Walking up to the door of the waiting room, I knew what lay behind it. The gnawing torment would start the day before, or sometimes two days prior. Three parts nausea, two parts dread, and a dash of anxiety — the recipe was always the same. Just add an organic grass-fed doctor, and you have yourself a nice little snack for the healthcare system to chew up and unceremoniously spit out.
This is my story: a successful emergency medicine physician by external parameters, but internally strained. The person who came out of residency — a supremely confident physician ready to take on the world — would never recognize himself 11 years later. My experiences in our healthcare system transformed me, and my story is not unique. There is a sickness that permeates our medical providers within our healthcare system: it is as easy to catch as influenza and as hard to treat.
But before we diagnose this sickness, I would like to describe the context within which we work, this so-called “healthcare system.” I find the phrase “healthcare system” difficult to write, because it is an inaccurate representation of what it purports to describe. If we take the word “healthcare” to mean the mishmash of hospitals, doctors, insurance companies, and vendors that profit from our physical and mental maladies, then perhaps it would be more accurate to call it “sickness-billing.” It is truly “sickness” rather than “health” that the industry focuses on, and “billing” rather than “care” on which it spends the better portion of its time. And if we take the word “system” to mean an organized set of people working together for a common goal, and if one has ever spent a day in a hospital, then one recognizes that the word “ataxia” better communicates the reality of the experience. “Ataxia” is a medical term we use to describe the inability of a person to move their body in a coordinated way. But “ataxia” may be too obscure, so I’ll use the term “industrial complex” — just think of the patients as our industry’s widgets.
This sickness-billing industrial complex, or SBIC — our healthcare system’s true identity — is an uncoordinated amalgam of special interests profiting from a series of unintended consequences of poorly designed policies. So how did we go from “healthcare” to the SBIC? What happened in the last 20 to 30 years? Here is my version of the story.
Government food policies, such as the subsidization of corn and the promotion of sugar- and carbohydrate-rich foods as “low-fat” alternatives, resulted in a massive increase in calorie-dense, nutrient-poor, and highly processed “foods” in our diet (corn syrup, other sugars, refined wheat, etc.). In addition, societal expectations of portion size and taste transformed as well. These dietary changes have led to dramatic increases in obesity, diabetes, heart disease, cancer, and autoimmune disorder rates in the United States. The costs borne by Medicare and insurance companies consequently swelled, producing a strained “system” unprepared to handle the increasing need for preventive care. In response to rapidly rising costs, Medicare (to which most insurance companies look for guidance) created a growing number of obstacles to reimbursing doctors and hospitals, and all payers followed suit. These obstacles started as documentation-focused rules, requiring doctors to record a certain number of data points for each medical visit, otherwise reducing reimbursement. This is why your doctor, during your visit for an ankle sprain, may ask if you have had any constipation, vaginal bleeding, or ringing in your ears.
Doctors — often slow, but never dumb — adapted to the new rules, and learned how to recover their lost revenue by spending extra time asking unnecessary questions and documenting endless nonsense in patients’ medical charts. Medicare created a game and the doctors learned how to play it, to the detriment of patients. Eventually Medicare piled on even more barriers, which they termed Core Measures. Of course, Medicare couldn’t call these things “barriers to paying doctors and hospitals,” so it spun the changes as a switch to “value-based care.” The problem was, most of the parameters on which it was basing “value” were questionable, with little basis in the scientific literature. Most doctors saw the parameters for what they were: barriers to reimbursement.
Sure enough, the Core Measure program went awry and led to a variety of unintended consequences. At a particular hospital emergency room where I worked, it was decided that all patients who had the remotest possibility of having pneumonia upon their initial evaluation in triage were to be given a dose of antibiotics by mouth immediately, because Medicare had decided that getting antibiotics within six hours of arrival to the ER was a measure of quality. Some patients ended up getting antibiotics they did not need, while others needed IV antibiotics but had just received oral instead. In order to meet our “quality” goal, we were practicing bad medicine.
After doctors and hospitals mastered the Core Measure game, Medicare created yet more games, represented by a seemingly never-ending litany of acronyms that read like a Sesame Street song, from “PQRS,” to “MIPS,” to “MACRA.” These new programs were of such complexity that many doctors were faced with three stark choices: 1) spend hundreds of hours trying to learn and adapt to the new rules, 2) sell their practice to a hospital or much larger group (an entity with the resources to hire a consultant to help them figure out how to play the game), or 3) give up and just accept the significantly lower payment.
Sadly, many physicians have opted to sell their practices and give up their autonomy to a corporate entity. This is a major loss to our communities, as independent physician practices are some of the last refuges against the corporate practice of medicine. Just as sad are those doctors who try to stay afloat in the sea of acronyms, barely keeping their heads above water and seeing patients ever more hastily, with less patient face-to-face time, more stress, more rushing, more mistakes, and more frustration — all of which may lead to a dangerous decrease in the physician’s capacity for empathy.
None of these new Medicare programs will work to solve the problems within our sickness-billing industrial complex, because we are not dealing with the core fundamental issues: we’re treating sickness instead of fostering health, we focus on billing instead of care, and we are completely ataxic (uncoordinated). We have a very unhealthy population gorging themselves on sugar-rich foods, developing preventable diseases, like type 2 diabetes, with very expensive complications (kidney failure, heart attack, stroke, blindness, etc.), and clinging to unrealistic expectations that doctors and medicines can work miracles to reverse the impact of years of horrendous nutrition. Meanwhile, we have doctors being coerced to spend a majority of their time figuring out how to play documentation games instead of engaging patients in real health-oriented change.
In 2006, within this context of the SBIC, came a fresh, young, eager new emergency medicine doctor. I truly loved learning about and practicing medicine when I began my career. It was exhilarating — the tight-knit teams of nurses, techs, secretaries, physician assistants, and doctors dealing with the chaos of endless streams of patients, with time pressure, challenging problem-solving, and quick decision-making. Great teamwork, amazing saves, and warm appreciation from patients were the norm.
Then, in my second year, came my first lawsuit as an attending (“attending” refers to doctors working without supervision, having graduated from residency). It was a case I remembered with photographic precision, because it was one of my most intense. A patient who’d been seen by several previous physicians was admitted for a complaint with a very atypical presentation. The patient later crashed during my shift and my team and I did our best to save him. I remember having a very heartfelt, warm, and sad moment with his family at his bedside before we sent him via helicopter for an emergency surgery that we could not perform at our hospital. Unfortunately he did not survive. That night, although very saddened about this gentleman’s death, I was proud of my team’s effort. In court I recounted the scene of the woman from the blood bank running her fastest into the ER with several units of O-negative blood in her hand, knowing that every second counted; every single person was doing everything he or she could to save this man’s life.
I felt like a leader of heroes. Yet, we were sued, and treated like criminals. To be sued when you’ve done something egregiously wrong is understandable. But when you’re proud of your own and your team’s effort, skill, and decision-making, and cannot imagine what you could have done better, being sued is demoralizing and discombobulating. To be sued when you remember standing by the patient’s bedside, your own eyes welling up with tears, because you are a human being who feels the suffering of those around you…
“I did my best. I did what I thought was right. Every medical decision and intervention I made was correct. And somebody hates me so much, they want to ruin my life and end my career. Somebody thinks I did everything wrong. Somebody thinks I am evil.” Such was the narrative swimming in my mind for the two years this case was active. Sleepless nights. Stressful shifts. Two years of self-doubt chipping away at my confidence and pride.
When self-doubt takes a foothold in an emergency medicine physician, it is poison. The hallmark of a great ER physician is the confidence to make quick decisions with limited time, information, and resources. No amount of training or knowledge can supplant low confidence, and patients can sense it immediately.
I remember as a young attending I could sense decreasing confidence in some of the older attendings with whom I worked. They shied away from some of the more complicated cases, and we younger attendings would happily take these more challenging cases. I remember thinking to myself back then, “I hope I never lose my confidence.” And yet here I was, starting to feel it — and I couldn’t understand why.
To my colleagues and bosses, my performance was great. I was seeing patients quickly, providing great medical care, and achieving high patient-satisfaction results. I posted some of the best numbers in my practice for quite a few years, but I felt increasingly unsure of myself. In fact, one of my older colleagues joked to me privately that emergency medicine is the only profession in which you can become more unsure the more you practice it. Not only do ER physicians rank amongst the highest lawsuit rates of all specialties, but they also deal with the unintended complications of medical procedures from every other specialty. This means that the more an emergency medicine doctor practices, the more acutely she experiences all the different tragic ways the SBIC can fail. We learn quickly, from seeing tens of thousands of cases of our own and our colleagues, that no matter how good a doctor you are, you are going to miss certain things, you are going to make mistakes, and certain things are going to happen to your patients that nobody could predict or prevent.
But we also learn that society is not okay with that. Society wants somebody to blame. Family members want somebody to blame. Hospitals want somebody to blame. Society expects perfection. Doctors aren’t supposed to make mistakes. I told my colleagues that being a doctor is like being a wildebeest crossing the Mara River: eventually the crocodile is going to snatch one of us and eat him. And then he’ll get another, and another, whenever he so chooses, each and every time a devastating shock to the chosen wildebeest and those around him.
In the ensuing few years I saw some of my colleagues get taken down by crocodile lawsuits while I continued to deal with my own. All the while, Medicare ramped up its “value-based” programs, increasing the documentation burden on physicians and hospitals. During the same period, the first and second generations of electronic medical records (EMR) systems were deployed in hospitals. Although intended to streamline medical documentation, EMRs dramatically reduced physician productivity. This was primarily because the EMR companies got away with designing software with horrendous user interfaces and user workflows. How? Unlike most consumer software, in the sickness-billing world those responsible for purchasing software (the hospital C-suite) are not its end users (the medical staff). The EMR developers sold the C-suite on “integration,” but nobody paid any attention to usability.
And the cost of these systems is astronomical. In May 2018, the Mayo Clinic announced that they were paying $1.5 billion to switch to the Epic EMR system. Pause for a moment: how could software cost $1.5 billion? Well, when your user interface is so unintuitive that you have to hire and deploy an army of consultants and trainers to hold each user’s hand for two weeks, it can lead to truly “epic” implementation costs. As if this were not bad enough, the internet buzzed with stories of Epic bullying anybody who criticized its software. Can you imagine the backlash if Microsoft or Google tried to place gag orders to prevent criticism of their software? Yet this is the world of the SBIC. The negative effects of poorly designed EMRs on physician morale and productivity are well documented.
With reimbursement declining due to Medicare’s new rules and doctors becoming less productive because of EMRs, physician practices were forced to make their doctors work faster and leaner than ever before.
My experience as a doctor transformed dramatically as a result of all of these changes. With reimbursement going down due to Medicare’s new rules and doctors becoming less productive because of EMRs, physician practices expected their doctors to work faster and leaner than ever before. Hospitals expected increasingly higher patient-satisfaction results. Patients and families expected perfection in care and no complications or unexpected events. Insurance companies expected perfectly documented charts, or else no payment. And EMR vendors expected you to use their dreadful software and keep your mouth shut.
These, then, were our directives: Work faster, make everybody happier, document more, and, oh yeah, don’t ever make a mistake.
For myself and many of my colleagues, our mindset before beginning an ER shift flipped from eagerness and energetic anticipation to nausea and dread. One of my colleagues developed this dread of ER shifts before even graduating from residency, and promptly quit emergency medicine the day he graduated. Only later did I truly appreciate what he must have felt.
All physicians and nurses, and especially those in our nation’s ERs, make personal sacrifices to enter a profession that provides the opportunity and the honor to heal, comfort, and advise their fellow human beings at all hours of the day. They work weekends, overnights, and holidays while most people are sleeping or spending quality time with friends and family. However, when the constituent forces in the SBIC described above repeatedly insult and interfere with the humanity and virtue of medical providers, they do great damage to the provider’s ability to empathize.
This loss of empathy is the sickness within our providers to which I referred at the beginning of this essay. Every condition needs a name, so I shall coin the term “empathitis.” Empathy, in my personal perspective of its application to the medical profession, is the ability to preserve your sense that you are treating another human being. They’re not just “room 12,” or “the hypertensive stroke patient,” but a human being with a name, a story, family, friends, hopes, and fears — a human being who deserves your full attention, your touch, and your diligent and meticulous thoughtfulness.
Empathitis: an acute or chronic reduction in a person’s ability to empathize, often affecting his/her work and life performance.
When the forces surrounding me made it difficult for me to be the type of physician I wanted to be and had trained to be, when those forces repeatedly directed my attention to documentation, billing, EMRs, and moving patients as fast as possible, and when those forces continually chipped away at my mountain of empathy, reducing it to scarcely a handful, I knew the time had come to say goodbye to emergency medicine. My last ER shift was in the summer of 2017.
Luckily, my departure did not signify the end of my medical career. I was fortunate to have worked for a medical practice that gave me the opportunity to develop skills and experience in healthcare technology, data analytics, business development, and telemedicine, and now I have the great pleasure of practicing telemedicine with CirrusMD, an innovative group of amazing human beings who are transforming how healthcare is delivered.
Now, when I see patients from my computer screen, I can chat with them as long as I want. They share stories with me and sometimes we laugh. I advise them the same as I would advise my own family. We don’t rush anything. More often than not, they just need reassurance and a little bit of guidance. Although I am no longer placing central lines or doing intubations, I feel more like a true physician than ever before. I spend time talking to patients about health and not just sickness. In addition to dealing with whatever the patient’s acute medical condition might be, we talk about food choices, exercise regimens, sleeping habits, behavior modifications, and stress-reduction techniques, and how these things may be connected to the patient’s acute condition. Sometimes we discuss fears and anxieties; I’ve even coached patients through full-blown panic attacks. Now I can truly focus on health and care, not just sickness and billing. Now I operate in a system that I actually like to use and supports me and my mission.
I feel blessed, but I know that many of my former colleagues and friends in the world of emergency medicine continue to endure and suffer. Less than half of my residency class is still practicing traditional emergency medicine. In an era of doctor shortages and long wait times in ERs, I felt this story was important to share, so that you might have some sense as to what lies behind the waiting room door.