Rethinking Institutional Metrics of Success

Recently, I was talking to a superstar surgeon who had travelled to Africa for two weeks to operate and teach. Lives were saved, a gift was given, but when he returned he was told that the two weeks he had spent in Africa resulted in not meeting his RVU target for the month…which he now had to “make up.”

Are you kidding? I can’t think of any physician that would think this is ok….

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I have held leadership roles and I am not naïve. “No margin, no mission” is a universal truth. Financial accountability and stability are necessary for us to heal patients, teach and change the future through research.   But, if we only measure and report productivity it will be the only metric that is perceived to matter…. and that’s not ok.

Financial and productivity metrics are critically important in any business. Healthcare is a very complicated business. But for physicians, medicine is a profession, not a business. This distinction explains why the standard business metrics of productivity don’t sit well with most physicians.

A stethoscope is on a balance sheet. Health care costs

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I’m becoming more and more convinced that we need to rethink how we define “success” for the physicians (professionals) who work in a business (healthcare). If we don’t, I’m afraid we will lose our way…. and potentially a generation of physicians.   So, as a starting point…. what if we thought about the following as potential new metrics of institutional “success”?

RVUs of the group, not the individual

It is human nature that what is counted is assumed to “count” the most. In addition to my friend who was almost despondent over having to “pay back” a mission trip that was part of his original contract, I have watched bright and hard-working physicians choose to stay to do one more little case or see two more consults instead of going home to their children because of this RVU pressure. By the way, these events were when a partner was on call and in the hospital, available and willing to take on this work.

Physicians are a competitive lot. If you give them a target to meet, they will do everything necessary to meet it. But the RVUs for an individual physician vary over time and with circumstances. Because medicine is a profession and not a “job”, there are very few physicians who are “slackers”.   Reporting the RVUs for individual physicians has the risk of hurting the morale of the physicians that are working hard, and rarely motivates people that don’t want to work hard. Besides, do we really want to send a report that monthly RVUs didn’t meet target to a physician who took time off to care for their own hospitalized child? (Yes, it happens.)

Let’s commit to a new institutional paradigm. Set RVU goals for the group. Trust the chiefs and chairs to be responsible for monitoring productivity. Let them take into account the normal ebbs and flows of work as a physican. Trust them to call in the few physicians who are consistently below expectations.

Turnover of physicians in the group

In an academic practice, it’s a good sign if strong, mid-level faculty members are recruited away to other institutions. In all groups there will be physicians who leave for family reasons or because a spouse has been recruited. But keeping track of physicians who leave for other reasons may be a metric that can reveal a bigger problem. Given the extraordinary cost of replacing physicians, isn’t this a metric that should be followed?

Burnout

Burnout is reported in 50% of physicians and costs institutions money. I strongly believe that every physician should have an assessment for burnout as part of their annual evaluation. Physicians that score high on the burnout scale need help – for their sake and the sake of the institution. The cost to the institution in decreased patient satisfaction and increased liability should be enough, but burnout is a life limiting or even life threatening condition. Let’s protect our most precious resource in medicine by paying attention to this epidemic. Why not reward divisions and/or groups that consistently demonstrate low levels of burnout? Why not use what they have learned to coach other groups who need help?

Support staff to physician ratio

I am quite certain that most people have no idea the amount of clerical work that physicians do today. For institutions, it’s a waste of extraordinarily profitable physician time and a major contributor to physician distress. No one knows what the ideal ratio of support staff to physicians should be, which support staff are more important, or what the differences should be between specialties.   So lets measure it, report this metric and compare between groups in our own hospitals and between institutions.  Let’s also make sure we understand how the ratio of support staff to physicians impacts burnout and physician turnover.

Teaching, research and innovation

Professionals work to make a difference but sometimes are not recognized for their successes. Even grown ups love a gold star.  Let’s make a big deal about teaching local physicians, publishing new research, receiving “Doc of the month” awards and building new programs. Celebrate successes – of all kinds – publically and sincerely.

Gifts of time

Likewise, let’s call out and celebrate the physicians who serve on boards of charitable organizations, who travel to treat patients and teach in underdeveloped areas, who sponsor student groups or who otherwise donate their time and expertise to make the world a better place.

Pay equity

I understand that salaries are “complex” in medicine, but it’s time to realize that they can be extremely unfair. When new physicians are hired at a higher salary than extremely successful physicians who have been there for 20 years, something is very wrong. When women and minorities consistently make less, something is very wrong.

There is no way that budgets can suddenly be changed to make pay equity a reality, but its time for all of us to make a commitment that pay equity will happen. Decide how long it will take … 5 years? 10 years? Once you have decided, let your physicians know you will commit to this change. To be transparent, report an annual metric of the percentage of physicians that meet the goal of pay equity. Make these changes. It’s the right thing to do.

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Sometimes it hurts…

A few years after I started as an attending in pediatric surgery, I was called to see a little girl who had been with her father at a construction site. For whatever reason, a wall under construction had fallen and she was caught under it. Her injuries were severe, with massive blood loss from a crushed liver. We opened her chest, packed the liver, transfused her massively but to no avail…

I vividly remember what happened next. Instead of the usual quiet moment of reflection, the team started talking about our week, carrying on a conversation as though this was just one more event in a busy day. It hit me how unusual this was as I was driving home. It was the middle of the night and, as I drove into my neighborhood, I noticed that I wasn’t feeling anything, that the sadness and other emotions I usually felt when I lost a patient weren’t there.

A cat darted in front of my car. I got out of the car, looked at the cat and burst into sobs… which continued for a good 30-40 minutes.

The loss of a patient, the loss of a pet, or even the loss of a dream related to your career leads to grief. Granted, the depth of grief may be, and should be, less than the loss of a family member, but it is grief nonetheless.   Because these losses are often viewed as “less serious”, people may feel that it’s somehow “not normal” to feel true grief when they occur. This is particularly true for physicians, who often have to suppress these feelings to be able to treat the next patient.

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Here’s the single most important message…It’s ok to feel the loss.

The ability to cry over a tragic injury or loss of a patient is the sign of a compassionate physician or provider, not a sign of weakness.   For all of us who experience these losses, It is important to allow ourselves to grieve, if that is what we are feeling. Although this will mean different things for different people, here are a few ways that might help…

Share your thoughts with someone you trust. Talk to your friends and, in particular, senior colleagues.   It is important for your future patients that you are allowed the space to grieve. It is also normal to worry about returning to work if you’ve experienced a particularly traumatic loss.  If you have a colleague who has lost a patient, let them know in direct or indirect ways that you are there for them if they need to talk.

If you are the team leader, talk to your team. It’s important to debrief with your team (and anyone else who was there) immediately afterwards and a few days later.   Make sure you acknowledge how hard this is and ask if people are ok. Remember for many of your learners, this may be their first time to experience the loss of a patient… how you respond will be remembered as their example for the future.

“Good models teach us to handle the experiences that change us.” Thomas J. Krizek.

 Communicate with the family. Immediately afterwards, just be with them. It is human nature to avoid “bothering them” in their time of grief but try to go. Bearing witness to their grief by sitting silently with them is a powerful way to help. Write a condolence letter. Call, email or write a note 3-6 months later to let them know you are thinking of them and to ask if they have any lingering questions. Offer to meet with them if they would like.

Go to the visitation and/or the funeral. Even after a hard journey together, even if you question if you could have done something different, go to the funeral if it feels like you should. Not just for the family, who will be very appreciative – but for you. There is closure in ceremony for everyone.

Take care of yourself. Focus on self-care by being with family and friends, eating good food, exercising, sleeping and doing the things you love.   It is both the burden and privilege of our profession that we experience these moments of intense and tender transitions…. but sometimes it hurts.

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What we can learn from pain…

The following was sent to me after I reached out to a dear friend who had suffered rib fractures (and more) in a fall.  I was so touched by his perspective and the potential power of these words to heal  that I asked permission to post it here.

I’ll say the week started last Thursday, when I sucked it up and scheduled a host of delayed medical procedures, got blood drawn for an array of things, and planned a weekend of work plus my first attempt at cycling since surgery over two years ago – on the place the bike seat hits. I dislike medical tests because I hate to not make great scores on tests, and unlike other tests, it is hard to study for a cancer marker test or blood pressure test. But it was past time.

By Saturday, the weather was Springlike, and all I had to do before climbing on a bike was some roof leak patching. See earlier missives on Facebook about how THAT went. By Sunday I was pushing a morphine pump (almost without effect) wondering just how crushing my skeleton into pieces was going to be the big breakthrough I knew was spiritually on the way to this week. But not doubting the breakthrough at all.

I was too messed up to use even a cellphone, but the outpouring of love, compassion, caring, helpfulness, prayer, gratitude, and ICU humor was so huge I could feel it even through the opioid mist and, I am told, Olympic class pain. It continues even today.

Did you know that gratitude is one of most biologically and spiritually powerful “drugs” ever tested? It measurably switches genes on and off, by the thousands, but always in a good way. Well my gratitude graph is off the chart this week, starting with so many close friends and family. I have reconnected with several long loved dear souls, and connected with several new dear souls. If I had gotten on the bike, death or paralysis were likely outcomes, due to medication issues. If I hadn’t been in ICU, several hidden medical issues would not have been detected.

My beloved wife has almost slipped up a couple of times this week and let her secret wings show. I believe the modern definition of marriage encompasses humans marrying Angels, so I can still call her “wife”.

Then we get to medical tests. Cancer markers – none, again. Extensive CT scans necessitated by my air cargo disaster – no sign of cancer etc. Vertebrae, spinal or brain damage, or chances of dying of testicular cancer? Approaching insignificant. Crickey, my body acted like a crumple zone protected Volvo. Major systems were cushioned by minor (numerous and very painful) fractures.

Medical issues? Of course. But the extensive testing and freak accident have revealed reversible issues, including ones caused by my medications, which would not have been detected in the ordinary course of things. Issues that might have been lethal if I hadn’t gone to ICU and smart people put the puzzle together.

Closer than ever to my wife. Reconnecting with dear friends of all ages. Making new friends. Confirming that my former cancer is truly leaving the building. Re-prioritizing work, play, health, etc. And remembering that the only shortages of Love in this Universe are from people kinking the hoses. We could never use the actual, Infinite, supply. As I write this, I prepare to go hang with beautiful souls tomorrow and share some healing. Pain is just the contrast needed to highlight the transcendent, joyous, beautiful, loving ride we call Life. Since I really should be dead or paralyzed right now, every breathtaking twinge is a reminder to be grateful. Easy peasy.

I had to postpone an appointment with an old, wise, preacher I have known since childhood. I was talking to him on the phone about the combination of joy, gratitude, pleasure, humor and serious pain, and he said he would quote one of his old buddies who is used to suffering. He says”Hallelujah anyway”. I hurt myself laughing at that one, so, just “Hallelujah ya’ll!” Sums it up for me.

Peace, Love, Joy.

They are choices.

Ouch, anyway.😘

Getting Organized:  The Bullet Journal

I’m a huge fan of using technology to organize my “to-do” list.  I’ve used (and loved)  Remember the Milk and Evernote as the backbone of my system.  But I recently discovered a simple, non-tech method which is proving to be the most effective tool I’ve used.

The Bullet List was designed by Ryder Carroll, who is a digital product designer.  The system is elegant, simple and requires only a blank notebook to get started.  (Although I adapted the system to use in Evernote to make it at least somewhat digital … and to avoid the inevitable crisis for an absent-minded person of losing the notebook!).

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The Bullet Journal is based on these five “sections” of the journal:

  • The Index – to know where things are in your notebook
  • Future log – to list big events for future months (ex: Plans for interviews for residency/job, rotation schedules, reading plan
  • Monthly log – a combination of tasks and events for the month (ex: reading plan to prepare for residency inservice exams)
  • Daily log – tasks, events, and notes for the day
  • Collections – list of things, for example books to read, track a goal (like exercise or sleep), technical points as you learn a procedure, or a gratitude log

Here’s the overview video from the site bulletjournal.com, which in 4 minutes explains the how to use a Bullet Journal.

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In addition to making sure you don’t miss important deadlines and events, the Bullet Journal also serves as an actual journal to help you remember important events.  For example, one of my entries last year was…  “Took residents to watch patient take first sip after Heller myotomy.  Everyone cried.”  Don’t underestimate the healing power of journaling during medical school, residency or after your training.  Recording these small moments will help, but using them as prompts for writing the story of your day can be even more powerful.

p.s. If you are in anyway an artist a) I’m jealous and b) have fun!

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Making a Bullet Journal Work in Residency from The Deliberate Doctor

Visual Bullet Journal from dxmedstudent.tumblr.com

How to Bullet Journal from thelazygeniuscollective.com

 

 

 

Last Minute Holiday Presents for Medical Students, Residents and Busy Docs

It’s the holiday season in a very short time, so I thought I’d put together a list of last minute presents!  These are presents that would work for anyone, but are particularly suited for medical students, residents and busy physicians.

A really good water bottle

None of us drink enough water at work …. having a water bottle does help!  There are many out there but make sure the one you choose doesn’t have BPA in it.  Glass and steel bottles are probably the safest, but BPA free plastic bottles are fine, too.   As an added bonus, you can put something in the bottle before you wrap it… chocolates or another favorite candy, gift cards to Starbucks, etc.

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Photo credit and link to a site listing “best” water bottles

 

Pandora One

Listening to music you like without commercials is a great gift for listening while studying, in the clinic or in team rooms.  Pandora can be played on any computer but also has apps for mobile devices.  There are other sites, too, but this one is my personal favorite.

pandora

Here’s where to go for a gift certificate.

 

iPad

I am a total fan of my new iPad Pro, which has taken over as my computer on a lot of days.  Because of it’s amazing power, there are medical apps, like this anatomy app that won’t run on other iPads.  But the iPad mini may be a better choice for students and residents …. mostly because it fits in the pocket of a white coat.  Make sure you get a cellular network plan with the wireless option, if this is the gift you choose.

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Link to information on the iPad mini

Anatomy Coloring Book

This is a great combination of the proven stress relief of adult coloring books and learning anatomy.  (or reviewing it, even for docs in practice) Don’t forget to order the pencils, too!

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Link to order

 

Electric Pressure Cooker

Pressure cookers in general are an amazing kitchen tool… but the modern electric pressure cooker is also a rice cooker, slow cooker, steamer which makes it the single best kitchen appliance for students and residents.

pressure-cooker  Link to order

 

Prepped meals (ready to cook)

If they like to cook, but don’t have the time to find the healthy recipes and prep the meal, this is a great idea.  Check out Green Chef, Blue Apron, and Hello Fresh as examples.  You might want to search locally to see if there others close to you.

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A gift card to get them started with Stitch Fix

Stitch Fix is perfect for both men and women that either a) hate to shop for clothes or b) love to shop for clothes but don’t have time.  It’s a service many of my friends use and love, so I can personally recommend it.  After you sign up, they send 5 items a month (or at whatever cadence you want).  You send back the ones you don’t want and get billed for the ones you keep.

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A membership to a local museum

If there are museums in the area that correspond to an interest this could be a great gift. Museums like the Houston Museum of Natural Sciences, the Museum of Modern Art in New York, etc. are a great way to enjoy time off. Include a note that says you are giving this to them as a break from their studying or work!

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Best wishes for a joyous holiday season, peace in your lives and on earth and a New Year filled with health, happiness and joy!

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Advice physicians should follow. But don’t.

This is a truly wonderful piece from Emily Gibson, re-posted here with her permission from her beautiful blog, Barnstorming.  Enjoy!

octevening298As we drown in the overwhelm of modern day health care duties, most physicians I know, including myself, fail to follow their own advice. Far too many of us have become overly tired, irritable and resentful about our workload.  It is difficult to look forward to the dawn of the next work day.

Medical journals and blogs label this as “physician burnout” but the reality is very few of us are so fried we want to abandon practicing medicine. Instead, we are weary of being distracted by irrelevant busy work from what we spent long years training to do: helping people get well, stay well and be well, and when the time comes, die well.

Instead, we are busy documenting-documenting-documenting for the benefit of insurance companies and to satisfy state and federal government regulations. Very little of this has anything to do with the well-being of the patient and only serves to lengthen our work days — interminably.

Today I decided to take a rare mid-week day off at home to consider the advice we physicians all know but don’t always allow ourselves to follow:

Sleep. Plenty. Weekend and days-off naps are not only permitted but required. It’s one thing you can’t delegate someone else to do for you. It’s restorative, and it’s necessary.

Don’t skip meals because you are too busy to chew. Ever. Especially if there is family involved.

Drink water throughout the work day.

Go to the bathroom when it is time to go and not four or even eight hours later.

Nurture the people (and other breathing beings) who love and care for you because you will need them when things get rough.

Exercise whenever possible. Take the stairs. Park on the far side of the lot. Dance on the way to the next exam room.

Believe in something more infinite than you are as you are absolutely finite and need to remember your limits.

Weep if you need to, even in front of others. Holding it in hurts more.

Time off is sacred. When not on call, don’t take calls except from family and friends. No exceptions.

Learn how to say no gracefully and gratefully — try “not now but maybe sometime in the future and thanks for thinking of me.”

Celebrate being unscheduled and unplanned when not scheduled and planned.

Get away. Far away. Whenever possible. The backyard counts.

Connect regularly with people and activities that have absolutely nothing to do with medicine and health care.

Cherish co-workers, mentors, coaches and teachers that can help you grow and refine your profession and your person.

Start your work day on time. End your work day a little before you think you ought to.

Smile at people who are not expecting it, especially your co-workers. Smile at people who you don’t think warrant it. If you can’t get your lips to smile, smile with your eyes.

Take a day off from caring for others to care for yourself.  Even a hug from yourself counts as a hug.

Practice gratitude daily. Doctoring is the best work there is anywhere and be blessed by it even on the days you prefer to forget.

 

I Forgot To Tell You About My New Favorite Breakfast!

This morning I was lecturing to the first year medical, PA and DNP students. At the end of my embryology lecture I included some advice on how to eat well as a busy student. I talked to them about how to set a good example for their future patients, how to increase vegetables in their diet by making Mirepoix every weekend, shopping at the farmer’s market, and how to plan for the week. I also talked about why it’s important to eat breakfast. I told them about one of my favorite fast breakfasts, but forgot the second one!

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MLB BREAKFAST TACOS

Here are the ingredients:

FullSizeRenderThis batch had beans, cheese, a red bell pepper, a jalapeño and some cilantro, but you can add anything!  Spread out the tortillas and divide up the ingredients between the tortillas.

IMG_3511-1024x1016Roll them up, put them in the freezer. Two minutes in the microwave and they are ready to eat!

 

OVERNIGHT OATS

This is SO easy and really delicious.  Put ~1/3 cup rolled oats in a bowl and add twice as much (~2/3 cup) liquid. (You may need more of both depending on your caloric needs)

My favorite liquid is kefir (liquid yogurt), but it can be milk, almond milk, soy milk, etc. Leave it in the refrigerator overnight. Eat it in the morning. That’s it!

You can add any variety of fruit, nut or nut butter the evening before or in the morning. My current favorite is blueberries and slivered almonds added in the morning.

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