most of our popular and political discourse has been captured by a belief system that can be variously called neoliberalism, market fundamentalism, or <a href="http://hcrenewal.blogspot.com/search/label/economism">economism</a>. The ideology can be summarized as a quasi-religious faith in the so-called “free market,” steadfast opposition to government regulation of the market, and opposition to just about any form of taxes (for more on the nature of economism, look <a href="http://theeconomismscam.blogspot.com/2012/09/economism-primer.html">here</a>.)</span></span></div><div class="MsoNormal"><span style="font-family: inherit;"></span><br /><span style="font-family: inherit;"></span></div><div class="MsoNormal"></div><div class="MsoNormal"> </div><div class="MsoNormal"><br /><span style="font-family: inherit;">Among other things, this ideology teaches us that everything important in our society can be accurately captured in objective measures of “productivity” and “efficiency.”  [This is akin to the "shareholder value" theory of management (look <a href="http://hcrenewal.blogspot.com/2012/04/health-care-dysfunction-explained-by.html">here</a>), or "<a href="http://hcrenewal.blogspot.com/search/label/financialization">financialization</a>." - Ed]  Once one has mastered the basic concepts taught in MBA school, there’s no need to learn anything about health care and what makes it a unique activity; there’s no basic difference between providing health care and flipping burgers at McDonalds or making widgets. [We have called this <a href="http://hcrenewal.blogspot.com/search/label/generic%20management">generic management</a>. - Ed.]. And so we get the crazy style of management well documented on this blog, not because of personal nastiness or ill will, but due to the ideological Kool-Aid everyone has been drinking for several decades now. </span></div><div class="MsoNormal"><span style="font-family: inherit;"><br /></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;">Today’s physicians seem to be like the proverbial frog being boiled in the pot of water because the heat was turned up so gradually the frog never figured out it needed to jump. [That is, they are suffering from "<a href="http://hcrenewal.blogspot.com/search/label/learned%20helplessness">learned helplessness</a>." - Ed] Dr. Ofri herself seems to represent a typical frog. Why? Perhaps it’s the style of the blog or op-ed writer to start off with a downer and then try to end on an upbeat note. Or perhaps it’s the natural physician’s tendency to stay away from policy questions. I’m not sure.</span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;"><br /></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;">After starting us off with this hard-hitting description of a dysfunctional system, Dr. Ofri ends by opining that things are going to be better in the future because more women are entering medicine and because today’s medical students are more tech savvy. She gives herself credit for managing to forge a bond with the patient because they sat together and faced this adversity. She cites an upbeat study, <b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;">“</i></b><i style="mso-bidi-font-style: normal;">when asked what was the most satisfying aspect of medical practice, the number one answer was relationships with patients. This is what keeps us going on even the most trying of days.”</i></span></div><div style="margin-bottom: .0001pt; margin: 0in;"><span style="font-family: inherit;"><br /></span></div><span style="font-family: inherit;"><span style="font-size: small;">Dr. Ofri gets full credit for remembering the importance of relationships, and feels that she bonded more firmly with her patient because they went through all this together. How about a word, though, about the people behind the curtain, who are responsible for all that she and her patient had to go through, and who don’t seem to have a clue how bad it is and what it all means? </span></span><br /><div class="MsoNormal"><br /></div><div class="MsoNormal"><span style="font-family: inherit;"><span style="font-size: small;">Dr Howard Brody </span></span></div><br />

Guest Post: Incompetent Management Breeds Demoralized Physicians

Health Care Renewal presents a guest post by Dr Howard Brody, John P McGovern Centennial Chair of Family Medicine, Director of the Institu...

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GUEST BLOG - What Can Doctors Do to Combat Business Malfeasance in Health Care?

<span style="color: blue;"><i>Dr Gene Dorio is a an internist and geriatrician in California, <a href="http://articles.latimes.com/2011/nov/27/local/la-me-1127-lopez-dorio-20111127">described</a> in the Los Angeles Times as an "old school physician."  He would welcome discussion with anyone interested in his proposal.  Please email him directly at <span class="gI"><span class="go">grd51 at aol dot com, or email me for forwarding.  </span></span>   </i></span><br /><br />As a <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> reader, learning of medical business malfeasance irritates my moral conscience, yet lack of legal intervention frustrates my inner core.<br /><br />I am chairman of the Department of Medicine at a small community hospital in Southern California, and as I battle the Administration during Medical Executive Committee meetings, I am a lone voice.  Some of my colleagues nod their heads, while others later tell me of their support, but few vocally nor in writing openly give their opinion.  Why?  <br /><br />Most fear hospital financial retaliation, but I also know they don’t have time to formulate an opinion.  You would think well-educated doctors who daily advocate on behalf of patients would be better attuned to being involved in our great medical debate.  Because they have remained silent, “big business” jumped in and took over financial medical decision-making. <br /><br />Using our medical license is the business scheme they use to make their money.  With sophisticated business techniques, they have shut out doctors and dangled dollars as we all jump for their “carrots.”  That successful business model and attitude is outside the realm of doctor’s poor business and public relations sense, with the noose continually tightening.  <br /><br />Realizing business would be nowhere without our medical license is our trump card...which we haven’t played yet! <br /><br />What can we do?  Logically, bring their business malfeasance forward on blogs (like <a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a>) with the hope physicians and the public will be upset.  It does stir the pot for some of our colleagues, but for the most part, doctor attention is now focused on just trying to survive.  The public is rendered helpless by the continually confusing medical legalese by the well-financed business propaganda machine. This is where our frustration arises, as the backlash-opinion tsunami of their business outrage never materializes, especially from doctors. <br /><br />Therefore, my first thought for a possible solution is focus on the public, clarifying the legalese, and use abhorrent stories of business abuse and patient care sacrifice for business profit.  We must make them the villain.   <br /><br />Secondly, organize physician writers into a small group launching a “counter offensive” against their propaganda.  The public still highly respect physicians and gravitates to their opinions and stories.  With the right motivated people, they would think-tank refined opinions for the national spotlight.  <br /><br />Thirdly, network with national blogs and magazines, and city-printed newspapers for article publication as op-eds, letters to the editors, journal articles, and personal stories. <br /><br />Fourthly, and probably the hardest, not get discouraged. <br /><br /><a href="http://hcrenewal.blogspot.com/">Health Care Renewal</a> defines the problem, but not always the solution.   Even when there might be solutions, they must be broadcast and directed at a higher level to ignite public opinion. <br /><br />If you think this might be worthy for 2013 (as if we aren’t all busy enough!), I will be happy to spearhead this project with those advocate colleagues and idealists who might be interested.  <br /><br />Our profession is under assault from big business, and finding clarity is the shield we need to defend society and our patients.<br /><br />Dr Gene Dorio

GUEST BLOG - What Can Doctors Do to Combat Business Malfeasance in Health Care?

Dr Gene Dorio is a an internist and geriatrician in California, described in the Los Angeles Times as an "old school physician." ...

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The Perils of Physicians Practicing as Corporate Employees: the Contract Trap

A seriously chilling cautionary tale corroborated some of my <a href="http://hcrenewal.blogspot.com/search/label/corporate%20physician">previously expressed fears</a> about the perils of physicians practicing as corporate employees.  It unlikely venue was the April 25, 2011 issue of Medical Economics.  The article, not yet on the web, was "Selling to a Corporation Poses Challenges," by Todd R C Neely.<br /><br />Here is how the case started:<br /><blockquote>A start-up company with a new medical treatment became a publicly traded corporation. <em>The company's top managers were not physicians; they were finance and business experts</em> familiar with the ways of Wall Street.<br /><br />To meet the corporation's goals and Wall Street expectations, the company used stock sale proceeds to <em>aggressively market itself to doctors and buy established physician practices</em> around the country. It quickly captured market share, exponentially raised the number of patients by the practices it owned, and developed substantial revenue streams.<br /><br />The physicians who sold their practices <em>thought that selling would be a win-win situation for them and for the corporation. As marketed to them, the company would handle the business aspects of owning a medical practice</em> - the ubiquitous paperwork, employee issues, and all the rest of the nonclinical task so distasteful to doctors. <em>The physicians would spend all their work time practicing medicine using the latest technology.</em> Benefiting from the company's promotion to the public, they would see an increase in their patient base. They would receive a base salary and, most significantly, <em>a percentage of the profits of their practice</em>.</blockquote><br />But here is how things turned out:<br /><blockquote>Everything was great until the end of the first year. The physicians expected large payments from their practices' increased profits, but <em>the large bonuses never came</em>. </blockquote><br />What went wrong? The physicians were so blinded by the marketing pitch that they apparently never read the fine print:<br /><blockquote>In negotiating the sale of the practices and the employee contracts,<em> the doctors had not required the company to specify in writing what expenses the corporation would charge an individual practice and what accounting rules would be followed. So the corporation charged the practices for marketing, accounting, human resources, financing, and other services, wiping out the profits of each practice.</em></blockquote><br />The contracts were apparently designed by the corporation to favor all its interests (which should not have been surprising), but was accepted as is by the physicians:<br /><blockquote>The contracts <em>specified in precise terms the physicians' responsibilities, noncompete provisions, confidentiality, dispute resolution and the like</em>. But although the contracts stated the corporation's initial responsibilities - mainly making payment on the negotiated purchase price -<em> it phrased the company's other obligations in remarkably vague terms, or, astonishingly, did not specify them at all</em>. The company was to make its 'best efforts' to accomplish certain goals, but the contract left the phrase 'best efforts' undefined. The phrase turned out to be quite malleable. The company's other responsibilities were to be determined at a later, unspecified time.<br /><br />The company's best efforts always turned out to be whatever efforts it chose to make.</blockquote><br />It was a trap,baited by marketing, into which the physicians neatly fell:<br /><blockquote>Many sought legal advice and were told they had no legal resource. <em>The noncompete clauses - fair provisions under the contract terms to which the physicians thought they were agreeing but that were disastrous under the terms (or lack thereof) of the actual contract - were broad, tight, specific, and ironclad.</em> Many of the physicians even were barred from practicing medicine within the geographic area in which they lived. <em>And under the equally ironclad confidentiality clause, the doctors could not publicly discuss their situations or, for that matter, anything else of significance about the corporation;</em> if they did, they would be subject to high fines and penalties.<br /><br />What had appeared to the doctors as a mutually beneficial situation turned into a nightmare for them. <em><strong>They lost their practices and money and took years to recover. They had no legal recourse. They could not even warn others. The corporation could, and did, continue with impunity.</strong></em></blockquote><br />Note that it is now obvious why the article was so vague about the identity of the corporation and the physicians it ensnared, and why it took so long for even such a vague version of this story to surface. The confidentiality (and probably anti-disparagement) clauses made it hazardous for anyone who signed these contracts to be forthright witnesses.  <br /><br />Obviously, the willingness of corporations to employ such clauses means that there may be many more cases like this out there, hidden behind the veil of contractual restrictions on free speech. <br /><br />We previously discussed how physicians often seem willing to blithely sign contracts without fully understanding them, thereby sacrificing their economic well-being and core values.  Here is another striking case of this phenomenon.  We previously attributed this tendency to <a href="http://hcrenewal.blogspot.com/2007/10/physicians-learned-helplessness.html">learned helplessness</a>.  <br /><br />The author of this article, however, suggested  that physicians were victims of carefully targeted marketing based on psychological manipulation.  It was meant to capitalize on three major factors: physicians' naive belief that everyone involved with medicine is interested in helping people by behaving rationally and logically; physicians' over-confidence in their ability to avoid failure (presumably including failure due to ignorance or misinterpretation of legal contracts); and physicians' feelings of entitlement.  <br /><br />In addition, the physicians seemed (probably foolishly) unaware that corporate executives are not interested in physicians' core values:<br /><blockquote>Unlike physicians, <em><strong>the corporation and its top executives, non-doctors all, were involved in the practice of medicine solely to make money; the medical practices, and the very practice of medicine, were just commodities</strong></em> [to them].</blockquote><br />This observation corresponds with numerous observations about how leaders of health care organizations may ignore, or be expressly<a href="http://hcrenewal.blogspot.com/search/label/mission-hostile%20management"> hostile</a> towards physicians' core values. Thus, while the article went on to give some straight-forward advice about negotiating combined practice buy-out and corporate employment agreements, it becomes obvious that the main lesson is: <strong>physicians should not practice medicine as corporate employees.</strong> They should not sell their practices to and become employees of for-profit corporations as a way to practice medicine.  Otherwise, rather than being practitioners, they will end up as medical assembly line workers for bosses who only care about the revenue they generate. <br /><br />Physicians who have already inadvertently, foolishly, or under duress signed contracts that could threaten their professionalism and their patients' welfare need to do the right thing and challenge these contracts.  , or else there will soon be nothing left of the medical profession, and no one left to ethically care for patients.  <br /><br />With each new anecdote, it becomes clearer that the corporate practice of medicine will end up exploiting physicians and patients alike. So there is also a main lesson for patients: <strong>you should not go to doctors who are corporate employees, or practices or clinics that are run by corporations</strong>. If you do, you will end up being used only as a means for the bosses to make money. <br /><br />At a policy level, if we do not stop the corporate practice of medicine, we will all end up as increasingly unhealthy cogs in the corporate health care machine.

The Perils of Physicians Practicing as Corporate Employees: the Contract Trap

A seriously chilling cautionary tale corroborated some of my previously expressed fears about the perils of physicians practicing as corpor...

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