Unintended consequences of ???progress??? – safety, burnout, and ACA


Category : Medical Rants

Bob Wachter writes in frustration today – Is the Patient Safety Movement in Danger of Flickering Out?

All too often legal remedies lead to unintended consequences.  In medicine we are all too familiar with well intentioned laws.  We moved to RBRVS to have a more intelligent payment system, but our new system became unwieldy and penalized primary care.  We have seen coding gaming reactions and CMS spends way too much money in physician payments.

HIPAA represents a really good idea, but in practice it hampers the necessary exchange of medical information.

RBRVS abuse led to requirements for documentation that have made most notes unreadable.

Meaningful use of EHR leads to frustration and more time needed per patient.

Now the threat of the ACA is leading to hospitals focusing more on preparing for the ACA than continuing progress on patient safety.  

I would add to Bob's lament that we too often confuse performance measures and safety measures.  We can clearly decrease central line infections and complications, and the strategies are clear and doable.  We can clearly decrease medication errors through improving processes.  We can make wrong site surgery a thing of the past.

Those measures make sense as do the efforts to improve patient safety.

However, too many in government and in insurance companies conflate performance measures with safety measures.  Performance measures can lead to worse safety, for example, the 4 hour pneumonia rule, trying to achieve HgbA1c < 7 through the addition of a 3rd drug, anticoagulation for patients with high risk of bleeding.

Here is the real problem, patients need physicians who focus completely on them and their problems.  We know from the safety movement that multi-tasking leads to errors.  When we ask physicians to multi-task and do not pay them for the extra work, then attention often leaves the patient.

I wrote on burnout last September:

What are the common root causes of burnout? Primarily burnout comes from loss of control and overwhelming undesirable activities.

Burnout occurs when the job becomes overwhelming.

These many interventions lead to burnout.  Bob recognizes that the unintended consequence of increasing rules and regulations without attached pay is burnout.  And burnout decreases attention to safety.

But Bob's focus on safety is the tip of the iceberg.  Physician burnout impacts every aspect of patient care.  We need common sense, not more laws.  We need a payment system that focuses on time spent.  We need to calculate the true cost of electronic health records, and any economist will tell you that extra time spent is a true cost.

If we truly care about patient safety, if we truly care about patients, and if we truly care about physicians, then we must radically change our health care system to allow physicians to work with their patients.  We should pay physicians and others to improve safety.  

We must reconsider the toll that government interference has on physicians as human beings.

None of us wants a burned out physician to provide our care.  

This is not just a safety issue.



Comments (4)

Robert, some of these issue would be resolved were Docs paid for their time spent w the patient, not by cpt codes.

I could not agree more.

Super excellent post; but we are so off from all these great recommendations. How come people who make policy (some of them docs) cannot see these? There is so much money to save everywhere……without spending more money.

To your list I would add increasingly ridiculous Board/MOC requirements, impending ICD-10 implementation, and, for primary care doctors, the pressure to put time, money, and staff into becoming PCMHs.  The frustration is compounded by the fact that almost none of these initiatives have any evidence supporting them: they're all based on beliefs.
With so many of us planning on retiring early, it's hard not to feel that the entire physician work-force is getting ready to collapse. Our medical societies give the impression of not understanding the seriousness of the situation, and, many of us think, are in many ways actually contributing to the problem.

Post a comment