Chapter 8
COGNITIVE DISSONANCE AND DEFINING MEANING IN MEDICINE
Scenario
Christina Alfonso looked across the candlelit dinner table at her childhood sweetheart and husband, Roberto, as he gesticulated animatedly to illustrate a key point in his conversation. He was a handsome man. Roberto had pulled out all the stops tonight—new beige sport coat and an open-neck, bright white shirt that showed off his strong, classically Hispanic features and jet-black hair. She thought to herself how much she loved him and how lucky they were to have been able to make their life work together so successfully. She was pleased she had dressed up tonight; she had loved hearing Roberto tell her how beautiful she looked in the car on the way to the restaurant. Her long, dark hair showed off her ivory complexion and dark brown eyes. She was wearing the black cocktail dress Roberto had surprised her with earlier that day and her grandmother’s antique gold necklace and earrings.
The restaurant lights in the upmarket Mexican restaurant in Southern California were dim, punctuated by multiple carefully lit fountains of colored water that played over the wine bottle displays hanging from the walls and cascaded down to the floor. Despite the many noisy groups of diners and constant clashing of plates and cutlery from the busy serving staff, the four close friends, seated at a corner table away from the bar, were able to hear each other easily.
Roberto had just been describing his latest architectural success, a carbon-neutral luxury resort he and his team had designed on the Baja coast. A partner in an international group of architects, Roberto was usually the point man on such projects, which meant going to, and living at, the locations while they were constructed, working with local builders, and supervising the construction of a range of increasingly large and sophisticated building complexes. His hands whirled like out-of-control windmills as he demonstrated how he had finished off the massive entertainment complex by incorporating a solid rock face as one wall, a masterpiece of art and engineering as well as a huge energy saver in a hot climate. Christina had heard this story before and was happy to only half listen as she thought about their life together and how lucky they were. Their friends at the table, Jose and Alexia, were both family medicine physicians who had been classmates of Christina’s at medical school. Jose had given up trying to interrupt the almost-unstoppable Roberto, but Alexia was successful at last after playfully grabbing Roberto’s hand and pulling it back down to earth to halt his torrent of excitable explanations.
“Roberto. We know you love your architecture, but why can’t you just show us some pictures? Your hands are very mobile, and your voice descriptive, but it’s hard to visualize a multipurpose entertainment complex in a cave,” she said.
“Of course,” Roberto laughed. “Here, let me show you on my phone. I have hundreds of photos; let me find the best ones for you.” He pulled out his smartphone and tapped on the photo icon immediately, bringing up several dramatic photos of his work.
“Wow. That’s cool, Roberto,” said Jose. “The walls facing away from the rock face remind me a bit of that building you designed a couple of years ago in Santiago. You know the one I mean. You had a whole series of eels featured throughout the building as a theme, because they are such a delicacy in Chile. Wasn’t that the building you got the big architectural award for?”
“Yes, you’re right. I always try to bring in a local theme or important set of cultural beliefs whenever I build a major complex, but I combine that with making sure the complex is as energy efficient as possible. You know how important combating climate change is to both Christina and me. In Baja, you see those tall, red figures that look like they emerged from the cave. They’re meant to remind you of the ancient rock paintings, hieroglyphs and pictographs, painted all over the Baja Peninsula by indigenous people in the prehistoric age. Those paintings were included on the World Heritage list in the 1990s, so it’s hard for visitors to see the magnificent artwork of the ancients unless they have an official guide. Now, they can visit this beautiful resort and experience the feel of these amazing 30-foot-high motifs for themselves, just as Christina and I did when we traveled the peninsula while I researched which figures would fit the hotel environment best. The big difference, though, is that in the resort they can keep cool without damaging the planet!”
Alexia took Roberto’s phone and started flicking through his photos. Spain, Italy, Morocco, Canada, and Australia all appeared in rapid succession. Many photos included Christina and their two sons, now aged 4 and 6 years.
“I can’t believe how many countries you’ve worked in during the past few years. What an amazing array! It’s no surprise we only see you here occasionally, with all these trips,” Alexia said. “Our kids are only slightly younger than yours, and we’re constantly rushing to keep up with their needs and our work. It seems as though we never get a break, except when we come out to dinner with you guys to find out about your most recent travels. How do you do it? Especially you, Christina. You’re a physician, like us. I would love to know more about your virtual practice. You’ve never really told us a lot about it, but I looked up your website earlier today and have some understanding of what you do. I must say, it looks very interesting. I didn’t realize you had so many colleagues involved. Can you tell us some more about it?”
Christina looked gratefully across the table at her friend, thanking her inwardly for giving her an insert into the conversation and for diverting Roberto, who could have continued with his dramatic stories for hours yet, and probably would, later. As she prepared to respond, however, Roberto interrupted enthusiastically.
“She’s amazing, my wife. See how beautiful she is! She is my dream girl and 10 times more intelligent than me. She manages to work with patients all over the U.S. while she travels with me around the world, and she still manages our boys! All I do is spend time yelling at local builders and negotiating with owners who want to spend as little as possible while building as much as possible. I can’t understand how she does it. She’s a miracle worker. I love her.”
“Now, Roberto. That’s enough,” Christina chided him gently. “It’s my turn to talk. Let me get in and explain what I do.” She gave him a look that was a combination of love and steely determination, which he well understood as denoting his time to take a back seat and control his energy.
“I’m glad you looked at our website, Alexia. Did you see it also, Jose? Or did Alexia explain much about it to you?”
“She mentioned it in the car, but she didn’t go into a lot of detail. Of course, you talked about it a bit when we last met a year ago, but it was all in the early stages then,” said Jose. “Why don’t you just fill us in properly? We’re both eager to hear about it and rather jealous of what you’ve done, living this amazing international lifestyle you have through Roberto’s work. We’re constantly stressed and only managed a short holiday to the Grand Canyon this year, yet you’ve been working in several countries, and you both look remarkably well and relaxed. How do you do it?”
“Well, it’s no great secret. I mainly work as a virtual physician coach, which I can do from anywhere with broadband. I love what I’m doing and really feel I’m making a difference. It’s so meaningful. I get to use many of the communication and planning skills that I learned in our internal medicine training, but on top of that I’ve gotten my MBA1 and qualified as an executive coach over the past few years—all through online courses and mentoring, with occasional in-person retreats. I was doing reasonably well up until about a year ago, mainly with individual physician clients whom I would see regularly on videoconferencing. The physicians I helped were generally self-referred and were often burned out and at the end of their tether, so it was a hard process getting enough individual referrals to keep me busy. Physicians are just so reticent to get help for themselves, as I’m sure you both know. Why, I used to spend as much time finding clients as I did helping them! It was almost like trying to develop a private practice that consisted only of patients who either really didn’t want to see you or were ashamed that it was necessary. There’s still so much stigma over counseling for anything related to mental health.”
“So what changed?” asked Alexia.
“What changed is that I had forgotten that medicine is a team sport and that we live in a rapidly changing world,” Christina said, smiling. “It’s really very obvious when you think about it. What I did was connect with a range of colleagues to form a virtual group consulting practice. We have several doctors, some behavioral health experts and psychiatrists, one addiction specialist, and a few lifestyle and strategic-planning consultants. This level of expertise is so much more than any one of us could achieve individually. Instead of taking on individual physicians as clients, although we still do that sometimes, we now consult to large health systems around the world and take a systemic and organizational view toward changing their cultures and their future planning. It’s so much more interesting, and I’ve been able to incorporate my longstanding interest in climate change as well, because so many health systems are now trying to be more carbon focused.”
“Hmm, I can see how that must feel rewarding, and why you need such a wide range of skills and expertise,” Alexia said. “But why now? I can’t imagine my clinic having the level of interest to bring you in. I suspect you must be very expensive—” She laughed. “Certainly judging by the quality of your jewelry tonight!”
Christina smiled and explained the jewelry had been inherited long ago from her grandmother. After a few minutes, she returned to the story of her business.
“All the recent work on physician burnout and the implications of that in terms of cost and quality has really made CEOs2 around America sit up and think. This is the hot topic of the moment. Have you noticed how many articles on burnout and physician well-being are appearing in the medical journals? I’ve heard colleagues talk about how physicians are suddenly being seen as the equivalent of canaries in a coal mine; they’re the first group showing symptoms as a reflection of the underlying stress on the whole current health care system. Is this not something you are hearing?”
“Yes, it is. You’re right,” said Jose. “Attitudes are changing toward the whole topic of physician well-being. We had a grand rounds presentation on the topic of burnout a few weeks ago. I’ve never seen such a well-attended presentation. The whole room was full to overflowing, and the presenter was inundated with questions afterward. Several of our physicians talked openly about how burned out they felt. I’ve always thought a lot of stigma was attached to admitting symptoms of burnout, but that seems to have almost gone now. It was actually a very interesting lecture. The main point made was that physicians should not be blamed as the cause of their burnout because they are somehow weak. Instead, the lecturer showed evidence that most physicians are actually very resilient people who are simply working in a crazy, unreasonable system that doesn’t allow them to perform. He showed data that upon entry to medical school students are less burned out than other postgraduate students, but 10 years into practicing they’re twice as burned out as nonmedical professionals. It was compelling and made perfect sense to me. Also, it was something I’d read about previously. It was clearly good news for much of the audience; why, one of the surgeons, during the question section, openly thanked the lecturer for being the first person he’d ever heard who didn’t blame physicians for getting burned out through lack of moral strength or resilience. The presenter received a massive round of applause from the audience, and we all talked about the lecture among ourselves afterward. I suspect there’ll be some active follow up and, I hope, some action, although I’m not sure what will happen or help.”
Christina laughed. “Well, that’s why you need to contact us, Jose! Your story is typical of many health groups around the country. They’ve started to hear about this problem of burnout and lack of physician well-being. Some even call burnout a moral problem rather than a health problem. I’m actually quite sympathetic toward that view. And when you combine that with the threat of climate change, and how many of our current health practices are actually harming us through excess carbon emissions, the argument for change is compelling.”
“What do you mean by a moral problem?” said Alexia. “Surely burnout is a set of symptoms, like a syndrome, if not a full diagnosis?”
“Well, the people who talk about a moral problem point to the fact that almost all students, when they enter medical school, do so because they want to spend lots of time with patients, have therapeutic relationships, and cure people. Nowadays, with the excessive amount of administrative work needed in American medicine, most physicians spend more time doing nonpatient work for billing and administration while using electronic records. Burnout is seen as a moral problem because it’s an indication that physicians are not allowed sufficient time to do their jobs properly, or in the way that they want. That raises the moral question of whether they should continue this way, which leads to the symptoms that we recognize as burnout. It actually makes a lot of sense to me.”
Christina saw Alexia nod in comprehension, and then she went on. “Although most physicians have read about the size of the burnout problem, how up to 50% of physicians have at least one of the three major symptoms or behavioral components of burnout, what no one really knows is what the solution, or solutions, are. The market is rapidly expanding for groups like mine that can refocus whole health systems, and hundreds of physicians and other key providers, to work more efficiently, effectively, and happily. What we do is present a range of possible solutions. We try to make self-care, and the care of colleagues, core aims of a changed health care culture. If necessary, we can coach or provide psychiatric treatment for individual physicians within the system using our team of experts spread all over the world. Climate change is surprisingly similar, so we usually include some simple advice on carbon-saving strategies. After all, no medical student entered medicine intending to make the world a less healthy place to live in as an unintended consequence of providing care. So, as a consulting group, we aim to make clinician well-being and carbon neutrality strategic aims of the organizations we work with, aims that are just as important as quality of patient care. We go into organizations—we have both in-person and online consultants—and learn how to better support their physicians as the core individuals driving quality and patient safety. This increases physician retention and reduces the costs of impaired patient care. That’s why we need a multidisciplinary consulting team.”
“See, I told you, my wife is a genius!” exclaimed Roberto, who was feeling rather left out of the conversation as the only nonphysician at the table. “Christina is always looking forward. She’s a builder, just like I am, only she builds teams and organizations in a healthy way, whereas I stick to bricks and mortar. And she does it while still looking after our family, wherever we happen to be living at the time. Let’s all toast Christina, and all the technologies she uses to help her professional colleagues!” Roberto raised his glass and clinked it with those of his wife and two friends. “You know what? Why don’t you tell Alexia and Jose that story you told me last week about the work you’ve been doing in New York over the past year? Some of the feedback you’ve been getting is phenomenal, and from what you said, has already led to you being asked to help a number of other health systems.”
Christina looked at her husband doubtfully. “I’m not sure Alexia and Jose really want to hear that much about my work over dinner. I thought we were here for a pleasant social evening, not a work-dominated meetup.”
“Actually, we’d love to know how you do it, Christina,” said Jose. “We’re both fascinated by how you manage to maintain a professional lifestyle, using your medical training, while at the same time living all around the world, and seemingly without major stress on your family. We’d love to know how to do that.”
“Jose is right, Christina,” Alexia agreed. “We’ve been looking seriously at resigning from our current jobs and both feel quite burned out at times, but we haven’t yet found a good alternative, so we stay where we are because we really like our patient panels and just hope our environment will improve over time. Finding out how you do this is of real interest to us.”
“I’m so sorry to hear that, Alexia; I hadn’t realized you were having such difficulty at work.” Christina paused. “Well, if you want to hear what I do, let me tell you.” She looked around the restaurant and nodded at a passing waiter, asking him to bring more sparkling water. Then she began to explain.
“When we start a contract, one or more of the company’s principal consultants goes and spends a week or two with the health system to get to know it in some detail and to examine its data systems. I tend to do most of my work remotely; I rarely go to the health system in person. The EMRs3 of course contain a lot of data sources, such as time logged, unfinished notes, and numbers of inbox messages, and many other sources can be found on the dashboards that many hospitals keep nowadays, including clinical and operational data. We are particularly interested in patient complaints and staff incident reports, especially those describing possible behavioral problems in physicians, because these are often a marker of high levels of burnout and systemic dysfunction. Then I look at the data on sick days, holidays not taken, physician turnover, numbers of legal suits, satisfaction surveys from patients and staff, and even the system’s social media presence. It’s fascinating. Increasingly, our clients already have gathered specific data from one of the many burnout surveys available, and their surprise at the results of those surveys is sometimes what leads to us being called in. After all, you can hardly do a burnout survey and not offer some sort of intervention when you find high levels of burnout!”
Christina took a sip of her water before continuing. “We look at the data and any other relevant information and interview key physicians and other senior managers. It’s a bit like a root cause analysis. The aim then is to define the solutions most likely to be effective for whatever is happening, and that is the series of interventions we propose. Most of my work is carried out online, in collaboration with the health system, although we always have an in-person consultant working locally. We use a model that’s very similar to that of the EMR companies. You know how they typically charge a certain amount for their software and consulting but always insist that health systems employ their own IT4 teams to do most of the implementation, support, training, and local management?” Her friends nodded. “Most health systems know that the cost of an EMR to the hospital is usually, at most, half of the total cost once all the mandated internal costs are taken into account. It’s a clever model because everyone has skin in the game—the EMR company gets paid for a carefully identified scope of work, and the buying health system, although they usually underestimate how much their costs will be, cannot get away without sustaining them if they want to manage the EMR independently. So we do the same. We provide in-person and online expertise and consulting, the latter of which I do, but we insist that the health system pay some of their own staff to work with us while we actually implement solutions and change over time. The big advantage is that, like the EMR, the health system owns the change process and can continue on without us after our contract is finished. Or, of course, they can invite us back to do more consulting!” Christina chuckled. “Now that we’ve been doing our consulting for a while, we’re in a position where we don’t need to go out hunting for work. The need for what we do is so great that we now get most of our referrals by word of mouth.”
“That’s a clever financial model, I must say, and the partnership approach you take must be interesting. I see how you can do all this online using that model, but what sorts of interventions do you suggest?” Alexia asked. “Most of us know what the problems are, we just can’t work out how to find an effective solution.”
“Well, the solutions vary, of course, but we’ve become experts in some that almost always provide significant early gains and an early win. We focus carefully on how the system uses the EMR, which EMR they have, and their process for training their providers on the EMR, to see how efficiently they use the software itself. We also examine how much time the physicians are spending on the EMR, especially pajama time at home in the evenings and weekends, to see how efficiently—or otherwise—they are using it. You’d be amazed by how many physicians spend upward of a dozen hours per week catching up on their notes and inboxes at home! We also examine what clinical payer contracts the health system has, because it’s the payers’ requirements for billing and data collection that often lead to physicians doing excessive documentation, much more than is needed for normal clinical notes.”
“Why all that disparate data?” said Jose. “I get that most of us use the EMR badly and would love to have more time to spend with our patients. I read one paper last week describing a time and motion study that observed doctors at work; it showed that they spent more time on the EMR each day than actually talking to patients. I know that’s what I do some days. It’s so frustrating, and I feel so out of control. What do you do with the data?”
“Good question, Jose. This is where our consulting company has its ‘secret sauce,’ so to speak. We usually focus on two things as our early intervention, and between them they reduce the amount of physicians’ screen time on the EMR by as much as 10%–20%. That gives them way more time to spend with their patients or, preferably, with their spouses and children. At the same time, we suggest some easy, quick changes they can make to save carbon emissions, which is always popular with physicians in particular.”
“You’re making us drag it out of you!” laughed Alexia. “What on Earth can you do to get results like that? Training us to use the software better would make a difference, I’m sure, but not that much. And if you can make that sort of change, why isn’t every health system in the country doing the same?”
Christina was pleased at the obvious interest being shown by her friends. “Well, you mentioned training. Let me ask both of you—you use an EMR, which is a highly complicated and sophisticated piece of software. How much training have you actually had on it?”
Alexia responded first. “When the EMR was introduced a few years ago, we had 2 days of training and then access to some super-users who taught us shortcuts for a few months. Mostly, we taught ourselves. I usually look around for the youngest physicians I can find, often the residents, and ask them for help when I’m stuck. They seem to manage the supposedly intuitive parts of the EMR better than those of us who were brought up on paper records.”
“So how much regular training do you get now?” Christina asked. “And what happens when your EMR is upgraded, as they are most years? Do you get any extra training?”
“We try to plan our holidays for those times,” laughed Jose. “It’s always impossible. Everything changes, and we just get sent a list of apparent improvements along with complicated screen shots showing how to access them. I know the help desk gets a lot more calls after an upgrade, and we take a lot longer writing our notes in the first few days while we explore the changes and figure out what the EMR does now and how that differs from the previous version. It’s crazy, but I guess we’re all just used to it and accept the process. The last time that happened, it took me more than a month to really work out properly how to prescribe online, and I must have wasted 10–15 hours using my own workarounds, which, in retrospect, were very ineffective. The good news is that I have learned that physicians are superb at finding workarounds, but I really wish someone could have just told me in the first place how to prescribe using two-factor identification on my phone.”
“I’m so sorry, Jose,” Christina responded. “That sounds frustrating. But what you’re describing is the norm for most physicians around the country. For some reason, training on how to use the EMR efficiently so that it fits into your workflow, and not the other way around, is simply not common. You spent years and years learning the pharmacology of drugs, with constant updates, but are given almost no time to learn how to prescribe them electronically, which with today’s narcotic epidemic is becoming much more complicated. My company implements regular one-on-one training for physicians on how to effectively use the EMR in their own clinical environment. It’s complicated, because different physicians have different uses for the EMR and, therefore, different training needs. Compare yourself as a primary care physician with an emergency medicine or inpatient doc. You need access to very different sets of information and colleagues, and the way you document is also different. So training has to be individualized to a great extent, and we have to convince our clients, the CEOs, that this relatively expensive training approach makes financial sense. Return on investment still rules their brains. Fortunately, we can now do that reasonably easily, but we have to use their own data to convince them. Hence the need for data.”
“Can you believe that my physician wife uses more math skills than I do as an engineer and architect?” said Roberto, keen to keep himself involved in the conversation somehow. “It’s taken me a while to get used to seeing her poring over large spreadsheets of numbers so she can convert them into language that proves the need for the changes she is proposing. I always used to think I was the math expert in the house, but I’m now outdone.”
“The training makes sense, but what about the issue of extra documentation that you mentioned? How can that be changed?” said Alexia. “This is becoming a hot issue for physicians around the country. I imagine you’ve read the recent article that compared documentation in the clinical notes of physicians in the U.S., Australia, and Europe; we reviewed it at our last case conference. The results were amazing! U.S. physicians wrote at least three times more than doctors in the other countries, yet we really don’t work differently. That’s why I feel like a data-entry clerk much of the time, and it’s a reflection on the amount of administrative pressure put on us to collect data for billing and reporting.”
“You got it in one, Alexia!” said Christina. “We spend a lot of time working with the health systems and their physicians, usually via video, and that’s the part of the job I specialize in—reviewing this issue with them. We also make it clear that, if they copy us and use more video visits for meetings and with patients, that that also saves gas with less traveling. In our company, we are fanatical about actually trying not to fly for work, so most of the traveling I do is related to our home life and Roberto’s jobs around the world. With our clients, we have to negotiate with the funders and payors, of course, to determine the minimum amount of documentation required for their administrative or billing purposes, and we work with the IT and coding teams, but once we’ve been given the go-ahead to reduce unnecessary documentation, we can usually cut it down markedly. I often end up having a lot of individual sessions with physicians, during which I essentially give them permission to write less and not just replicate large parts of their notes from visit to visit. All that duplication makes notes very hard to review rapidly. I’ve learned a lot about physicians through this consulting and how, as a profession, we are inherently good people. One of the harder parts of this problem is that often the physicians themselves are so afraid of doing the wrong thing, of perhaps being accused of billing fraud, that they tend to go overboard and write way too much rather than just enough. Of course, we all hear of occasional colleagues who are jailed for awful, fraudulent behavior, which drives this fear more, but the reality is that almost all physicians are good, honest people who write too much because they’re afraid of not writing enough. It’s crazy, when you think of it.”
“That’s a really interesting insight, Christina,” said Alexia. “I can remember way back in medical school, all those rumors and stories of doctors being charged with fraud, or getting a DUI,5 and then never being able to practice again. The stories frightened me, and I was extra-careful never to put myself at any risk. I would never drive even after a single drink, and I became super honest. I was desperately afraid something I did would lead to a false accusation that might put my career at risk. You’re right; we’re trained to be almost too good. I know I am one of the physicians it sounds like you counsel. When I was first told I needed to document at least 15 specific pieces of medical information to be able to bill for a new patient assessment, I immediately decided 15 was just the minimum, and if I could write more than that, I would be less at risk of failing this billing gauntlet. I guess in that respect it was partly me, and my determination to do things right, that was causing my notes to be excessively long.”
“Well, maybe this conversation will help you focus more on the minimum good, quality notes you need to write in the future. I hope it does.”
Alexia nodded in agreement. “What you do is fascinating. You must have such an interesting professional life; I’m really quite jealous. I thought all your online work was probably a bit like second-class medicine, just something you do because you travel around the world. Not something you really enjoy and find fulfilling.”
“Thanks. That’s a very interesting comment. Having been working online in one form or another for several years now, I just see it as another approach to a rewarding professional career. One of the really good things I learned early on, when I first got into telemedicine, is that I actually had more time with my patients because I could write my notes while I was seeing them. That saves time and is much easier on video than it is in person, because it doesn’t interrupt your eye contact with the patient. So I ended up spending more time with them overall, which I loved. I realized I also saved 3 or 4 minutes per consultation because there was no clinic-rooming process; I just logged on and started talking to them. It’s made me think about how rigid and conservative traditional medical practice is, and how destructive it is to doctors and inconvenient for patients. Our consulting really involves working with physicians and health systems and giving them permission to change. Why do most doctors work business hours when, in fact, patients want to be seen outside business hours? Why can’t we be more flexible and in control of our work and our hours? Why do patients have to come to us in a brick-and-mortar world when it‘s entirely possible for us to go to them using technology, or for us to work in a hybrid manner, both in person and online? When we wish to consult with our colleagues, which is what I do a great deal nowadays, why do we have to travel when we both have access to sophisticated multimedia systems? If we want to educate ourselves about something, why do we go to formal lectures, which are seldom very interactive, when we can use ‘just in time’ learning online on any topic almost any time? Think of the demise of encyclopedias and the rise of YouTube if you want evidence supporting this educational change. Of course, none of this stops any of us from working in person with our patients in the traditional way. I expect that I will continue with my current work style for the next 5 years or so, but at some stage we’ll have to settle down somewhere when the children are old enough for high school. At that point I can see myself changing my work style again. Maybe I’ll become a more traditional clinic physician, although I doubt it, because I love the flexibility of my current work.”
Just then, the restaurant server came by with dessert, and the topic of conversation moved on to food and children. Alexia signaled to Christina that she wanted to go with her to the restroom. The two friends negotiated the crowds around the bar and made for the women’s restroom, where Alexia knew they would be able to talk in private.
“Christina, it’s so fascinating listening to you talk about your life,” Alexia began. “Is it really as good as you describe? It’s hard to believe you are both personally and professionally satisfied. Is that really the case?”
“It really is. I know it’s hard to believe, but I really do think I’ve worked out the work-life balance equation. I have time for my family and children, and I really enjoy my work. Most importantly, I find my work really meaningful. I feel like I’m making a difference. That’s why we all went into medicine in the first place, right? I’m so lucky, but it hasn’t been that easy, and it hasn’t all been as good as it is now. Why do you ask? And why so privately?”
“I’ve been trying to put on a good face all evening, and being with you and Roberto is so good because you’re both so positive and uplifting, which is lovely. But we’ve been having a much harder time than we told you. Jose talked about us possibly resigning from our jobs, but that’s really only half the story. We’re being pushed out by the clinic owners. They’re putting more and more demands on us both, and on several other doctors in the clinic, and it’s clear we have to either knuckle under and see ridiculous numbers of patients per day, essentially practicing bad medicine to meet their requirements for billing totals, or we have to leave. It’s corporate medicine at its worst, all driven by the dollar. We have no time during the day to keep up with our EMR work, and because we’re both conscientious and really believe in what we’re doing for our patients, we do it after hours to make sure our notes are good.”
Alexia’s face crumpled, and she started crying. “I can’t believe it’s come to this. Jose and I are always fighting. We’re constantly tired. We never do anything nice together. You know, coming out with you tonight is the first date night we’ve had in more than 2 months. What do you think we do instead?”
“I don’t know,” answered Christina. “Are you just tired and watching TV?”
“I wish! If only. No, we spend most of our evenings, after the children are in bed, just playing dueling laptops—both of us sitting and catching up on our medical notes and the wretched inbox. We have to answer all direct patient inquiries within 24 hours, and we have no medical assistant support at work since all those staff were fired a few months ago. Jose is more pragmatic about the situation than I am; he started keeping a schedule of the number of hours of work we both do after our notional clinic day, which is usually at least 10–11 hours itself. I was horrified. We both averaged about 15 hours per week extra at nights and on weekends. So when you add up the 55-hour week at work, and this extra 15 hours, we’re each working about 70 hours and only get paid for the 40 when we’re actually seeing patients. None of this makes any sense. We’re trying to work well in the way that we were trained, but it’s just impossible. I’ve done all sorts of reading about our situation, but the cognitive dissonance we’re facing, with our belief in good medical practices being contradicted by the need for commercial practices, is just too much.”
Alexia started crying again. Tears flowed down her face, smudging her freshly reapplied makeup. Christina put her arms around her and gave her a loving hug while Alexia let off steam and openly expressed her distress. Gradually Alexia calmed down and broke away from Christina, wiping her tear-soaked face with tissues.
“So you see, we have to change. We can’t go on working like this, being controlled at work and constantly facing a sea of increasing work and demands. So much of our time is taken up with silly busy work that could be done by others, but the system doesn’t understand that and expects us physicians to do all the constantly increasing administrative work. It’s all very well to be ‘patient focused,’ but the way we work, with patients messaging us through the EMR all the time, it just leads to more work for which we aren’t compensated. The health system is proud to boast that all its patients have immediate physician access with a 24-hour response time, but we don’t get paid to fulfill those mandates. Jose and I are both completely burned out. We’ve been seeing a therapist to keep our marriage together. We’re just not ourselves. It’s all too tragic, and I’m so afraid we’re not going to make it and stay together. What can we do? How can we change? Please help us.”
“I am so sorry,” Christina said. “I do know somewhat how you feel. I remember being overwhelmed by the EMR and all those dreadful prior authorizations for drugs that used to take so long. They were just a way for the drug companies to stop us from prescribing anything expensive or unusual, a way to take out all the art in medicine and make us perform as though we follow the same recipe every time. But patients can’t be treated that way.”
“It’s so good to hear that you’ve managed to get away from all this, from this approach to medicine that feels as though we’re tied to a wagon wheel. So many little annoyances and frustrations. Tonight has been interesting. I’m sorry to end up crying like this; I must look like the stereotypical depressed housewife, pouring out her heart in the restroom.” She smiled sadly at Christina. “Maybe this is all to the good. I think Jose and I needed a wakeup call, and seeing how we are such a contrast to you guys is just amazing for me. I can’t believe how brave you’ve been to make your career so different from mine. And you’ve even managed to continue practicing medicine while you’ve done it, and in such a meaningful way! Three of my former classmates have moved out of medicine altogether in the past year—one into journalism, one to business, and one who simply retired way too early and is traveling by himself after his wife left and took his children away. Jose and I have actually talked about maybe working part-time to give ourselves more time like that, but I don’t really think that’s an answer. The wakeup call I’ve had from tonight is that we have to make some changes. You know, I used to have a really good mentor who helped me make career decisions, and I’ve never forgotten what he used to say to me. He told me that if you’re stuck in a career that you don’t want, and you don’t change the way you work or leave the position, then you’re making an active decision to stay. At the time, it really helped me change my decision about residency, because when I saw that by not doing something, I still was making a choice, it gave me the strength to plan changes and make alternative choices. I think Jose and I have been making the choice not to change our work and lifestyle for too long, and now we have to do something different.” She put on a slight smile and looked to Christina. “Enough of that. I think we need to join our husbands. They will have missed us by now and might be worried about what we’re plotting in the restroom.”
Christina grinned at her friend conspiratorially as they walked out of the restroom and into the noisy restaurant. “Nothing much, really,” she teased. “Just aiming to send you and Jose off on a new life together.”
Commentary
Four issues of importance arise in this scenario, which contrasts the very different lifestyles of the two couples. The first is the use of information technologies and telemedicine to help physicians work differently and less stressfully. This was discussed in Chapter 4 within a single-clinic setting, whereas in this scenario, Christina runs an international health consulting practice by telemedicine, combining some individual work with a strong emphasis on data analysis to help health systems change strategically. Christina mentioned patient complaints and staff incident reports as being essential to review; when such reports are at a high level, they likely indicate systemic problems within a health care organization and may act as a proxy for burnout in providers. It is possible her consulting company was working closely with the Vanderbilt Center for Patient and Professional Advocacy (ww2.mc.vanderbilt.edu/cppa), whose Patient Advocacy Reporting System and Co-Worker Observation Reporting Systems are evidence-based tools and processes that promote professional accountability and self/group regulation through identifying and intervening with physicians at increased risk for malpractice claims and adverse surgical outcomes. These two quality systems are now in place in about 150 hospital and academic systems in the United States and provide very useful benchmarking data for all involved. A number of other quality systems are in place nationally, such as the Press Ganey (www.pressganey.com) alignment and engagement surveys; thus it is not always necessary to run formal burnout surveys because these other tools may be used as proxies, making the job of consultants like Christina much more straightforward.
The second issue is that of alternative careers from traditional medical practice. Many of these are described in Chapter 10, but Christina’s practice is one rarely seen at present. Her career trajectory will likely become more common in future, as technology becomes increasingly less of a barrier and as the constant air travel required in many international companies becomes seen not only as financially expensive and tiring but also as costly from a carbon perspective.
The other two issues here have not been discussed previously. First is climate change and how physicians can contribute to reducing our carbon emissions, thereby improving their own and everyone’s well-being. The second is the importance of meaning, and a meaningful life, to physicians and how to overcome the cognitive dissonance many of us face daily and focus on the meaning of our work and careers in a positive, impactful way.
Many physicians and other health providers are becoming increasingly interested in how they can change their work and lifestyle habits in order to reduce the long-term impact of climate change. What are the basic relevant facts, and what changes can individuals and health systems make that will have an impact?
The United States as a whole is a major producer of total carbon dioxide emissions, and the health care sector is responsible for 9.8% of this total (Eckelman and Sherman 2016), which is proportionately less than other industries, and health care consumes 18% of our gross domestic product. Eckelman and Sherman (2016) noted that in the health care industry,
health damages from these pollutants are estimated at 470,000 DALYs6 lost from pollution-related disease, or 405,000 DALYs when adjusted for recent shifts in power generation sector emissions. These indirect health burdens are commensurate with the 44,000–98,000 people who die in hospitals each year in the U.S. as a result of preventable medical errors, but are currently not attributed to our health system. Concerted efforts to improve environmental performance of health care could reduce expenditures directly through waste reduction and energy savings, and indirectly through reducing pollution burden on public health, and ought to be included in efforts to improve health care quality and safety.
These numbers should be impossible to ignore. The U.S. health care footprint by itself is larger than the entire footprint from many countries around the world, including the United Kingdom, Brazil, Mexico, and Saudi Arabia. We have to change and reduce our overall carbon footprint at home and at work.
What, then, can individuals do to reduce this communal damage from the impact of climate change? First, we should all measure our carbon footprint (www.conservation.org/act/carboncalculator/calculate-your-carbon-footprint.aspx). Despite thinking that I am fairly energy efficient, I found out that I am not; I produce about 21 tons of carbon per year, approximately the U.S. average, compared with the world average of 7 tons and those of Europe (8 tons) and China and India (4 tons each). The website gives you a series of useful tips to effectively reduce your carbon footprint, which in my case means trying to fly less. For those who wish to examine how their lifestyle and personal choices can reduce their contribution to climate change, Wynes and Nicholas (2017) described concrete choices we can all make, from upgrading lightbulbs (low impact), through recycling and buying a hybrid car (medium impact), to eating a plant-based diet, living car free, avoiding one transatlantic flight, and having one fewer child (all high impact).
What sort of interventions should Christina be recommending to her health system clients to reduce the carbon footprint of health care? We know that the four large carbon-producing areas in the health industry are hospital care, physician and clinical services, prescription drugs, and physical structures and equipment. Activities such as turning off the lights, recycling, and avoiding single-use disposable waste items, which we tend to embrace already, actually save very little carbon overall. So Christina could be advising the following:
Hospital care: Change volatile anesthetics to sevoflurane to dramatically reduce carbon dioxide emissions by a factor of 20 (Alexander et al. 2018). Reduce food waste and serve less beef and pork.
Clinical services: Use telemedicine (Holmner et al. 2014; Yellowlees and Shore 2018), mobile devices, and information technologies as much as possible and do not waste or use excess equipment. Avoid unnecessary flying for conferences and meetings.
Prescription drugs: All drug companies are not the same. Deal with companies that are serious about reducing their carbon impact and are hitting their Paris Accord agreements (Belkhir and Elmeligi 2019). Many are not. Also avoid polypharmacy; give small prescriptions where indicated and take patients off unnecessary medication. Think about social prescribing (Bickerdike et al. 2017) if possible, especially for patients with behaviorally related disorders.
Physical structures and equipment: Build Leadership in Energy and Environmental Design (LEED)-certified buildings that have good environmental quality and are designed and operated to be centered on people and health requirements (Oaks 2018).
Finally, Christina could quote the University of California (UC)’s Carbon Neutrality Initiative to her customers and suggest that they follow this policy objective. UC, which includes five major medical centers, has long been a leader in sustainability and has now pledged to become carbon neutral by 2025, expecting to become the first major university to accomplish this achievement (Office of the President 2019).
In the discussions in the scenario, the meaningfulness of a medical career was accentuated in the contrast between the work and home lives of the two couples. It was evident that Christina and Roberto were fulfilled by their work and their approach to work, whereas Alexia and Jose were not, suffering from longstanding cognitive dissonance as to the meaning of their work and careers and from burnout.
Why is meaning so important to most of us? What exactly is it, and how can it be improved if it is lacking or missing? These are core questions for the great majority of health care providers, especially physicians, who entered medical school to join a helping profession and to have relationships with and assist patients. Few physicians go to medical school primarily because they want to be rich, and although most appreciate and value the salaries that they earn, they are usually not as valuable to them as the community respect that they gain. Those graduate students who primarily measure their success in life in dollar terms do not tend to go to medical school, preferring business administration or legal routes where they may ultimately earn significantly more than an equivalent doctor.
So what is meaning as it relates to work? How do we define a meaningful job or career? Why is meaning so important for physicians? Dictionaries typically describe meaning as being the end, purpose, or significance of something, while meaningful is something that is sincere, deep, serious, and important. Not surprisingly, meaning in medicine has been studied by several groups, especially in the setting of burnout and, as described in Chapter 1, in relation to professionalism. This is also a popular topic in many management books and MBA courses and is comprehensively covered by Shell (2014), who focused on whether a work role is really a career, a job, or a calling. He described various definitions of success, ranging from what he called “outer” definitions, such as recognition, achievement, pay, and authority, to “inner” definitions of prosperity such as fulfillment, respect, and happiness. His book will resonate with many physicians who may have desired the inner definitions from their future careers when they entered medical school but have moved over the course of those careers more in the direction of the outer definitions, creating some internal cognitive dissonance or dissatisfaction and possibly symptoms of burnout. Shell also noted that basing a personal definition of success and meaning on “outer” factors such as money and influence is not a recipe for long-term or sustainable happiness and concluded that finding meaningful work consists of the intersection of three core factors. These are:
Work that others will reward you for doing. This includes many “outer” components such as promotions and status, compensation to meet lifestyle needs, and opportunities for growth.
Work that ignites you emotionally. This component attracts most physicians and can also be achieved with volunteer work and other after-hours pursuits.
Work that uses your talents and strengths in the service of larger goals.
If physicians use these factors as guides for finding meaningful positions, and health care as an industry is replete with positions that allow all three core factors to be met, how should individual physicians attempt to measure their own definition of success and fulfillment? Shell defined seven categories that are especially relevant to physicians seeking meaning in their work. In possible order of importance to the typical career of a physician, they are:
Personal growth and development—leave your comfort zone and learn new skills to progress.
Community care—help others in need and serve a cause bigger than yourself.
Talent-based excellence—aspire to become a subject matter expert.
Independence—work autonomously and control your own future.
Religious or spiritual features—practice your beliefs, faith, or values consistently in service of the greater good.
Family involvement and support—provide your loved ones with the means for a better future.
Self-expression—pursue ideas, research, teaching, or invention.
In an earlier fascinating qualitative study of physicians, Horowitz et al. (2003) collected 83 stories from internists about what gave them meaning in their professional work. The authors developed three major themes, which they described as follows:
In the first theme, doctors changed their perspectives about themselves, their roles, human nature, illness, and patient care after being part of a profound event or emotional experience with a patient or sharing or reflecting on their own life experiences. The second theme is about connecting with patients in moments of intimacy. These moments occurred in the course of relationships lasting anywhere from hours to decades, and in settings ranging from mundane to profound. The third and most common theme in the doctors’ stories was making a difference in someone else’s life. These were success stories, but not of brilliant diagnoses or adroit technical interventions. Most of these stories took place in the context of chronic, incurable conditions, or end-of-life care. In these situations, the doctors themselves were the principal therapeutic agents. They felt awed and deeply rewarded that their mere presence could be healing and comforting to patients. (p. 772)
Perhaps the most important aspect of this study, which bears repetition and may be a useful well-being intervention for others to use, was the authors’ conclusion (Horowitz et al. 2003):
We now have a better and richer understanding of what doctors find meaningful about their work. The internists in our study wrote about miracles and mistakes, sharing their own lives and their patients’ lives, witnessing profound experiences, and receiving acknowledgment for a job well done. Through these events, they were rewarded unexpectedly with a deeper appreciation of what it means to be a human being and a doctor, and of how their caring actions, not just their technical ability, was so important to their patients.
The doctors who participated in our workshops found the process of exchanging stories to be valuable and personally renewing. They experienced a sense of community and reaffirmation. Amid so much discussion of what is wrong with medicine, the workshops seemed to help them remember what is right. With a clearer understanding of what nourishes and sustains them, doctors can be more proactive in advocating for their needs, and, if assured of this, may be more capable of embracing other changes that need to happen. (p. 775)
It is fascinating how this particular study, and the concept of meaning in medicine, is reflected in the process and approach of Balint groups (www.americanbalintsociety.org). A Balint group, developed from the work of Michael Balint in London, is a group of clinicians who meet regularly to present clinical cases in order to improve and to better understand the clinician–patient relationship. Such groups are becoming increasingly popular around the world, partly because of the difficulties that many physicians have working in our current health systems, their cognitive dissonance between how they wish to work and how they have to work, and the frequent occurrence of symptoms of burnout. Balint groups focus on enhancing the clinician’s ability to connect with and care for the patient sustainably, and they may well be one effective solution for improving the lives of physicians by bringing more meaning back to their practice of medicine.
In summary, physicians who recognize similarities between themselves and Alexia and Jose in the scenario should consider reviewing their career directions in light of the concepts of meaning discussed here and perhaps even investigate whether a Balint group exists in their area. Alternatives include thinking about changing practice styles using the many options discussed throughout this book or taking up some rewarding outside interest, such as being involved in the climate change debate and improving the planet.
References
Alexander R, Poznikoff A, Malherbe S: Can J Anesth 65(2):221–222, 2018 29119467
Belkhir L, Elmeligi A: Carbon footprint of the global pharmaceutical industry and relative impact of its major players. J Clean Prod 214:185–194, 2019
Bickerdike L, Booth A, Wilson PM, et al: Social prescribing: less rhetoric and more reality: a systematic review of the evidence. BMJ Open 7(4):e013384, 2017 28389486
Eckelman MJ, Sherman J: Environmental impacts of the U.S. health care system and effects on public health. PLoS One 11(6):e0157014, 2016 27280706
Holmner A, Ebi KL, Lazuardi L, et al: Carbon footprint of telemedicine solutions—unexplored opportunity for reducing carbon emissions in the health sector. PLoS One 9(9):e105040, 2014 25188322
Horowitz CR, Suchman AL, Branch WT Jr, et al: What do doctors find meaningful about their work? Ann Intern Med 138(9):772–775, 2003 12729445
Oaks L: What it takes for healthcare facilities to earn LEED certification. LEED Leadership in Energy and Environmental Design, October 2, 2018. Available at: https://www.laboratoryequipment.com/article/2018/10/what-it-takes-healthcare-facilities-earn-leed-certification. Accessed May 24, 2019.
Office of the President: Carbon Neutrality Initiative (website). University of California, 2019. Available at: https://ucop.edu/carbon-neutrality-initiative/index.html. Accessed May 24, 2019.
Shell RG: Springboard: Launching Your Personal Search for Success. New York, Portfolio, 2014
Wynes S, Nicholas K: The climate mitigation gap: education and government recommendations miss the most effective individual actions. Environ Res Lett 12(7), 2017
Yellowlees P, Shore J: Telepsychiatry and Health Technologies: A Guide for Mental Health Professionals. Washington, DC, American Psychiatric Association Publishing, 2018
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