Dr Lara Goitein: In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System

An Interview With Luke Kervin

Make access to health care a universal right — First and foremost, the issue of access to health care must be addressed, and the most important part of this issue is health insurance. The uninsured have dramatically worse care and health outcomes than the insured, and even insured people now have such high out-of-pocket costs that they can’t afford the care they need. Until the issue of underinsurance is fixed, any focus on quality improvement will be just tinkering at the margins. There should be a single-payer, publicly financed program that guarantees health care to everyone as a basic right.

The COVID-19 Pandemic taught all of us many things. One of the sectors that the pandemic put a spotlight on was the healthcare industry. The pandemic showed the resilience of the US healthcare system, but it also pointed out some important areas in need of improvement.

In our interview series called “In Light Of The Pandemic, Here Are The 5 Things We Need To Do To Improve The US Healthcare System”, we are interviewing doctors, hospital administrators, nursing home administrators, and healthcare leaders who can share lessons they learned from the pandemic about how we need to improve the US Healthcare System.

As a part of this series, I had the pleasure to interview Dr. Lara Goitein. Dr. Goitein is a pulmonary and critical care physician (a specialist in ICU and lung medicine) who trained at Harvard Medical School and University of Washington Seattle hospitals, and now practices in Santa Fe, New Mexico. She is an expert in healthcare quality improvement and founded a hospital quality program called Clinician-Directed Performance Improvement, which has received national attention for its success in improving patient outcomes as well as physician engagement. She writes frequently about healthcare quality, physician burnout, resident education, and end-of-life care, and she is author of the book The ICU Guide for Families: Understanding Intensive Care and How You Can Support Your Loved One (Rowman & Littlefield; December 1, 2021).

Thank you so much for joining us in this interview series! Before we dive into our interview, our readers would like to get to know you a bit. Can you tell us a bit about your backstory and a bit about what brought you to this specific career path?

I’m a recovering college English major. This is despite the fact that since I was a girl, I wanted to be a doctor, like my mother. It seemed to be one of the best and most direct ways to help people. But through my senior year in college, I thought of myself as a “humanities person,” and assumed that I wouldn’t do well in the pre-med sciences. At some point, though, it occurred to me that you should try to behave like the person you want to be. So I decided to try. And it turned out that I loved the sciences — they’re so clean and logical. And I also was right about the rewards of doing something so important for people in need.

I’m something of a moralist, I suppose, and during my training, I became increasingly disillusioned and distressed by the inadequacies of our healthcare system — and how it fails patients. Moreover, I think that the awareness of failing our patients is the most important factor behind the burnout and moral injury that plagues so many doctors today. I became very interested in trying to improve quality not only by the way I personally treated my patients, but by working on the complex systems in healthcare organizations that support the work doctors and nurses do. This is why I started a hospital quality program, designed to support practicing doctors and nurses in finding solutions to the problems they find in our systems of care.

One of the consequences of the failures of our healthcare system is that doctors and hospitals are pressured to be as “productive” as possible and see patients very quickly. Often, doctors and nurses are so rushed that they don’t have much time to provide good explanations. This is profoundly distressing for patients and their families. It’s not uncommon for me to meet a patient who was recently discharged from the hospital — but doesn’t know why he was there, what was done, and what the implications are. So I’ve also become very interested in how to improve communication between doctors and patients and in writing about medicine with patients in mind as readers. I guess this brings me full circle, back to my English major. I enjoy finding the words to explain medicine to patients and their families. The subject of medicine can seem opaque and incomprehensible, especially when shrouded in jargon — but in fact there’s no other topic so logical, interesting, and even beautiful when put in plain language.

Can you share the most interesting story that happened to you since you began your career?

The story of my career shift from big urban academic medical centers to a community hospital is interesting to me, because it made me realize that the best career path is not necessarily the one you might predict. I grew up in Boston in the heart of academic medicine, and I always assumed that one day I would be a department chair in a major urban academic medical center — and I was right on track until my mid-30s. But like so many women, my career took a hard left turn when I had children. My husband, also a physician, and I were both working very long hours, and our babies were being raised by a nanny. Life seemed completely overwhelming and out of control. At some point, we hit a wall and had our early mid-life crisis. We had always loved the desert southwest (I used to be a river guide in the Grand Canyon), and we picked up and moved to Santa Fe, New Mexico, for a job opportunity for my husband. I stayed home for a couple of years with the kids — which was, incidentally, the best decision I ever made.

At the time though, all this felt like completely going off the rails in terms of my career, and made me very anxious. There goes my resume, I thought. But going off the rails had the unexpected effect of removing all the “shoulds” — the resume-building expectations you have for yourself that can obscure what it is you really want to do. I was suddenly free to look around and ask myself, what is it you’re really interested in doing here? And I realized that what I wanted to do was work on improving quality in our local hospital. And because there was so much room for creativity and leadership in a small community hospital, I was able to implement some novel ideas and accomplish a lot. In a big academic medical center, I would have been just another cog in a big machine, and almost certainly wouldn’t have been able to do what I really wanted to do. So in the end, my going off the rails turned out to be the best choice I could have made for my career.

Can you share a story about the funniest mistake you made when you were first starting? Can you tell us what lesson you learned from that?

When I was a resident in internal medicine at the Massachusetts General Hospital in Boston, a well-known cardiothoracic surgeon from another institution was invited to speak to the department about heart transplantation. I was woefully unprepared for the topic and exhausted from being on call the previous night. I slouched in the dark back row of the auditorium, trying to be inconspicuous, and hoping to get a few minutes of sleep.

The speaker was terrific, but terrifying in a gruff, hierarchical surgeon type of way. At one point he asked his audience how the heart rate of a transplanted heart can be controlled by the patient’s nervous system. “How can the vagal nerve control the transplanted heart rate? You, there, in the back row!” To my horror, I realized he was pointing at me. I had no idea what the answer was. I stood up very slowly, as if in a dream or a nightmare. I took a deep breath and shouted out, in my best military bark, “It’s a wonder the damn thing works at all, sir!” To my huge relief the audience and the speaker burst into loud laughter. It even made it into the “famous quotes” notebook that the residents kept at the time. I guess what I learned is that in your moments of greatest embarrassment, you can compensate at least a little with humor and courage.

Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?

A quote from my mother — also a doctor — has followed me throughout my medical career. Shortly before I began my residency in internal medicine, she told me to remember: “They’re sick, you’re not.” When people are sick and afraid, you often see the very best of human nature: courage, selflessness, and resilience. But sometimes, you see negative reactions: defensiveness, rage, peevishness, selfishness. Doctors in training are often subject to rudeness or other bad behavior from worried patients and families. This usually evaporates quickly as a relationship and trust are built, and the patient becomes less fearful — but it can be upsetting. My mother’s words were meant to remind me of the great inequities between my situation and my patients’ situation, and that I was the lucky one because I had my health, and therefore the latitude to be generous and forgiving. Her words have followed me like a mantra on hospital wards, repeated over and over through trying shifts. They also follow me in the rest of my life — reminding me to be sympathetic not just to sickness, but to the weight of other life challenges that I may not share or fully understand.

Are you working on any exciting new projects now? How do you think that will help people?

I just finished writing a book called, The ICU Guide for Families: Understanding Intensive Care and How You Can Support Your Loved One, due to come out on December 1, 2021. I’ve been meaning to write this book for 15 years, and being home with my children while they were in online school during the pandemic has been the perfect opportunity.

I wrote this book to answer what I see as a desperate need for explanations on the part of many family members of ICU patients. For most people, the ICU is an intimidating and overwhelming world, full of incomprehensible jargon, equipment, and information. Doctors and nurses are so busy and rushed that they often don’t have time to help orient family members. I realized that over time I’ve accumulated a collection of explanations that I’ve given to patients and their families repeatedly. This book is essentially a compilation of those explanations, organized chronologically as you might need them during the course of an ICU admission for a family member. Answered questions range from the mundane ( “What is that hose in his nose?”) to the philosophical (“How could I even think about withdrawing life support, and how will I make that decision?”)

In addition to providing explanations, the book provides families with concrete recommendations for how they can support their loved one’s best care. Families often feel utterly powerless and pushed off to the periphery. But family members have a central role to play and can have a major effect on the quality of care. My hope is that this book will empower family members to be the best possible advocate for their loved one and to replace some of that terrible feeling of helplessness with a sense of purpose and understanding.

How would you define an “excellent healthcare provider”?

An excellent healthcare provider takes responsibility. Medicine has become so complicated, specialized, and fragmented that most patients receive their care from a team of people, rather than an individual. This has the advantage of bringing specialized expertise to the table. But the downside is that there is a tendency for each specialist to consider her role as very circumscribed, focused on one event or procedure or organ system — and for the most part her role pauses at the end of a shift. When I see failures in the quality of patients’ care, they usually fall into the category of things falling through the cracks of this jigsaw puzzle, where it’s not quite clear who has responsibility. Good clinicians recognize the area of their expertise as their focus, but don’t lose a sense of responsibility for the ultimate welfare of the whole patient. They go the extra mile to make sure the gaps are closed and that all aspects of the patient’s problems are taken care of.

Other crucial qualities are that the provider is compassionate and meticulous. These three qualities — responsibility, compassion, and meticulousness — are far more important than education, fund of knowledge, experience, technical skills, and raw intelligence all put together.

Ok, thank you for that. Let’s now jump to the main focus of our interview. The COVID-19 pandemic has put intense pressure on the American healthcare system. Some healthcare systems were at a complete loss as to how to handle this crisis. Can you share with our readers a few examples of where we’ve seen the US healthcare system struggle? How do you think we can correct these specific issues moving forward?

The COVID-19 crisis brought failures that have been present in our healthcare system for a long time into sharp relief. First, our healthcare system is so expensive and unwieldy, with such high out-of-pocket costs, that many people avoid medical care if they can. This is always a problem, but more so when damping down the pandemic relies on patients’ presenting to the healthcare system early and getting tested.

Second, we saw a dramatic manifestation of the tremendous inequities in access to insurance and care that characterize our system. The life expectancy for the entire US population dropped during the COVID-19 pandemic, but the reduction was 3–4 times greater for Latinx and black populations than for whites.

Third, we weren’t able to leverage the central coordination that countries with national healthcare systems and well-developed public health systems enjoy. We didn’t have the infrastructure or central planning mechanisms to ensure equitable distribution of goods and services like ventilators, masks and other personal protective equipment, medical staff, and vaccines, and this led to unacceptable shortages and delays.

Fourth, we saw the extraordinary latitude given to pharmaceutical companies that is typical of the US. Many of the drugs that pharmaceutical companies produce — including the COVID-19 vaccines — were actually based on publicly funded research by the NIH. But unlike other countries, the US leaves pharmaceutical companies free to charge the government or individuals whatever the market will bear — and drug companies have reaped a fortune from selling the COVID-19 vaccine. They’ve done so with almost no public accountability demanded of them. For example, pharmaceutical companies haven’t been forced to reduce their pricing enough to make vaccines easily accessible in poorer countries — something that should be done not only for moral reasons, but because it’s of great public health importance to the US as well.

I believe that a single-payer national healthcare system is the best answer to all these problems, whether during a pandemic or not. A single-payer system would provide insurance and access to health care for all Americans, regardless of race or economic background. It would provide central coordination and support public health infrastructure, and it would better allow us to hold pharmaceutical companies accountable to the interests of the public.

Of course the story was not entirely negative. Healthcare professionals were true heroes on the front lines of the crisis. The COVID vaccines are saving millions of lives. Can you share a few ways that our healthcare system really did well? If you can, please share a story or example.

While the pandemic underscored the flaws in our system as a whole, it highlighted the resilience, ingenuity, and generosity of many individuals, organizations, and local governments — who rushed in to close the gaps during this crisis. Healthcare workers worked for long hours under incredibly stressful circumstances, despite lack of personal protective equipment, and real danger to themselves. They slept in garages, attics, and guest houses during pandemic peaks to protect their families while they kept working. Hospitals repurposed operating rooms, equipment, and staff to meet patients’ needs, and coordinated with one another to share resources. Researchers dropped other interests and generated an incredible body of research on COVID-19 in a very short time. Doctors and nurses shared anecdotes, experiences, recommendations, and emotional support with one another through a frenzy of social media communication.

Some states and their public health departments stepped into the vacuum left by the federal government and did herculean work to try to coordinate resources, build temporary hospitals, repurpose other facilities, support mask mandates and social distancing, provide testing and distribute vaccines, and support people out of work to reduce the ripple effects of homelessness and hunger.

Neighbors took care of one another. In my community, almost everyone — even young children — have cheerfully accepted a mask as part of life and a social obligation. They see it as their small part in controlling this pandemic on behalf of us all. I find the resilience, toughness, and generosity of most people during this crisis extremely uplifting.

Here is the primary question of our discussion. As a healthcare leader can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.

1. Make access to health care a universal right

First and foremost, the issue of access to health care must be addressed, and the most important part of this issue is health insurance. The uninsured have dramatically worse care and health outcomes than the insured, and even insured people now have such high out-of-pocket costs that they can’t afford the care they need. Until the issue of underinsurance is fixed, any focus on quality improvement will be just tinkering at the margins. There should be a single-payer, publicly financed program that guarantees health care to everyone as a basic right.

2. Take the money out of medicine

In my opinion, no one should be allowed to make a profit from someone’s illness — and this is particularly so when the US struggles so much with the astronomical costs of our health care. Right now, our system is not a system at all, but is driven by a fragmented market, which charges whatever it can get away with. Because people who are sick are in no position to negotiate, that means high costs for us and profits for many organizations and industries. The conventional wisdom that the market will control healthcare costs through competition has been thoroughly refuted by now. As the old saying goes, “The definition of insanity is doing the same thing over and over again and expecting different results.”

All healthcare-related businesses should be required to be nonprofit organizations, preferably paid for by a public single-payer system. In particular, Medicare (or a new, more comprehensive single-payer program) should be permitted to negotiate reasonable prices with pharmaceutical companies. Finally, doctors and researchers have become much too dependent on funding from industry in the form of gifts, paid “consultancies,” and research grants. This creates conflicts of interest and changes the way doctors treat patients and the way researchers conduct and interpret studies. Conflicts of interest in medicine should be much more strictly regulated or prohibited.

3. Shift our national strategy for healthcare quality to one that empowers and listens to the front line

We should fundamentally change our national approach to improving health care quality. As with other struggling sectors, such as public education, our society has chosen to simply pay for better outcomes (like the good capitalists we are), rather than address root problems. This is called pay-for-performance, in which payers base reimbursement on performance on certain metrics. So for example, if a hospital has fewer infection complications, it is paid more. But large, good studies have consistently shown that pay-for-performance doesn’t work very well in health care — and it causes all sorts of unintended consequences, like high administrative burden, “teaching to the test” (in which you focus too narrowly on reported metrics, neglecting other problems), “gaming” to make the numbers appear better than they are, and in some cases, worse patient outcomes. It also demoralizes many providers, who feel the value of their work is being simplified and trivialized, and are offended by the implication that they must be bribed to provide good patient care.

I believe we need a different approach. Our frontline nurses and doctors know very well where our quality problems lie and have good ideas for how to fix them, but they’re generally not given the protected time, support, and training to do the hard work of improving our systems. At my hospital, I implemented a program called Clinician-Directed Performance Improvement that was designed to do just that. The positive effects on our quality of care, patient outcomes, and our physician and nurse morale were transformative for our organization, which went from 1 to 5 stars on CMS ratings in the first 3 years of the program. I’d like to see insurers, healthcare organizations, and policymakers shift focus from holding providers accountable for certain metrics (which may or may not reflect the most urgent local problems), and instead give our frontline the support they need to study and fix the local problems they think are most important to their patients.

4. Cut the red tape

The requirements for documentation placed on doctors, nurses, hospitals, and other providers are extraordinarily burdensome in the US. This partly reflects the problems I identified in #1 and #3 above. Because the US has almost 6,000 healthcare insurance companies, rather than a single payer as in many countries, billing and coding and negotiating for payment is overwhelmingly complex. Furthermore, the pay-for-performance strategy I talked about earlier requires a huge amount of effort and documentation just to stay compliant with reporting metrics. All of this is expensive, and many physicians and nurses must spend half or even most of their time on computers completing documentation rather than interacting with their patients.

The expense and hassle of this bureaucracy is driving physicians out of small private practices and into arrangements with large employers — a trend that has only accelerated during the pandemic. This is contributing to a general disenfranchisement of physicians, who are unable to control their own practices — something that’s not good for patients.

Because there are so many entities at play in our current system, it’s hard to design a single approach to reducing documentation requirements. A starting place would be for every healthcare organization to regularly review its electronic medical record explicitly to get rid of unnecessary or duplicative documentation requirements.

5. Stop trying to manipulate providers with financial incentives

We should stop trying to manipulate providers with financial incentives — because unfortunately it works. When we pay doctors every time they do something (fee-for-service), they do more things. When we pay especially high fees for high-technology procedures, they do too many high-technology procedures. When we pay hospitals to admit as many patients as possible and keep them as short a time as possible, they admit more patients and cut the length of stay (by about half since 1980). When we pay bonuses to doctors for seeing more patients in clinic, they see too many patients too fast (primary care physicians now see a patient every 18 minutes, on average). When we pay doctors not to refer patients to specialists or order too many tests, they make too few referrals and order too few tests.

Our healthcare system has layered these incentives on top of one another in a crazy-quilt effort to try to nudge medical care this way and that so that it’s just right. But the care that’s just right is the care that a well-trained, dedicated doctor would provide in the absence of financial sticks and carrots. We should do our best to remove financial incentives from doctors’ decisions about care, rather than keep layering them on and tinkering with them.

Let’s zoom in on this a bit deeper. How do you think we can address the problem of physician shortages?

We have three problems contributing to physician shortages. First, there’s a growing overall imbalance in supply and demand: the population is growing and aging faster than medical school enrollment is increasing, and physicians are retiring earlier. Second, fee schedules disproportionately reward care in certain specialties, leading to shortfalls in lower-paid specialties (such as primary care). Third, unlike many countries with a single-payer system, the US system doesn’t regulate the number of training spots and physician jobs according to public need, by either geography or specialty, so we end up with a haphazard distribution of specialties, disproportionately clustered in urban areas, with major shortfalls in rural areas.

To address doctor shortages, we need to address the low morale and burnout plaguing US physicians. Until we do, we won’t be able to attract a sufficient number of qualified applicants to medical school, and doctors will retire earlier and earlier, and seek more part-time arrangements. Second — and I hate to sound like a broken record — a single payer system would allow the central coordination needed to plan our distribution of doctors in a way that responds to the needs of the country.

How do you think we can address the issue of physician diversity?

I don’t mean to sound simplistic, but the way to address the issue of physician diversity is to train and hire more women and non-white physicians. Healthcare organizations should make specific commitments to diversity in hiring and promotion, as well as in board representation. Particularly strong efforts should be made in medical schools, the pipeline for physician diversity. Medical schools have made notable gains in the proportion of women medical students — now over 50 percent. But the increase in non-white students in medical schools has been anemic, with these students still matriculating at rates far lower than their representation in the general population (with the notable exception of Asian students).

I think it’s important to recognize that while women have made great strides in achieving parity in medical school, they lag further and further behind as you look further up the promotional ladder, and the glass ceiling remains thick. Fewer than 20% of department chairs and healthcare CEOs are women. Among other things, we need to make both work schedules and criteria for promotion more flexible to accommodate the needs of parents (whether women or men).

How do you think we can address the issue of physician burnout?

There is no good reason why physicians shouldn’t love their jobs. Taking care of sick people is important, purposeful work. The knowledge base is fascinating, and it feels great to have mastery over a highly specialized area. The medicine allows an intimacy with people at the most critical moments of their lives, which feels like nothing less than an honor. Not surprisingly, up until a couple of generations ago, physicians almost always wrote or spoke of tremendous joy in their work.

Yet today, physicians are severely demoralized, and in many specialties about half suffer from a syndrome called burnout — a combination of emotional exhaustion, and a sensation of numbness and loss of empathy. In my opinion, the reasons aren’t inherent to the field, but stem from the many frustrations and injustices present in our healthcare system and organizations. Some of these are dramatic — like learning that your young patient with diabetes has died because she couldn’t afford the insulin she needed. Most are small barriers, like having to fight with an insurance company to obtain preauthorization, glitches or time wasters in the electronic medical record, a hospital insisting you use a cheaper prosthetic hip implant even though you know it’s associated with more complications, or having too many patients to spend enough time with each of them. But in aggregate, all prevent you from doing your work well.

Most doctors care passionately about giving the best care possible; they take their professional obligation to their patients very seriously. So not being able to care for them well, regardless of how hard you work, causes moral injury, which I believe is the most important factor behind burnout.

Of course, COVID-19 has heaped on moral injury in spades. Doctors and nurses in many parts of the world, including the US, have had to make ethically impossible decisions to ration ventilators and life-saving care. They have had to work in situations of understaffing, mismatched expertise, inadequate equipment, and on-the-fly troubleshooting. They haven’t been able to interact with or comfort their patients well, because of infection control issues. They’ve been working at a frantic pace for months, knowing that they’re cutting corners in patient care just to keep their heads above water. That doesn’t feel good.

Many people are trying to address burnout among physicians by training them in personal coping methods, like resilience and mindfulness. But remember, physicians have chosen to undergo intense medical training; they’re self-selected to be among the toughest and most resilient people in the world. What they need are changes to their work environments to allow them to give the best possible care to their patients, without having to fight and struggle to close the gaps at every step of the way. I was delighted to see the recent National Academy of Medicine Report on physician burnout, highlighting the importance of improving the systems in which physicians work.

What concrete steps would have to be done to actually manifest all of the changes you mentioned? What can a) individuals, b) corporations, c) communities and d) leaders do to help?

As we’ve been discussing these things, I realize I come back again and again to a national single payer system (such as a more comprehensive Medicare-for-All) as the best solution to many of our most intractable problems. A single payer system would improve access, decrease costs, reduce the burden of documentation, improve physician burnout, enable the coordination and infrastructure needed for public health — especially in times of crisis like the COVID-19 pandemic — and enable us to better address physician shortages. Individuals and policymakers should advocate for such a system, for example through the organization Physicians for a National Health Program (PNHP).

Corporations (other than the private insurance and pharmaceutical industries, perhaps) would also stand to benefit tremendously by advocating for a single-payer system, as they could shed the costs of healthcare insurance that they now carry for employees. Those costs constitute a major competitive disadvantage for US companies.

You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be? You never know what your idea can trigger. :-)

This is going to sound completely out of the blue, but if we’re thinking really big picture — the most amount of good to the most people — I think global population control is the most important effort we can make. Right now the world population is almost four times what it was a century ago. That just isn’t sustainable. The most immediate and scary threat to the world is climate change, but even if we each make huge changes in our individual carbon emissions, we won’t make a dent if our numbers are multiplying so fast. Similarly, overpopulation is at the root of other huge problems, like famine and war. The sheer number and density of people on the planet also increases the risk of pandemics such as COVID-19.

How to dramatically slow global population growth is controversial, but the first, easiest step is making sure women all over the world have access to birth control.

How can our readers further follow your work online?

I’d like to invite them to visit my website, medicalexplainer.com.

Thank you so much for these insights! This was very inspirational and we wish you continued success in your great work.