Blog | Tuesday, March 26, 2013

Unintended consequences of progress--safety, burnout and health care reform


Bob Wachter, MD, FACP, wrote in frustration, "Is the Patient Safety Movement in Danger of Flickering Out?"

All too often legal remedies lead to unintended consequences. In medicine we are all too familiar with well-intentioned laws. We moved to resource-based, relative-value units (RBRVS) to have a more intelligent payment system, but our new system became unwieldy and penalized primary care. We have seen gaming the coding system as a reaction, and the Centers for Medicare and Medicaid Services spends way too much money in physician payments.

Privacy aspects of the Health Insurance Portability and Privacy Act (HIPAA) represent a really good idea, but in practice it hampers the necessary exchange of medical information.

RBRVS abuse led to requirements for documentation that have made most notes unreadable.

Meaningful use of EHR leads to frustration and more time needed per patient.

Now the threat of the Affordable Care Act (ACA) is leading to hospitals focusing more on preparing for the ACA than continuing progress on patient safety.

I would add to Bob's lament that we too often confuse performance measures and safety measures. We can clearly decrease central line infections and complications, and the strategies are clear and doable. We can clearly decrease medication errors through improving processes. We can make wrong site surgery a thing of the past.

Those measures make sense as do the efforts to improve patient safety.

However, too many in government and in insurance companies conflate performance measures with safety measures. Performance measures can lead to worse safety, for example, the 4-hour pneumonia rule, trying to achieve HgbA1c less than 7 through the addition of a third drug, anticoagulation for patients with high risk of bleeding.

Here is the real problem. Patients need physicians who focus completely on them and their problems. We know from the safety movement that multi-tasking leads to errors. When we ask physicians to multi-task and do not pay them for the extra work, then attention often leaves the patient.

I wrote on burnout last September:

What are the common root causes of burnout? Primarily burnout comes from loss of control and overwhelming undesirable activities.

Burnout occurs when the job becomes overwhelming.

These many interventions lead to burnout. Bob recognizes that the unintended consequence of increasing rules and regulations without attached pay is burnout. And burnout decreases attention to safety.

But Bob's focus on safety is the tip of the iceberg. Physician burnout impacts every aspect of patient care. We need common sense, not more laws. We need a payment system that focuses on time spent. We need to calculate the true cost of electronic health records, and any economist will tell you that extra time spent is a true cost.

If we truly care about patient safety, if we truly care about patients, and if we truly care about physicians, then we must radically change our health care system to allow physicians to work with their patients. We should pay physicians and others to improve safety.

We must reconsider the toll that government interference has on physicians as human beings.

None of us wants a burned out physician to provide our care.

This is not just a safety issue.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Associate Dean for the Huntsville Regional Medical Campus of UASOM. He also serves as a frequent ward attending at the Birmingham VA Hospital. This post originally appeared at his blog, db's Medical Rants.