Care Redesign I

Poor Care Is the Root of Physician Disengagement

Article · January 10, 2017

In many locales around the country, hospitals and health systems are scrambling to respond to poor physician engagement scores. Boards of directors are becoming exercised, task forces on “physician alignment” are being assembled, and managers are losing bonuses and even their jobs. But beneath this hubbub lie important truths about “engagement,” many of which are just emerging into view.

The cause for concern is clear: disengaged physicians are bad for health care. They reduce recruitment and retention rates. They increase the frequency of errors. They lower rates of patient adherence to treatment recommendations and quality of care. Broadly speaking, disengagement undermines morale. Health care organizations at which physicians do not like to work are generally bad places to get care.

How Disengagement Happens

I have been interviewing young physicians who are thinking of leaving or have in fact left the practice of medicine. The stories they tell would be humorous if they weren’t so sad. One physician, Jill, a family physician in her late 30s who works in a highly productivity-driven hospital-based practice, describes practicing medicine as “running on a hamster wheel.” Throughout each day, she feels that she is “constantly behind, and never doing quite well enough.”

As Jill sees it, her hospital-based manager’s principal role is to keep raising productivity targets, with the expectation that physicians will work harder. “It becomes a mentality for them, and they don’t question it.” From her point of view, however, the complexity of her patients’ needs makes practicing faster impossible. As a physician, her goal is not simply to meet productivity targets, but “to take the time to get to know my patients and intervene in ways that actually improve their lives.”

Quality indices, which are supposed to improve care, “are the bane of my existence,” she says. “Many times those numbers reflect not what my patients or I perceive as quality of care, but simply what managers are able to extract from the health record system.” And often, she says, the data turn out to be wrong. “In one case, our managers were wildly miscalculating well-child visits. Only those who actually cared for patients could recognize the error.”

Jill continues, “Getting in and out quickly, ticking off all the boxes, and getting your records completed promptly — these are the things the system values. But my patients want me to listen to them and make sure their concerns are addressed. Being assessed every day by measures that don’t really improve patient care — over time, it takes a real toll on you. The people in charge don’t realize that you simply can’t pull real quality out of large data sets.”

To my surprise, Jill says that the problem that bedevils her most is hypocrisy. As an academic physician, she spends a substantial amount of her time with medical students and residents, and as she expresses it, “I can no longer practice medicine the way I teach it to the next generation of physicians. Either I take the time necessary and fall further and further behind, or I stay ‘on task’ and cut corners on being really present and attentive to my patients.”

For now, Jill worries most about her younger colleagues. “A friend of mine is brand new in practice. She takes care of medically complex patients. She is extremely smart and caring and provides excellent care. But the demands are wearing on her. When you talk to her, you can just see the physical exhaustion. She is so new in practice, yet the need to make her numbers is already burning her out.”

Jill describes another colleague, a pediatrician who took care of children with developmental issues and chronic diseases. “She is an exceptional physician, but now she has gone to work for a health insurance company. She doesn’t see patients. I thought she would hate it but it turns out she likes it. All day she is doing the paperwork for insurance approvals. Knowing that patients are losing a physician like her — it just makes me want to cry.”

What Is Medicine For?

The core problem, then, isn’t managerial. It isn’t even ethical. It’s ontological, pertaining to the most fundamental question of all: what in medicine is most real?

Recent efforts to convert medicine from a relationship-centered profession to an efficiency-focused production process have shifted the focus of attention from aspects of care that Jill regards as real and significant to others she sees as neither. What she and others are describing is a health care culture seriously out of step with what matters most in patient care. This imbalance inevitably erodes the engagement of health professionals.

The term disengagement, when used to describe physicians, is both revealing and symptomatic. To call physicians or other health professionals “disengaged” presumes that there is something they ought to be committed to. As many managers see it, doctors and nurses are not sufficiently aligned with health care organizations’ priorities, their extensive metrics, and the need for efficiency.

Yet those who care for patients feel differently: that face-to-face interactions with patients, not board meetings or creative huddles, are where health care needs to focus.

Viewed from this perspective, it is not difficult to see why physicians and other health professionals would become disengaged. The problem is not simply that paperwork is proliferating, compliance standards are becoming more onerous, and health professionals are spending less time actually caring for patients — though each of these is highly problematic. The fundamental problem is deeper: hospitals and health systems are becoming increasingly detached from the reality of medicine.

As organizations grow in size, they rely less on relationships and more on aggregate data and policies. As health care shifts from relationships to data-driven, process-oriented approaches, it inevitably discounts the needs of particular patients and the people who care for them. As many physicians see it, collecting evidence to demonstrate that health care organizations and their executives are performing well is ultimately less important than taking good care of patients.

Jill and other disengaged physicians are not asking for a promotion, lighter work hours, or more money. Instead they are seeking something much more significant: the ability to take good care of their patients. When it comes to disengagement, we don’t need a new electronic information system, a new set of metrics, or a new CEO. We need a renewed commitment to the most central of all medicine’s ends: caring well for patients.

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