There is a lot that’s broken in healthcare. Costs are soaring, insurance is a fiasco, and many people don’t get the care they need.

Though healthcare is a rewarding career, it can be relentless. The hours can be challenging, but more than that, the responsibility and stress tend to weigh on on every single person involved in a patient's care. (So much so that more than 50% are experiencing healthcare provider burnout.)

So it’s understandable if you’re a healthcare provider that you might feel a sense of frustration and hopelessness about the work.

The reality is that despite all of that, you are a hero. No superhero in any movie does as much good as any aide or doctor or nurse in their career. Healthcare providers save lives and change lives hourly.

Yes, it’s something I already know — but two things happened in the last week that brought this reality into vivid relief for me.

On a personal level, last Friday my 8-month-old grandson was swept away by ambulance and admitted to the PICU after airway issues began to severely restrict his breathing. Perhaps healthcare is broken, but it wasn't for him. Dozens of people cared for him over 4 days — and each and every person did so flawlessly, compassionately, attentively, and brilliantly. The people who cared for him saved his life — and the way they cared for him got him and his family quickly on the road to health and calm. 

On a national level, that same weekend, a shooter killed 22 people and horrifically wounded 20 others. A New York Times story shows the incredible heroism, selflessness, ingenuity, and courage of the medical providers (from surgeons to housekeeping staff) who saved the lives of the wounded and kept the death toll from rising still higher. Of course, this was integrally linked with the professionalism, efficacy, and bravery of the first responders that day. 

People who provide medical care take on the stress, trauma, and everyday struggles of their patients. And they do so in service of their patients' lives — placing the patients' well-being above their own, in many cases. That's the definition of selfless courage in my book. 

Whether you do medical collaboration or not... whether you do telemedicine or not... whether you feel it on any given day... you are a hero. And while that can't make the job easier — it should let you feel pride for what you do. 

 

Find more inspiring stories about healthcare providers working together here:

 

 

Many doctors avoid going to the doctor.

There are probably many reasons for that — among them, the reality that we can answer many of our own health questions. But I think there is also an unfortunate reality to the fact that doctors know how flawed the current medical system is… and they don’t have the patience to deal with it.

So I have to admit that I was interested to read a description of what sounds like the doctor’s office of the future. Although I was skeptical, I have to say — it sounds pretty good! But there are some important caveats to keep in mind.

A startup called Forward is trying to reinvent how primary care happens. It's part of an overall shift and exploration of tech-enabled concierge medicine... using different forms of telehealth to support an all-in-one paid medical model. 

First, you subscribe to Forward, as you would a gym. Called “tech-enabled direct primary care,” you pay a monthly fee that covers labs and care. The experience is meant to merge the best of hospitality, tech, and healthcare. "We're trying to make healthcare like all the other services we're accustomed to using in our lives,” Forward's Chief Medical Officer Nate Favini, M.D. told Fierce Healthcare

Admittedly, that’s a description that puts my hackles up. To me, healthcare should be much more than hospitality. Truly good healthcare isn’t about making sure patients are comfortable all of the time. It’s about collaborating with patients to go on a journey of their own healing.

But the reality is that Forward’s model has a lot of compelling elements. Patients don’t wait; every appointment begins on time. Costs are saved by reducing the number of support staff involved in patient check-ins and even taking basic stats (that’s done with a body scanner.) The care room has been reinvented to allow doctor and patient to face each other in a serene and comfortable setting. Every appointment is a luxurious 60 minutes and covers a variety of holistic elements, including things like nutrition and even genetics.

So much of what Forward is doing is simply better than how we do it today.

But I worry about a model like this for a few reasons:

• Patients should be treated as people, not consumers.
  The “shadow side” of a model based on hospitality is that we begin to view our patients as “customers” not as people whom we have a sacred duty to care for. In the new model, doctors become more interested in profit margins and satisfaction scores than they do about the Hippocratic oath… and perhaps giving patients the care they need, even if it’s not always the care they want in that moment.
• Everyone deserves excellent care, not just those who can pay for a membership.
  Although this membership seems affordable, I worry that having too many of the country’s healthiest people buying their own memberships could create a situation where we’re not considering healthcare as a community. Rather, that we’re considering healthcare as something that we must get for ourselves, above all.
• People forget that healthcare is both for primary care, and for situations when we are truly sick.
  Not all healthcare should be fun or comfortable. Sometimes healthcare is a battle for your life. In many cases, healthcare demands the highest level and intensity of care and collaboration. And that’s a reality that even a beautiful lobby can’t gloss over.

 

Long story short: I think what Forward is doing is great. Also: we need more than just prettier healthcare or easier healthcare or healthcare the way patients want it. We need to make better healthcare — and that involves patient experience as well as making sure healthcare providers can work in profoundly better ways.

 

In recent years, some of healthcare has become more of an industrial, technician-oriented, conveyor belt model. The “glory days” (many of which weren’t so glorious) of gentleman doctors and their code of honor are definitely a thing of the past.

In some ways, the new world order — more democratic, more distributed across a team — in medicine works well. It helps contain costs. More providers across the continuum of care are able to make decisions and care for patients. People are able to be great doctors and have a sane personal life.

But sometimes we are reminded that there is something timeless and sacred about the relationship between a doctor and a patient. And that may just be something we need to honor more in today’s healthcare environment.

There is something timeless and sacred about the relationship between a doctor and a patient. There is also a sacred and unique relationship between a nurse and his patient; and between a caregiver or aide and her patient. They are all equally valuable, but the nature of each relationship is different. And there is something unique about the quiet, hallowed space between a doctor and the patients they have the ultimate responsibility to care for.

But in the ever-growing pursuit of a more democratic but also more “factory-style” medical system, healthcare has tried to gloss over the importance and primacy of that relationship. It’s tempting to argue that you can spread care out between an aide, a nurse, a Nurse Practitioner, with little “star appearances” by a doctor — and that nothing is lost. Or, similarly, that you can have a doctor provide telehealth in 4-minute video calls with people across the country… and that nothing is lost.

I think that the real risks and downsides of this approach becomes brutally clear in the most extreme care situations. For instance, dramatic news stories have come up recently that, in one way or another, touch on the role of the doctor as ally, guide, leader, and healer — not just as a technician. For instance:

• Maine has become the eighth state in the country to legalize physician aid-in-dying, and although the AMA opposes the decision, they insist it could be ethical for a doctor to assist a patient in dying. 
• Doctors tend to feel responsible to go to more extreme treatment lengths at the end of life, if the patient leaves that decision entirely up to them. 
• The new ECMO "miracle machine" saves lives but leaves patients in limbo, prompting serious ethical quandaries for doctors and for their patients.
• The American Medical Association is now even suing states, insisting that abortions should be the result of a decision between a doctor and her patient.

These are all hot-button issues. And politically or ethically, you may have strong opinions about them. My point isn't which side you fall on each of these. My point is that in each situation, there is an extreme responsibility that the doctor has to collaborate with his/her patient and make a decision that is truly life or death. They're not situations where you can simply follow protocol. They're not situations where there's a single right answer. And they're not situations where a doctor can make a unilateral decision without truly understanding the patient and the patient's family. 

The truth is that, just as was true 200 years ago, doctors today have a grave responsibility to understand their patient — and act (as well as lead the patient to act) in a way that is truly in the patient's service. I believe that even as we keep an eye on costs, efficiencies, and teams — it's also fundamentally important that we honor the seriousness of the decisions that providers make with their patients. And that we support them — practically and emotionally -- in making them. That's where the role of medical collaboration comes in. It's not about 5-minute telemedicine videoconferencing. It's about helping doctors (and others across the continuum of care) in getting the collaboration and support they need to make the life-or-death decisions that they must make.

 

 

In medicine, we tend to separate the “hard” skills of medicine from the “soft” things that simply don’t matter so much. For instance: surgical skill matters; the comfort of your waiting room chairs doesn’t.

Many providers have an ethos that is almost sports-like in its single-minded focus on executing the hard calls, crucial maneuvers, and life-saving techniques on behalf of the people we serve. Things like the tone we use with our colleagues, whether we sit down and listen to an aide with an idea, or even seeing a patient post surgery — these can all be dismissed as relatively inconsequential.

Well, it turns out this approach is wrong — and there’s data to back me up.

I’m not sure whether professionalism and teamwork are getting better or worse in healthcare, but there is certainly a lot of room for improvement. It used to be that there was a bit of a “gentleman’s club”  attitude, that, while exclusive to a very specific group of people and often excessively hierarchical, at least it had high standards for the work. Flash forward to current times, and (thankfully) medicine is less exclusive and more democratic… but many providers also treat it more like a job than a calling.

All of which is to say: not every provider has high standards for their personal conduct, professionalism, and team leadership. For so long, at ClickCare, we’ve been advocates of all of these things. Our own medical experience is that politeness, professionalism, respect, listening, collegiality, and leadership all are the foundation of good medicine. In fact, we've always believed that good patient care simply can't exist unless these "softer" elements are in place. 

This has not always been a popular viewpoint. Many doctors and healthcare providers have challenged us on the importance of these approaches, saying that they don't have time to concern themselves with that kind of thing. Certainly, we have the ROI of iClickCare to prove the validity of these approaches. But we've never had a more general confirmation of the importance of professionalism — until now. 

A recent study in JAMA found that “Patients whose surgeons had higher numbers of coworker reports about unprofessional behavior in the 36 months before the patient’s operation appeared to be at increased risk of surgical and medical complications."  Other studies also found links between the way healthcare providers treated their teams and the effect on their patients.  Why?  Well, as JAMA reminds us, “For surgical teams, high reliability and optimal performance depend on effective communication, mutual respect, and continuous situational awareness.”  Part of the core job of a surgeon is to be a team leader — and that means creating a team that displays and expects respect and professionalism. If that's not the case, the team doesn't function as well, and outcomes simply aren't as good.

I'll be blunt. Just as it is your responsibility to scrub before surgery, it is your responsibility to collaborate effectively with your team. Good patient outcomes depend on both; and both are within your control. Demand the tools to collaborate, certainly. But don't let yourself off the hook. 

 

Learn how other providers do medical collaboration quickly and easily here: 

 

 

Telemedicine has its limits. There will never be a completely virtual replacement for in-person visits and care. 

Where that limit really is, though, I don't know. I find I hear about more and more unbelievable telemedicine programs every day. The most recent? A tele-ICU program that actually seems to be working. 

Honestly, I'm not positive whether this program is ultimately "good medicine" or whether it's a shortcut that shouldn't be taken. But I do think that the very extremeness of the the program gives us some insights about telemedicine and medical collaboration more broadly (not all of which are positive.)

Recently, Lou Silverman of the telemedicine company Advanced ICU Care sat down with Fierce Healthcare to share thoughts about his program and about telemedicine more generally. 

And these are 5 insights about telemedicine and telehealth that that came out of that conversation:

• Good care is what matters -- not whether it has "tele" in front of it.
  We've always said that if you put the individual patient first, the means for caring for them will follow. For instance, you get a telemedicine consult via iClickCare because the patient's case demands it -- not because it's routine. As Mr. Silverman says, "The industry has done itself a disservice by continuing to imply that 'health' is distinct from 'telehealth' or that 'medicine' is distinguishable from 'telemedicine.'  My view is that we are all part of a singular ecosystem with uniform goals and a unified vision around improving care for patients and delivering the care where and when it is needed in a manner that is both clinically and cost effective."
• Medical collaboration gives us the best answer, regardless of who contributed it. 
  Most people in medicine are altruistic; but egos can also creep in. That's why Mr. Silverman's reminder about team collaboration is crucial: "Success is achieved by the team, that performance counts and politics do not. Our attitude is that the best answer always wins. Period. It doesn’t matter who had the idea or how we got there."
• Expensive technology does not make a program "important."
  We've had hospitals turn down iClickCare because it doesn't require any expensive hardware -- it's shocking how much people connect expense, novelty, and quality. But Mr. Silverman is right: "Great healthcare delivery is a fusion of data, expertise, experience and empathy. Viewing technology as a facilitator—and not a shiny new toy unto itself—is also an important part of the mindset. Healthcare is about people helping people. Twenty-first century healthcare is about helping the most people possible achieve outcomes that they did not think were possible."
• Broad telemedicine adoption is on its way. 
  It's so heartening to know that telemedicine is finally finding broad support. "Today, there are very favorable tailwinds regarding government policy in telemedicine. Individual states and the federal government are making tangible progress in advancing telemedicine initiatives," Lou Silverman confirms. 
• Just because something is possible, doesn't mean it's desirable. 
  The fact that a tele-ICU program is even possible is reflective of just what an amazing time we live in. That said, the fact that it's possible doesn't necessarily mean it's the best way to provide care. The truth is that I am not completely familiar with the realities of this program. But I do think it's crucial to always look beyond ROI to what makes an impact on the patient. 

 

Telemedicine is an exciting and important tool. But as the insights above illustrate -- it's not an end unto itself. It's about finding the best tool for the best care. And that's for each provider and hospital to decide. 

Curious about using telemedicine for medical collaboration in your setting? You can get started here. 

 

My mentors in surgery never allowed us to view surgery as solely the surgical event.

Truly knowing the patient, preparing the patient mentally and physically, and working with other providers to ensure excellent post-operative care were all inherent parts of the job — not “extras.”

The truth is that the structure of the medical system has made this approach increasingly difficult to carry out. Ironically, though, many of our most pressing health issues demand this kind of approach. So I was inspired recently to hear about a new program using just this kind of holistic approach -- achieving tremendous success, in a major hospital system. 

As we know, recovering from surgery can be slow and complex, even in the best of times. In the midst of an opioid epidemic, however, there are even more reasons that surgical recovery can touch off opioid addiction. On the face of it, it doesn't sound like a problem you could do much about -- but Geisinger Health System, a major Pennsylvania-based hospital system, decided they could do something about it. 

Rather than trying to address opioid problems directly and after-the-fact, Geisinger's program uses a holistic model to prevent issues before they start.

As Fierce Healthcare explains, “Pennsylvania-based Geisinger Health System is launching a program to "redesign" the surgical experience aimed at improving the healing process following surgery while ultimately tackling one of the major sources of opioid addiction: postsurgical care. Officials said their Proven Recovery program rethinks the surgical experience by pushing patients to be healthier before surgery, which leads to fewer complications.”

Since June 2017, when the program began, opioid usage across the system has dropped 18%. Perhaps even more astounding, hospital stays for neurosurgery and colon surgery went down by a full 50%.

The program focused on pre-surgery and post-surgery approaches, like making it easy for patients to achieve proper nutrition, a focus on non-opioid and targeted pain approaches, as well as focusing on mobility after surgery.

In many ways, this program isn’t cutting-edge medicine. It’s appropriate pre- and post-surgical care. “Appropriate” care is always holistic in these ways — and at other points in the history of healthcare, this kind of approach wouldn’t be out of the ordinary.

That said, the frustrating truth is that this kind of holistic program is so rare that the results Geisinger is getting are truly exceptional. The way the medical system is structured, a program like this — which is preventative, collaborative, and holistic — simply isn’t easy to create or get support for.

We hope that models like this pave the way for more programs that tackle challenging problems in smart, holistic, collaborative ways. And we will continue to make sure that courageous healthcare providers like these have the tools they need to overcome silos and work in medical collaboration, together. 

 

Moody’s Investors Service came out with their 2019 projections and predictions for nonprofit hospitals.

And unfortunately the summary is: things don’t look great.

Although I don’t put tons of confidence or stock in this type of projection, I do think that the report captures many of the challenges that nonprofit hospitals face.

Fierce Healthcare does a good job summarizing Moody’s report: Moody’s says that nonprofit hospitals are on an “unsustainable path” because of “soft revenue growth, weak inpatient volumes and single-digit reimbursement increases in the coming year.”

Other challenges in 2019 may include lower cashflow, an increase in bad debt, lower inpatient admissions, and pressures like nursing shortages and increasing wages.

So much of healthcare is conservative. We don’t change until we need to. And for many nonprofit hospitals, there has been a consistent tendency to maintain the status quo in an almost superstitious fashion — if I don’t change, then nothing will change around me.

Reports like this demonstrate that things are surely changing around us. Our only choice as healthcare providers, as hospital administrators, and as citizens is whether and how to act proactively so that the things that matter to our organizations and to ourselves can be supported and pursued.

Healthcare is changing around us -- for better and for worse. 2019 will bring new technologies, shifts in reimbursement, demographic changes, and developments in our own practice as healthcare providers. Our goal can't be to not change within that. Our goal has to be to change towards what we envision for ourselves and for our patients. And with the new year here already, I encourage all of us to take the opportunity to reflect on what that might look like this year.

 

In our community, there are two nonprofit community hospitals and one Catholic hospital. All are excellent. Each has slightly different founding values and ways of operating. All three have a strong heart and soul, which has been more or less apparent at different times depending on leadership.

So a recent article exploring the shift in how Catholic Hospitals have approached their values and leadership — and the effect that can have — certainly caught my eye.

Catholic Hospitals used to be run, of course, by nuns. Increasingly, however, as the Fierce Healthcare article describes, “Catholic hospitals are much more likely to be run by lay executives who don’t serve as a human embodiment of religious roots.”

There may be multiple positive aspects of this shift. Perhaps the hospitals are able to serve a broader base of people with a greater diversity of religious backgrounds or values. Perhaps the lay leadership is stronger in some technical aspects of running or managing the hospitals. But the author of this article points out that the shift away from hospitals’ original values “can actually hurt their bottom line, as Catholic hospitals lose the loyalty of community members who sense an erosion of the values that were long integrated into their care.”

In other words, although it may seem that the immediate effect is one of broadening and strengthening, there may be side effects — as of any strong medicine — that outweigh the positives. As the author concludes, we in medicine are in a unique place that is at the intersection of art, science, morality, and human caring. Indeed, “hospitals are seen as more than just a business – they are often seen a reflection of the overall health of a community.”

I don’t have a detailed understanding of the specifics of Catholic hospitals and how these shifts to lay leadership have affected them. That said, I have found on a personal, business, and medical level — that when you dilute or don’t lead with your values, it may seem practical but leads to negative consequences.

Collaboration is about declaring to ourselves and our colleagues that we have a unique perspective, unique skills, and unique values as individual providers. We’re not a generic “healthcare provider” that can be swapped in for any other provider. If that were the case, any provider could provide the same care as any other — and collaboration would be far from necessary.

Let there be no mistaking it: when we lead with our values, and care for patients from our unique set of strengths, weaknesses, and values — we are more interdependent with our colleagues and we end up with a more unique role in the process. For providers who want to see themselves as invincible, this can be uncomfortable. But, as with the example of the hospitals, there may be immediate, short term benefits to diluting our values and trying to be all things to all people — but ultimately, it results in weaker care.

In fact, I think that is one reason that iClickCare, and telemedicine-based medical collaboration in general, is so effective. When we are able to collaborate, to reflect on cases, and to lead (and treat patients) with our values, we get better results. As the article author emphasizes, “There’s benefit in continuing to cultivate the essence of local hospital’s unique personality and roots, even as the benefits of system affiliation are stressed.”

It takes courage to practice medicine from your own unique perspective and strengths, rather than from an imaginary “generic” place. But the rewards are great — and so is the care.

For more stories of courage, medicine, and medical collaboration, download our Quick Guide to Medical Collaboration:

After declining steadily through the early 2010s, gun violence has been rising in the US. Mass shootings, while a very small percentage of total gun deaths, have also risen significantly in the past few years — thus the reason that it feels like we hear about a new shooting every week. Of course, the overall numerical significance of gun deaths may not be as sizable as other causes of death -- but gun deaths remain a killer in our country.

For these reasons, gun violence is sometimes seen as a public health issue. Although not an “unpreventable biological disease,” it is a killer and a factor in the well-being of our citizens. Similar to the opioid epidemic, gun deaths have social, public health, political, and behavioral dimensions. So it makes sense that doctors may have perspectives and concerns about gun violence, especially trauma or ER doctors who are literally on the front lines of battling to save patients who have suffered from a gunshot wound. (That said, the overall deaths from gun violence each year are tiny compared to many other public health problems.)

But a recent kerfuffle highlighted how difficult this topic can be to broach.

As is highlighted in a recent New York Times article, Bronx doctor, Dr. Marianne Haughey was outraged when the National Rifle Associated tweeted: "Someone should tell self-important anti-gun doctors to stay in their lane.”

She replied, "I have cared for victims of gun violence for the past 25 years. THAT must be MY lane." 

The politics and practicalities of gun control and mitigation of gun violence are beyond my sphere of expertise. And the analysis of the relative significance of gun deaths relative to other causes of death is a matter of real research to understand -- not something to address flippantly or scandalize.

But regardless of those more specific questions, for me, the conversation brought up an important question -- what does it mean for a doctor to "stay in their lane"?

What is our lane as doctors, generally, and as individual doctors?

Does our “lane”…

• End after the last stitch is sewn, as surgeons, or does it extend to stopping by to check on the patient post-surgery?
• End after we refer a patient to a specialist, or does it extend to following up on their care?
• Include the societal, social, behavioral, and economic determinants of health?
• Necessitate medical collaboration, or is seeing a patient during the visit the only job we have?
• End at the end of our shift?

The answers to these questions have evolved for physicians and healthcare providers over time. And the truth is that there are no right answers. There do have to be boundaries to our sphere of influence as doctors -- both to remain within our expertise and to maintain sanity and efficiency. 

But I think that as a healthcare culture, we've drawn our "lane lines" too narrowly. I do believe that doctors have an important voice when it comes to questions of gun violence. I do believe that surgeons have a responsibility to care for patients long after the surgery is complete. And I believe that medical collaboration is a bare minimum requirement for adequate care. 

Most doctors I know can’t conceive of doing any more of anything.

Their patient visit slots are completely maxed out. Lunch is nonexistent. Every day, it seems like managers and administrators have a new request, demand, or memo to share about yet another thing that must happen during the visit, during the workday or at home.

So a recent article in Fierce Healthcare made me both nod in recognition and cringe with concern.

The takeaway of the article is that patients wished their doctors would talk to them about — and perhaps even support them with — more non-medical or quasi-medical issues. The Harris Poll surveyed over two thousand adults. Those adults shared that doctors (of course), tend to focus on physical health, even though the most common health issues were actually depression, anxiety, chronic pain, and diabetes. According to the poll, however, doctors touched on the mental, behavioral, or spiritual components of health, less than half as frequently (sometimes as little as 10% of the time), as more cut-and-dried physical components of health.

Of course, these “soft” elements — mental, behavioral, or spiritual components of health — are often the things (like exercise, sleep, etc) that can prevent illness or treat chronic conditions. Also, they often relate more intimately to issues like addiction or suicide which are, of course, epidemic in the US. So it could be deeply helpful to patients if doctors were able to broach more of these subjects.

“With what time?!”  I can hear doctors exclaiming in my head. I know from experience that within the visit time allotted by our bosses and by the healthcare industry, it’s difficult to cover even the basics of the patient's complaint and to satisfy all of the EMR’s buttons and requests. When we read an article like this, we feel like one more thing is being demanded from us that may as well just be deducted directly from our sanity.

Interestingly, an article in the New York Times that came out around the same time looked at doctor burnout and may indicate different conclusions. Dr. Mukherjee reminds us that burnout can be predicted by three things (termed the “Maslach Inventory”):

• Emotional exhaustion (being “chronically overextended”)
• Depersonalization (“becoming disconnected from the recipient of your services”)
• Lack of personal accomplishment “a feeling that nothing is being achieved.”

I think many of us tend to talk about and experience the first one — that of being chronically overextended. But the truth is that depersonalization and lack of personal accomplishment are equally important to remaining satisfied and having longevity in our work.

Ironically (or perhaps predictably), the very things that our patients want more of from us — more engagement, more deep interaction, more holistic care — are the very things that would keep us from getting burned out. And so perhaps there is a bit of a chicken-and-egg situation. We feel overworked (emotional exhaustion), so we pull away from the personalization and sense of personal accomplishment that would keep us from getting drained. In the process, we miss the very things that could treat our patients more meaningfully.

It's true that most elements of the medical system right now do not support us in this pursuit. Productivity metrics, EMRs, and decreasing visit times all hinder us in this kind of approach. But the truth is that we still have the autonomy to take an extra 45 seconds and ask that softer question. Or to try a new medical collaboration tool for a week, if we think it would help us feel supported by our colleagues and give us some followup. The changes, perhaps, don't need to be as dramatic as one might initially think -- to be deeply satisfying to both our patients and to ourselves.