Physicians Are All Alone Together

It is a time of great change and challenge in health care. The challenges are best seen in those who deliver the health care. Marginalization of nursing has been present for decades. Financial designs have long resulted in pressures for fewer nurses doing more as patient care gets more complex. Now this is seen in physicians and across those in health care. 

The chronic provocations of the broken-down 
healthcare "delivery system" relegates physicians into a chronic 
and unsustainable fight-or-flight mode. (Hood)
It is indeed a cruel irony that we are all alone – together. (RCB)

Innovation and disruption discussions have been converted into policies, regulation, and the push for digitalization. This rapid change focus is fixed on fixing health care. Instead the relentless bandwagon of disruptive innovation has rolled over those who deliver health care. 

Rapid regressive changes are taking the humanity out of health care. They are taking the health out of those who deliver health care. Those promoting the changes think that they are being progressive and they are helping to improve health care. They are not.

Worst of all is the isolation that is epidemic as our electronic devices devour our time at home and at work. The Loneliness of Being a Physician is a work by Gregory Hood. He brings together a number of reflections worth a review.

If you are a physician or are near one, much of this will not be a surprise. If you are trying to figure out what happened to the people component of health care, this will help you understand what is happening. 

The financial design changes are bad enough as those who deliver health care have fewer team members and more tasks – and less time with patients and each other. But worst of all is that the designers appear to have no clue regarding the consequences.

There is a great division that has yet to be addressed between those who actually deliver health care and those who do not deliver health care - designers, policists, managers, executives, associations, foundations, and leaders in institutions. Those delivering care are keenly aware of the changes that impair their ability to care. Those not delivering care seem more oblivious to the consequences of their actions or their inactions.

The stress, suicide, and burnout rates are going through the roof. Instead of moving toward understanding and a true solution, we have quick fix efforts. Once again these benefit those involved in the quick fix with minimal potential for addressing the multitude of consequences arising from the designs in constant turmoil.

Not surprisingly there has been a rise in the promotions of conferences and other activities for a quick fix. But the designs continue to get worse with less support and greater stress loads.

Those who do not delivery, the ones who shape and implement the design, do not know and do not seem to care.

Tearing at the Heart of Health Care Delivery

Working with people to help figure out diagnosis and treatment is the heart of health care delivery, but those who deliver health care must function despite those who make no attempt to diagnose and address the needs of those who deliver health care. 

Do No Harm is one of the top priorities of those who deliver health care. Those who design health care clearly cause harm specific to those who deliver the care and indirectly to the patients that they work with. Researchers have been restrained with human subject protections. This protects hundreds or even thousands at a time from past abuses although some slip through. On the other hand, there are no human subject protections from design changes - changes that regularly impact millions of Americans and those who attempt to serve them despite the changes.

Frustrations About Ability to Help Patients

Physicians are more frustrated with inability to impact the lives of their patients. Some are in withdrawal from interactions. This is hard to identify unless you have been through such a withdrawal. In Balint groups at the University of Nebraska, I was able to identify my own withdrawal from patient interactions. I had experienced some recent deaths of patients that I had seen for years. There are many reasons why physicians minimize the patient experience. In recent years, there are many more.

"There are many reasons that people choose to practice clinical medicine, but those reasons are often based in an essential priority of connecting with other people and helping them. The relentless corporate trend of fragmenting healthcare delivery has been exerting an inexorable pressure on the soul of the physician.
"In my practice lifetime, I've seen the dissolution of the connected professional community."
"As John J. Frey 3rd, MD,[1] wrote recently in a must-read treatise, such changes "have led to an increasing sense of professional loneliness that not only threatens the quality of clinical care by replacing personal discussions about patients but also poses risks to physician personal and professional wellbeing." "

Furthermore, Dr Frey is correct to explain, "Today, lunches are solitary, eaten at desks from plastic containers from home or takeout from local restaurants while catching up on email, writing charts before the afternoon begins, or answering online patient inquiries. Even in common spaces and nurses' stations, everyone sits silently in front of a computer screen."[1]  Frey, Annals of FM,Professional Loneliness
The modern psychological study of loneliness is often traced back to Frieda Fromm-Reichmann. She estimated that loneliness lay at the heart of nearly all mental illness and that the lonely person was just about the most terrifying spectacle in the world. As the neurobiology of loneliness has been deciphered, her assertions have been confirmed.

The life of a modern American physician is replete with rejections. There are the rejections of orders via incessant prior authorization criteria, some of which are insurmountable; of nonadherence and no-shows; and of the "Dr Google" experts who, perhaps unintentionally, repudiate the entirety of the physician's training, education, and experience on the basis of a self-fulfilling, nonacademic Internet search, as well as the omnipresent sense that harder, faster, quicker is never going to be enough.

For general internists, there can be the rejection of their entire life's calling, as generations of medical students have rejected this career path, thanks to the draconian and vampiric effects of the American Board of Internal Medicine's certification policies, and the repudiation of the value of the training and experience of the "doctor's doctor" by the government and private payers.

To practice in the backdrop of these rejections in a healthcare system that has isolated us very effectively should be of fundamental concern to the nation, as it continues to face a physician shortfall, particularly in primary care.

One would wonder whether there is not a design flaw for stress to affect our bodies and longevity thus. The answer, though, is more sublime. The remedy for such stressors and challenges is, rather simply, to congregate, to bond, to not be alone, to not be lonely.

The chronic provocations of the broken-down healthcare "delivery system" 
relegates physicians into a chronic and unsustainable fight-or-flight mode. 

The chronic provocations of the broken-down healthcare "delivery system" relegates physicians into a chronic and unsustainable fight-or-flight mode. This, along with sleep deprivation (by quantity and quality) and myriad deleterious effects (including those on systemic vascular resistance and tissue inflammation, among others) exact a significant toll on those who have committed their lives to being of service to others.

The tragic nature of these circumstances is not that physicians who have assumed these service roles do not live trouble-free lives. Rather, it is that people of goodwill, great intellect, and compassion are not perceived by society and those around them and, further, that these consequences curtail the longevity and effectiveness of those healthcare providers, who are a critically limited resource to our society today.

One of the chief limitations of our society, and our language, is that we recognize each other but we do not "see" each other. In parting, we may say to others that we will "see them," but we don't "see."

This realization was well represented in the interactions of the Na'vi in the movie Avatar. Neytiri says, "I see you"-the traditional Na'vi greeting meaning "I see who you truly are." There was an interesting effect in the wake of that movie of a "blue funk," of heightened pain caused by the sense of human loneliness standing in stark, 3D contrast to the idealized relationships portrayed on the silver screen.[5]   Piazza, John  Audiences Experience Avatar Blues CNN

We can't hope to replicate that world in this one, but we can surely do better than we are doing currently in this one."

End of Hood Quotes

It is my hope that those that make design changes begin to actually SEE physicians, practitioners, nurses, and other who deliver health care. Perhaps then they could begin to make personal and professional lives better - instead of steadily worse.

Bob Bowman
Basic Health Access


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