COMMENTARY

For the Quadruple Aim to Succeed, Keep Doctors Doctoring

Melissa Walton-Shirley, MD

Disclosures

April 18, 2018

How many times have you heard, "You knew what you were signing up for when you applied to medical school"?  I have always challenged that notion. Dedication to our profession and to our own humanity was never meant to be mutually exclusive. That is why I applaud, no, laud American College of Cardiology (ACC) President C. Michael Valentine and his publication in the Journal of the American College of Cardiology, "Tackling the Quadruple Aim: Helping Cardiovascular Professionals Find Work-Life Balance."[1] His enthusiasm to achieve this aim gives me hope. I have read it and re-read it.

Valentine's statements come closest to conveying what's necessary to preserve the integrity of our profession and to keep physicians healthy and productive. But we must be careful with the term "productive." It does not mean staying on the hamster wheel of medicine of 2- to 4-minute patient visits. Productivity must be redefined as a patient visit (in office or bedside) where symptoms and concerns are addressed, a real examination is performed, eye contact instead of screen contact is paramount, and the visit culminates in the promotion or development of a plan for quality of life and longevity.

Unless we define the specifics of what it will take to decrease burnout, the quadruple-aim movement will be a passing fad with little impact. Our professional societies, employers, and colleagues should not couch these goals in a veiled macro that can be left to broad interpretation. We need to start with a few specifics that if not implemented are deal breakers.  Here they are:

1. Get Us Off the Phone

Revamp the current "prior authorization" process.  Company physicians who participate in inappropriate denials[2] should be subject to medical board sanctions that risk their medical license. Food and Drug Administration–approved medications for the appropriate indication should be filled.  The prior authorization process should be streamlined by implementation of a real-time chat option that can be accessed later as a record of our appeal.

A chat format would allow us to engage in a dialogue throughout the day (as our schedules allow), untethering us from long waits for the company physician to get on line. Physicians who are not keyboard capable should have the option to dictate their request to a tech, nurse, or scribe. Our medical societies should push for legislation that impacts all of these issues.

2. Get Us Off Screens

Employers should offer transcriptionists based on physician preference. We should push for a mandated "one-click option" for all EHRs. Provided a good history and set of diagnoses have previously been entered, stable patients don't need a 10-minute keyboard entry. The relegation of physicians to transcription is the single greatest waste of talent, time, and money in the history of medicine. Consequently, re-establishing our role as practitioner is the greatest opportunity in medicine today.

3. Implement Tort Reform

This is a most basic pillar for achieving the quadruple aim. Even if you haven't been sued, the possibility is a distraction.[3] Fear of litigation drives overtesting and overtreatment. Drawn-out and costly lawsuits have led to physician suicide and early retirement. The goal of mediation should be paramount. Damages should be capped, and every corporation and hospital should foster physician support during the process. There should be good risk management strategies that run toward and not away from dissatisfied or injured patients and families.

4. Give Autonomy Back; Award Effective Productivity

If a human is capable of navigating 4 years of medical school, we are capable of managing our day. A good start would be to salary physicians based on the "eat what you kill" philosophy—that way, we have some control over how hard we are driven in our practices. Our base salary should cover malpractice insurance and health insurance, pay our overhead, and cover projected living expenses. We should be offered an average salary for our specialty. On the basis of productivity we should "split the pot." Our workday schedule should reflect our changing family responsibilities as we mature.

Pediatricians and family practice physicians, classically lower-paid specialties, should see an increase in reimbursement for their time as drivers of primary and secondary prevention. This would promote the classic definition of productivity and at the same time serve the masses. Smoking cessation, medication adherence, dietary restriction, and weight management visits should be reimbursable and factor heavily in the classic productivity formula.

5. Promote Mental Health Services

The fear of being ostracized or the stigma of requiring counseling or treatment should end. Suicide is a cancer in our profession. Unfettered access to mental health assessments and therapy should be promoted. If we are competent to proceed in our profession without endangering others or ourselves, prior mental health treatments are absolutely no one's business, so omit that question on the next job application. Good references and background checks should suffice. I make this claim in the name of my good friend and wonderful physician who committed suicide in 2012.

6. Physicians, Be Considerate

Bring back the curbside consult. Let on-call physicians stay home at night. If standing at the bedside along with other providers is not absolutely necessary, don't request it. Don't interrupt sleep for resting docs unless their input is going to contribute to the case or you have information that will change the course of therapy. Don't get an acute consult for a chronic illness that can be addressed as an outpatient. Discuss cases, teach each other, learn from one another, trust each other, and be considerate.

7. Reform Patient Education

Students at levels K-12 are ripe for learning basic self-preservation techniques that we aren't teaching. They need good information on how to maintain a healthy weight, practical nutrition education, basic pharmacology, an understanding of where organs are located, and their basic functions. We should also teach basic disease recognition. We are missing a 12-year opportunity to drive down the cost of healthcare by teaching primary prevention and more appropriate utilization of health resources.

There is a place for all of us in medicine who are competent and enthusiastic. Employers and colleagues should respect the fact that our roles change as our home life and level of maturity change. We should avoid pasturing physicians who are still competent low-risk practitioners. We should nurture young physicians in order to preserve their longevity. Unless physicians regain support and respect, applicants for medical school will approach extinction on the current trajectory. We will be happily replaced with the burgeoning workforce of nurse practitioners and physicians assistants who require less training and lower salaries.

We should pull out all the stops to restore our dignity and our hope as physicians. Thank you, Dr Valentine, for recognizing that need, and I look forward to what you may accomplish. I'll bet the majority of us who are still in love with our profession stand ready and willing to help you.

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