Patients come second (so that everyone does better)! Addressing Physician Burnout

Our Physician Informatics Group (PIGs) has a book club. We read a book every couple months, and a recent book we read together was Patients Come Second. It is a provocatively titled book, but also timely, in the setting of physician burnout in our country.

There are lots of goals we have in Informatics. We have ASPIRATIONAL GOALS, with lofty thoughts of building or partnering with Deep Mind or IBM’s Watson, and have the Machine learn about healthcare and build predictive models and seek and destroy wasteful non-productive treatments. These are like building the upper floors of a would-be skyscraper.

We have KEEP THE LIGHTS ON goals, squashing software bugs, seeking out reasons for “slow performance,” upgrading to the new software version, fixing various things as they stop working. One wonders, exactly how many lines of code are required to run an enterprise EHR? 2 million? 10 million? Its is a wonder more doesn’t happen day-to-day. This is like keeping the first floor of a building running smoothly.

Our FOUNDATION IS CRUMBLING, however. And this puts the entire structure at risk. I’ve been in Informatics since 1998, seen 3 major and countless minor EHR’s come and go at our institution. I’ve played the cheerleader for years, setting the vision to Modernize Healthcare, one doctor, one clinic, one patient, one organization at a time. We’ve all held our breath, that “the next version of software” will finally reduce the burden on our physicians. I’ve implemented major changes in the system for the benefit of patients (Open Notes, Open Results, Online communication between patients and physicians), and physicians (Dragon speech recognition, remote access to charts, eliminating shadow paper charts, unifying many clinics around a single EHR database, establishing APSO notes as a default standard for improved readability, building EHR Genius Bars, creating EHR Sprint teams (more on this another time)).

And yet.

Between the burden of increasing federal regulation, the burden of increased documentation to justify the hard work that physicians do (“I certify that I personally updated the past medical, surgical and family histories in this patient’s chart”), the requirements from the Joint Commission, interpreted from Medicare regulation:

The patient’s smoking status is …, the patient’s fall risk is …, the patient’s main concern today is …, the patient’s score on depression screening is …, the patient’s vital signs are …, the patient’s past medical, surgical, family history is …, the patient’s substance abuse history is …, I certify I have reviewed the patient’s State Opiate Registry to ensure no inappropriate opiate use by the patient … the patient’s “exercise minutes per week” are …, the patient’s answers to the 40 Review of Systems symptom questions (not related to current visit) are …

AND THEN after being grilled like this, the patient can finally tell us:
“why I am here today.”

And, on top of that, there are RAC audits: The Recovery Audit Contractor, the wolf-hounds contracted by Medicare to sniff out fraud, with the explicit arrangement that any inappropriately Medicare-billed visits in the past will be labelled fraudulent, and the monies returned to the Feds, often with penalities in the $$ millions, with a substantial fraction “earned” by the obviously highly motivated RAC auditor.

The joy of medicine has a smaller and smaller corner of the office to thrive in. Burnout.

Fast Company writes about it:

JAMA writes about it:

It is a stake through my heart that EHR’s are commonly cited as the reason for burnout, and many of my major decisions of the past decade have been in the service of reducing this burnout, balancing what is best for patients with what is best for doctors.

Maybe it is time to ramp up the care-and-feeding of doctors, and let Patients Come Second, so that patient care can be joyful again, and patients can enjoy better relationships with their docs, and better overall healthcare. Sometimes a shake up in attitude helps us look at the world differently.

I hear that some organizations are giving their docs the gift of time: giving docs certificates for “time” that can be spent asking a “gofer” to shop, to buy groceries, to help with laundry or dry cleaning, to shuttle kids to/from child care, to put gas in the car. Some are flexing their doc’s work hours to match family obligations (school children), others are finding other ways to give back valuable time to harried docs.

How can we help Patients Come Second (so that everyone does better)? What can we all do to think outside the box, and bring joy back to medicine?

Truth and the Dragon (too good not to share)


I did not attend HIMSS this year. Sounds like the Epic vendor booth handed out copies of a very old book called Truth and the Dragon, about combating propaganda, written in the 1960’s (the days of the Red Scare). (Thanks to Pete Wenzlick for the hot tip.) What is old, is new again. I plan to read this with my kids.

So, so well done.

Review: Death’s End

Death's End
Death’s End by Liu Cixin

My rating: 5 of 5 stars

I did not believe the reviews. Three-Body was a terrific book, but reviewers said that book 2 was better, and then book 3 was even better. Well, believe it.

I was enthralled by the Three Body Problem. Celestial mechanics, virtual reality gaming done right, alien interaction over galactic distances, political upheaval, insoluble problems pulled together into a tight narrative.

I boggled at Dark Forest. Description of the principles of Cosmic Sociology (no kidding! I loved this construct and its corollary ideas), the suspicions across light-years. Just so well constructed and told.

And, now Death’s End. The author broadens his view to illustrate his point “The Universe is big, but Life is bigger.” And another point, that older civilizations end up using the laws of physics as weapons. What?!? Suffice it to say, the narratives set up in the previous books are kicked up another notch. Moreover, the author creates 3 compelling fairy-tales that are not only terrific stories in themselves, but completely crucial to the larger story-arc. This is my new favorite trilogy of all time.

What are you waiting for? Go read it.

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Review: The Power of Habit: Why We Do What We Do in Life and Business

The Power of Habit: Why We Do What We Do in Life and Business
The Power of Habit: Why We Do What We Do in Life and Business by Charles Duhigg

My rating: 5 of 5 stars

I read lots of what I call “popular psychology” books, the way I used to devour “popular science” magazines when younger. I find the intricate and contradictory patterns of the mind even more interesting than the latest scientific or technological breakthroughs. Having numerous habits that I wish I could change, and, as importantly, having numerous colleagues, and perhaps most importantly, patients who have habits I wish I could influence positively, I was eager for the anticipated advice.

Duhigg writes clearly and compellingly. He stocks the chapters with story after dissected story of how habits can change at an individual, small group, or large corporate or even national level.

This main tenet is the sequence of links between CUE-BEHAVIOR-REWARD, and how even our best conscious intentions are overwhelmed with the subtle, insistent, irresistable patterns in this habit-sequence. Want fries and a drink with that burger? That TV remote and barcalounger calling to you at the end of a long day? The gym too far away AGAIN?

He finds fault with those (like me) who believe that IT’S JUST WILLPOWER. No, it’s not. Habit will win every time (in the long run). His idea, at the individual level, is that it’s worth taking stock of the habit you’re interested in changing (say, getting enough sleep at night), and determining, really what the cue (it’s 11pm and quiet in the house) and the reward (now I can finally think, and read!) are. Then, it’s a matter of retaining the reward and figuring out what other behavior can sustainably be substituted: audible books to listen in the car? turning off your screens in the evening and reading for 2 hours? carving out 2 hours some other time in the day?

Furthermore, his insights on strong ties, weak ties, sense of community, obligation, make this more than just a self-help book.

CMIO’s take? This one clearly demands a re-reading. I’m going to use this to analyze my own habits, and see which of my behaviors I can hack. Furthermore, I’m wondering if, as a physician, I can create concrete new habits and rewards for my patients, whether’s there’s a simple formula, or whether that work is so much more self-driven, so much harder, as it seems to be.

It’s no longer adequate to tell patients “just go get some exercise”. Now its time to discuss: what is the cue-behavior-reward of exercise? Cue: get home from work. Behavior: sit down, turn on TV, Reward: relax and enjoy the evening. However, there are those who, once started on an exercise habit, find the behavior: exercise leading to its own reward: feeling better about yourself.

But, how to get over the hump of change? Some other mini-reward for 30 days to establish the new habit and start feeling the new reward? Using a calendar and marker? Perhaps a prescription from the doctor taped to the fridge with checkboxes to complete? A doctors fake-pill bottle of minty tic tacs that you can take daily AFTER exercise, and then we count the pills together at the end of 30 days? There’s something powerful here for all of us.

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Wall Street Journal: How to get patients to take more control of their medical decisions (news)

Courtesy of Wall Street Journal original article

At UCHealth, based in Aurora, Colo., as soon as a doctor finishes signing a note, it is available to patients in their electronic record, according to CT Lin, chief medical information officer. Doctors are encouraged to use language such as “you and I have agreed that you will take these actions,” Dr. Lin says. Bella Wong, 39, who had a double lung transplant four years ago at UCHealth’s University of Colorado Hospital, says online access to her own records and doctors’ notes has helped her become a more engaged patient than when she was first diagnosed with lung disease eight years ago and left decisions mostly to doctors. Though she once viewed the word of doctors as “gospel,” she says of her relationship with them now, “I want to know everything that is available to me and understand all my options—you are not just telling me what to do, we are making a decision together.”

Thanks to the Journal and Laura Landro for a great writeup. Proud of our team, our patients and our organization for sharing this journey.

Review: Dark Matter

Dark Matter
Dark Matter by Blake Crouch

My rating: 5 of 5 stars

Some books slink onto the bookshelf and lay there for months or years. Some books keep popping up insistently until you say “FINE” and buy it, just to shut up the voice in your head. This is one of the latter. I saw this on my feed, highly recommended among my friends on Goodreads, and finally(!) as a first-ever flyer for “Book Club” near the restrooms in my building in Academic Office One at work. A Sci-fi book for nerdy academic physicians and their staff?

Once I picked up this book, I couldn’t put it down. Sure, the Spielberg-like, idyllic family life for the protagonist, check. The “gotta go out for just a minute” (don’t do it!), check. The inevitable “event” that upends the world for the protagonist, check. Sure, I’ve read (and maybe some of you, following me on this blog?) about the Hero’s Journey at the root of so many stories, and maybe, with my new eyes, I was anticipating some of the next steps.


Sometimes an author pulls you along, and then starts unwinding some big ideas. Okay, maybe the title “Dark Matter” should have been a giveaway. Maybe the first chapters, as the protagonist’s grogginess wears off, seemed to telegraph the author’s hidden intentions.

But then, as my favorite sci-fi books do, the author shifts it into a higher gear and starts spinning a terrific yarn: a tale of hard choices, yearning, “what-if’s”, superpositions, love, Schroedinger’s cat(?), and nape-of-the-neck Spidey-sense tinglers. Any book that includes the phrase: “that person will decohere the quantum state” is okay in my book. Especially if it makes total sense when you get to that point in the narrative.

CMIO’s take? There are times in our lives that we wished we did something differently, and wonder if things would have turned out differently, at work, at home, whether we would be happier, wouldn’t we have fewer regrets, if only…

I suggest: live your life in the present. This present. This one, where you have to read this amazing, thoughtful, science-fiction-isn’t-even-as-weird-as-real-science book, ‘cuz I’m not gonna spoil it for you.

BONUS ROUND: Book club at work was hilarious and fun. Met with staffers at the academic center, all of whom had interesting backgrounds, found very different points of the book to be fascinating, and we had a great exchange. Why don’t we have more book clubs at work? We should.

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Review: We Are Legion (We Are Bob)

We Are Legion (We Are Bob)
We Are Legion (We Are Bob) by Dennis E. Taylor

My rating: 5 of 5 stars

Not all Sci-fi books are BIG idea, massive-world-building enterprises, clearly researched and diagrammed to the infinite detail, to sustain disbelief over multiple volumes (I’m talking to you: Foundation, and The Expanse, and Three Body Problem, and Quicksilver, and anything by Alastair Reynolds). This one doesn’t take itself seriously, AND YET is a rollicking read, full of laugh-out-loud moments, and then chin-scratching “hmm” moments. Reminiscent of Ender’s Game and Hitchhiker’s Guide in tone and action.

CMIO’s take? If you get the chance to “freeze” your head after a massive accident, AND someone offers you the chance to be the brains behind a Von Neumann probe that can self-replicate and explore the universe? Do it.

Seriously, it is not necessarily good to have a team of “yes-men” to rubber-stamp your actions; instead, a team of those with common strategic goals, with varied expertise and opinions (see: Wisdom of Crowds by Surowiecki) that is most likely to succeed.

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