Posts Tagged ‘Work-life balance’

For several years now, I’ve been the social media curmudgeon in medicine. In a 2011 New York Times op-ed titled “Don’t Quit This Day Job”, I argued that working part-time or leaving medicine goes against our obligation to patients and to the American taxpayers who subsidize graduate medical education to the tune of $15 billion per year.

But today, eight years after the passage of the Affordable Care Act, I’m more sympathetic to the physicians who are giving up on medicine by cutting back on their work hours or leaving the profession altogether. Experts cite all kinds of reasons for the malaise in American medicine:  burnout, user-unfriendly electronic health records, declining pay, loss of autonomy. I think the real root cause lies in our country’s worsening anti-intellectualism.

People emigrated to this country to escape oppression by the well-educated upper classes, and as a nation we never got past it. Many Americans have an ingrained distrust of “eggheads”. American anti-intellectualism propelled the victory of Dwight Eisenhower over Adlai Stevenson – twice – and probably helped elect Bill Clinton, George Bush, and Donald Trump.

Don’t make the mistake of thinking that American anti-intellectualism today is exclusive to religious fundamentalists and poorly educated people in rural areas. Look at the prevalence of unvaccinated children in some of America’s most affluent neighborhoods, correlating with the location of Whole Foods stores and pricey private schools. Their parents trust Internet search results over science and medical advice.

Remember when physicians were heroes?

For a long time, physicians were exempt from America’s anti-intellectual disdain because people respected their knowledge and superhuman work ethic. The public wanted doctors to be heroes and miracle workers. The years of education and impossibly long hours were part of the legend, and justified physician prestige and financial rewards. Popular TV series in the ‘60s and ‘70s lionized the dedication of Ben Casey, Marcus Welby, Dr. Kildare, and Hawkeye Pierce. In real life, heart surgeons Michael DeBakey, who performed the first coronary bypass operation in 1964, and Christiaan Barnard, who performed the first heart transplant in 1967, became famous worldwide.

But over the next decades, greater opportunities for women to enter medicine coincided with a decline in public respect for physicians. Though many women in medical school and residency worked just as hard as men — or harder — to prove themselves, the money and prestige didn’t follow. Women physicians working full-time today earn an average 28 percent less than men, a gender wage gap that persists across specialties.

Could it be that the anti-intellectual tradition in America tolerates highly educated men in the doctor’s role, but can’t quite stomach giving the same respect and pay to highly educated women? Nearly everyone has heard of the Apgar score for assessing the health of newborn babies, but how many people know that Virginia Apgar, who developed it in 1952, was a physician?

Less formality, less respect

Even as more women entered the medical profession, other social trends dimmed the public image of physician infallibility. The tragic Libby Zion case in 1984, in which exhausted residents made a series of errors resulting in the death of the 18-year-old college freshman, prompted the first-ever law to limit resident work hours.

While Depression-era parents raised the “baby-boomer” generation to work hard without questioning it, their grandchildren in Generation X demanded extended parental leave, shorter work days, and more vacation time. “Work-life balance” became their mantra. Workplaces everywhere became more informal and dress codes more casual.

Patients and hospital staff began to address physicians by their first names. (As a Baylor medical student, I would have loved to see the fallout if anyone in the operating room at Methodist Hospital had addressed Dr. DeBakey as “Mike”.) Younger physicians, especially women, went along with it so they wouldn’t seem elitist or unfriendly; they started answering their phones saying, “This is Emma,” instead of  “This is Dr. Smith.” It should come as no surprise that the line between physician and non-physician “care providers” began to blur.

The trap of “evidence-based medicine”

The concept of “evidence-based medicine” gained traction, mandating that every disease and procedure must be managed according to a standardized set of guidelines. Never mind that science evolves, and that early research findings often don’t pan out in large-scale studies. Forget that some published research proves to be fraudulent or tainted by conflict of interest. Ignore the fact that a protocol that works well for one disease may be exactly the wrong treatment for another, and that many patients have multiple diseases.

Individual physician judgment today is presumed wrong if it defies a standardized protocol. Compliance with checklists is viewed as proof of quality care. Ezekiel Emanuel, one of the architects of the Affordable Care Act, has even suggested that medical training be cut by 30 percent, as he believes healthcare by protocol makes all that book-learning unnecessary. In this view, all “providers” are interchangeable pawns.

Today, young physicians start their careers in a world where their advancement and pay may depend on patient satisfaction surveys, and the Internet fuels distrust of medical advice. They spend their days functioning as data-entry clerks, with more face-time in front of a computer than with patients. Innovation is stifled. Their clinical decisions are reviewed for compliance with protocols, and their hospitals are run by administrators for whom the delivery of healthcare quickly and cheaply is the main objective. They fear replacement by mid-level “providers” who can be trained to follow a protocol without question.

Today’s medical students and residents see the dissatisfaction all around them, and they note the growing number of physicians who want to change careers. Many look for pathways out of clinical care from the start of their training, obtaining additional degrees — in public health, information technology, bioengineering, or business administration — that can lead to creative careers outside medicine. Some young physicians turn away from clinical care to become entrepreneurs, designing smartphone apps or using mobile vans to deliver IV therapy for hangovers.

The dystopian future

American anti-intellectualism is growing worse. Our national inability to debate political issues with reason rather than emotion is a symptom of this disease. So is the distrust of higher education and of experts in every field including medicine. I wonder every day if we are being honest with college students about the future when we encourage them to apply to medical school.

The Association of American Medical Colleges predicts a shortage of up to 120,000 physicians in 2030, both in primary care and specialties. A third of currently practicing physicians will be older than 65 within ten years. They’ll be retiring soon, and too many young physicians already are looking for an exit strategy. Even if we train more physicians, if the malaise in American medicine doesn’t get better we won’t keep them in clinical practice.

Unless something changes, we may find ourselves in a dystopian future with only 10 physicians who spend all their time in Washington writing “evidence-based” protocols, while people without the education to realize the full implications of what they’re doing will decide at your bedside which protocol applies to you. Are you feeling lucky?

Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

The perspective beyond the ramparts

As CSA President, I’ve had the opportunity recently to attend two remarkable meetings:  the ASA’s Strategic Dialogue Summit, which took place on January 18-19 in Chicago, and the CSA’s Winter Meeting January 22-26 in Maui. The planners of both meetings took the forward-thinking step of inviting people from outside the walls of the ASA and of traditional academic anesthesiology. They weren’t just telling the attendees—and each other—what they wanted to hear.

The ASA Strategic Dialogue Summit was organized by Immediate Past President Jeff Plagenhoef, MD, FASA, and President James Grant, MD, MBA, FASA. It brought together more than 40 anesthesiologists from private, corporate, and academic practice, both ASA loyalists and outsiders. Some of us who were there practice clinical anesthesia every day; others haven’t touched an anesthesia machine in years.

The meeting gave us an opportunity to speak candidly about the specialty of anesthesiology:

What threatens the specialty?

Are current payment models stifling progress, and what can be done?

How will new technologies make us obsolete or help us work smarter?

Are we training too many anesthesiologists, or should we train more?

How should training be revised to meet the needs of the future?

What disruptive innovations are just over the horizon?

The participants can’t say more than that at present, as we are considering the next steps that the process should take:  whether and when to engage different demographic groups of anesthesiologists in the dialogue, and involve outside stakeholders (such as third-party payers, patient advocate groups, healthcare administrators, and other physician specialties).

Beyond the Strategic Dialogue Summit, these questions should be considered by all of us, as we think about our profession and where we are going from here.

How trauma surgery reinvented itself

A prominent surgeon, Gregory Jurkovich, MD, FACS, of the University of California at Davis, gave a fascinating talk at the CSA Winter Meeting on how the specialty of trauma surgery has reinvented itself over the past 20 years in response to a crisis.

Back in 2001, the US faced a critical shortage of surgeons who were willing to take trauma call for emergency departments, Dr. Jurkovich explained. The cases often occurred at night and on weekends, and the pay didn’t begin to match the work involved. Younger surgeons going into practice no longer considered emergency call a duty as previous generations had done. Emergency departments became severely overcrowded, and the harm to patients from delays in care turned into a national scandal.

The leaders in surgery had to face facts. The profession of surgery as it existed in 2001 wasn’t delivering the best possible care to trauma and other emergency surgical patients, Dr. Jurkovich said. Not all general surgeons or orthopedic surgeons, let alone sub-specialists, were willing to assume care of emergency cases, and a surgeon who rarely sees trauma cases probably shouldn’t be managing them anyway.

A new Committee on the Future of Trauma Surgery, with broad representation from surgical boards and subspecialties, convened in 2003. The committee members decided that they didn’t want to let the specialty of trauma surgery die out, and they didn’t want to turn all non-operative care over to non-surgeons or hospitalists.

They decided to create a new specialty, which would serve emergency patients better, offer an attractive career and lifestyle, and stand as a valuable specialty in its own right. The new specialty would provide critical care training as well as operative training in trauma and other acute emergencies.

The new specialty came to be called “Acute Care Surgery”, and it has been a resounding success, Dr. Jurkovich said. It consists of a two-year fellowship after general surgery, combining trauma care, general surgery, and surgical critical care, and there are now 25 fellowship programs. Graduates work for academic and private hospitals alike, typically on a salary plus stipend basis. Their practices may include routine emergency cases (appendectomy, bowel obstruction) along with trauma cases, and acute-care surgeons admit and make rounds on surgical intensive care patients. Their round-the-clock availability helps avoid dangerous operative delays.

The shift-based work appeals to younger surgeons who seek a more predictable schedule, Dr. Jurkovich said. He pointed out generational challenges which affect surgery and every other specialty today, with more women entering medical school than ever before, more interest in a “balanced” lifestyle, and less interest in general practice than in subspecialty “niches”.

What lessons can we learn?

If the specialty of anesthesiology needs to reinvent itself—redesign what we do and how we do it—it isn’t too late if we start now. The exact solutions and details of implementation will vary by location and practice setting. But inaction, and futile attempts to defend the status quo, are the biggest threats.

For the past several years, I’ve had the privilege of traveling and speaking with anesthesiologists from a wide variety of practice settings, during my work as a CSA officer, a delegate to the ASA, and now as CSA President. The problems and the fears are evident; many anesthesiologists feel as though we are being squeezed in an ever-tightening vise of production pressure and cost constraints. The question is how to break free.

Here are my crystal ball’s top three best-case predictions—those of you who are in practice 20 or 30 years from now will have a chance to see how right or wrong they turn out to be!

The training of anesthesiologists will break the mold of today’s iron-fisted control by the ACGME, the RRC, and the match system.

We’ll no longer insist that every program train every resident with exactly the same cookie-cutter requirements. Residency and fellowship programs will develop and excel along different lines. Some will focus on scientific research, some on the economics and operational management of healthcare, and others on the clinical management of patients and teams in procedural settings. Cross-training with other specialties will expand, and anesthesiology’s influence will expand accordingly.

You’ll never hear the question, “But how will we get paid for it?”

If a peri-procedural service needs to be delivered, anesthesiologists will figure out how to do it safely and efficiently, without being hobbled by fee-for-service constraints. New care models will involve sedation nurses, ICU nurses, pharmacists, and other staffers—in addition to anesthesiologist assistants and nurse anesthetists—under the direction of anesthesiologists across the continuum of every episode of care that includes an interventional procedure. The current rigid supervision ratios and definitions will no longer apply.

Technology will redefine delivery of care.

Operating suites will have command centers where multiple rooms can be viewed and monitored simultaneously. Physician anesthesiologists will no longer spend disproportionate amounts of time performing nursing and pharmacy tasks: injecting drugs into IV lines, or mixing antibiotics. Better drug delivery systems, with feedback loops and decision support, will replace minute-to-minute manual fine-tuning. As we work smarter, the desires of upcoming generations for predictable schedules AND career satisfaction can be fulfilled.

If we face the future squarely, and make changes now that set our specialty up to survive and thrive, we can bring the joy back to the practice of anesthesiology. Then we’ll have good reason to celebrate Physician Anesthesiologists Week for many years to come.

 

Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine:  Then and Now“, in the journal Anesthesia and Analgesia.

I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:

“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.

2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.

3. Women should be careful not to fall into the trap of feeling entitled to special considerations or engage in special pleadings. Our patients want their physician to be the best, whatever his or her sex. There is no room for a physician of either sex who is less qualified or less committed because of outside responsibilities.

4. Women no longer need to “prove themselves” against the sea of doubters who dominated medicine 40 years ago. Fortunately, we are now past that point and such doubts, are I hope, antediluvian. Women are where they are today, however, because many of us felt that demonstrating that women really could “do it” was a moral imperative and one to which we were fully committed.

5. Parents need to manage their work and family responsibilities to ensure that both receive their full attention. This will often mean ensuring that they have excellent childcare to allow them to have the confidence to focus on work when that is required. This may be expensive, but it is a critical investment by both parents in their family’s future. Successfully raising children is a joint responsibility of both partners; what is critical to women is also critical to men, and vice versa. Women starting out on this journey can be assured that it is possible to raise well-adjusted children in a home in which both partners have challenging and successful careers, provided there is a true partnership in the family.”

Is Dr. Wood a curmudgeon, or perhaps a dinosaur? That could be, but I find her honesty refreshing.

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