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Healthcare And The Importance Of Hope

Hope is a tricky thing. On the one hand, false hope can lead patients to opt for painful, futile treatments at the end of life. On the other, unnecessarily bleak outlooks can lead to depression and inaction. When health is at stake, presenting information with the right amount of hope can guide patients away from both suffering needlessly and/or succumbing to treatable disease.

I was reading a sad story about a patient whose physician had made her feel hopeless. She was an elderly widow with some real, but not immediately life-threatening, medical conditions. His attitude led her to believe that she was sick and useless – with little to look forward to but ongoing testing, disease progression and eventual death. His professional opinion held special weight for her, coloring her entire outlook. It wasn’t until a friend reminded her of the doctor’s fallibility that she began to question her diagnoses, treatment options, and even prognosis.

When faced with concerning new medical diagnoses, even the most educated among us tend to imagine the worst case scenario. Knowing this, physicians should take care to offer reassurance and optimism whenever it is warranted. Hope provides the energy to course correct, to fight battles that can be won, and to hold on to trust in a brighter future. Why be stingy with it when it is so easily given?

As a rehab physician I have regularly encountered bias on the part of healthy people in regards to certain injuries. I hear them whisper, “I wouldn’t want to go on living if I couldn’t walk” or “That poor man’s life must be ruined.”  And yet, these feelings are not shared by those fighting the battles. In many cases, losing an ability focuses the mind on what’s important – and on all the things that can still be achieved and enjoyed. Life is a gift, and while we all still have breath – we can make meaningful contributions.

It breaks my heart to see patients lose hope, and it is sadder still when physicians facilitate the loss. What we say carries psychological weight, and we should recognize the duty we have to deliver information with kindness and respect – focusing on the possible, dispelling unreasonable fears, and emphasizing that inner peace is attainable no matter the circumstance.

In healthcare we ought to always have hope – not for perfect health, or longer life – but in our ability to overcome obstacles, to make good come from bad, and to have a positive impact on others. The choice to live our best life is ours to make, no matter the disease or condition. Never let a doctor steal your hope, but adopt the rehab mission: to add life to years.

What Causes A Toxic Hospital Culture?

Hospital culture is largely influenced by the relationship between administrative and clinical staff leaders. In the “old days” the clinical staff (and physicians in particular) held most of the sway over patient care. Nowadays, the approach to patient care is significantly constricted by administrative rules, largely created by non-clinicians. An excellent description of what can result (i.e. disenfranchisement of medical staff, burn out, and joyless medical care) is presented by Dr. Robert Khoo at KevinMD.

Interestingly, a few hospitals still maintain a power shift in the other direction – where physicians have a strangle hold on operations, and determine the facility’s ability to make changes. This can lead to its own problems, including  unchecked verbal abuse of staff, inability to terminate bad actors, and diverting patients to certain facilities where they receive volume incentive remuneration. Physician greed, as Michael Millenson points out, was a common feature of medical practice pre-1965. And so, when physicians are empowered, they can be as corrupt as the administrations they so commonly despise.

As I travel from hospital to hospital across the United States (see more about my “living la vida locum” here), I often wonder what makes the pleasant places great. I have found that prestige, location, and generous endowments do not correlate with excellent work culture. It is critically important, it seems, to titrate the balance of power between administration and clinical staff carefully – this is a necessary part of hospital excellence, but still not sufficient to insure optimal contentment.

In addition to the right power balance, it has been my experience that hospital culture flows from the personalities of its leaders. Leaders must be carefully curated and maintain their own balance of business savvy and emotional I.Q.  Too often I find that leaders lack the finesse required for a caring profession, which then inspires others to follow suit with bad behavior. Unfortunately, the tender hearts required to lead with grace are often put off by the harsh realities of business, and so those who rise to lead may be the ones least capable of creating the kind of work environment that fosters collaboration and kindness. I concur with the recent article in Forbes magazine that argues that poor leaders are often selected based on confidence, not competence.

The very best healthcare facilities have somehow managed to seek out, support and respect leaders with virtuous characters. These people go on to attract others like them. And so a ripple effect begins, eventually culminating in a culture of carefulness and compassion. When you find one of these gems, devote yourself to its success because it may soon be lost in the churn of modern work schedules.

Perhaps your hospital work environment is toxic because people like you are not taking on management responsibilities that can change the culture. Do not shrink from leadership because you’re a kind-hearted individual. You are desperately needed. We require emotionally competent leaders to balance out the financially driven ones. It’s easy to feel helpless in the face of a money-driven, heavily regulated system, but now is not the time to shrink from responsibility.

Be the change you want to see in healthcare.

Living La Vida Locum: This Is Why I Love Being A Traveling Physician

Credibility & Prestige In Medicine: How Are They Measured?

In my last blog post I discussed how harmful physician “thought leaders” can be when they are dismissive of the value of other specialists’ care. I must have touched a nerve, because a passionate discussion followed in the comments section. It seems that physicians (who spend most of their time involved in clinical work) are growing tired of the leadership decisions of those who engage in little to no patient care. Clinicians urge lawmakers to turn to practicing physicians for counsel, because those who are out of touch with patients lack real credibility as advisers.

Interestingly, the credibility question was raised in a different light when I  was recently contacted by a prestigious medical organization that was seeking expansion of its board membership. I presumed that this was a personal invitation to join the cause, but soon realized that the caller wanted to use my influence to locate “more credible” candidates with academic gravitas.

When I asked what sort of candidate they wanted my help to find, the response was:

“A physician with an academic appointment at a name brand medical school. Someone who isn’t crazy – you know, they have to be respected by their peers. Someone at Harvard or Columbia would be great. You must know someone from your training program at least.”

While I appreciated the honesty, I began thinking about the age-old “town versus gown” hostilities inspired by academic elitism. In medicine, as with many other professions, it is more prestigious to hold an academic position than to serve in a rural community. But why do we insist on equating credibility with academics?

Another facet of credibility lies in physicians’ tendencies to admire only those at the top of their specific specialty. Dr. Lucy Hornstein described this phenomenon in her powerful essay on “How To Drive Doctors To Suicide:”

“Practice that condescending look and use it at hospital staff events. Make it a point to ignore newcomers. Concentrate on talking just with your friends and laughing at inside jokes, especially when others are around. Don’t return their calls, and don’t take their calls if you can possibly help it. If you accidentally wind up on the phone with the patient’s primary physician, just tell them you’ve got it all under control, and that he (and the patient) are so lucky you got involved when you did.”

A reader notes:

“And perhaps those of us who do see patients should get some self esteem and stop fawning all over [physician thought leaders] at conferences like needy interns.”

And finally, there seems to be an unspoken pecking order among physicians regarding the relative prestige of various specialties. How this order came about must be fairly complicated, as dermatology and neurosurgery seem to by vying for top spots these days. I find the juxtaposition almost amusing. Nevertheless, it’s common to find physicians in the more popular specialties looking down upon the worker bees (e.g. hospitalists and family physicians) and oddballs (e.g. physiatrists and pathologists).

While I try very hard not to take offense at my peers’ dismissiveness of my career’s value, it becomes much more concerning when funding follows prejudicial lines in the medical hierarchy. As a sympathetic family physician writes:

“I have observed the inequitable distribution of resources from the less glamorous to the sexy sub specialties despite obvious patient needs. Unfortunately, the administridiots who usually lack any medical training, opt to place resources where they are most likely to attract headlines.”

Yes, caring for the disabled (PM&R) is “less glamorous” than wielding a colonoscope (GI) (again, not sure who made that decision?) but it should not be less credible, or become a target for budget cuts simply because people aren’t informed about how rehab works.

It is time to stop specialty prejudice and honor those who demonstrate passion for patients, regardless of which patient population, body part, or organ system they serve. Excellent patient care may be provided by academics, generalists, or specialists, by those who practice in rural areas or in urban centers.  The best “thought leaders” are those who bring unity and an attitude of peer respect to the medical profession. With more of them, we may yet save ourselves from mutually assured destruction.

The Underbelly Of Vendor Management Systems And The Commoditization Of Physicians And Nurses

In an effort to save on human resources costs, some hospitals have decided to make locum tenens* doctors and nurses line items in a supply list.  Next to IV tubing, liquid nutritional supplements and anti-bacterial wipes you’ll find slots for nurses, surgeons, and hospitalist positions. This depressing commoditization of professional staffing is a new trend in healthcare promoted by software companies promising to solve staffing shortages with vendor management systems (VMS). In reality, they are removing the careful provider recruiting process from job matching, causing a “race to the bottom” in care quality. Instead of filling a staff position with the most qualified candidates with a proven track record of excellent bedside manner and evidence-based practice, physicians and nurses with the lowest salary requirements are simply booked for work.

In a policy environment where quality measures and patient satisfaction ratings are becoming the basis for reimbursement rates, one wonders how VMS software is getting traction. Perhaps desperate times call for desperate measures, and the challenge of filling employment gaps is driving interest in impersonal digital match services? Rural hospitals are desperate to recruit quality candidates, and with a severe physician shortage looming, warm bodies are becoming an acceptable solution to staffing needs.

As distasteful as the thought of computer-matching physicians to hospitals may be, the real problems of VMS systems only become apparent with experience. After discussing user experience with several hospital system employees and reading various blogs and online debates here’s what I discovered:

1. Garbage In, Garbage Out. The people who input physician data (including their certifications, medical malpractice histories, and licensing data) have no incentive to insure accuracy of information. Head hunter agencies are paid when the physicians/nurses they enter into the database are matched to a hospital. To make sure that their providers get first dibs, they may leave out information, misrepresent availability, and in extreme cases, even falsify certification statuses. These errors are often caught during the hospital credentialing process, which results in many hours of wasted time on the part of internal credentialing personnel, and delays in filling the position. In other cases, the errors are not caught during credentialing and legal problems ensue when impaired providers are hired accidentally.

2. Limitation of choice. The non-compete contracts associated with VMS systems typically prevent hospital physician recruiters from contacting staffing agencies directly to fill their needs. This forces the hospital to rely on the database for all staffing leads. At least 68% of staffing agencies do not participate with VMS systems, so a large portion of the most carefully vetted professionals remain outside the VMS, inaccessible to those who contracted to use it.

3. Extra hospital employee training required. There are hundreds of proprietary VMS systems in use. Each one requires specialized training to manage everything from durable medical equipment to short term surgical staff. In cases where hospital staff are spread too thin to master this training, some VMS companies are pleased to provide a “managed service provider” or MSP to outsource the entire recruitment process. This adds additional layers, further removing the hospital recruiter from the physician.

4. Providers hate VMS systems. As anyone who has read a recent nursing blog can attest, VMS systems are universally despised by the potential employees they represent. VMS paints professionals in black and white, without the ability to distinguish quality, personality, or perform careful reference checks. They force down salaries, may rule out candidates based on where they live (travel costs), and provide no opportunity to negotiate salary vis-a-vis work load. When a hospital opts to use a VMS system as a middle man between them and the staffing agencies, the agencies often pass along the cost to the providers by offering them a lower hourly rate.

5. Provider privacy may be compromised. Once a physician or nurse curriculum vitae (CV) is entered into the VMS database the agency recruiter who entered it has 1 year (I can’t confirm that this is true for all systems) to represent them exclusively. After that, the CV is often available for any recruiter who has access to that VMS to view or pitch to any client. There is a wide variety of agency quality in the healthcare staffing industry, with some being highly ethical and selective in choosing their clients (only quality hospitals) and providers (carefully screened). Others are transactional, bottom-feeders with all the scruples of a used car salesman. When your data is in a VMS, one minute you might be represented by a caring, thoughtful recruiter who understands and respects your career needs, and the next (without your informed consent) you’ll be matched to a bankrupt hospital undergoing investigation by the Department of Health by a gum-chewing salesman who threatens you with a lawsuit if you don’t complete an assignment for half the pay you usually receive.

6. No cost savings, only increased liability. In the end, some hospitals who have tried VMS systems say that their decreased hiring costs have not resulted in overall savings. While they may see a downward shift in salary paid to their temporary work force, they get what they pay for. Just one “bad hire” who causes a medical malpractice lawsuit can eat up salary savings for an entire year of VMS. Not to mention the increased costs associated with a slower hiring process, attrition from poor fits, and the inconvenience of having to re-recruit for positions over and over again. Providers also lose out on career opportunities while they’re “on hold” during a prolonged hiring process. And for those who layer on a MSP, they lose control of the most important hospital quality and safety line of defense – choosing your own doctors and nurses.

In summary, while the idea of using a software matching service for recruiting physicians and nurses to hospitals sounds appealing at first, the bottom line is that reducing care providers to a group of numerical fields removes all the critical nuance from the hiring process. VMS, with their burdensome non-competes, cumbersome technology, and lack of quality control are an unwelcome new middle man in the healthcare staffing environment. It is my hope that they will be squeezed out of the business based on their own inability to provide value to a healthcare system that craves and rewards quality and excellence in its staff.

Job matching requires thoughtful hospital recruiters in partnership with ethical, experienced agencies. Choosing one’s hospital gauze vendor should involve a different selection algorithm than hiring a new chief of surgery. It’s time for physician and nurse groups to take a stand against this VMS-inspired commoditization of medicine before its roots sink in too deeply and we all become mere line items on a hospital vendor list. So next time you doctors and nurses plan to work a temporary assignment, ask your recruiter if they use a VMS system. Avoiding those agencies who do may mean a much better (and higher paying) work experience.

*Locum tenens (filling hospital staffing needs with part time or traveling physicians and nurses) is big business. Here is a run down of the estimated market size and its key industry leaders (provided by CompHealth):

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